Psychiatry Flashcards
HISTORY: depression
Mood - dep, worth, guilt, hope
Pleasure Energy Sleep Appetite Concentration Slowness
Suicide
Pattern (everyday?)
Triggers + impact (how are things at home/work)
ASK ABOUT MANIC EPISODES
Alco drugs
Personal family history
Components of mental state examination
- Appearance and behaviour
- Speech (tone, rate, vol, paucity, pressure)
- Thought form and content
- flight, block, delusion, - Mood (subjective) and affect (objective)
- Perception (delusions, hallucinations etc)
- Cognition
- Insight
Differentials depression
bipolar affective disorder schizophrenia seasonal affective disorder bereavement substance abuse hypothyroidism dementia
Investigations person suspected depression
Screening tools
- HAD
- PHQ-9
FBC U+Es TFTs Folate + B12 LFTs- alcohol/drugs/cancer
EXPLAN: Treatment depression
CBT
exercise
SSRIs
- se: GI upset (pain, n/v, diar), headache
- take in morning (cause sleep disturbance)
TCA
- se: wg, drowsy, dry eye/mouth, constipation
long term - review and support
lag time
don’t stop suddenly
SSRI
Fluoxetine
Citalopram
Sertraline - used if anxious
se:
GI upset, headache, wg
Anticholinergic
sleep disturb - so take in morning
Considerations
lag - 4 weeks for effect
dont stop suddenly (w/drawal)
long term but review
HISTORY: suicide and self harm
1) Event
- what, where, who
- intoxicated?
something you’d thought about
- spec plan, note? told? discov?
or impulse
- what trigger
as happ
- think die or disc?
- panic or relief?
what then?
now: guilt? anger? relief?
2) past
- prev attempts - prev psych - gen mood
3) future
- try again - why not? - feel about future?
4) social
***alcohol and drug use
support at home?
HISTORY: anxiety
hx of physical complaint
- what are you concerned about
- what makes you think/worry about this
- do you think you are someone who worries about things a lot
things in life causing stress
do you
- feel on edge
- irritable
- difficulty concentrating
experience
- fatigue
- sleep
- muscle tension
physical panic:
- palp/cp/SOB
- sweat, tremor, tingle, dizzy, h/a
ASK ABOUT LOW MOOD - suicide
ASK ABOUT ELATED MOOD
other: past psych, fh, alc drugs meds
Definition generalised anxiety disorder
Persistent anxiety and worry that patient recognises is out of proportion to actual events or circumstances
symptoms assoc w anxiety
Worry anxiety
On edge
Irritability, overreaction
Diff concentraing
Fatigue
Muscle tension
Sleep disturbance
Physical
- palp, sweat, tremor
- sob, cp, sick/abdo
- dizzy, tingly
Treatment GAD
CBT - good
1) Sertraline (ssri)
2) Venlafaxine (snri)
3) Pregabalin
Treatment panic disorder
psychological intervention
- relaxation training,
- cognitive techniques
- exposure
antidepressants
condition that often goes alongside panic disorder
Agoraphobia- fear about being in places or situations from which escape may be difficult
leads to avoidance many social situations, eventually can lead to imprisonment in person’s home
Definition obsession
sterotypical thoughts, phrases and words that people find difficult to control or put out of his/her mind
In OCD thoughts are usually unpleasant, concerned with dirt, contamination
Definition compulsion
Senseless and repeated rituals
Treatment OCD
CBT
graded exposure + response prevention to trigger
antidepressants- SSRIs
3 main types PTSD symptoms
- Recurrent + obtrusive thoughts, images, dreams relating to event
- persistent avoidance stimuli associated with trauma
- persistent symptoms of increased arousal (sleep disturbance, irritability, poor concentration, increased startle response)
Definition post traumatic stress disorder
characteristic set of psychological symptoms following exposure to serious traumatic event
treatment PTSD
CBT including anxiety management
antidepressants may be helpful
HISTORY: psychosis
tell me whats been happening/going on/why here?
can see v distressed
sounds like been through a lot
you’re safe, I’m here to help
talk through more
investigate delusion
thought disorder
passivity
hallucination
mood
***THOUGHTS OF HARMING SELF OR OTHER
***ALCOHOL AND DRUG USE
psych hist, fh
First rank symptoms of schizophrenia
Hallucinations:
- thought echo
- 3rd person auditory hallucinations
Formal thought disorder: insertion, withdrawal, braodcasting
Somatic passivity (someone controlling my thoughts, feelings or actions)
Delusional peception- real perception gives rise to a false meaning eg saw you open the door, means your going to kill me
negative symptoms of schizophrenia
self-neglect
blunted affect, mood, anhydonia
–> poverty or slowness of thought/motivation/speech
other symptoms
- neologism
- catatonia
Differential diagnosis schizophrenia
Schizoaffective disorder
- Severe depression with psychosis
- Bipolar disorder with psychosis
- Schizoid personality disorder
- Drug induced psychosis
prognosis schizophrenia
20% have only one episode psychosis
70% will recover from episode but relapse in future with increased negative symptoms between episodes
10% will never recover from first episode
Small inc risk in family members
mental health act sections
2 - assessment 28 days
2 docs 1 amhp
3 - treatment 6 months
2 docs 1 amhp
- approval of relative
4 - emergency 72 hours
1 doc
treatment psychosis
atypical antipsychotic drug
- minimum 6 weeks - slow build up of effect
eg
First line: - olazepine - risperidone
Others - quetiapine, zotapine, clozapine, aripiprazole
(also haloperidol is first gen antipsychotic - more extrapyramidal se)
Side effects of antipsychotic drugs
Sedation - drowsy (driving, machinery)
Anticholinergic activity (dry eye, mouth, constip)
Hypotensive effects - postural
Extrapyramidal activity - parkinsons, dyskinesia (head,eye,mouth) - more w first gen
Also weight gain
Hormonal - impot, gynec, periods
Heart rhythm
Neuroleptic malignant syndrome
- delirium, rigidity, tachy/sweaty
EXPLAN: Olanzapine
se: wg, sedation, antichol
look out for dyksinesia
lag
do not stop suddenly
will be long term
- but regularly reviewed
***monitor ECG
prognosis in schizophrenia
- 20% 1 episode
- 70% recover but relapse in future, -ve sx between
- 10% don’t fully recover
when is clozapine used?
Used in treatment resistant schizophrenia only after min 2 drugs have failed to work
- olanzapine and risperidone and first line
risk: neutropenia in 4% of users
»weekly blood tests for first 6 months treatment
Support for patients with schizophrenia
Care programme approach (CPA)
Key worker
MDT: psychiatrist, CPN, social worker
Typical features manic episode
Mania vs hypomania
- elated mood, tinged with irritability
- pressure of speech + flight of ideas
- loss of insight with delusions of grandeur
- hyperactive behaviour with sexual inhibition, excessive spending etc
- hallucinations (not present in hypomania)
In mania have psychotic symptoms (delusions, halluc)
Cyclothymia - rapidly changing mood
Hyperthymia - periods of elated mood
Treatment acute attack MANIA
Aim to control abnormal mood + behaviour as soon as possible with either:
- sedative eg diazepam
- atypical antipsychotic eg olanzapine
- older neuroleptics - haloperidol
mood stabiliser (lithium) given alongside but usually takes about 5 days to get effective dose
Considerations w lithium
Alternatives: sodium val, carbamez
weight gain
N+V
tremor, ataxia
diabetes insipidus - polydip, polyuria
signif:
- renal toxicity
- thyroid
- toxicity
toxicity:
- coarse tremor, unstead, confused, unwell (cerebellar)
- watch w ace, nsaids, diuretics, any illness causing dehydration
Lithium monitoring
weekly until therapeutic dose
- Li level - every 3m
- kidney and thyroid - every 6m
EXPLAN Lithium
long term but reviewed and monitored
therapeutic window
- is it working
- is it causing se
- is there risk of toxicity
SE:
polyuria/dip
wg
GI
sig: thyroid and kidney (monitor bloods)
toxicity: tremor, GI, unsteady, confus
»so will do blood test every week at first, then monthly
»need to be aware
also pregnancy (depend necessity) and new meds (especially diuretic)
EXPLAN: dementia
brain gradually functioning less and less as normal
- progressive, irreversible
causes memory problems - short term also language, confusion, get lost personality unable to look after self
later require a lot of assistance
OT, social care
may require residential care eventually
- mention carer support
in alzheimers meds can be used to slow progression
- used in mod/mild - for 6 months
HISTORY dementia/ memory loss
is it acute confusion
- infection, timescale, constipation
is it vascular
- hx cvd disease inc tia
- stepwise progression
- shuffling gait
is it alz
- family history
- slow gradual progression
lewy body
- tremor, rigid, slow
- visual halluc
- fluctuating consciousness
Picks (frontotemporal)
- personality, disinhibition
is it pseudodementia
- depression
other: alco, past psych, FH
dementia sx
memory confusion visuospatial concentration language behaviour/ emotion
later: neglect, motor, req care
MMSE
where
- coutnry, county, town, building, room
when
- year, season, month, day, date
repeat: ball, dog, pen
WORLD
recall: ball, dog, pen
name two objetcs
repeat: NIAB
task
read
write
draw
what is depressive pseudodementia?
Important differential for dementia
Patient has cognitive disturbance due to depressive illness
px has prominent affective symptoms such as sadness, loss interest in activities, thoughts about death
Treat with antidepressives
Capacity
understand and retain
weigh up to make decision
communicate decision
specific to decision
Drugs used vs alzheimers
Acetylcholinesterase inhibitors
Can slow/delay decline for up to 6m in 40%
May also be helpful vs dementia of parkinsons, and LBD (rivastig)
Use if mmse between 10-20 (moderate)
DONEPAZIL
RIVASTIGMINE
GALANTAMINE
se: gi, headache
Memantine (nmda antag) reserved for mod-severe
Causes of delirium
CONSTIPATION
UTI
Metabolic- hyponatraemia, hypercalcaemia
Endocrine- hyper/hypothyroid, addisons, hypoglycaemia
Drugs eg antidepressents, benzodiazepines, antiepileptics
Alcohol- acute ingestion or withdrawal
Infections- systemic or intracranial (encephalitis)
Trauma
Vascular- haemorrhage
HISTORY: alcohol
1) talk through normal 24 hours drinking specifically: - drink what (narrow) - in morning - alone - vs withdrawal getting worse?
2) do you think this is problem?
cut down? guilt? annoyed?
3) impact
- work, relationships, social act
- health
4) cutting down
- done before? pros cons
6) other subs, other psych, health
Management acute alcohol
1) Pabrinex - vitamins B+C
2) IV fluids
3) LIBRIUM (chlordiazepoxide = benzodiazepine) every 4-6 hours, reduced after 2-4 days
4) monitor blood glucose levels, close obs, reassure
Features of alcohol withdrawal syndrome
N+V coarse tremor paroxysmal sweats anxiety increased arousal, agitation, restlessness headache visual hallucinations
Recommended safe drinking limits
2-3 units/day men
1-2 units/day women
Electro convulsion therapy
For resistant depression
- especially where element of eating disorder, sleeping disorder, motor disorder
Twice a week 6-8 weeks
GA (nil by mouth), muscle relax, o2, atropine
CI: mi, stroke, arrhyth
SE: headache, memory
Post natal depression
Starts within month
Peaks at 3month
(Baby blues - few days)
Edinburgh score
Avoid fluoxetine
