Psychiatry Flashcards
psychiatric history components
Information, introductions, PC, HPC, SH, ICE, PPH, PMH, DH, FH, PH, PP
Information, introductions, PC, HPC, SH, ICE, PPH, PMH, DH, FH, PH, PP
categories for a psychaitric history
psychiatric history: information
PT details, under section vs informal visit, PT vs collateral history
PT details, under section vs informal visit, PT vs collateral history
points to cover in the information section of a psych history
psych history: introductions
who’s who, roles, purpose of interview, consent, permission to take notes
who’s who, roles, purpose of interview, consent, permission to take notes
points to cover in the intriductions section of a psych history
psych history: PC
ideally get PT’s own words
ideally get PT’s own words
for psych PC in hisory
psych history: HPC
can use SOCRATES, cause, triggers/recent precipitating events, coping strategies, ever happened before
psych history: HPC depression
SOCRATES, is mood always low, when worst, anything to lift mood, look forward to anything, tearful, guilty, worthless, hopeless, self harm, suicide (–> RISK), LOA, weight loss, sleep (trouble getting to sleep indicates mild, early waking indicates severe), lack of motivation, aches/pains, libido, caused probems at home/work, thoughts abouth themselves, the world, the future
SOCRATES, when worst, look forward to anything, tearful, guilty, worthless, hopeless, self harm, suicide (–> RISK), LOA, weight loss, sleep (trouble getting to sleep indicates mild, early waking indicates severe), lack of motivation, aches/pains, libido, caused probems at home/work
HPC things to ask about if depressive PC
can use SOCRATES, cause, triggers/recent precipitating events, coping strategies, ever happened before
for HPC psych
psych history: HPC psychosis
strange thoughts, others commented on strange things, plots against you/out to get you, interference with thoughts (insertion, withdrawal, broadcasting), see/hear things that others can’t, get messages from things you see/hear, insight, controlled by others, how longs has this been going on, has it changed over time
strange thoughts, others commented on strange things, plots against you, interference with thoughts, see/hear things that others can’t, insight, how longs has this been going on, has it changed over time
questions to ask in HPC for psychosis
psych history: HPC generalised anxiety
general feeling, on edge, worry, irritable, unable to relax, fears, increased vigilance, insomnia (initial/middle/fatigue on waking), tremor, tachycardia
general feeling, on edge, worry, irritable, unable to relax
psych history HPC to ask for generalised anxiety
psych history: HPC panic attacks
hyperventillation, SOB, CP, palpitations, sweating, tremor, duration of attacks, triggers, fear, impending doom
hyperventillation, SOB, CP, palpitations, sweating, tremor, duration of attacks, triggers
HPC questions to ask in panic attacks PC
psych history: HPC phobias
fears that you/others may consider irrational, obsessive thoughts
fears that you/others may consider irrational, obsessive thoughts
things to ask in HPC for someone presenting with phobias
psych history: SH
lives with, where, friends/family to confide in, ADLs, additional support/benifits, job, dependencies, financial/legal problems
lives with, where, friends/family to confide in, ADLs, additional support/benifits, job, dependencies, financial/legal problems
psych history: SH
psych history: PPH
contact with MH services, MH admissions/treatment, sections, history of self harm/attempted suicide, triggers
contact with MH services, MH admissions/treatment, sections, history of self harm/attempted suicide, triggers
psych history: PPH
psych history: DH
current medication, allergies, previous regimes, recreational drugs, alcohol (CAGE), side effects, compliance/feelings towards their medications
current medication, allergies, previous regimes, recreational drugs, alcohol, side effects, compliance/feelings towards their medications
psych history: DH
psych history: FH
who is in their family, who close to, occupations, an MH disease in family/suicides
who is in their family, who close to, occupations, an MH disease in family/suicides
FH psych history to ask
psych history: PH
childhood: where born, parents together, schooling (attendance, grades, friends), moved a lot, siblings, enjoyed childhood, abuse
occupational: jobs held, reason for leaving, free time
psychosexual: first sexual encounter, orientation, relationships/marital status, reasons for ending, children
forensic: any problems with the police
childhood, occupational, psychosexual, forensic
ask about in PH
psych history: PP
(maybe good to get a collateral history here)
personality (happy go lucky, tense, shy, greedy, insecure, anxious, obsessive), relationships (peers, superiors), hobbies/interests
(maybe good to get a collateral history here)
personality (happy go lucky, tense, shy, greedy, insecure, anxious, obsessive), relationships (peers, superiors), hobbies/interests
psych hisotry: PP
CAGE questionnaire
have you ever felt that you should cut down your drinking?
have you ever felt annoyed by someone commenting on your drinking?
have you ever felt guilty about the amount that you drink?
have you ever had an eye opener?
have you ever felt that you should cut down your drinking?
have you ever felt annoyed by someone commenting on your drinking?
have you ever felt guilty about the amount that you drink?
have you ever had an eye opener?
CAGE questionnaire
psych assessment includes
psych history + MSE
psych history + MSE =
full psych assessment
MSE components
appearance, behaviour, speech, mood, thoughts, perception, cognition, insight
appearance, behaviour, speech, mood, thoughts, perception, cognition, insight
MSE components
appearance + behaviour
self care, eye contact, face, pupils, aggitation, psychomotor retardation, posture, abnormal movements
self care, eye contact, face, pupils, aggitation, psychomotor retardation, posture, abnormal movements
appearance + behaviour
speech
form: rate + flow, incoherent
content: appropriateness, congruency
tardive dyskinesia
involuntary movements fo face + neck, may follow use of antipsychotics
involuntary movements fo face + neck, may follow use of antipsychotics
tardive dyskinesia
waxy flexibility
PT stays in the same position that they’ve been put in e.g. schizophrenia/structural brain disorder
PT stays in the same position that they’ve been put in e.g. schizophrenia/structural brain disorder
waxy flexibility
forced grasping
takes examiner’s hand whenever offered, e.g. dementia/chronic schizophrenia
takes examiner’s hand whenever offered, e.g. dementia/chronic schizophrenia
forced grasping
stereotypies uniform
repetitive non-goal directed actions e.g. schizophrenia
repetitive non-goal directed actions e.g. schizophrenia
stereotypies uniform
form: rate + flow, incoherent
content: appropriateness, congruency
speech
presure of speech
goal directed, jumping from one thought to another e.g mania (if connections between thoughts), schizophrenia (if no connection between thoughts)
goal directed, jumping from one thought to another e.g mania (if connections between thoughts), schizophrenia (if no connection between thoughts)
pressure of speech
mutism
severe depression/schizophrenia
perseveration
repeating the same words/phrases e.g. dementia/frontal lobe trauma
repeating the same words/phrases e.g. dementia/frontal lobe trauma
perseveration
neologisms
creating new words e.g. schizophrenia
creating new words e.g. schizophrenia
neologism
echolalia
repeating the same words/phrases as examiner e.g. schizophrenia
repeating the same words/phrases as examiner e.g. schizophrenia
echolalia
mood
subjective vs objective, depression, anxiety, mania, congruency, lability
subjective vs objective, depression, anxiety, mania, congruency, lability
mood
thoughts
delusions, disorders (ask RE concentration/thoughts block), obsessions, compulsie rituals
delusions in schizophrenia
primary delusions, thought alienation, presecutory delusions
primary delusions, thought alienation, presecutory delusions
delusions in schizophrenia
delusions in depression
nililistic, hypochondrial, worthless, guilt, hopelessness
nililistic, hypochondrial, worthless, guilt, hopelessness
delusions in depression
delusions in mania
grandiose
grandiose
delusions in mania
thought alienation
insertion, withdrawal, broadcast, plots to harm you
insertion, withdrawal, broadcast, plots to harm you
thought alienation
depersonalisation
feeling unreal/any part of the body is unreal e.g. in anxiety disorders
feeling unreal/any part of the body is unreal
depersonalisation
derealisation
feeling that things around them are unreal e.g. in anxiety disorders
feeling that things around them are unreal
derealisation
delusions, disorders (ask RE concentration/thoughts block), obsessions, compulsie rituals
thoughts
perception
aka hallucinations, illusions
aka hallucinations, illusions
perception
cognition
orientation to person, place + time, MMSE, AMTS, ACE-R
MMSE, AMTS used to assess
cognition
insight
recognise abnormal experiences as extraordinary, result of disease process, can be controlled by medicaiton, risk assessment
recognise abnormal experiences as extraordinary, result of disease process, can be controlled by medicaiton, risk assessment
insight
auditory illusion
auditory sound misinterpreted by listener
auditory sound misinterpreted by listener
auditory illusion
illusions
can occur in any sensory modality and aren’t usually an indicator of a mental illness/psychiatric problem
can occur in any sensory modality and aren’t usually an indicator of a mental illness/psychiatric problem
illusions
affect illusion
associated with specific mood state e.g. someone may see a loved one who has recently died
associated with specific mood state e.g. someone may see a loved one who has recently died
affect illusion
completion illusion
inattention when reading e.g. misreading words, completing faded letters
inattention when reading e.g. misreading words, completing faded letters
completion illusion
pareidolia
perception of vivid picture via vague/obscure stimulus e..g seeing images in the clouds
perception of vivid picture via vague/obscure stimulus e..g seeing images in the clouds
pareidolia
most common side efffect of clozapine
urinary incontinence
side effect of clozapine that we’re most worried about
agranulocytosis
agranulocytosis
side effect of clozapine that we’re most worried about
urinary incontinence is the most common side effect of
clozapine
methylphenidate
CNS stimulant used to treat ADHD, also used as an apetite surpressor + in the treatment of sleep disorders e.g. narcolepsy
CNS stimulant used to treat ADHD
methylphenidate
methyylphenidate SE
insomnia, agitation, HTN, weight loss
insomnia, agitation, HTN, weight loss
methylphenidate SE
psychiatric drugs which cause weight gain
olanzapine (SGA), mirtazapine (NaSSA)
olanzapine + mirtazapine can cause
weight gain
Schneider’s 1st rank symptoms of schizophrenia
auditory hallucinations (thoughts spoken aloud/voices referring to themselves in the 3rd person/commentary) thought withdrawal/insertion/interruption/broadcasting delusional perceptions feelings/actions controlled by external agents (passisivity)
auditory hallucinations, thought disordered, delusional perceptions, feelings/actions controlled by external agents
schneider’s 1st rank symptoms
schizophrenia diagnosis
6/12 duration, at least 2 symptons (1 must be positive)
6/12 duration, at least 2 symptons (1 must be positive)
schizophrenia
negative symptons schizophrenia
avolition, asocial, apathetic, affect blunting, alogia, attention deficit, paucity of speech, poor memory
avolition, asocial, apathetic, affect blunting, alogia, attention deficit
negative symptons schizophrenia
brief psychotic disorder
symptoms <1/12
psychotic symptoms <1/12
brief psychotic disorder
schitzoaffective disorder
mix of psychotic and affective symptoms, alternating not simultaneously
mix of psychotic and affective symptoms, alternating not simultaneously
schizoaffective disorder
ICD-10 diagnostic criteria for depression
- persistent low mood/sadness
plus at least 1 of the following most days/most of the time for at least 2/52: 2. loss of interest/pleasure 3. fatigue/low energy
associated symptoms: 4. disturbed sleep 5. poor concentration/indecisiveness 6. low self-confidence 7. poor/increased appetite 8. suicidal thoughts/acts 9. agitation/slowing of movement 10. guilt/self-blame
of the ICD-10 10 symptoms of depression 0-3/10
not depressed (don’t forget to also assess functional impact)
of the ICD-10 10 symptoms of depression 4/10
mild depression (don’t forget to also assess functional impact)
of the ICD-10 10 symptoms of depression 5-6/10
moderate depression (don’t forget to also assess functional impact)
of the ICD-10 10 symptoms of depression 7-10/10
severe depression +/- psychosis, symptoms >1/12, every symptom should be present for most of every day
not depressed score according to ICD-10
0-3/10 (don’t forget to also assess functional impact)
mild depression score according to ICD-10
4/10 (don’t forget to also assess functional impact)
moderate depression score according to ICD-10
5-6/10 (don’t forget to also assess functional impact)
severe depression score according to ICD-10
7/10 every symptom should be present for most of every day, symptoms for >1/12
first line medical management of depression
SSRI
second line medical management of depression
switch to a different SSRI
DSM-IV criteria for subthreshold depression
<5/10 symptoms
DSM-IV criteria for mild depression
few if any symptoms > the 5/10 to make the diagnosis, minor functional impairment
DSM-IV criteria for moderate depression
symptoms/functional impairment -/- mild + severe
DSM-IV criteria for severe depression
most of the /10 symptoms, marked interference with functioning, +/- psychotic symptoms
DSM-IV <5/10 symptoms
subthreshold depression
DSM-IV 5/10 symptoms
mild depression
DSM-IV most of the /10 symptoms
severe depression
all severities depression management
treat comorbid physical ailments, treat substance misuse problems
mild depression management
self help groups, structured physical activity groups, guided self help, computerised CBT, behavioural couples therapy
moderate depression management (+ unresponsive mild)
add antidepressant, individual CBT, interpersonal therapy
severe depression management
ECT (poor PO intake), admission, crisis team, antipsychotic (if psychotic)
third line medical management of depression
SNRI
flight of ideas
mania
thought block
sudden interruption in train of thought e.g. schizophrenia, depression
circumstantiality
thinking proceeds slowly via convoluted path, final point is eventually reached e.g. particular personality traits, mania
psychomotor retardation
slowing of thoughts/speech e.g. depression
tangentiality
deflected path of speech, never reaching point/answering question e.g. psychosis, dementia, delerium
sudden interruption in train of thought
thought block e.g. schizophrenia, depression
thinking proceeds slowly via convoluted path, final point is eventually reached
circumstantiality e.g. particula personality traits, mania
slowing of thoughts/speech
psychomotor retardation e.g. depression
deflected path of speech, never reaching point/answering question
tangentiality e.g. psychosis, dementia, delerium
delusional mood
feels something going on around them, can’t describe it, becomes > clear /specific when the delusional idea/perception occurs
feels something going on around them, can’t describe it, becomes > clear /specific when the delusional idea/perception occurs
delusional mood
delusion of love
2’ delusion (come about from another experience), certain that s/o else is in love with them, even if they havent met
2’ delusion (come about from another experience), certain that s/o else is in love with them, even if they havent met
deluson of love
de Cleraumbault’s syndrome
delusion of love involving a celebrity
delusion of love involving a celebrity
de Cleraumbault’s S
delusional perception
delusion forms in response to an ordinary object e.g. traffic light changing sending a message
delusion forms in response to an ordinary object e.g. traffic light changing sending a message
delusional perception
autochthonous delusion
delusional ideas that arise out of nowhere, appear fully formed in the PT’s mind
delusional ideas that arise out of nowhere, appear fully formed in the PT’s mind
autochthonous delusions
delusions of jealousy
2’ delusions, e.g smell of perfume on partner’s coat means they’re having an affaire
2’ delusions, e.g smell of perfume on partner’s coat means they’re having an affaire
delusions of jealousy
other side effects of clozapine
neurtropaenia, myocarditis, sedation, seizures, hypersalivation, postural hypotension
neurtropaenia, myocarditis, sedation, seizures, hypersalivation, postural hypotension
side effects of clozapine
obsessional thoughts
recurrent, intrusive, unpleasant/disturbing thoughts/ideas/images, that are one’s own, but unwanted, recognises them as absurd
compulsions
repettitive, purposeful, obsessional motor/mental actions, PT recognises as unnecessary but can’t resist performing them w/o anxiety
obsessional motor actions, PT recognises as unnecessary but can’t resist performing them w/o anxiety
compulsions
unpleasant/disturbiing thoughts/ideas/images, that are one’s own, but unwanted
obsessional thoughts
histrionuc PD
self-dramatisation, theatrical, exaggerated emotions, suggestible/easiy led, shallow + labile affect, seeking to be centre of attention, inappropriate disinhibition/flirtiness, over concern with physical attractiveness
EUPB/boarderline PD
self-image disturbances, short term v intense relationships, emotional crisis when relationships end, self harm, feeling of chronic emptiness
anakastic PD/obsessive-compulsive PD
preoccupied with detail/rules/organisation/schedules, perfectionism hinders completion of tasks, pedantic + preoccupied, reduced enjoyment, loss of relationships
schizoid PD
emotionally detached, asocial, little interest in others, preoccupied by fantasy
paranoid PD
high/inappropriate suspicion of people + their intentions, feel victim of ‘ganging up’/plots, difficult to convince otherwise
self-dramatisation, theatrical, exaggerated emotions, suggestible/easiy led, shallow + labile affect, seeking to be centre of attention, inappropriate disinhibition/flirtiness, over concern with physical attractiveness
histrionic PD
self-image disturbances, short term v intense relationships, emotional crisis when relationships end, self harm, feeling of chronic emptiness
EUPD/borderline PD
preoccupied with detail/rules/organisation/schedules, perfectionism hinders completion of tasks, pedantic + preoccupied, reduced enjoyment, loss of relationships
anakasticPD/obsessive-compulsive PD
emotionally detached, asocial, little interest in others, preoccupied by fantasy
schizoid PD
high/inappropriate suspicion of people + their intentions, feel victim of ‘ganging up’/plots, difficult to convince otherwise
paranoid PD
trailing illusion
associated with hallucinogenics, moving object perceived as a series of images
associated with hallucinogenics, moving object perceived as a series of images
trailing illusion
LBD
deteriorating cognition, visual hallucinations, Parkinsonianisms
deteriorating cognition, visual hallucinations, Parkinsonianisms
LBD
Charles Bonnet S
psychophysical visual disturbances, complex visual hallucinations, in partial/severe blindness, PT is aware that hallucinations aren’t real
psychophysical visual disturbances, complex visual hallucinations, in partial/severe blindness, PT is aware that hallucinations aren’t real
Charles Bonnet S
Li toxicity
anorexia, diarrhoea, vomiting, drowsiness, restlessness, dysarthria, dizziness, ataxia, incoordination, m twitches, coarse tremor, hyperreflexia, convulsions, AKI, collapse, coma, death
anorexia, diarrhoea, vomiting, drowsiness, restlessness, dysarthria, dizziness, ataxia, incoordination, m twitches, coarse tremor, hyperreflexia, convulsions, AKI, collapse, coma, death
Li toxicity
drugs associated with Li toxicity
thiazides
hypnogogic hallucinations
going off to sleep, auditory>other modalities
going off to sleep hallucinations, auditory>other modalities
hypngogic
hypnopompic hallucinations
waking up
waking up hallucinations
hypopompic
reflex hallucination
true sensory stimulus causes a hallucination in a different sensory modality
true sensory stimulus causes a hallucination in a different sensory modality
reflex hallucination
autoscopy
experience of seeing oneself + knowing that it is oneself
experience of seeing oneself + knowing that it is oneself
autoscopy
autoscopy aka
phantom mirror image
phantom mirror image aka
autoscopy
lilipitian hallucination
visual hallucination associated with micropsia e.g delerium
visual hallucination associated with micropsia
liliputian hallucination e.g. delerium
elementary hallucination
flashes of light
flashes of light hallucination
elementary
extracampine hallucination
hallucination outside of limits of sensory field e.g. seeing someone behind them when they’re looking forward
hallucination outside of limits of sensory field e.g. seeing someone behind them when they’re looking forward
extracampine
SNRI stands for
selective noradrenaline-seratonin reuptake inhibitors
duloxetine
SNRI
asessing memory
repeat something back after 5 mins
assessing orientation in time, place + person
day, date, time, identity/job, names
assessing attention + concentration
counting backwards
assesing dyspraxia
drawing intersecting pentagons
assessing receptive dysphasia
following a command
assessing expressive dysphasia
naming objects
assessing the components of executive (frontal lobe) functioning test
approximation (guessing distances), abstract reasoning (1, a, 2, b, next in sequence), verbal fluency (words beginning with a, 1 min), proverb interpretation
repeat something back after 5 mins tests
memory
day, date, time, identity/job, names tests
orientation to person, place, time
counting backwards tests
attention + concentration
drawing intersecting pentagons tests
dyspraxia
following a command tests
receptive dysphasia
naming objects tests
expressive dysphasia
risk assessment is the balance between
PT risks factors vs PT rights
risk assessment components
risk to self (suicide, DSH, self neglect, accidental harm), risk to others, risk from others, safeguarding children/vulnerable adults
tools to help assess risk
Hx, MSE, past behaviour, collateral, previous notes
risk of self harm determine
suicidality: thoughts, plans, intentions, things that prevent them acting, DSH: previous episides, circumstance, method, management, predisposing factors: FH suicide, social isolation, substance misuse, disengagement from/unwillingness to engage with support services, hopelessness, worthlessness
risk of harm to others determine
(to whom, f, severity, methods) acts/threats of violence, arson, sexual inappropriateness, containment, compliance with previous/current psychaitric intervention, increased risk: discontinuation of medicaton, change in recreational drug use, EtOH/drug misuse, impulsive/unpredictable behaviour, recent stressful life event, persecutory delusions, delusions of control/passivity phenomenon, command hallucinations)
passivity phenomenon
the belieft that one is no longer in control of one’s own body, thoughts or feelings, controlled by some external agent
risks of self neglect/accidental self harm can manifest as
malnutrition, failure to access health care, living in squalid conditions, falls (fraility, intoxication), failure to safeguard against fire/explosion, wandering (getting lost, unsafe t to be out), poor road safety, accidental OD/under dose, vulnerability to crime (front door open, inviting in strangers)
risks to vulnerable adults mneumonic
how safe
how safe mneumonic means
HOme safety (leaving gas on), Wandering, Self neglect, Abuse, crime vulnerability, Falls, Eating (malnutrition)
the belieft that one is no longer in control of one’s own body, thoughts or feelings, controlled by some external agent
passivity phenomenon
how safe mneumonic to remember
risk to vulnerable adults
psychiatric investigations
FBC, ESR, U+E, glucose, TFT, LFT, Ca, folate, B12, syphilis, MSU, CXR, CT head/MRI, EEG
classes of medications used in psychiatry
antipsychotics, antidepressants, antimanic drugs/mood stabilisers, hypnotics/anxiolytics, stimulants, antidementia
DoLS applies to
people in hospitals/care homes who lack capacity, are deprived of their liberty (i.e. not able to come + go as they please), not under a section of the MHA
DoLs authorisatoinis granted by
2 assessors
DoLS must conform to the following
> 18 y.o., no LPA/advinced decision/court of protection conflicts, lacks capacity, MH disorder, not under MHA, not to enable MH treatment, best interest
DoLS must be renewed
annually
MHA section 2
28/7, authorised by 2 Drs, for assessment purposes
MHA section 3
6/12, 2 Drs, treatment purposes
MHA section 4
72h, 1 Dr, urgent assessment from community, no t to arrange section 2
MHA section 5(2)
72h, 1 Dr, urgent detention of inPT
MHA section 5(4)
6h, registered MH nurse, urgent detention of psych inPT in the absence of a Dr
MHA section 135
72h, police officer, removal from home to place of safety
MHA section 136
72h, police officer, premouval from public space to place of safety
28/7, authorised by 2 Drs, for assessment purposes
MHA section 2
6/12, 2 Drs, treatment purposes
MHA secion 3
72h, 1 Dr, urgent assessment from community, no t to arrange section 2
MHA section 4
72h, 1 Dr, urgent detention of inPT
MHA section 5(2)
6h, registered MH nurse, urgent detention of psych inPT in the absence of a Dr
MHA section 5(4)
72h, police officer, removal from home to place of safety
MHA section 135
72h, police officer, premouval from public space to place of safety
MHA section 136
in order to warrent sectioning
PT deemed to have MH disorder sufficient to warrent detention due to risk, unwilling to attend voluntarity
who can apply for a MHA section
AMHP - approved MH professional: social worker, nurse, psychologist, OT (not a Dr)
at least one of the Drs completing the MHA section has to be
section 12 approved
depression DD
normal sadness (berevement, physical illness), psychotic depression, schizophrena, EtOH/drug withdrawal
biological mechanism behind depression
reduction in seratonin/noradrenaline availiability in the brain
duration of antidepressant therapy
at least 6/12, taper off dose, can continue for prophylaxis
depression prognosis - single episodes
duration 3-8/12, 50% recurrence
depression prognosos - severe depression
80% recurence, suicide risk
reduction in seratonin/noradrenaline availiability in the brain is the hypothersises mechanism behind
depression
biological mechanism behind anxiety
low GABA levels, frontal cortex remodelling in stress, heightened amygdala activation
anxiety is associated with
childhood abuse, separations, demand for high achievement, excessive conformity, life stresses, physical health probelms
panic attack definition
unpredictable recurrent episodic panic attacks, not restricted to a particular situation, associated with persistent worry RE another attack/maladaptive behavioural changes
panic attack vicious cycle
catastrophic misinterpretation of ambiguous physical sensation e.g. SOB increase arousal, creating a +ve feedback loop
generalised anxiety discorder
generalised, persistent, excessive anxiety/worry RE a number of events that the individual finds difficult to control, >6/12 duration
generalised anxiety disorder DD
withdrawal from drugs/EtOH, excessive caffeine, depression, psychotic disorder, thyrotoxicosis, parathyroid DZ, hypoglycaemia, phaeochromocytoma, carcinoid S
management of generalised anxiety disorder
individual guided self help (CBT principles), psychoeducational groups, face to face CBT, aplpied relaxation, SSRI, SNRI, pregabalin, BZD (not regularly, just for crises)
CBT for generalised anxiety disorder aims to
identify morbid anticipatory thoughts, replace with > realistic cognition, learn + use distractions, breathing + relaxation exercises
agoraphobia
fear + avoidance of places/situations from which escape may be difficult/help unavailable in the event of a panic attack
agoaphobia diagnosis required anxiety to be restricted to these
crowds, public places, travelling away from home, travelling alone
management of agoraphobia
CBT, graded exposure to situations, SSRI
social phobia
persistent fear of social situations involving unfamiliar people/possible scrutiny by others, fear of humiliation/embarrasement
management of social phobia
CBT, self help material, graded exposure to situations, social skills training, SSRI
specific phobias
fear of specific people/objects/situations
management of specific phobias
graded exposure to situation, response prevention, short term BZD
low GABA levels, frontal cortex remodelling in stress, heightened amygdala activation might underly
anxiety disorders
unpredictable recurrent, not restricted to a particular situation, associated with persistent worry RE another attack/maladaptive behavioural changes
panic attack
catastrophic misinterpretation of ambiguous physical sensation e.g. SOB increase arousal, creating a +ve feedback loop
panic attack vicious cycle
generalised, persistent, excessive anxiety/worry RE a number of events that the individual finds difficult to control, >6/12 duration
GAD
fear + avoidance of places/situations from which escape may be difficult/help unavailable in the event of a panic attack
agoraphobia
persistent fear of social situations involving unfamiliar people/possible scrutiny by others, fear of humiliation/embarrasement
social phobia
fear of specific people/objects/situations
specific phobia
risk factors for generalised anxiety disorder
35-54 y.o., divorced, separated, living alone, lone parent
persecutory delusions e.g.
having enemies, feeling that someone is out to get you
delusions of reference e.g.
getting specific messages for you from the TV
Schneider’s 2nd rank symptoms
persecutory delusions, delusions of reference, hallucinations, neologisms/disorganised speech
psychotic disorders include
schizophrenia, delusional disorder, schizoaffective disorder, psychotic depression, bipolar affective disorder
DSM-V criteria for schizophrenia
6/12 duration, 2/5 of: delusions, hallucinations, disorganised speech, disorganised/catatonic behaviour, negative symptoms
subtypes of schizophrenia
paranoid, catatonic, hebephrenic, residual, simple
paranoid schizophrenia
delusions + auditory hallucinations are evident
catatonic schizophrenia
psychomotor disturbances are prominent (motor immobility to excessive activity), rigidity, posturing (waxt flexibility), echolalia, echopraxia
echopraxia
copying behaviours
hebephrenic schizophrenia
early onset, poor prognosis, unpredictable + irresponsible behaviour, innapropriate mood, incongruous affect, giggling, mannerisms, pranks, thought incoherance, fleeting delusions, hallucinations
residual schizophrenia
Hx of paranoid/catatonic/hebephrenic schizophrenia, but in current illness negative/cognitive symptoms predominate
simple schizophrenia
uncommon, negative symptoms w/o preceeding overt psychotic symptoms
psychosis prodrome
anxiety, depression, ideas of reference, distress, declune in social functioning
risk factors for developing psychosis
FH, advanced paternal age, winter birth, obstetric complications, developmental delay, smoking week in adolescence, childhood abuse
other forms pfo psychosis
schizoaffective disorder, delusional disorder, brief psychotic episodes
schizoaffective disorder
affective + schizophrenic symptoms occur together + with equal prominence
delusional disorder
fixed delusion/delusional system with other areas of thinking/functioning preserved
brief psychotic episodes
<6/12 duration
management of acute psychotic episode (schizophrenia)
antipsychotics (lowest effective dose, PO, monitor SE, adherence), psychological therapy (self help, CBT, family therapy, art therapy), social support (engagement, hope, reduce stigma, supported employment, accommodation)
two types of antipsychotic
typical/first generation, atypical/second generation
antipsychotics are not so good at treating
the negative symptoms
duration of treatment with antipsychotic before determining its effectiveness
4-6/52
medication used in treatment R schizophrenia
clozapine
schizophrenia good prognostic factors mneumonic
finding plans
finding plans mneumonic meaning
Female, In relationship, good social support, No -ve symptoms, aDherence, Intelligence (> educated), No stress, Good premorbid personality, Paranoid subtype, Late onset, Acute onset, No substance misuse, Scan (CT/MRI) N
suicide risk in schizophrenia is higher among
young men, 1st few y of illness, persistent hallucinations/delusions, illicit drug Hx, previous suicide attempts
persecutory delusions, delusions of reference, hallucinations, neologisms/disorganised speech describe
Schnieder’s 2nd rank symptoms
delusions + auditory hallucinations are evident describes
paranoid schizophrenia
psychomotor disturbances are prominent (motor immobility to excessive activity), rigidity, posturing (waxt flexibility), echolalia, echopraxia
catatonic schizophrenia
early onset, poor prognosis, unpredictable + irresponsible behaviour, innapropriate mood, incongruous affect, giggling, mannerisms, pranks, thought incoherance, fleeting delusions, hallucinations
hebephrenic schizophrenia
Hx of paranoid/catatonic/hebephrenic schizophrenia, but in current illness negative/cognitive symptoms predominate
residual schizophrenia
uncommon, negative symptoms w/o preceeding overt psychotic symptoms
simple schizophrenia
fixed delusion/delusional system with other areas of thinking/functioning preserved
delusional disorder
finding plans is a mneumonic for
good prognositic factors in schizophrenia
young men, 1st few y of illness, persistent hallucinations/delusions, illicit drug Hx are at higher risk of
suicide attempts in schizophrenia
self harm demographics
women, <35 y.o., lower socioeconomic classes, single, divorced
self harm is associated with
depression, personality disorders
self harm assessment
motivaiton (interrupt a sequence of events, attention, communication, wish to die), current psychiatric illness, suicide note, will, continued determination to die, hopelessness, method, discovery, employment
self harm management
reduce risk, initiate/continue treatment, address ongoing social difficulties, what seems feasible to the PT, crisis team, SSRI, psychological therapy
PTSD onset w/i
6/12 (ICD-10), 1/12 (DSM-5) of stressor
dissociative symptoms of an acute stress reaction predict and increased risk of
PTSD
dissociative symptoms of an acute stress include
wandering aimlessly, reduced sleep, nightmares
symptons of PTSD
> 1/12 duration, persistent intrusive thoughts, reexperiences (memories, nightmares, flashbacks), avoidance of reminders, numbing, detachment, estrangement from others, sense of foreshortened future, increased arousal (hypervigilance, sleep disturbances, irritability, poor concentration, exaggerated startle response)
treatment for PTSD
trauma-focused CBT, EMDR (eye movement desensitisation + reprocessing therapy), antidepressants (paroxetine, mirtazapine)
PTSD definition
follows severe stressful experiencs of exceptionally threatening/catastrophic nature: assult, accident, disaster, act ro terrorism, war
PTSD comorbidities
EtOH/drug abuse, depression
PTSD risk factors
proportional to stressor, man-made>natural disaster, continuation of stress, lack of social support, other adversities, premorbid personality
> 1/12 duration, persistent intrusive thoughts, reexperiences (memories, nightmares, flashbacks), avoidance of reminders, numbing, detachment, estrangement from others, sense of foreshortened future, increased arousal (hypervigilance, sleep disturbances, irritability, poor concentration, exaggerated startle response) may indicate
PTSD
ex of obsessions
thoughts (blasphemy, sex, violence, contamination, numbesr), images (vivid, morbid, violent scenes), impulses (fear of jumping infront of a train), ruminations (continuous pondering), doubts
ex of compulsions
had washing, cleaning, counting, checking, touching _ rearranging objects to achieve symmetry, checking _ repeating thoughts, hoarding, counting, desire to utter a forbidden word, asking endless Q’s to seek answers to commonplace facts, inappropriate + excessive tidiness
OCD is characterised as
time consuming >1h/d, obsession +/- compulsion, most days for >2/52, distressing + interfere with activities
other features of OCD
avoidance of trigger stimuli/activities, onset during adolescence
OCD can be divided into 4 categories
obsessions + compulsions - hand washing concerned with contamination
checking compulsions in response to obsessional thoughts about potential harm - leaving gas on
obsessions w/o any covers compulsive acts
hoarding
complications of OCD
depression, anxiolytic/EtOH abuse
FH in OCD ask about
OCD, tics, Tourette’s S, parental overprotection
a FH of tics, Tourette’s S, parental overprotection is associated with
OCD
diagnostic features of anorexia nervosa
morbid fear of fatness, distorted body image, deliberate weight loss, amonorhoea, BMI <17.5, loss of libido
anorexia nervosa DD
psychosis, DM, depression, substance/EtOH abuse, Addison’s, malabsorption, malignancy
anorexia nervosa management
family therapy, motivational counselling, CBT, IPT (interpesonal psychotherapy), focused psychodynamic therapy, hospitalisation (sig physical abnormalities, suicide risk, BMI >13.5)
anorexia nervosa FH ask about
eating disorders, OCD, depression
anorexia nervosa personal Hx
abuse, overprotective/overcontrolling environment, overvaluation of food/eating/weight/body shape, troubled family relationships, bullied because of size
anorexia nervosa subtypes
restrictive vs bulimic
other features of anorexia nervosa
preoccupation with food, self-consciousness RE eating in public, socially isolating behaviour, vigorous exercise, constipation, cold intollerance, depressive/OCD symptoms
physical signs of anorexia nervosa
emaciation, dry/yellow skin, lanugo hair on face/trunk, bradycardia, hypotension, anaemia, leucopenia, consequences of repeated V (hypokalaemia, alkalosis, pitted teeth, parotid swelling, Russell’s sign)
bulimia nervosa diagnostic features
morbid fear of fatness, distorted body image, craving for food, uncontrolled binge eating, purging/V/laxative abuse, fluctuating weight, preoccupation with body weight/shape
bulimia nervosa managemetn
CBT, IPT (interpersonal therapy), SSRIs (fluoxetine)
bulimai nervosa associations
N/excessive body weight (fluctuant), loss of control/trance-like binges, self-loathing, depression, EtOH/drug abuse, DSH, stealing/sexual disinhibition, poor impulse control
physical signs in bulimia nervosa
amenorrhoea, hypokalaemia, oesophageal tears
opiates of abuse
heroin, morphine, methadone
stimulants of abuse
cocaine, amphetamines
hallucinogens of abuse
MDMA, GHB, GBL, LSD, mushrooms
signs of opiate dependence
miosis, tremor, malaise, apathy, constipation, weakness, impotence, neglect, malnutrition
opiate OD
miosis, resp depression, death
cannabis negative effects
conjunctival irritation, reduced spermatogenesis, L DZ, flashbacks, transient psychosis, schizophrenia, depression, apathy
opiate detox medications
methadone/buprenorphine
mneumonic to assess dependence
CAN’T STOP
cant stop mneumonic stands for
Compulsion to take substance, Aware of harms but persists, Neglect of other activities, Tolerance, Stopping causes withdrawal, Time preoccupied with substance, Out of control use, Persistant/futile wish to cut down
psychoactive substance ICD-10 classification classes
acute intoxification, harmful use, dependence, withdrawal state, psychotic disorder, amnesic disorder, residual + late onset psychotic disorder
acute intoxification (psychoactive substance)
transient disturbances of consciousness, cognition, perception, affect or behaviour following administration of psychoactive substance
harmful use (psychoactive substance)
damage to individual’s health + adverse effects on family + society
dependence (psychoactive substance)
signs of dependence (mneumonic), associated neglect of important social, occupationsal or recreational activities
withdrawal state (psychoactive substance)
physical + psychological symptoms occuring on absolute/relative withdrawal of the substance, after repeated, usually prolonged +/- high dose use
psychotic disorder (psychoactive substance)
psychosis during/immediately after use, vivid hallucinations, abnormal affet, psychomotor disturbances, delusions of persecution + reference
amnesic disorder (psychoactive substance)
memory or other cognitive impairments caused by substance use
residual + late onset psychotic disorders (psychoactive substance)
effects on behaviour, affect, personality or cognition that last beyond the period during which a direct psychological substance’s effect might be expected e.g. flashbacks
management of substance misuse
rehab, hospital, community, CBT, motivational interviewing, self-help groups
early opiate withdrawal signs
24-48h, craving, flu like symptoms, sweating, yawning
late opiate withdrawal signs
7-10 days, mydriasis, abdo cramps, diarrhoea, agitation, restlessness, piloerection, tachycardia
stigmata of alcohol abuse O/E
jaundice, spider naevi, palmar erythema, gynaecomastia, peripheral neuropathy
complications of alcohol abuse
Wernike’s encephalopathy, peripheral neuropathy, ED, ejaculatory impotence, cerebellar degeneration, dementia, other physical + social complications, psychiatric complciations (depression, suicidal ideations, suicide attempts, severe anxiety, insomnia), foetal alcohol S (reduced m tone, poor coordination, developmental delay, heart defects, facial abnormalities)
alcohol abuse management
abstinence, detoxificaion (in hospital if risk of delirium tremens), chlordiazepoxide, motivational interviewing, psychological therapies, self-help groups, disulfiram (flushing, headache, N, anxiety if EtOH ingested)
treatment of delirium tremens
lorazepam, haloperidol or olanzapine
miosis, tremor, malaise, apathy, constipation, weakness, impotence, neglect, malnutrition are signs of
opiate dependence
conjunctival irritation, reduced spermatogenesis, L DZ, flashbacks, transient psychosis, schizophrenia, depression, apathy are negative effects of
canabis
can’t stop is a mneumonic to remember factors suggestive of
dependence
transient disturbances of consciousness, cognition, perception, affect or behaviour following administration of psychoactive substance
acute intoxification
damage to individual’s health + adverse effects on family + society
harmful use
signs of dependence (mneumonic), associated neglect of important social, occupationsal or recreational activities
dependence
physical + psychological symptoms occuring on absolute/relative withdrawal of the substance, after repeated, usually prolonged +/- high dose use
withdrawal state
psychosis during/immediately after use, vivid hallucinations, abnormal affet, psychomotor disturbances, delusions of persecution + reference
psychotic disorder
memory or other cognitive impairments caused by substance use
amnesic disorder
effects on behaviour, affect, personality or cognition that last beyond the period during which a direct psychological substance’s effect might be expected e.g. flashbacks
residual + late onset psychotic disorder
craving, flu like symptoms, sweating, yawning
early opiate withdrawal signs 24-48h
mydriasis, abdo cramps, diarrhoea, agitation, restlessness, piloerection, tachycardia
late opiate withdrawal signs 7-10 days
bipolar affective disorder definition
recurent episodes of altered mood, activity + energy: depressive, manic, hypomanic, mixed
mania characteristics
increased psychomotor activity, exaggerated optimism, inflated self esteem, decreased social inhibitions (sexual overactivity, reckless spending, dangerous driving, inappropriate business/religious/political initiatives), heightened sensory awareness, rapid thinking and speech, uninterruptible/pressured speech, flight of ideas, lack of insight
bipolar affective disorder DD
substance abuse, endocrine disturbance, epilepsy, schizophrenia, schizoaffective disorder, personality disorder, ADHD, transient psychoses
management of acute mania
haloperidol, olanzapine, quetiapine. risperidone
mood stabilsers
Li, Na valproate
bipolar affective dosirder management
indicidual/family/group therapy, Li (most effecive long tern treatment for BPAD, required blood monitoring)
