Psychiatry Flashcards
what is a confabulation?
In psychiatry, confabulation is a disturbance of memory, defined as the production of fabricated, distorted, or misinterpreted memories about oneself or the world, without the conscious intention to deceive.
A 24-year-old man is admitted to the acute psychiatric ward with a history of psychotic symptoms and is given a diagnosis of schizophrenia.
Which of the following symptoms is a first-rank symptom of schizophrenia?
A. Nihilistic delusion. B. Confabulation. C. Pressured speech. D. Thought insertion. E. Apathy.
The first-rank symptoms of schizophrenia include:
auditory hallucinations:
- thought withdrawal, insertion, and interruption.
- thought broadcasting.
- somatic hallucinations.
- delusional perception.
- feelings or actions experienced as made or influenced by external agents.
A research student wishes to conduct a project on anxiety disorders and wishes to use a standardized classification system.
Which of the following is the classification system used for mental illness?
A. ICD-10 B. ICD-9 C. SCID D. SCAN E. CAGE
A. ICD-10
An 8-year-old boy is referred with behavioral problems to the Child Psychiatry Department. He is always active at home and moves from task to task. He finds it difficult to concentrate to read or watch TV. He often puts himself into dangerous situations like climbing onto high roofs. His performance at school is poor where he is distractible and causes distractions to others.
What is the most likely diagnosis?
A. Mania. B. Schizophrenia. C. Somnambulism. D. Conduct disorder. E. Attention Deficit and Hyperactivity Disorder.
E. Attention Deficit Hyperactivity Disorder
Well done, correct.
An elderly man has been admitted to hospital with acute onset disorientation, visual hallucinations, and agitation. He has no psychiatric history and lives alone and requires no support.
What is the most likely diagnosis?
A. Alzheimer's Disease. B. Lewy Body Dementia. C. Schizophrenia. D. Depression. E. Delirium.
E. Delirium
You are a GP and have diagnosed a 27 year old lady with depression. You are confident that she does not require to be treated in hospital and wish to start her on treatment.
Which of the following would be appropriate first-line treatment?
A. Benzodiazepines. B. MAOI. C. SNRI. D. SSRI. E. Tricyclic.
D. SSRI
A 29 year old junior doctor is being treated for depression with CBT.
Which of the following is a term used in CBT?
A. Interpersonal Map B. Negative Automatic Thoughts C. Pre-contemplation D. Separation Anxiety E. Thought Blocking
B. Negative automatic thoughts
A middle aged man is admitted to hospital with gall stones. Part of the admission history is to screen for alcohol problems.
Which of the following is an appropriate questionnaire to screen for alcohol problems?
A. FAST. B. GCS. C. BDI. D. MADRS. E. MOCA.
A. FAST
A 23 year old man is assessed by his GP. He has a severe dermatological condition affecting his hands which is caused by his washing them 13 times before he leaves his house.
What is the most likely diagnosis?
A. Autistic Spectrum Disorder B. Contact dermatitis C. Delusional Disorder D. Obsessive Compulsive Disorder E. Psoriasis
D. Obsessive Compulsive Disorder
A 67 year old woman arranges for her daughter to be able to manage her money as her own mother developed dementia at the age of 70.
power to use in this situation?
A. Assessment Order B. Guardianship Order C. Place of Safety Order D. Power of Attorney E. Restriction Order
D. Power of Attorney
A 24 year old man has recently been started on new medication by his psychiatrist. One of the side effects is an unpleasant sensation of restlessness.
What is the correct term for this?
A. Akathisia B. Anhedonia C. Catatonia D. Dysarthria E. Dystonia
A. Akathisia
A 28 year old man has recently started on antipsychotics. He has been told about a side effect of muscle stiffness and contraction sometimes caused by antipsychotics.
What is the correct term for this?
A. Akathisia B. Anhedonia C. Catatonia D. Dysarthria E. Dystonia
e. Dystonia
79 year old man who has had two hospital admissions for depression in the past is brought to the GP by his daughter. She is concerned that he is spending lots of money, has a reduced need to sleep, is full of energy and wants to run a marathon.
Which is the most likely diagnosis?
A. Alzheimer’s Disease B. Bipolar Affective Disorder C. Delusional Disorder D. Lewy Body Dementia E. Vascular Dementia
B. Bipolar Affective Disorder
You are a psychiatrist treating a 34 year old woman with depression. You are confident of the diagnosis. You have already tried two antidepressants and the second has had only partial effect. Her mood has lifted slightly but she complains of poor sleep, lack of energy and motivation and poor appetite.
Which of the following is the most appropriate next step?
A. Add amphetamine based stimulant drugs B. Add lithium C. Add thyroxine D. Psychosurgery E. Stop the medication
B. Add lithium
A 28 year old woman is an inpatient in the general adult ward. She is being treated for schizophrenia and her symptoms are improving on medication. She is allowed to go to the cinema with a friend and on return to the ward is convinced the nurses have been replaced by aliens, the radio is playing songs especially for her and she can hear voices telling her to sit up all night.
What is the most appropriate investigation to order?
A. Blood glucose B. CT Scan C. Full Blood Count D. Temperature E. Urinary drug screen
E. Urinary Drug Screen
treatments for cerebral palsy based pain?
- psychological treatments
- paracetamol
- opioids
- amitriptyline
- clonidine
Prevalence of incontinence in those living in institutions? (Nursing home, residential care, hospital care)
Residential care 25%
Nursing home care 40%
Hospital care 50-70%
Marrow tissue tumours
- malignant: Ewing’s sarcoma, lymphoma, myeloma
Where do Rivaroxaban, Edoxaban apixaban act in the clotting process?
They act on Factor Xa - preventing the formation of thrombin from prothrombin
- thrombin is required for the formation of fibrin from fibrinogen
When is a structural scoliosis at its most obvious?
When bent forward into flexion
What does paracetamol treat well?
- Mild pain (on its own)
2. Mod-severe pain (with other drugs)
What safety precautions are needed when taking a psychiatric history?
o USUALLY NO SAFETY PRECAUTIONS ARE NEEDED as it is unusual for psychiatric patients to be violent Inform staff who you are going to interview and where Attempt to predict episode • Autonomic over-activity • Posture • Verbal aggression Consider risk assessment o If UNCOMFORTABLE, END THE INTERVIEW
What is included in a psychiatric history?
o Very similar to a normal history Presenting complaint(s) History of presenting complaint(s) Past Medical History Past Psychiatric History Current and recent medication Social history • Alcohol & drug use • Smoking • Social circumstances • Main relationships/supports/carers Family History of Psychiatric Illness Personal History • Developmental milestones • Schooling/Education • Occupational History • Relationships • Pre-morbid personality
What should be included in the introduction of the psychiatric history?
o Introduction
Greet verbally and introduce self
Orientate and check
• Explain purpose of the interview
• Advise of likely duration of interview (approx. one hour)
• Advise of note taking, confidentiality, and that will likely be shared with the team
Use the introduction to orientate the patient and establish where they will sit etc.
Concerns or questions?
when taking a psychiatric history, what questions do you want to ask when discussing:
- referral
- presenting complaint
- history of presenting complaint
o Referral
Why?
Who?
What might be going on?
• Ask questions to confirm or refute
What were the circumstances of the referral? (e.g. informal or formal)
o Presenting complaint
“can you tell me in your own words why you are here?”
• Record each one (in their own words)
• Come back to each one in turn
Clarify:
• “what’s been the trouble?”
• “why have you come to see me?”
• “what do you feel is the problem?”
• “How have you been feeling recently?”
• “tell me how it started”
• “when did you last feel well in yourself?”
• “what was the first thing you noticed?”
• “what happened after that?”
• “have you noticed anything else different from usual?”
o History of presenting complaint
Clarify each point in turn
• Onset, precipitants, course, severity
o Establish what was happening when they started
• Associated symptoms
o Ask about extras after the patient has finished volunteering symptoms
o “what other changes have your partner/family/friends noticed in you?”
o Systematic enquiry and check lists (e.g. ICD10)
Depression
Obsessions
Anxiety
psychosis
• Timing
• Effects on daily living
• Is it getting better or worse?
• Has it responded to any treatment?
o Have they recently started any treatment?
o Are they taking their medications?
• What are the most troublesome symptoms?
• Suicidal/homicidal thoughts?
o Intention
o Planning
what are the aspects to consider when asking about
- family history
- past medical history
- current and recent medication
o Family history
Parents, siblings, grandparents, etc.
Age, employment, circumstances, health problems, quality of relationship (ability to start and maintain)
Major mental illness in more distant relatives is important
Genogram can be helpful
o Past medical history
Developmental problems
Head injuries
Endocrine abnormalities
Substance abuse: liver damage, oesophageal varices
Peptic ulcers
• Other stress related conditions such as hypertension
o Current and recent medication
Tablet and injections
• Compliance?
Recent medication
Any discontinued drugs in the past 6 months
How long for? What dose?
Adverse reactions and allergies
when taking the psychiatric history what are the important questions to ask in gather:
- social history
- personal history
o Social history Current social circumstances Current occupation Current financial situation/stressors Smoking Alcohol/illict drug use • Regular or intermittent? • Amount (units) • Pattern • Dependence/withdrawal symptoms • Impact on work, relationships, money, police • Screening questionnaire e.g. CAGE Current relationship/stressors Children – contact o Personal history Developmental milestones Early life Schooling (have they achieved appropriately since school?) Occupational Relationships • Sexual • Marital • Can they start and maintain relationships? Financial Friendships, hobbies, interests
after considering the following in a psychiatric history:
- introduction
- referral
- presenting complaint
- history of presenting complaint
- family history
- past medical history
- current and recent medication
- social history
- personal history
what other topics may you want to cover?
o Forensic history
“have you ever been in contact with the police? Charged with any crime?”
• Offences included in the sentences
Recidivism (relapsing)
….particularly about violent or sexual crimes
o Pre-morbid personality
Rarely comprehensive
• Can’t really achieve without getting an objective third person view
Emphasis on consistent patterns of behaviour, interaction, mood
“how would your best friend describe you as a person?”
o Mental state examination
What are psychopathology, descriptive psychopathology and phenomenology?
o Psychopathology: psychopathology is concerned with abnormal experience, cognition and behaviour
o Descriptive psychopathology: descriptive psychopathology describes and categorises the abnormal experience as described by the patient
o Phenomenology: phenomenology, in psychiatry, refers to the observation and understanding of the psychological event or phenomenon so that the observer can, as far as possible, know what the patient’s experience feels like
what are the aspects of the Mental State Examination? ?
- Appearance
- Behaviour
- Affect (emotions conveyed and observed objectively during an interview)
- mood (patients subjective report)
- speech
- thoughts/thinking
- beliefs
- percepts
- cognitive function
- insight
- suicide/homicide
what are mood disorders?
o Mood disorders are disorders of mental status and function where altered mood is the (or a) core feature
A term referring to states of depression and of elevated mood (to a point of problem) = mania
o These are the commonest group of mental disorders
generally, what is depression?
o Depression is a term to describe a state of feeling, or mood, that can range from normal experience to severe, life-threatening illness
o Depression is a ‘systemic’ symptom (complaint) with similarities to fatigue and pain
o Depression is typically considered as a form of sadness (and not just and absence of happiness)
When does depression become abnormal?
o There is no clear or convenient division It is often a matter of perspective o In psychiatry emphasis is placed on: Persistence of symptoms • ≥ 2 weeks (although it is often much longer before help is sought Pervasiveness of symptoms • How encompassing is the disease? • Does it vary? Or is it all the time? Degree of impairment Presence of specific symptoms or signs
• What are the symptoms of depressive illness?
o The symptoms of depressive illness occur in three spheres:
Psychological
• Change in mood
o Depression (may find diurnal variation i.e. worse in the morning)
o Anxiety – the inability to relax
o Perplexity¬ – feeling of bewilderment (particularly in puerperal illness)
o Anhedonia – inability to get pleasure from normal sources of enjoyment
• Change in though content
o Guilt (disproportionate)
o Hopelessness
o Worthlessness
o Any neurotic symptomatology (e.g. hypochondriasis, agoraphobia, obsessions & compulsions, panic attacks)
o Idea of reference – perceiving something normal to be something other than it is e.g. secret messages in songs
o Delusions and hallucinations (if depression is severe)
Delusions – strong belief/idea even when there is evidence to the contrary e.g. rotting inside
Hallucinations – smell the rotting
Physical
• Change in bodily function – “feel like they’ve put on a lead cloak”
o ↓ energy – fatigue
o Difficulty sleeping – getting to sleep; staying asleep; early morning waking
o ↓ appetite → weight loss
o ↓ libido
o Constipation
o Pain
• Change in psychomotor functioning
o Agitation
o Retardation = a slowing of motor responses including speech
Stupor = a state of extreme retardation in which consciousness is intact. The patient stops moving, speaking, eating and drinking. On recovery they can describe clearly events which occurred whilst stuporose
social
• loss of interests
• irritability
• apathy = lack of interest in own surroundings
• withdrawal, loss of confidence, indecisive
• loss of concentration, registration and memory
what are some of the physical manifestations of depression?
• Change in bodily function – “feel like they’ve put on a lead cloak”
o ↓ energy – fatigue
o Difficulty sleeping – getting to sleep; staying asleep; early morning waking
o ↓ appetite → weight loss
o ↓ libido
o Constipation
o Pain
• Change in psychomotor functioning
o Agitation
o Retardation = a slowing of motor responses including speech
Stupor = a state of extreme retardation in which consciousness is intact. The patient stops moving, speaking, eating and drinking. On recovery they can describe clearly events which occurred whilst stuporose
DEpression often presents with psychological aspects of pathology. this may be change in mood or change in thought content. suggest 4 pathological changes in thought content that may be symptomatic of a diagnosis of depression
• Change in though content
o Guilt (disproportionate)
o Hopelessness
o Worthlessness
o Any neurotic symptomatology (e.g. hypochondriasis, agoraphobia, obsessions & compulsions, panic attacks)
o Idea of reference – perceiving something normal to be something other than it is e.g. secret messages in songs
o Delusions and hallucinations (if depression is severe)
Delusions – strong belief/idea even when there is evidence to the contrary e.g. rotting inside
Hallucinations – smell the rotting
how is depression diagnosed with ICD-10?
o Must last for at least two weeks
o Must never have had a hypomanic or manic episode in their lifetime
o Must not be attributable to psychoactive substance use or an organic mental disorder
If there are psychotic symptoms or stupor then = severe depression with psychotic symptoms
• Need to exclude other psychotic illnesses like schizophrenia first
What is somatic syndrome in depression?
o Marked loss of interest or pleasure in activities that are normally pleasurable
o Lack of emotional reactions to events or activities that normally produce an emotional response
o Waking two hours before normal time
o Depression worse in the morning
o Objective evidence of psychomotor agitation or retardation
o Marked loss of apetite
o Weight loss – 5%+ of body weight in a month
o Marked loss of libido
What are the criteria for mild, moderate and severe depression?
o All must fulfil the general criteria
o + have at least two of:
Depressed mood that is abnormal for most of the day almost every day for the past two weeks, largely uninfluenced by circumstances
Loss of interest or pleasure
Decreased energy or increased fatiguability
o + 2 of the following for mild; 4 for moderate; and 6 for severe:
Loss of confidence or self esteem
Unreasonable feelings of guilt or self-reproach or excessive guilt
Recurrent thoughts of death by suicide or any suicidal behaviour
Decreased concentration
Agitation or retardation
Sleep disturbance of any sort
Change in appetite
What is the epidemiology of post-natal depression?
o There is a 7x ↑ in psychiatric admissions in the month following childbirth with an increased risk lasting for 24 months
o 75% of women experience the baby “blues” within 2 weeks
o 10% of women develop a major depressive disorder within 3-6 months
o ‘puerperal psychosis’ occurs in 1 in 500 deliveries with a risk of recurrence of 1-3 with subsequent deliveries
• What are some differential diagnosis for depression?
o Normal reaction to life event o SAD (seasonal affective disorder) o Dysthymia – more mild than depression o Cyclothymia – more mild than bipolar o Bipolar o Stroke, tumour, dementia o Hypothyroidism, Addison’s, Hyperparathyroidism o Infections – influenza, infectious mononucleosis, hepatitis, HIV/AIDS o Drugs
What are the treatments for depression?
o Antidepressants
SSRIs (Selective Serotonin Reuptake Inhibitors
Tricyclic antidepressants (TCAs)
Monamine Oxidase Inhibitors (MAO Inhibitors)
Other antidepressants
o Psychological Treatments
Cognitive behavioural therapy, interpersonal therapy, individual dynamic psychotherapy, family therapy
o Physical treatments
Usually reserved for more severe disease
Electro-convulsive therapy, psychosurgery, deep brain stimulation, vagus nerve stimulation
What is the epidemiology of depression?
o lifetime prevalence rate (n per 100): 2.9 - 12
point prevalence rate of depression: 3.7 - 7.7
• lifetime risk for less severe manifestations - 20
o rates for females exceed rates for males - 2:1
o highest risk from age 18-44 (median 25)
mean age of onset = 27
onset during old age is not unusual
o no overall association with socioeconomic status
MDD less common in those employed
MDD less common in those financially independent (N.B. - direction of effect)
association with lower educational attainment
stable marriage negatively associated with MDD
o increased risk in 1st0 relatives where proband has MDD (3x) or BPD (2x)
twin studies: MZ ‘v’ DZ = 27% ‘v’ 12%
o onset of depression (first episode) associated with excess of adverse life events
‘exit events’ - separations, losses
What is mania?
o Mania is a term to describe a state of feeling, or mood, that can range from near-normal experience to severe, life-threatening illness (suicide is a big risk)
o Mania is rarely a symptoms: it is often associated with grandiose ideas, disinhibition, loss of judgement (has similarities to the mental effects of stimulant drugs (AMPH, cocaine)
o Mania is typically considered as a form of pathological, inappropriate elevated mood
When is an elevated mood mania?
o There is no clear and convenient division
o It is often a matter of judgement of deviation from ‘normal self’
o In psychiatry emphasis is placed on:
Persistence of symptoms
Pervasiveness of symptoms
Degree of impairment
Presence of specific symptoms or signs
• What are the different types of mania according to the ICD-10?
o Hypomania
Lesser degree of mania, no psychosis
Mild elevation of mood for several days on end
Increased energy and activity, marked feeling of wellbeing
Increased sociability, talkativeness, overfamiliarity, increased sexual energy, decreased need for sleep
May be irritable
Concentration reduced, new interests, mild overspending
Not to the extent of severe disruption of work or social rejection
o Mania without psychotic symptoms
o Mania with psychotic symptoms
1 week of symptoms severe enough to disrupt ordinary work and social activities more or less completely
Elevated mood, increased energy, over activity, pressure of speech, decreased need for sleep
Disinhibition
Grandiosity
Alteration of senses
Extravagant spending
Can be irritable rather than elated
o Other manic episodes
o Manic episode, unspecified
What are differential diagnosis for mania?
o Psychiatric Mixed affective state Schizoaffective disorder Scizophrenia Cyclothymia ADHD Drugs and alcohol o Medical Stroke MS Tumour Epilepsy AIDS Neurosyphilis Endocrine – Cushing’s, hyperthyroidism, SLE
what tools are used to measure symptoms of mania?
o SCID
o SCAN
o Young Mania Rating Scale (YMRS)
What is the treatment for mania?
o Antipsychotics Olanzapine Risperidone Quetiapine o Mood stabilisers Sodium Valproate Lamotrigine Carbamazepine o Lithium o ECT
What is bipolar affective disorder?
o Bipolar affective disorder consists of repeated (2+) episodes of depression and mania/hypomania
If there is no mania/hypomania = recurrent depression
If there is no depression = hypomania
What is the epidemiology of bipolar disorder?
o lifetime prevalence rate (n per 100) : 0.7 - 1.6
o point prevalence rate of mania : 0.08 - 0.8
o industrialised nations = non-industrialised
o rates for males = rates for females
o mean age of onset = 21 (unusual >30)
o some studies - 1/3 onset < 20
o early onset (15-19) usually with positive FH
o no differential prevalence according to income, occupation or educational status
o prevalence consistently increased in 1st0 relatives
o other forms of depression also more common
How are mood disorders classified?
o European classification = ICD-10
o American, and used in research, classification = DSM-5
What causes mood disorders?
o Can be a primary problem
o Can present as a consequence of another disorder or illness e.g. cancer, dementia, drug misuse or medical treatment (steroids)
They are also often associated with anxiety symptoms and anxiety disorders
What is the clinical course and outcome for the different affective disorders?
o Major depression Typical episode lasts 4-6 months 54% recovered at 26 weeks 12% fail to recover 80%+, where hospitalisation was needed, have further episodes • 40% in those whose condition was mild enough to be treated in primary care 15% die by suicide o Bipolar disorder/mania Typical manic episode lasts 1-3 months 60% are recovered at 10 weeks 5% fail to recover 90% have further episodes 1/3 have poor outcome 1/3-1/4 have good outcome 10% die by suicide
What is cognitive behavioural therapy about?
CBT explores how our thoughts relate to our feelings and behaviour
It is particularly good for depression, anxiety, phobias, OCD and PTSD
CBT focuses on the here and now
Problem-focussed, goal-oriented
Can be given individually, in groups, through self-help books or computer programmes
What does the therapist in CBT do?
The therapist helps the client:
• Identify thoughts, feeling and behaviours
• Assess whether thoughts are unrealistic/unhelpful
o Automatic thoughts – anxiety/fear
o Unrealistic beliefs
o Cognitive distortions – catastrophising
• The client then engages in “homework” which challenges the unrealistic or unhelpful thoughts
o Graded exposure
Gradually builds up to e.g. putting hand in the toilet
Response prevention
What is the rationale behind behavioural activation theory?
The idea behind behavioural activation therapy is that not enough positive reinforcement/too much punishment can contribute to depression
The patient focuses on avoided activities
• As a guide for activity scheduling
• For a functional analysis of cognitive processes that involve avoidance
Focus on what predicts and maintain an unhelpful response by various reinforcers
Client is taught to analyse unintended consequences of their way of responding
What are common avoidance activities in depression?
Social withdrawal • Not answering the telephone • Avoiding friends Non-social avoidance • Not taking on challenging tasks • Sitting around the house • Spending excessive time in bed Cognitive avoidance • Not thinking about relationship problems • Not making decisions about the future • Not taking opportunities • Not being serious about work/studies Avoidance by distraction • Watching rubbish on TV • Playing on computer games • Gambling • Comfort-eating • Excessive exercise Emotional avoidance • Use of alcohol and other substances
How is behavioural activation carried out?
Collaborative/empathic/non-judgemental
Structured agenda – review progress
Small changes → build to long term goals
What is interpersonal psychotherapy?
Interpersonal psychotherapy is a treatment for depression/anxiety
It is a time-limited treatment
• Lasts for about 12-16 weeks
Focuses on the present
What is the idea behind interpersonal psychotherapy?
Depression often follows a disturbing change in or with a significant interpersonal event e.g.: • A complicated bereavement • A dispute • A role transition • An interpersonal deficit
How is interpersonal psychotherapy put into practice?
“sick role” given Construct an “interpersonal map” • Identify the interpersonal context “focus area” maintaine • Depressive symptoms linke to interpersonal events (weekly The goal: • Reduce depressive symptoms • Improve interpersonal functioning
What are the strengths and limitations of interpersonal psychotherapy?
Strengths
• ‘A’ grade evidence for treating depression
• No formal homework – may be preferable
• Client can continue to practice skills beyond the session ending
Limitations
• Requires a degree of ability to reflect which may be difficult for some (especially in personality disordered patients)
• If the patient has poor social networks they will have limited interpersonal support
what are the name of the photoreceptors that have a high threshold for light and operate best in daylight
Cones
What is motivational interviewing?
Motivational interviewing is used where behaviour change is being considered but the patient is unmotivated or ambivalent to change
Motivational interviewing is used in treating problem drinkers
It promotes behaviour change
• …therefore it can be used in a wide range of health care settings
It is more effective that advice giving
What are the principles of motivational interviewing?
Express empathy
• Understand the person’s predicament
Avoid argument
• Challenging the patient’s position will only make them defensive
Support self-efficacy
• Patient sets their own agenda and generates, themselves, what they might consider changing
Run with resistance
in motivational interviewing, what are the stages of change?
Pre-contemplation: the stage at which there is no intention to change behaviour in the foreseeable future. Many individuals in this stage are unaware or under-aware of their problems.
Contemplation: the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action.
Planning: is a stage that combines intention and behavioural criteria. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year.
Action: is the stage in which individuals modify their behaviour, experiences, or environment in order to overcome their problems. Action involves the most overt behavioural changes and requires considerable commitment of time and energy.
Maintenance: is the stage in which people work to prevent relapse and consolidate the gains attained during action. For addictive behaviours this stage extends from six months to an indeterminate period past the initial action.
what does FRAMES mean in motivational interviewing/alcohol brief intervention?
Feedback • What is good? What is bad? Emphasise the link between this and the alcohol (or behaviour trying to change) Responsibility • You’re an adult; all is your choice Aid/Advice Menu • …of alternatives o E.g. ↑ drinking, drink the same amount, ↓ drinking, stop drinking • What do you want to do? Empathy Self-efficacy • Helping them believe they can do it
what is forensic psychiatry?
o The area where psychiatry meets the law
o Assessment and treatment of mentally disordered offenders in various settings
How can psychiatric interventions affect criminal proceedings?
o Psychiatric intervention can occur at all stages of the criminal proceedings:
Option to divert from prosecution (section 297)
Police/court cells
• Civil detention under the provision above
OR
• Remand to hospital for assessment under the Criminal Procedure (Scotland) Act 1995
Post-Conviction
• Various psychiatric ‘disposals’ on a compulsion order + restriction order, guardianship order, etc.
• Treatment can also be a condition of bail or parole
Sentenced prisoners
• May receive compulsory care and treatment in hospital in two ways:
o At sentencing the court may, in addition to imposing a custodial sentence, impose a hospital direction in terms of section 59A of the Criminal Procedure (Scotland) Act 1995 which allows prisoners to be detained initially in hospital for medical treatment in accordance with Part 16 of the Act
o Transfer for treatment direction (section 136) which allows for the transfer for sentenced prisoner to the hospital for medical treatment
Procurator fiscal
• Diversion
• Diminished responsibility – available in cases of murder
• Criminal Justice and Licensing (Scotland) Act 2010 outlines statutory basis for criminally responsible and grounds for being found unfit for trial
What is the sentencing for murder and how can this be affected by mental disorders?
o Murder carries a mandatory life sentence when the offender is of sound mind and had malice aforethought
o If the criteria for murder is not met = Manslaughter/culpable homicide
E.g. can be reduced to this on the grounds of diminished responsibility: “if the person’s ability to determine or control conduct for which a person would otherwise be convicted of murder was, at the time of the conduct, substantially impaired by reason of abnormality of the mind”
How is manslaughter/culpable homicide on the grounds of diminished responsibility got?
o The procurator fiscal need two psychiatric reports
o Fitness to plead
o Need to be grounds for diminished responsibility
o Alleged offender examined soon after arrest
Where are forensic psychiatry patients treated and where have they come from?
o In-patients
From courts, prisons, secure hospital, general wards
o Out-patients
Hospital based, prisons
o Psychiatric reports
Parole board, procurator fiscal, sheriff
How common is criminal behaviour in mentally disordered (particularly psychotic) patients?
o Most psychotic patients are neither criminal nor violent
A small number of offenders with major mental illness perpetrate serious violence
o There is a clear association demonstrated between major mental disorder and violence in the last 15-20 years
Crime is more associated with YOUTHFULNESS
o Much of it goes unreported or unrecorded
o Much more common in men
What is the relationship between crime and mental disorder?
o Complex relationship
o Issue of responsibility
Not criminally responsible as grounds for acquittal and diminished responsibility
o Compulsion orders +/- restriction or transfer from prison (transfer for treatment direction)
o Hospital direction
What mental health legislation is there?
o Mental Health (Care & Treatment) (Scotland) Act 2003
Opens with a set of guiding principles
Civil – emergency/short term/compulsory treatment order (hospital or community based)
Criminal – assessment order/treatment order/transfer for treatment direction/compulsion order +/- restriction order
What is a mental disorder under the mental health act?
o A mental disorder means any: Mental illness Personality disorder Learning disability • However they were caused or manifested o A person is NOT mentally disordered based purely on: Sexual orientation Sexual deviancy Transsexualism Transvestism Dependence on, or use of, alcohol or drugs Behaviour that causes, or is likely to cause, harassment, alarm or distress to any other person Acting as no prudent person would act
What are the different types of orders that are used in civil psychiatric cases?
- Emergency detention certificate
- Short term detention certificate
- compulsory treatment order
what are the general outlines of the emergency detention certificate?
Can be applied by any registered medical practitioner
Lasts for a maximum of 72 hours
Must be likely that the patient has a mental disorder
Patient’s ability to make decisions about medical treatment for a mental disorder must be significantly impaired
There must be a significant risk to health, safety or welfare, or to the safety of others
Used when there are no alternatives to treatment in hospital which is required urgently
Used when short term detention is impractical
• Emergency detention certificate = short-acting intervention for someone who is likely to have a mental disorder
describe the outline of the short term detention certificate
Can only be applied for by an Approved Medical Practitioner (AMP) with Mental Health Officer (MHO) consent
The patient has a mental disorder
• This mental disorder must be significantly impairing their ability to make decisions about the provision of medical treatment
Used when it is necessary to detain the patient in hospital for the purpose of determining what medical treatment should be given to the patient or of giving them medical treatment
Used when there would be a significant risk to the health, safety or welfare of the patient or to the safety of any other person if the patient were not detained in hospital
Granting of STD must be necessary
• Short-term detention certificate = intervention when someone has a mental disorder for them to be detained for up to 28 days so that treatment needed needs to be ascertained
what is a compulsory treatment order?
Granted by the Mental Health Tribunal following an application by an MHO with two supporting medical reports one of which must be from an AMP
Must have a mental disorder
There must be medical treatment available to prevent the mental disorder worsening or which can alleviate its effects
• …and when medical treatment cannot be provided informally
Used when there is a significant risk to health, safety or welfare, or to the safety of others
With significant impairment in their decision making ability
• Compulsory treatment order = intervention to provide long-term treatment to someone who has a mental disorder
What orders can be put in place during criminal proceedings?
o Assessment Order (section 52D) used to assess if a patient has a mental disorder
o Treatment order (section 52M) intervention to provide treatment to someone who is awaiting trial
o Compulsion Order (section 57A) this allows someone to be sent to hospital for treatment/treated in the community rather than being sent to prison
o Restriction Order (section 59) stops the release or moving of a patient
o Hospital Direction (section 59A-C) used when a patient needs psychiatric intervention but the disorder being treated is not a substantial part of the crime they are being prosecuted for
What mental health disposals are available to the court?
If further assessment and/or treatment is required prior to a final disposal being made: • Assessment order • Treatment order • Committal to hospital • Interim compulsion order Final mental health disposals available are: • Hospital disposals: o Compulsion order o Compulsion order + restriction order o Hospital direction • Community disposals: o Compulsion order o Guardianship rder o Treatment as a condition of probation o Voluntary treatment In some cases, courts may impose non-mental health disposals, such as: • Prison sentence • Probation order • Community service order • Fine • Deferred sentence In some cases, offenders may be admonished
What are the indications for antidepressants?
o Unipolar and bipolar depression o Organic mood disorders o Schizoaffective disorder o Anxiety disorders, including: OCD Panic Social phobia PTSD Premenstrual dysphoric disorder Impulsivity associated with personality disorders
How do you choose an antidepressant for a patient?
o Antidepressant efficacy is similar
Selection is based in past history of a response, side effect profile and coexisting medical conditions
When do you decide to switch to another agent?
o There is a delay, typically of 3-6 weeks after therapeutic dose is achieved before symptoms improve
o If no improvement is seen after a trial of adequate length (at least two months) and adequate does, either switch to another antidepressant or augment with another agent
How is treatment resistant depression treated?
o Combination of antidepressant e.g. an SSRI or SNRI + mirtazapine
o Adjunctive treatment with Lithium
o Adjunctive treatment with an atypical antipsychotic
Quetipaine
Olanzapine
Aripiprazole
o Electro-convulsive therapy
What prophylaxis is recommended in depression?
o After first episode of depression
Once an episode of depression is under control antidepressant prophylaxis should continue for 6-12 months
• Evidence: 80% relapse in five years vs 20% in those on prophylaxis
o After >2 episodes of depression
Antidepressant prophylaxis is recommended life-long
What are the different classes of antidepressants?
o Tricyclics (TCAs)
Older style of anti-depressants
o Monoamine Oxidase Inhibitors (MAOIs)
o Selective Serotonin Reuptake Inhibitors (SSRIs)
o Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs)
o Novel antidepressants
What are the advantages and disadvantages of TCAs?
o Advantages
Very effective
Cheap
o Disadvantages
Potentially unacceptable side-effect profile
Lethal in overdose (even a one week supply)
Can cause QT lengthening even at therapeutic serum level
What are tertiary TCAs?
o Tertiary TCAs have a tertiary amine side chain
These side chains are prone to cross react with other types of receptors which leads to more side effects
They have active metabolites including desipramine and nortriptyline
What are some side-effects caused by tertiary TCAs?
o Antihistaminic Sedation Weight gain o Anticholinergic Dry mouth Dry eyes Constipation Memory deficits Potentially delirium o Antiadrenergic Orthostatic hypotension Sedation Sexual dysfunction
What are some examples of tertiary TCAs?
o AMITRIPTYLINE (also used for neuropathic pain
o CLOMIPRAMINE
o Imipramine
o Doxepin
What are secondary TCAs?
o Secondary TCAs are often metabolites of tertiary amines and they primarily block noradrenaline. they have similar side effects to tertiary TCAs but are generally less severe
What are some examples of secondary TCAs?
o Desipramine
o Nortriptyline
What mode of action do MAOIs have?
o MAOIs bind irreversibly to monoamine oxidase
This prevents inactivation of amines such as norepinephrine, dopamine and serotonin
• This leads to increased synaptic levels
What are the advantages and disadvantaged of MAOIs?
o Advantages Are very effective for depression o Disadvantages Side effects “Cheese reaction” Serotonin Syndrome
What side effects are associated with MAOIs?
o Orthostatic hypotension o Weight gain o Dry mouth o Sedation o Sexual dysfunction o Sleep disturbance
What is the “cheese reaction”?
o Cheese reaction: the cheese reaction is the name for the hypertensive crisis which can develop when MAOIs are taken with tyramine-rich foods (e.g. cheese) or sympathomimetics
What is serotonin syndrome?
o Serotonin syndrome: serotonin syndrome can develop if MAOIs are taken with medication that increases serotonin or which have sympathomimetic actions.
o Serotonin syndrome symptoms:
Abdominal pain
Diarrhoea
Sweats
Tachycardia
Hypertension
Myoclonus
Irritability
Delirium
• …can lead to hyperpyrexia, cardiovascular shock and death
o To avoid serotonin syndrome when switching from and SSRI to and MAOI you should wait two weeks
If switching from fluoxetine you need to wait five weeks due to its long half-life
What is the action of SSRIs?
o SSRIs block the presynaptic serotonin reuptake
What are the advantages and disadvantages of SSRIs?
o Advantages
Treat both anxiety and depressive symptoms
Very little risk of cardio-toxicity in overdose
o Disadvantages
Side effects
Discontinuation syndrome
What side effects are associated with SSRIs?
o GI upset o Sexual dysfunction o Anxiety o Restlessness o Nervousness o Insomnia o Fatigue o Sedation o Dizziness
What are the symptoms of discontinuation syndrome in SSRIs?
o Agitation
o Nausea
o Disequilibrium
o Dysphoria
What are some SSRIs?
o Paroxetine o Sertraline o Fluoxetine (Prozac) o Citalopram o Escitalopram o Fluvoxamine
What are the advantages and disadvantages of paroxetine?
o Advantages
Short half-life with no active metabolite – no build up
• This is particularly good if hypomania develops
Sedating properties (take dose at night)
• Offers good initial relief from anxiety and insomnia
o Disadvantages
Significant CYP2D6 (cytochrome, member of P450, produced by the liver, used in the metabolism of drugs)
Sedating, weight gain, anticholinergic effects
Likely to cause a discontinuation syndrome
What are the advantages and disadvantages of sertraline?
o Advantages
Very weak P450 interactions
Short half-life with lower build-up of metabolites
Less sedating compared to paroxetine
o Disadvantages
Maximum absorption requires a full stomach
• Risk of nausea if taken on empty stomach
Increased number of GI ADRs
What are the advantages and disadvantages of fluoxetine (Prozac)?
o Advantages
Long half-life so decreased incidence of discontinuation syndromes
• Can give one tablet to taper off, when stopping an SSRI, to prevent SSRI discontinuation syndrome
Initially activating so may provide increased energy
o Disadvantages
Long half-life + active metabolites → build-up
Interactions with P450
Initial activation may increase anxiety and insomnia
More likely to induce mania than some other SSRIs
What are the advantages and disadvantages of citalopram?
o Advantages ↓ inhibition of P450 Intermediate ½ life o Disadvantages Can cause QT interval prolongation • Dose-dependent o NOT >40mg/day Can be sedating GI side effects (although less than sertraline
What are the advantages and disadvantages of fluvoxamine?
o Advantages
Shortest ½ life
Some analgesic properties
o Disadvantages
Shortest ½ life
GI distress, headaches, sedation, weakness
Strong inhibitor of cytochromes in the P450 family
What is the mode of action of SNRIs?
o SNRIs inhibit both serotonin and noradrenergic reuptake like tricyclic antidepressants
They do not have the antihistamine, antiadrenergic or anticholinergic side effects
What are the indications for SNRI use?
o SNRIs are used for depression, anxiety and possible neuropathic pain
What are some SNRIs?
o Venlafaxine
o Duloxetine
What are the advantages and disadvantaged of Venlafaxine?
o Advantages ↓ drug interactions, almost no P450 activity Short half life Fast renal clearance o Disadvantages Can cause ↑ BP • Dose dependent Nausea • Particularly immediate release tabs Can have a bad discontinuation syndrome QT prolongation Sexual side effects
What are the advantages and disadvantages of duloxetine?
o Advantages
Efficacy on the physical symptoms of depression
Far less ↑ BP than venlafaxine
o Disadvantages
Inhibits cytochromes in the P450 family
Active ingredient is not stable in the stomach → issue if capsule is broken
Higher dropout rate
What is the mechanism of action of Mirtazapine?
o Mirtazapine is a 5HT2 and 5HT3 receptor antagonist
What are the advantages and disadvantages of Mirtazapine?
o Advantages
Different mechanism of action → ?good augmentation for SSRIs
Can be used as a hypnotic (at lower doses)
o Disadvantages
↑ serum cholesterol and triglycerides in some patients
Very sedating at lower doses
• Can be activating at doses of ≥30mg
Weight gain
What is the mechanism of action of Buproprion?
o Buproprion likely works via reuptake inhibition of dopamine and norepinephrine
What are the advantages and disadvantages of Buproprion?
o Advantages
Good as an augmenting agent
No weight gain, sexual side effects, sedation or cardiac interactions
Low induction of mania
Second line ADGD agent → co-curring diagnosis use
o Disadvantages
↑ seizure risk at high doses
• Should be avoided, for this reason, in patients with traumatic brain injury, bulimia and anorexia
Does not treat anxiety
• …can cause anxiety, agitation and insomnia
Abuse potential due to psychotic symptoms at high doses
What are the indication for mood stabiliser use?
o Bipolar Affective Disorder
o Cyclothymia
o Schizo Affective disorder
o Hypermanic episodes
What are the classes of mood stabilisers?
o Lithium
o Anticonvulsants
o Antipsychotics
What are the advantages and disadvantages of Lithium?
o Advantages
Only medication shown to reduce suicide rate
Effective in long-term prophylaxis of both mania and depressive episodes in a high number of BAD patients
o Disadvantages
Side effects
Lithium toxicity
What factors predict positive response to Lithium?
o Prior long-term response
Or a family member with good response
o Classic pure mania
o Mania is followed by depression (as opposed to the other way round)
What side-effects are associated with Lithium use?
o GI distress = MOST COMMON ↓appetite Nausea and vomiting Diarrhoea o Thyroid abnormalities: hypothyroidism o Non-significant leucocytosis o Polyuria/polydipsia Due to ADH antagonism • Can cause interstitial renal fibrosis o Hair loss o Acne o ↓ seizure threshold o Cognitive slowing o Intention tremor
What investigations should be carried out prior to Lithium therapy being commenced? And what should be monitored throughout?
o Prior Baseline U&Es Baseline TSH In women: pregnancy test o Monitor creatinine levels TSH
What are the symptoms of Lithium toxicity?
o Mild Vomiting Diarrhoea Ataxia Dizziness Slurred speech Nystagmus o Moderate Nausea Vomiting Anorexia Blurred vision Clonic limb movement Convulsions Delirium Syncope o Severe Generalised convulsions Oliguria Renal failure
What are some causes of lithium toxicity?
o Taking lithium at the same time as other drugs excreted by the kidneys e.g. NSAIDs
o Dehydration
o Fever
What are the advantages and disadvantages of valproic acid?
o Advantages
As effective as Lithium in mania prophylaxis
Better tolerated than Lithium
o Disadvantages
Not as effect as Lithium in depression prophylaxis
What factors predict a positive response to Valproic acid?
o Rapid cycling patients
o Comorbid substance issues
o Mixed patients (= patients who experience mania and depression at the same time)
o Patients with comorbid anxiety disorders
What should be done before starting valproic acid therapy?
o Baseline LFTs
o Pregnancy test
o FBC
o Women should be started on a folic acid supplement
What side effects are associated with Valproic acid use?
o Thrombocytopenia o Platelet dysfunction o Nausea o Vomiting o Weight gain o Sedation o Tremor o ↑ risk of neural tube defect o Hair loss
What are the indications for carbamazepine use?
o Carbamazepine is a first line agent for acute mania and mania prophylaxis
o Carbamazepine is indicated for rapid cyclers and mixed patients
What should be done before starting carbamazepine therapy is started? And what should be monitored
o Before Baseline LFTs FBC ECG o Monitoring CBC and LFTs
What side effects are associated with carbamazepine?
o Rash (most common) o Nausea o Vomiting o Diarrhoea o Sedation o Dizziness o Ataxia o Confusion o AV conduction delays o Aplastic anaemia o Agranulocytosis o Water retention (vasopressin-like effect) → hyponatremia o Drug-drug interactions
What are some drug-drug interactions with carbamazepine?
o Drugs that ↑ carbamazepine levels and/or toxicity
Acetazolamide, cimetidine, clozapine, diltiazem, INH, fluvoxamine, erythromycin, clarithromycin, fluconazole, metronidazole, propoxyphene, verapamil
o Drugs that ↓ carbamazepine levels
Neuroleptics, barbituates, phenytoin, TCAs
o Valproic acid can ↑/↓ carbamazepine levels
o Carbamazepine increased the metabolism of some drugs
Oestrogen & progesterone (contraceptives), warfarin, methadone, many psychotropics, cyclosporine, theophylline
What are the indications for Lamotrigine?
o The indications for Lamotrigine are similar to other anticonvulsants
Lamotrigine is also used for neuropathic/chronic pain
What should you do before beginning Lamotrigine therapy?
o Baseline LFTs
What side effects are associated with Lamotrigine?
o Nausea/vomiting o Sedation o Dizziness o Ataxia o Confusion
if there is any rash then stop immediately.
what are some common drug-drug interactions with lamotrigine?
o Valproic acid doubles the concentration of Lamotrigine
o Sertaline
What antipsychotics are approved in BAD? And for what types of the condition?
o Aripiprazole → manic, mixed, maintenance
o Risperidone → manic, mixed
o Quetiapine → manic, maintenance
o Quetiapine XR → manic, maintenance, depressed
o Olanzapine → manic, mixed, maintenance
What are the indications for use for antipsychotics?
o Schizophrenia
o Schizo Affective disorder
o Bipolar Affective disorder
For mood stabilisation and/or when psychotic features are present
o Psychotic depression
o As augmenting agent in treatment resistant anxiety disorders
What side effects are associated with antipsychotic therapy?
o Tardive dyskinesia: involuntary muscle movement that may not resolve with drug discontinuation
o Neuroleptic Malignant Syndrome: characterised by severe muscle rigidity, fever, altered mental state, autonomic instability, elevated WBC, CPK and LFTs. Potentially fatal
o Extrapyramidal side effects: Acute dystonia, Parkinson syndrome, Akathisia
How are some of the side effects of antipsychotics managed?
o Agents for Extrapyramidal side effects:
Anticholinergics
• Benztropine
• Trihexyphenidyl
• Diphenhydramine
Dopamine facilitators such as Amantadine
Beta blockers such as propranolol
• Need to watch for anticholinergic side effects (particularly if taken with drugs with anticholinergic activity e.g. TCAs)
What pathways in the brain are affected by dopamine?
- mesocortical
mesolimbic - nigrostriatal
- tuberoinfundibular
describe the mesocortical pathway
o Mesocortical: projects from the ventral tegmentum (brain stem) to the cerebral cortex
this pathway is thought to be where the negative symptoms and cognitive disorders (lack of executive function) arise
Problem here for a psychotic patient is too little dopamine
describe the mesolimbic pathway
o Mesolimbic: projects from the dopaminergic cell bodies in the ventral tegmentum to the limbic system
This pathway is where the positive symptoms come from (hallucinations, delusions and thought disorders)
Problem here for a psychotic patient is there is too much dopamine
describe the nigrostriatal pathway
o Nigrostriatal: projects from the dopaminergic cell bodies in the substantia nigra to the basal ganglia
This pathway is involved in movement regulation
Dopamine suppresses acetylcholine activity so dopamine hypoactivity can cause Parkinsonian movements i.e. rigidity, bradykinesia, tremors, akathisia and dystonia
describe the tuberoinfundibular pathway
o Tuberoinfundibular: projects from the hypothalamus to the anterior pituitary.
Dopamine release inhibits/regulates prolactin release so blocking this pathway predisposes the patient to hyperprolactinaemia → gynecomastia, galactorrhea, decreased libido, menstrual dysfunction, bony problems (particularly in female patients
What is the mechanism of action of typical antipsychotics?
o Typical antipsychotics are D2 dopamine receptor antagonists
High potency typical antipsychotics bind to the D2 receptor with high affinity
• This means they have a high risk of extrapyramidal side effects
o FLUPHENAZINE, HALOPERIDOL, PIMOZIDE
Low potency typical antipsychotics have less affinity for the D2 receptors but tend to interact with non-dopaminergic receptors
• This results in more cardiotoxic and anticholinergic effects including sedation, hypotension
o CHLORPROMAZINE
What are some examples of atypical antipsychotics?
o Risperidone o Olanzapine o Quetiapine o Aripiprazole o Clozapine
What are the indications for anxiolytic therapy?
o Panic disorder
o Generalised anxiety disorder
o Substance-related disorders and their withdrawal
o Insomnias
o Parasomnias
o Used in anxiety disorders in combination with SSRIs or SNRIs
What are some anxiolytics?
o Buspirone
o Benzodiazepines
What are the advantages and disadvantages of Buspirone?
o Advantages Good augmentation strategy • Mechanism of action is 5HT1A agonist • Works independently of endogenous release of serotonin No sedation o Disadvantages Takes around two weeks for effects Will not ↓ anxiety in those used to benzodiazepines
What are benzodiazepines used to treat?
o Insomnia
o Parasomnias
o Anxiety disorders
o Often used for CNS depressant withdrawal protocols e.g. alcohol withdrawal
What are the associated side effects of benzodiazepines?
o Somnolence o Cognitive deficits o Amnesia o Disinhibition o Tolerance o Dependence
Alcohol Fatty Liver disease is reversible - true or false?
true
Most heavy drinkers will have fatty liver disease
20% will go on to develop cirrhosis
Disappears within 6 weeks of abstinence
o Alcoholic hepatitis can be reversed if drinking is stopped immediately
What is the risk of cirrhosis in binge drinkers vs constant drinkers?
o Cirrhosis rates after 13 years:
Binge drinkers – 7.5%
Daily drinkers – 16.1%
What are the criteria on the Glasgow alcoholic hepatitis score?
- age
- WCC
- urea
- PT ratio or INR
- bilirubin
a score that is greater than or equal to 9 has a poor prognosis
What is the association between alcohol and malnutrition?
o 60% of chronic abusers have malnutrition
Most of their calories come from alcohol
• 7kcal/g → 1300kcal per day
• They have decreased total energy intake
o Nausea and vomiting
o Abdominal pain
o Diarrhoea
All put them off eating
What happens in decompensated liver disease?
o Decompensated liver disease is when the liver isn’t doing its job anymore
↑ prothrombin time → GI bleeding
↓processing of toxins → encephalopathy
Ascites
o 10% of patients with cirrhosis decompensate per year
Although the vast majority of patients with cirrhosis have a liver that works well
Is it worth stopping drinking if you already have cirrhosis?
o Abstinence increases 7 year survival from 44% - 72%
What kills people with alcoholic cirrhosis?
o 75% die of liver disease
o 20-25% will die of hepatocellular cancer
Also die from varicele bleeds, spontaneous bacterial peritonitis
• What is the treatment for a hepatoma?
o Surgical resection Possible if it’s a small tumour, restricted to one lobe of the liver o Liver transplant One tumour <5cm Up to 5 tumours <3cm o Chemotherapy = sorafanib o Embolisation o Radiofrequency ablation
what are some resistant complications of cirrhosis?
o Jaundice
o Ascites
o Coagulopathy
o Encephalopathy
What is a safe amount to drink in men and women?
o Women = 14 units/week
o Men = 21 units/week
o Should not drink the week’s units in one go
Should have some alcohol free days per week
What are the physical effects of alcohol abuse?
o Skins Redness over nose and cheeks Broken veins “weathered” appearance o Bone Bone marrow suppression • Megaloblastic anaemia due to lack of vitamin B and folate ↓ bone density • Often old rib # o Brain Fits Delirium tremens • Tremor and hallucinations; often of swarming animals Wernecke’s encephalopathy • Opthalmaplegia, nystagmus, confusion, ataxia Korsakoff’s • Loss of the ability to form new memories o Cardiovascular system ↑ risk of MI and stroke • ↑ BP and cholesterol Alcoholic cardiomyopathy • Muscles are “baggy” → ↓ efficient pump o Lungs/respiratory system Aspiration pneumonia o GI Ulcers Reflux Stomach and oesophageal cancer GI bleeds • Varicele bleeds o Can see caput medusa and spider veins o Endocrine ↓testosterone in men ↑ risk of diabetes o Nervous system Peripheral neuropathy • Ulcers o Falls o Ataxia
How do you treat alcoholism?
o Treating when they have been drinking at least 10 units/day for the past ten days o Acute treatment Diazepam and pabrinex for DTs • Oxazepam in end stage liver disease + IV thymine (given orally in the community) o Chronic treatment Psychological • AA o Helpline, sponsor, meetings • Drugs Action o Psychological support • Alcohol diary and monitoring Pharmacological • Acamprosate (anti-craving) • Disulferom (reacts badly with alcohol – unpleasant) • Naltrexone (takes buzz out of drinking → fewer heavy drinking days)
How would you treat delirium tremens?
o Diazepam and Pabrinex
What tools can be used to help cut down alcohol intake?
o Diary and monitor So they can see how much they drink To identify triggers o Alternate alcohol and soft drinks o Pace self i.e. drink slowly o Don’t buy rounds o Rehearse turning down drinks
what si the definition of dependence
- Strong compulsion to take the substance
- Difficulties in controlling substance intake
- Physiological withdrawal state
- Emergence of tolerance
- Neglect of other aspects of life
- Persistent use despite clear evidence of harm
• ↑tolerance
• Withdrawals (e.g. fit, tremor, anxiety)
• Craving
• ↑salience (becoming higher in list of priorities)
• Continued harm despite clear evidence of harm
o Liver (aka physical harms)
o Lover (relationships)
o Law
o Lows (psychiatric effects → anxiety, low mood, psychosis = alcoholic hallucinosis)
o Life (job, studies, etc.)
• Narrowed repertoire (only drinking one thing)
• Loss of control (can’t stop drinking)
what is the definition of recreational use?
Recreational drug use is the use of a drug (legal, controlled, or illegal) with the primary intention to alter the state of consciousness (through disruption of the CNS) in order to recreate positive emotions and feelings
what is definition of problem use?
: Problem or problematic drug use tends to refer to drug use which could either be dependent or recreational. In other words, it is not necessarily the frequency of drug use which is the primary ‘problem’ but the effects that drug-taking have on the user’s life (e.g. they may experience social, financial, psychological, physical or legal problems as a result of their drug use).
what is the definition of dependence?
A state in which an organism functions normally only in the presence of a drug. It manifests as a physical disturbance when the drug is removed (=withdrawal)
what is a withdrawal state?
: group of symptoms of variable clustering and severity occurring on absolute or relative withdrawal of a psychoactive substance, after persistent use of that substance
When should you suspect drug addiction?
o Obvious intoxication or withdrawal o Convictions for crime o Any odd behaviour e.g. hallucinations o Unexplained nasal discharge o Burns on hands or around mouth o Results of injecting E.g. track marks, BBV o Drug seeking behaviour
What are the basic management principles in drug addiction/quitting?
o Full assessment o Establish diagnosis (level of use) o Motivational interviewing o Reassurance and explanation o Practical advice and harm reduction o Counselling/psychological input o Medication e.g. substitution therapy, detox
What help and community support is there for somebody who is giving up drugs?
o GP o Specialist Integrated drug service/Rehabilitation service o DA Drugs action o Narcotics anonymous o Cyrenians - housing o Foyer – employability, training o Debt counsellors/legal advice
What are the signs of opiate intoxication?
o Apathy o Sedation/drowsiness o Disinhibition o “slowed up” o Reduced attention, impaired judgement o Interference with personal function o slurred speech o pupillary constriction
What CNS effects do opiates have?
o Euphoria o Warm feeling o Pain relief o Drowsiness o Sedation o Nausea o Vomiting o Respiratory depression o Cough reflex depression o Heavy feeling o Convulsions High doses only Very rare with methadone
What other effects are associated with opiate use?
o Dry mouth o Constipation o Constricted pupils o Difficulty passing urine o Itching o Sweating o Constriction of airways
What are the signs of opiate withdrawal?
o Craving o Insomnia o Yawning o Sweating o Muscle pain and cramps o Increased salivary, nasal and lacrimal secretion o Dilated pupils o Piloerection (‘cold turkey’)
What medication is there for opiate addiction?
o Methadone Substitution/maintenance therapy o Buprenorphine Detox or maintenance o Non-opiate detox Lofexidine, Buscopan and Zolpidem o Naltrexone Opiate blockers o Naloxone Opiate antagonist – “reverses” effects
What is methadone?
o Liquid mixture – often green
o Opiate substitute
o Available in sugar and sugar free
What is the average effective dose of methadone?
o 60-120mg daily
Once daily dosing; usually supervised
What are the benefits of methadone?
o counteracting opiate withdrawal symptoms
o ↓ ILLICIT OPIATE USE
o ↓ CRIME AND DEBT
o NOT INJECTABLE → less disease
o Stabilises/normalises mood
o ↑ PHYSICAL HEALTH, NUTRITION AND ↓ MORTALITY
o Well tolerated
o Easy to supervise
o Cheap
o Doesn’t necessarily interfere with driving or working
What are the disadvantages of methadone?
- Substitute therapy (ongoing physical dependence)
- overdose
- Stigma
- Long term
- Difficult to stop
- Potential for abuse/diversion
- Inconvenient (daily + supervised)
- Ongoing contact with other users
A middle aged man is admitted to hospital with gallstones. Part of the admission history is to screen for alcohol problems.
Name an appropriate questionnaire to screen for alcohol problems?
FAST
A man is admitted to A&E after being found semi-conscious in the street. He is unkempt. And does not have any information on his person; he appears to be street homeless. In A&E he has a tonic clonic seizure which is self-limiting after 3 minutes. The man is postictal for a short time but soon becomes restless, tremulous and sweaty. His speech is rambling, and he complains about the bed sheets being filthy and ‘filled with mites’. He is tachycardic with a blood pressure of 186/114 mmHg.
- What is the most likely diagnosis?
- You order a full set of bloods on this man. Which of the following results would be most indicative of the underlying cause of his delirium?
- Delirium tremens
2. Low serum vitamin B12
Amnesia may be a form of dissociation.
true or false?
true
medical treatment for anorexia nervosa is with antipsychotic (olanzapine) and antidepressant therapy (fluoxetine). aside from medical treatment, name 4 other methods of treatment of anorexia nervosa
- CBT for eating disorder
- IPT
- socialised family work - particularly for younger children
- mantra (20 session)
- re-nutrition - especially in younger children for growth and development
- specialist supportive clinical management
- sympathetic awareness (patient is scared and upset so no accusations)
A rather thin young student presents to her GP complaining that she has not had a menstrual period for over a year although she is not taking the contraceptive pill. She has been ‘very stressed’ by her university course but is still doing well academically, and belongs to the University triathlon club. She becomes tearful when the GP suggests weighing her, and insists she eats very well, indeed she finds herself often eating far more than she intended and is worried that she may gain weight. Blood results are normal apart from a low potassium value, low total white count and mild neutropenia and slightly low TSH.
what is the most likely diagnosis?
anorexia nervosa
binge-purge subtype
A 23 y/o man experiences irritability, grandiose delusions as a reduced need for sleep. He has previously been in a psychiatric hospital treated for depression. Which is the most likely diagnosis
Bipolar affective disorder (BAD)
A 79 y/o man who has had 2 hospital admissions for depression in the past is brought to the GP by his daughter. She is concerned that he is spending lots of money, has a reduced need to sleep, is full of energy and wants to run a marathon
what is the most likely diagnosis?
bipolar Affective disorder
A 45 y/o man is assessed in the outpatient department. He has an intense interest in rare woods and has a very rigid timetable which he sticks to each day. He is upset that the doctor assessing him was 10 minutes late. What is the most likely diagnosis?
Autistic Spectrum Disorder
what are the management options for autism spectrum disordeR?
- early speech therapy
- behavioural interventions
- social skills training
- risperidone
autism diagnostic observation schedule will be helpful for diagnosis
A 39 y/o woman presents with a complaint that she is fearful that something bad may happen to her. This fear occurs wherever she goes and she cannot describe what might happen. She also complains of pains in her chest, a tremor and sweating at times. What is the most likely diagnosis?
Generalised anxiety disorder (GAD)
constipation is a typical presentation of anxiety, true or false?
false
The presence of major depression excludes a diagnosis of GAD - true or false?
false
Cognitive theories propose that anxiety is the result of distorted thinking, such as catastrophizing and labelling, true or false?
true
An 80 year old man is admitted with weight loss, poor motivation, social isolation, lack of interest in bowling which he previously did regularly, suicidal ideation and tearfulness. Which of the following is the most likely diagnosis?
Depression
A 38 year old woman has consulted her GP and a diagnosis of moderate depression has been made. Which of the following would be an appropriate first-line treatment?
Sertraline
Which of the following psychological treatments is recommended in the first line treatment of depression?
Cognitive Behaviour Therapy
You are a GP and have diagnosed a 27 y/o lady with depression. You are confident that she does not require to be treated in hospital and wish to start her on treatment. Which of the following would be appropriate 1st line treatment?
SSRI
A 34 y/o man develops depression and suffers the inability to experience pleasure but can experience other emotions. What is the correct term for this?
Anhedonia
A 68 y/o woman has been diagnosed with severe depression. One of the symptoms is that she believes her bowels are rotting. What is the correct term for this?
Nihilistic delusion
A 24 y/o woman presents who has a 1 month history of low mood, early morning awakening, irritability, reduced appetite and some suicidal thoughts. She also feels guilty that she feels too tired to take her 2 y/o daughter to nursery. Which is the most likely diagnosis?
Depression
You are a psychiatrist treating a 34 y/o woman with depression. You are confident of the diagnosis. You have already tried 2 antidepressants and the 2nd has had only partial effect. Her mood has lifted slightly but she complains of poor sleep, lack of energy and motivation and poor appetite. Which of the following is the most appropriate next step?
add lithium
Hyperphagia is a core symptom of depression according to ICD-10. true or false?
false
Which of the following medications is most likely to be associated with an organic depressive disorder?
Prednisolone
what is the most common psychiatric symptom following a stroke?
Depressive
A 35 y/o woman complains of low mood after the death of her husband in a car accident. She does not speak and remains immobile for long periods. What is the most likely diagnosis?
Depressive stupor
A 45 y/o female has had persistent mild depressive features since her late teens. She sometimes experiences loss of energy and tearfulness. She believes her low mood began after she was abused by her stepfather as a teenager. She has no other symptoms. What is the most likely diagnosis?
Dysthymia (chronic low grade mood disorder)
What is the most likely condition causing a depressive episode in a 76 y/o man with a history of smoking and hypertension?
stroke
A 35 y/o female visits her GP complaining of low mood and weight loss. On questioning she also experiences fatigue which is exacerbated by pain in her legs. Blood tests reveal high potassium. Which of the following is most likely to cause her depression?
Addisons disease
A 43 y/o female visits her GP complaining of a 4-week history of fever, fatigue, low mood and lower back pain. She had visited China in the previous month and mentioned she was drinking plenty of goat’s milk as this was the only type of milk available. What is the most likely infective cause?
Brucellosis
A 35 y/o woman has had a low mood for 2 months associated with fever, fatigue and joint pain. She has a rash on her face which gets worse with exposure to the sun. What is the most likely cause of her low mood?
Systemic Lupus erythematosus
Methyl dopa is known to have depression as a side effect - true or false?
true
A 23 y/o man is assessed by his GP. He has a severe dermatological condition affecting his hands which is caused by his washing them 13 times before he leaves his house. What is the most likely diagnosis?
Obsessive compulsive disorder (OCD)
OCD affects women and men equally true or false?
true
Antidepressants do not have a role in the management of OCD. true or false?
false
use SSRI - fluoxetine and TCA - clomipramine
constipation is not a typical feature of anxiety true or falsE?
true
A 46 y/o woman is referred to 2ndary psychiatric services by her GP. Over the last 6 months she has suffered multiple losses, including the death of her sister and close friend. She lives alone with few social contacts. She has become extremely withdrawn, and is leaving the house less, stating that she gets ‘terrified that I won’t be able to get back to my house’. She reports that when she does go out, she feels breathless, sweaty and like ‘she might faint and make a fool out of myself’. What is the most likely diagnosis?
Agoraphobia
A woman is diagnosed with agoraphobia. She is willing to try any form of treatment as her condition is very disabling. would you give lorazepam as first line treatment for agoraphobia?
no
Men are less likely to report symptoms of social phobia than women - true or false?
true
Cognitive theories propose that anxiety is the result of distorted thinking, such as catastrophizing and labelling
- true or false?
true
The behavior must affect the ability to control impulse is needed for the diagnosis of personality disorder - true or false?
false
It is now generally accepted that personality can be described by 3 factors - true or false?
false
it is 5.
A 22 y/o woman with a diagnosis of borderline personality disorder attends A&E after saying she has taken an overdose of paracetamol following an argument with her mother. She is an outpatient at the local personality disorder service where she has a key worker. This is her fourth attendance in A&E for similar reasons in the last 6 weeks. A full assessment reveals no evidence of depression. Her blood results reveal low levels of paracetamol. She does not want to die but cannot say she will not try and harm herself again. What would the most appropriate management be?
Discharge from A&E with follow-up from her key worker
A 29 y/o man is arrested for aggravated assault on a former girlfriend. It is his 9th offence of a similar nature. The court asks for a psychiatric opinion. He is noted to be emotionally cold with an extremely reduced tolerance to frustration. He feels no remorse for his actions, blaming his girlfriend for ‘putting it about’. What is the most likely diagnosis
Antisocial personality disorder
A 19 yo man is referred to the local psychiatric community team as his new GP is worried he is schizophrenic. The letter states that he is ‘extremely odd and does not seem to have an emotional response to anything’. On assessment, he states he has only come to understand the psychiatric care pathway; a little more but does not feel he has any problems. He seems aloof and disdainful of the psychiatrist. He appears to have few hobbies except for inventing his own mathematical equations. What is the most likely diagnosis?
Schizoid personality disorder
A soldier who has recently returned from active combat attends his GP as he has frequent nightmares, startles easily, tries to avoid his army friends and anything to do with his job and is always on edge. What is the likely diagnosis?
Post Traumatic Stress Disorder
A 42 y/o man sees his GP after witnessing a horrific motorway pile-up. For the last 6 weeks he has been experiencing recurrent and intrusive images of the event where he relives what happened, both at night and during the day. At night he is also having vivid nightmares about the crash which is now stopping him from going to sleep. He has not driven his car since, although he himself was not involved in the crash. Every time a car starts he jumps and becomes extremely upset. His mood is low and he feels disconnected from his wife and children and he has been thinking about killing himself.
- does this patient have night terrors?
- What is the most likely diagnosis in the case?
- no
- PTSD
`
A 42 y/o man is involved in a serious road traffic accident caused by a drunk driver. He is hospitalised for several weeks. Following discharge, friends and family notice that he is not going out, has become withdrawn and appears withdraw and appears frightened and anxious all the time. He reluctantly agrees to see his GP. in PTSD, do patients usually present with a diminished startle response?
no
A woman presents hearing the national anthem playing when there is no music in the house. Which of the following symptoms is this an example of?
Auditory hallucination
An elderly man has been admitted to hospital with acute onset disorientation, visual hallucinations and agitation. He has no psychiatric history and lives alone and requires no support. What is the most likely diagnosis?
Delirium
A 22 y/o man with no previous psychiatric illness sees a street lamp flicker and suddenly knows that he is the next Scottish ambassador to Wales. What is the correct term for this?
delusional perception
A man is admitted to A&E after being found semi-conscious in the street. He is unkempt. And does not have any information on his person; he appears to be street homeless. In A&E he has a tonic clonic seizure which is self-limiting after 3 minutes. The man is postictal for a short time but soon becomes restless, tremulous and sweaty. His speech is rambling, and he complains about the bed sheets being filthy and ‘filled with mites’. He is tachycardic with a blood pressure of 186/114 mmHg. What is the most likely diagnosis?
delirium tremens
dont forget that the cause of delirium is a low serum vitamin B12
A 73 y/o woman is admitted to hospital with an infective exacerbation of chronic obstructive pulmonary disease (COPD). Apart from COPD and hypertension she has no other medical problems. On the 3rd day of her admission, she becomes acutely confused. During the night she is awake, shouting constantly for her husband, claiming that the nurses are prison guards and that they are keeping her against her will. She is slightly calmer the day after. You are the FY1 on call and are asked to come and see her over the weekend as the nurses are worried it will happen again at night. What should your initial management be
prescribe nothing at this stage
A 24 y/o student presents with a 3-month history of social withdrawal and low mood. She is difficult to interview because she talks about random themes and has difficulty answering questions. She has vague paranoid ideation. She is childish and pulls faces at you during the interview. The most likely diagnosis is?
Hebephrenic (disorganised) schizophrenia
What is the lifetime prevalence of schizophrenia in the UK
0.4 per 100
) A 28 y/o woman presents in the GP surgery. She is over-talkative and over-familiar with you. It is difficult to get a full history, but it seems for the last 4 weeks she has been elated and experiencing voices telling her that her mother was a descendent of the VIrgin Mary and that she is a female ‘second coming’. This was the result of an experiment by the Nazi party who genetically engineered her grandparents. She believes that remnants of the Nazi party are now controlling her arms and legs, which results in her alternately trying to hug you and then kicking out at the desk. What is the most likely diagnosis?
Schizoaffective disorder
An 8 y/o boy is referred with behavioural problems to the child psychiatry department. He is always active at home and moves from task to task. He finds it difficult to concentrate to read or to watch TV. He often puts himself into dangerous situations like climbing onto high roofs. His performance at school is poor where he is distractible and causes distractions to others. What is the most likely diagnosis?
ADHD
what is buprenorphine?
an opiate based treatment for opiate addiction
when is buprenorphine used?
MILD opiate addiction and for detox
it is administered in tablet form that dissolves under the tongue (2-24mgs)
what si suboxone?
partial opiate with a high affinty for the receptor and pushes other opiates off the brain - apart from naltrexone
name some advantages and disadvantages of suboxone
- blocks additional opiates if used on top and has similar effects to methadone
- safe - less likely to cause sedation and overdose
- risk of sending people into withdrawal
- more expensive than methadone
- can make giving analgesia difficult
what is naltrexone?
a blocker that is used as a deterrent tablet. it is an opiate with very high affinity for the receptor./
how does naltrexone work?
displaces existing opiates and doesnt produce effects (just sits there)
protects from heroin when heroin is used on top and has implications for analgesia
it can help maintain abstinence
When are drugs such as Lofexidine, Buscopan and Zolpidem used?
they are useful in MILD opiate addiction/withdrawal.
they are also useful in short-term non-opiate treatment regime for symptomatic relief only.
what is the mechanism of action of lofexidine?
it is an alpha-adrenergic agonist that blocks noradrenaline and decreases sympathetic tone.
it will counteract opiate withdrawal/craving and may cause hypotension
what is the mechanism of action of buscopan?
it is an antimuscarinic that relaxes smooth muscle.
it is indicated to stop stomach cramps
what is the mechanism of action of Zolpidem?
it is a non-benzodiazepine hypnotic and helps people to sleep
what is nalxone?
it is an opioid antidote that is administered IM.
It is used to reverse opioid overdose
it will temporarily reverse opioid overdose an is beneficial because it cannot cause overdose.
describe the management of cocaine and cannabis addiction
- counselling/psychological work
unfortunately there is no methadone equivalent for cocaine.
how do you manage benzodiazepine addiction
depends on use and motivation. decrease the diazepam regimen may be appropriate.
counselling and motivational work.
what is the management for legal high addiction?
- counselling
- harm reduction
- depends on substance - not usually a ‘medical equivalent’, may give some symptomatic treatment
