Psychiatry Flashcards
What are the 5P’s of formulation?
- Presenting problem
- Predisposing factors ie genetics
- Precipitating factors ie a change of job
- Perpetuating factors ie not liking the new job
- Protective factors ie pets
What should a psychiatric assessment involve?
- PC
- HPC
- Past psychiatric hx
- Medications
- Family hx
- Personal hx
- Social hx
- Use of alcohol and illicit substances
- Forensic hx
- Pre-morbid personality
- Mental state examination
- Physical examination
- Risk assessment
What should the personal history involve?
- Early development
- Childhood behaviour
- Education including bullying
- Employment
- Relationships and psychosocial
What should the forensic history include?
- Convictions
- Consequences
- Other offending behaviours or crimes
- Remorse
What should be explored in a patient’s pre-morbid personality?
- Patient’s views of pre-morbid personality
- Informant’s view
- Hobbies/interests
- Predominant mood
- Character
- Relationships
- Habits
What is included in the mental state examination?
ASEPTIC
- Appearance/behaviour - Clothes, weight, eye contact, abnormal movements, guarded/suspicious psychomotor retardation
- Speech - volume, rate and form
- Emotions (MOOD) - subjective and objective view
- Perceptions - hallucinations and delusions
- Thoughts - content, suicidal thoughts, delusional beliefs vs ideas
- Insight - finding out what the patient understands about their health
- Cognition - time and place orientation, language construction
What does the risk assessment include?
- Harm to others
- Harm to self
- Accidental harm to self - ie in dementia pt leaving hob on
- Vulnerability to exploitation
- Self-neglect
Illusions:
Misperceptions of real external stimuli. Can be normal ie when falling asleep
Hallucinations and modalities:
Perceptions occurring in the absence of an external stimulus
Visual, auditory, tactile, somatic, olfactory gustatory
Hypnopompic vs hypnogogic
Hypnopompic: hallucinations when waking up
Hypnogogic: hallucinations when going to sleep
Both are normal
Reflex hallucination:
A stimulus in one modality causes a hallucination in another ie ‘when you write, i feel your pen pressing on my heart’
Extracampine hallucination:
Experiencing something impossible ie hearing someone talking from Australia
Auditory hallucinations 2nd vs 3rd person
2nd: ‘you are a bad person’
3rd: running commentary, talking about the pt between themselves
Overvalued idea:
A false or exaggerated belief which is illogical, but with less rigidity as a delusion. Patient’s mind can be changed with reasoning
Delusion:
A false, unshakable idea or belief which is out keeping with the pt’s educational, cultural and social background
-absolute certainty and extraordinary conviction held about belief
Persecutory delusion
The belief that an outside agency wants to cause the pt harm ie the police want to kill the pt
Grandiose delusion
Inflated importance or self esteem ie thinking they have super powers or have found the cure for cancer
Self-referential delusion
Believing that messages are being given to them through unrelated things ie hearing a song on the radio means that the world is going to turn against the patient
Misidentification types:
Capgras: a close relative has been replaced by an identical imposter
Fregoli: various people met are the same person in disguise
Intermetamorphosis: people in the environment swap identities with each other but keep the same appearace
Subjective doubles: a doppelganger is carrying out independent actions elsewhere
Nihilistic delusion
the belief that they’re dead/parts of their body are dead. sometimes a delusion about the body ie thinking they have no legs
Hypochondriacal delusions
illness, somatisation (feelings of pain, GI complaints)
Delusional guilt
Feeling responsible for harm or things not caused by them ie a mass shooting or natural disaster
Delusional perception
A normal event/stimulus/perception which results in a delusional belief ie a traffic light turning red means that the MI5 is following the pt
Thought insertion:
Certain thoughts are not pt’s own and they are inserted into pt’s mind
Thought withdrawal:
Belief that thoughts have been stolen from ones mind by an entity
Thought broadcast:
ones thoughts are being broadcast out loud so they can be perceived by others
Thought echo:
a form of auditory hallucination in which the pt hears thoughts spoken aloud
Thought block:
sudden interruption in the train of thought, leaving a complete blank
Concrete thinking:
lack of abstract thinking, everything is take literally ie ‘i’ve got a frog in my throat’
Loosening of association:
A lack of logical association between succeeding thoughts. It’s impossible to follow patients train of thought
Circumstantiality:
Irrelevant wandering in the conversation, talking around the houses
Perseveration:
Repetition of a word, theme or action beyond that point at which it was relevant and appropriate
Confabulation:
giving a false account to fill a gap in memory
Somatic passivity:
a delusional belief that one is a passive recipient of bodily sensations from an external agency
Made act/feeling/drive
MADE: the experience/process is done by the pt, but the pt has been made to
ACT: action
FEELING: feeling
DRIVE: impulse
Catatonia
a state of excited or inhibited motor activity in the absence of a mood disorder or
neurological disease. Increased muscle tone.
Akinetic autism or stupor
Complete loss of activity with no response to stimuli
Psychomotor retardation
Slowing of thoughts and movements.
Mainly seen in depressive episodes
Flight of ideas:
rapid skipping from one thought to distantly related ideas.
relation can be rhyming
Pressure of speech:
Rapid rate of delivery of speech, associations may be unusual. Can’t interrupt pt. Wanders off the point of the original conversation
Anhadonia:
defined as the inability to experience pleasure from activities usually found enjoyable
Apathy:
loss of emotional engagement and energy levels
Incongruity of affect:
emotional responses that seem grossly out of tune with the situation/subject being discussed ie smiling about your dog dying
Blunting of affect:
an objective absence of normal emotional response without evidence of depression of psychomotor retardation
Conversion
psychological conflict transposed into somatic symptoms ie blindness
Belle indifference:
a lack of concern about a disability/symptom when psychological conflict has caused somatic symptoms ie blindness
Depersonalisation:
a feeling of some change in the self association with a sense of detachment from one’s own body. Pt feels like an apathetic spectator of his own activities
Derealisation:
a sense of one’s surroundings is lacking reality - often appearing grey, dull, lifeless
Dissociation
an experience where a person may feel disconnected from themselves/their surroundings
Mannerism:
a bizarre elaboration of normal activities ie twirling hair when speaking to someone. not abnormal if the only symptom
Obsession:
a recurrent persistent thought, image, impulse that enters consciousness unbidden, is recognised as being ones own and often remains despite efforts to resist
Compulsion
a repetitive apparently purposeful behaviour performed in a stereotyped way accompanied by a subjective sense that it must be carried out despite recognition of its senselessness and often resistance by the pt
Akathisia:
motor restlessness, anxiety and inability to relax
caused by SSRIs and anti-psychotics
causes some patients to end their life as so intolerable
Gender dysphoria
Persistent aversion toward some or all of those physcial characteristics or social roles that connote one’s own biological sex
Gender identity:
a person’s inner conviction of being male or female
Transvestism:
sexual pleasure derived from dressing/masquerading in clothing of opposite sex, with strong wish to appear as a member of opposite sex
Phobia
an irrational intense and persistent fear and repulsion towards certain situations, objects activity or people. Can limit patients autonomy
Transference
the redirection to a substitute of emotions that were originally felt in childhood
ie if abused by father with a beard the pt would be hostile to a therapist with a beard
Psychological treatments available for psychiatric problems
Psychotherapy: identifying patterns in behaviour
Psychoanalytic: helps the person to become more aware of the unconscious process which are giving rise to symptoms or to difficult repeating patterns
CBT: focuses on here and now and problems in daily life
Counselling: help with recent difficult events
Interpersonal therapy: helps pt understand how problems are connected to their relationships
Dialectic behavioural therapy: balancing acceptance and change
Family and marital therapy
Section 2:
Used for assessment
28 days
2 drs and 1 amhp
pt suffering from mental health disorder of a nature/degree that warrants detention in hospital for assessment and the pt ought to be detained for their own health and safety/protection of others
Section 3:
Used for treatment
6 months
2 drs and 1 amhp
pt suffering from mental health disorder of a nature/degree that warrants detention in hospital for treatment and the pt ought to be detained for their own health and safety/protection of others and appropriate treatment must be available
Section 4
Emergency order
72 hours
1 dr and 1 amhp
pt suffering from mental health disorder of a nature/degree that warrants detention in hospital for assessment and the pt ought to be detained for their own health and safety/protection of others and there isn’t enough time for 2nd dr to attend
Section 5(4)
For a patient already admitted but wanting to leave
6 hours
Nurse’s holding power until dr can attend
can not be treated
Section 5(2)
For a patient already admitted but wanting to leave
72 hours
Dr’s holding power until section 2/3 carried out
can not be treated
Section 135/136
Police
S136 - person suspected of having mental disorder in public space
S135 - court order to access pts home and remove them to a place of safety
Typical antipsychotics:
Haloperidol
Chlorpromazine
Prochlorperazine
Pipothiazine
Typical antipsychotics side effects:
Extra-pyramidal side effects:
- Akasthisia - inner restlessness
- Acute dystonic reaction
- Parkinsonism
- Tardive dyskinesia
Definition of schizophrenia
A syndrome characterised by disturbances of thinking, perception, affect and behaviour.
There is preserved consciousness and cognitive skills.
What are the 2 peak incidences of onset of schizophrenia?
Young men and middle aged women
What causes schizophrenia?
Genetic, environmental and social factors
What are the risk factors for schizophrenia?
- Family history
- Intrauterine/perinatal complications
- Intrauterine infection
- Abnormal early cognitive/neuromuscular development
- Social isolation
- Abnormal family interactions
What are the first rank symptoms of schizophrenia?
Thought alienation Passivity phenomena 3rd person auditory hallucinations Lack of insight Delusional perception
What are the secondary symptoms of schizophrenia?
Delusions 2nd person auditory hallucinations Hallucinations in any other modality Thought disorder Catatonic behaviour Negative symptoms
What are the positive symptoms seen in schizophrenia?
Hallucinations Delusions Passivity phenomena Thought alienation Lack of insight Disturbance in mood
What are the negative symptoms in schizophrenia?
Blunting of affect Amotivation Poverty of speech Poverty of thought Poor non-verbal communication Clear deterioration in functioning Self neglect
Investigations for schizophrenia
Exclude physical causes:
Bloods: FBC - macrocytic anaemia (alcoholics) LFTs - deranged
Serological tests: Syphilis and AIDs
Urine screen: drug abuse
Management for Schizophrenia
MDT support
Health promotion
OT assessment
Psychological support - education, advice, cbt, arts therapy
Drugs: Atypical anti-psychotics - risperidone or onlanzapine
Typical anti-psychotics - haloperidol
ECT
Definition of dementia
Global intellectual deterioration including memory loss but, without impairment of consciousness
Chronic progressive deterioration (>6m)
Personality and emotion affected as well as memory
Presentation of alzheimer’s
Insidious and progressive course of short term memory loss symptoms in early disease
Slow disintegration of personality and intellect
Decline in language - receptive and expressive dysphasia, visuo-spacial skills, apraxia (impaired ability to carry out skilled motor tasks) and agnosia (not recognising people/places/things)
Presentation of vascular dementia
Stepwise deterioration in cognitive function
Declines followed by short periods of stability
Usually a history of transient ischaemic attacks but can be a succession of acute cerebrovascular accidents or major stroke
presence of cardiovascular risk factors
More likely to be agitated at night
Presentation of lewy body dementia
Memory loss, decline in problem solving ability and spatial awareness difficulties.
fluctuating levels of awareness and attention.
visual Hallucinations -Small animals or children
Signs of Parkinsonism develop after cognitive impairment (tremor, rigidity, poverty of facial expression, festinating gait). Falls frequently occur.
Clinical triad: falls, hallucinations and memory loss
Presentation of fronto-temporal dementia
Progressive non-fluent aphasia (difficulty with speech/language).
Semantic (language or logic) dementia.
Loss of inhibition
Common under 65
Shrinking and damage of fronto-temporal lobes
Epidemiology of dementia
Age: 40-60 - less than 1% have dementia
70+ - >10% risk of having dementia
Dementia more common in females
Risk factors of dementia
Female Previous head injury Cardiovascular disease Family history Downs system ^^ alcohol Syphilis
Investigations of dementia
Addenbrooke’s cognitive examination
Bloods to rule out organic causes
Cxray, MSU, ECG
CT Head
Pharmacological management of dementia
Acetylcholinesterase inhibitors ie rivastigmine, donepezil, galantamine -Slows disease progression - s/e - nausea, diarrhoea, vomiting, hallucinations, confusion
N-methyl D antagonists ie memantine -Moderate to severe. Protects brain cells from excess glutamate (excitatory neurotransmitter) which prevents futher damage
Good for agitation
Risperidone - If patient gets agitated
Control cardiovascular risk factors
Treat underlying cause
Psychosocial management of dementia
Cognitive behavioural techniques Behavioural therapy Reality orientation Using clear calendars and clocks to orientate patient Reminiscence therapy Highlights distant but pleasurable memories Classes Seeing friends Puzzles/word searches Counselling Social OT assessment Pendent Labels on cupboards Reminders on doors to lock Key safe-on outside of house Carers - if condition deteriorates Stair lifts Handrails Encourage family members to visit, bring round photos, day trips Make sure house is as they remember it - no new diy/decor Animal/pet therapy Music Arts and crafts
What is delirium?
fluctuating changes in cognition, orientation, delusions and hallucinations and disturbances in consciousness
Symptoms usually worse at the end of the day
Can last up to 3 months
What are some of the risk factors for delirium
Age ≥65 years.
Male sex.
Pre-existing cognitive deficit - eg, dementia, stroke.
Severity of dementia.
Severe comorbidity.
Previous episode of delirium.
Operative factors - eg, type of operation - hip fracture repairs are more likely to be associated with delirium, as are emergency operations.
Certain conditions - burns, AIDS, fractures, infection, low albumin, dehydration.
Current hip fracture or severe illness.[1]
Drug use (implicated in nearly half of cases) and dependence - eg, benzodiazepines.
Substance misuse - eg, alcohol.
Extremes of sensory experience - eg, hypothermia or hyperthermia.
Visual or hearing problems.
Poor mobility.
Social isolation.
Stress.
Terminally ill.
Movement to a new environment.
ICU admission.
Urea/creatinine abnormalities.
What are the causes of delirium?
infection prescribed drugs post surgery toxic substances vascular disorders metabolic causes vitamin deficiencies endocrinopathies trauma epilepsy cancer
What are the clinical features of delirium
Fluctuating course.
Consciousness is clouded/impaired cognition/disorientation.
Poor concentration.
Memory deficits - predominantly poor short-term memory.
Abnormalities of sleep-wake cycle, including sleeping in the day.
Abnormalities of perception - eg, hallucinations or illusions.
Agitation.
Emotional lability.
Psychotic ideas are common but of short duration and of simple content.
Neurological signs - eg, unsteady gait and tremor.
What are the investigations done for delirium?
Bloods: FBC, U&E, CRP, ESR, B12 and folate, glucose LFT, thyroid functioning, syphilis serology, arterial blood gases, blood and urine cultures, drug screen
CXray, Head CT, MSU, ECG
What’s the social management for delirium?
Nurse in well lit, quiet environment - preferably a side room, make sure clocks are in view - 24 hour clock if possible
Maximise visual acuity and hearing ability to avoid misinterpretation of stimuli
Encourage familiar faces to visit and orientate the patient
What’s the drug management for delirium?
Olanzapine and Haloperidol - D2 antagonist
If agitated or disruptive; risperidone or haloperidol
Avoid sedative meds and anti-cholinergic med ie thioridazine
If treating alcohol withdrawal -diazepam
Investigate/treat any underlying cause - Antibiotics for infection, Change medications if required
What are personality disorders?
A severe disturbance in characterological condition and behaviour tendencies of the individual, involving several areas of the personality disrupts every day life
What’s the aetiology of personality disorders?
A dysfunctional early development prevents the evolution of adaptive patterns of perception, response and defence
Neuroplasticity
Factors include:
Sexual abuse
Physical abuse
Emotional abuse
Neglect
Being bullied
There is thought to be a genetic link - unknown currently
Emotional behavioural factors: Bullying others, expulsion/suspension, Deliberate self harm, Prolonged misery
Epidemiology of personality disorders?
Separated, unemployed men living in urban environments = highest incidence
Prisoners
Anti-social personality disorder:
A tendency to act outside social norms
A disregard for the feelings of others
An inability to modify behaviour in response to adverse events (eg, punishment). - no guilt
A low threshold for violence and a tendency to blame others may be features.
Puts self in risky situations
Have a criminal record
Histrionic personality disorder:
Often crave excitement and attention Like to be life and soul of the party Feel dependent on approval of others Easily influenced by others Reputation for being dramatic and over emotional May display la belle indifference
Borderline/emotionally unstable personality disorder
Tend to be impulsive and unpredictable.
Suicidal thoughts/self harming
They may act without appreciating the consequences.
Outbursts of emotion and quarrelsome behaviour may be exhibited.
Relationships tend to be unstable and there may be suicidal gestures and attempts.
Not sure of who they are and Feel lonely
Usually a trigger to changes in mood
Emotional explosion that can not be controlled which overrides normal behaviour within society
Paranoid personality disorder
They display pervasive distrust and suspicion. Common beliefs include:
Others are exploiting or deceiving them.
Friends and associates are untrustworthy.
Information confided to others will be used maliciously.
There is hidden meaning in remarks or events others perceive as benign.
Schizoid personality disorder
This is characterised by withdrawal from affectional, social and other contacts.
This type of person is isolated and has a limited capacity to experience pleasure and express feelings.
Anxious/avoidant personality disorder
This is characterised by feelings of tension and apprehension, insecurity and inferiority.
People with this type yearn to be liked and accepted, are sensitive to rejection.
Can avoid new relationships as don’t want to feel rejected
There is a tendency to exaggerate potential dangers and risks, leading to an avoidance of everyday activities.
Schizotypal personality disorder
Prominent eccentric behaviour
Overvalued ideas
Non-hallucinatory, perceptual abnormalities
Narcissistic personality disorder
Grandiose self-importance in both fantasy and behaviour
A persistent need for admiration
Dependent personality disorder
Excessive submissiveness and subordination to others with reduced capacity to take responsibility for their own actions
Excessive fears of being abandoned
Preoccupation with feelings of incompetence
Obsessive-compulsive personality disorder
‘Perfectionist’
Don’t have any insight into this behaviour unlike OCD which pts recognise what they have
History of family difficulties
Cluster A personality disorders:
Schizoid
Paranoid
Schizotypal
Cluster B personality disorders:
Dissocial
Borderline
Histrionic
Narcissistic
Cluster C personality disorders:
Dependent
Anxious
Obsessive-compulsive
Definition personality disorders:
Personality disorders are a type of mental health problem where attitudes, beliefs and behaviours cause long standing problems in life
occur over a long period of time
What’s the management of personality disorders
Psychotherapy
Dialectical behavioural therapy in borderline personality disorder
Medication
mood stabilisers
regular checks and reviews by health care professionals
Atypical antipsychotics:
olanzapine risperidone clozapine aripiprazole quetiapine ziprasidone
What is depressino
negative affect (low mood) and lack of enjoyment of activities (anhadonia) and lack of energy
epidemiology of depression
women are more likely to be depressed
males that are depressed are more likely to be substance misusers and more likely to commit suicide
what are risk factors for depression
female sex
history of depression
significant chronic illness
BME communities, homeless, refugees
presentation of depression
persistent low mood loss of interest/pleasure in most activities fatigue/loss of energy worthlessness recurrent thoughts of death/suicide attempts low concentration insomnia changes in appetite/weight loss reduced labido
what are the screening tools/investigations for depression?
PHQ-9
full history and MSE
blood tests to exclude organic causes
mild-moderate management for depression
watchful waiting (2 weeks)
CBT
interpersonal therapy
psychoanalytic therapy
moderate-severe depression management
talking therapy + SSRI
-monitor patient as when ssri started = increased suicidal thoughts
examples of SSRIs
- fluoxetine
- sertraline
- citalopram
treatment for resistant depression
monoamine oxidase inhibitors - isocarboxazid
alpha-adrenoantagonist - mirtazapine
when is inpatient treatment needed for a depressed patient?
if pscyhotic
if actively suicidal
deliberate self harm
lack of motivation causing self neglect
what is psychotic depression?
when a person’s mood gets so low that they start experiencing congruent psychotic symptoms.
the psychotic symptoms stop when mood increases
What is atypical depression?
- Mood is depressed but remains reactive (able to enjoy certain experiences, but not to ‘normal’ levels
- Hypersomnia - excessive sleeping
- Hyperphagia - excessive eating
- Leaden paralysis - heavy limbs
- Over-sensitivity to perceived rejection
Seasonal affective disorder:
- A clear seasonal pattern to recurrent depressive episodes - usually around January/February
- Mild to moderate low self esteem,
- hypersomnia,
- fatigue,
- increased appetite,
- weight gain
- decreased social and occupational functioning.
What is generalised anxiety disorder (gad)?
-ongoing anxiety and worry about thoughts and/or events that the patient generally recognises as excessive/inappropriate
Epidemiology of GAD
more common in women
risk factors for GAD
divorced/separated living alone single parent drug use - including tobacco and caffeine genetic predisposition
protective factors for GAD
aged between 16-24
married/co-habitated
Presentation of GAD
EXCESSIVE ANXIETY WHICH THE PT FINDS HARD TO CONTROL WITH
- restlessness
- ^fatiguability
- difficulty concentrating
- irritability
- muscle tension
- sleep disturbance
- palpitations, sweating, tachycardia, dry mouth, trembling
- chest pain/discomfort
- nausea
- derealisation, fear of dying
screening tool for GAD and cut offs:
GAD 7
mild: 5/21
moderate: 10/21
severe: 15/21
management for GAD
- CBT
- self help ie exercise and meditation
- sedative antihistamines or benzodiazepines for rapid response
- antidepressants
What is panic disorder
Panic attack - discrete episode of intense fear with 4 of the following symptoms
- Palpitations
- Chest pain
- Choking
- Tachypnoea
- Paresthesia
- Dry mouth
- urgency/micturition
- Nausea and abdominal distress
- Dizziness
- Blurred vision
What is the presentation of a panic attack
a sudden on set of panic usually lasting about 20-30 minutes
the patient has autonomic arousal signs ie sweating and feelings of sudden death
investigations of panic attack
exclude other causes:
- Myocardial infarction.
- Recurrent small pulmonary emboli.
- Epileptiform disorders, particularly temporal lobe epilepsy.
- Withdrawal from alcohol/sedatives/opiates.
Management of panic disorders
- Avoid anxiety-producing substances ie caffeine
- CBT
- SSRIs
- Self help
- Healthy eating
- Exercise
- Meditation
- Mental health services if not controlled
What is obsessive-compulsive disorder?
Obsessions- unwanted intrusive thoughts/urges that repeatedly enter the mind
Compulsions- repetitive behaviours that the person feels driven to perform
Usually a patient will suffer with both
Aetiology of OCD
genetics
developmental factors ie abuse, neglect, bullying
Epidemiology of OCD
usually develops in late teens/early adulthood
Presentation of OCD
- Either obsessions or compulsions (or both) present on most days for 2 weeks+
- Acknowledged as excessive/unreasonable
- Acknowledged as originating from inside patient’s mind and aren’t influenced by outside environment
- Repetitive or unpleasant
- Pt tries to resist them but unsuccessfully
- Carrying out obsessive thought/compulsive act is not pleasurable
- The obsessions and compulsions affect the person’s everyday life
Management of mild OCD
CBT
exposure and response prevention therapy
marital therapy (for pts in relationships)
management of moderate OCD
more intense psychotherapy
SSRI or cloprimamine for those who aren’t able to engage with psychotherapy
management of severe OCD
SSRI and intensive psychotherapy
Alcoholism:
regular alcohol consumption leads to alcohol dependence and during periods of abstinence = withdrawal
How does alcohol affect neurotransmitters in the brain?
- binds to GABA –> strengthens inhibitory effect
- activates opioid receptors –> releases endorphins
- antagonises glutamate –> reduces excitatory transmission
How does alcohol affect different ares in the brain?
- amygdala and nucleus accumbens: euphoria
- cerebral cortex: slows thinking and speech
- pre-frontal cortex: slows behaviour inhibition centres –> more relaxed and less self consious
- cerebellum: slows movements
- hypothalamus and pituitary: alters mood and hormones
- medulla: decreases breathing, consciousness and temperature
What is blood alcohol content affected by?
- amount of ethanol consumed
- male have larger blood volumes than women
- if the person has eaten
- medications
What is alcohol tolerance?
repeated consumption of alcohol leads to the body expecting alcohol and more alcohol is needed to reach the original response (when the person first starts drinking)
What are the symptoms of withdrawal?
- sweating
- increased heart rate
- anxiety
- depression
- irritability
- tremor
- clammy skin
- dilated pupils
- difficulty sleeping
- SEIZURES (alcohol is an anti-convulsant)
What is delirum tremens?
Severe alcohol withdrawal - can be fatal
- occurs a few days into alcohol withdrawal
- high fever, intense agitation, visual and tactile hallucinations, death
What are reasons for people to continue to drink?
Positive reinforcement: drinking to feel euphoric
Negative reinforcement: drinking to avoid the negative symptoms of withdrawal
What are the long term health effects of alcohol?
CVS: dilated cardiomyopathy, arrhythmia, strokes
Liver: steatosis, steatohepatits, fibrosis, cirrhosis
Pancreatitis
Cancer: Mouth, oesophagus, breast, liver
Vitamin deficiency: Wernickes-korsakoff encephalopathy (from thiamine deficiency)
Treatment for alcoholism
- individual and group therapy
- medications: naltrexone, acamprosate, disulfiram
- COMBINATION OF BOTH THERAPY AND MEDS IS MOST EFFECTIVE
What are the signs of dependence?
- Withdrawals
- Cravings
- Drinking despite -ve consequences (physical + mental health and social life)
- tolerance
- primacy (neglecting other activities in favour of alcohol)
- rapid reinstatement - Once someone has stopped drinking, if they restart, they rapidly reach the level they were previously drinking
- narrowing or repertoire - As dependence increases, the range of types of beverages decline - usually to the cheapest available
How do you work out alcoholic units?
volume drunk x % of alcohol
What is suicide? and how can it be done?
an act of intentionally bringing about one’s death
- poisoning
- violent means ie jumping off a bridge, cutting
What are the risk factors for suicide?
- performed one or more suicidal attempts (parasuicide)
- single, separated or divorced
- lack of employment
- living alone or being socially isolated
- male
- family history of committing suicide
- physical chronic illness
- psychiatric history
- alcohol dependence
- homelessness
Management of overdose
Paracetamol overdose: N-acetylcysteine
Opioid overdose: Nalaxone
Alcohol treatment: Naltrexone, Disulfiram, Acamprosate
Admission/^ in service involvement if discharged
talking therapies
increase social interaction and activities
Management of violent suicide
Treat the physical consequences
Admission/^ in service involvement
talking therapies
increase social interaction and activities
Definition of anorexia nervosa
Maintenance of a low body weight due to fear of fatness or pursuit of thinness. They believe they are fat and are terrified of becoming a normal shape/weight
What are the features of anorexia nervosa
Low body weight
Rapid weight loss
Weight loss measures (particularly extreme dieting)
Psychological features ie Distorted body image
Physical and endocrine sequelae
Aetiology and risk factors for anorexia nervosa
Female gender Adolescent age Western society and pressures Family history of eating disorder Premorbid experiences: -Sexual abuse -Dieting behaviour within family or personal experience -Occupational or recreational pressure -Model, dancer, gymnast -Onset of puberty -Criticism about weight Personal characteristics: Perfectionism, Low self esteem, Obsessional traits - associated with OCD, Premorbid obesity, Early menarche, Difficulty with dealing with conflict and life stresses, Anxiety, EUPD
Psychological clinical features of anorexia nervosa
Refusal to maintain normal body weight for age and height Weight below 85% predicted BMI <17.5kg/m2 Dieting or restrictive eating practices Having a dread of gaining weight Over-evaluation of weight or shape Denial of having a problem Social withdrawal; few interests
Physical features of anorexia nervosa:
Amenorrhoea >3 months GI symptoms: constipation, feelings of fullness after meals, dysphagia, abdominal pains Fatigue, dizziness, intolerance of cold Oedema, difficulties breathing, easy bruising, increased number of infections Delay in puberty (if young) Bradycardia and hypotension Lanugo hair acrocyanosis
What is the SCOFF questionnaire?
Questionnaire to establish how severe anorexia nervosa is
Do you ever make yourself SICK because you feel too full?
Do you ever feel you’ve lost CONTROL over your eating?
Have you recently lost more than ONE stone in 3 months?
Do you believe you’re FAT when others say you’re thin?
Does FOOD dominate your life?
When is inpatient admission required for anorexia nervosa?
- Nutrition: BMI of 13-15 conveys medium risk; a BMI <13 is high risk. Rate of weight loss: more than 0.5 kg per week
- Pulse rate: below 40 beats per minute.
- Blood pressure: systolic BP below 90 mm Hg; diastolic BP below 70 mm Hg; postural drop greater than 10 mm Hg
- Squat test: unable to get up from squatting or lying down without using arms for balance or leverage.
- Core temperature below 35°C.
- Blood tests: low potassium, sodium, magnesium or phosphate. Raised urea, creatinine or transaminases. Low albumin or glucose.
- ECG: prolonged QT interval, T-wave changes, bradycardia.
Management of anorexia nervosa
Food orientated CBT
oral supplements and multivitamin supplements - be careful of refeeding syndrome
What is refeeding syndrome?
Occurs when a starving patient is fed too much too quickly. The supplements trigger synthesis of glycogen, fat and protein in the cells and causes Electrolytes to move from serum to cells which leads to a further decrease in serum concentrations of potassium, magnesium and phosphorus
-leads to organ failure
What is bulimia nervosa?
an eating disorder characterised by repeated episodes of binge eating followed by compensatory weight loss behaviours
What are the features of bulimia nervosa?
- excessive preoccupation with body weight and shape
- emphasis on weight and shape in evaluation
- feeling of lack of control over eating
- compensatory weight control mechanisms ie self induced vomiting, laxative use, fasting, extensive exercise, abuse of medications ie thyroxine
Epidemiology of bulimia nervosa
- more common in western societies
- more common in females
- common in adolescence and early adulthood
Risk factors for bulimia nervosa
- Family and childhood obesity
- Family dieting
- Family history of eating disorders
- History of severe life stress ie Physical and sexual abuse
- Parental and premorbid psychiatric disorder or substance misuse
- Parental problems ie High expectations, Low care, Overprotection, Parental death, Alcohol dependency, Early experiences of criticism
- Perceived pressure to be thin
- Recreational pressure
- Premorbid personality characteristics
Clinical features of bulimia nervosa
BMI >17.5
Regular binge eating and attempts to counteract the binge
-may be Russell’s sign - calluses forming on back of hand from inducing vomiting
-erosion of dental enamel
Investigations of bulimia nervosa
-hypokalaemia and hypotension if dehydrated
Management of bulimia nervosa
- Self help
- Individual eating disorder focussed cognitive behaviour therapy
- Careful nutrition and weight management
- SSRIs
- Regular monitoring of U&Es
- Regular dental reviews
- Reduce laxatives slowly
- Screen for osteoporosis
Learning disibility vs learning difficulty
Learning disability is often confused with dyslexia and mental health problems. Mencap describes dyslexia as a “learning difficulty” because, unlike learning disability, it does not affect intellect.
