PSYCHIATRY Flashcards
What is dementia?
A clinical syndrome of acquired, progressive usually irreversible global deterioration of higher cortical function in clear consciousness
Name 5 areas of cortical deterioration that can occur in dementia
Memory Orientation Language Comprehension Judgement
Name 3 coexisting conditions often present with dementia
Behavioural problems
Depression/anxiety
Psychosis
When does dementia present?
Can be months/years after onset
25% have dementia over 90
What is the cutoff for early onset dementia?
Under 65
What is the most common type of dementia?
Alzheimer’s dementia, 55% of dementia
What is the onset of Alzheimer’s disease?
Gradual with memory loss
Name 3 changes observed in the brain in Alzheimer’s disease
Shrunken brain with sulcal widening and enlarged ventricles
Neuronal loss
Neurofibrillary tangles and amyloid plaques
What is the amyloid cascade hypothesis? (4)
Alzheimer’s is caused by too much beta amyloid protein production and not enough clearance
Beta amyloid forms amyloid plaques, cleaved from amyloid precursor protein by secretase
Build up also causes Tau dysfunction and neurofibrillary tangle formation
Leads to toxicity, inflammation
What neurotransmitters are deficit in Alzheimers? (3)
Acetylcholine
Noradrenaline
Serotonin
What gene mutation is associated with early onset Alzheimer’s?
Amyloid precursor protein
What causes Alzheimers? (7)
Age Low education Obesity Depression Social/physical inactivity Genes Hypertension
Give 4 typical symptoms of Alzheimer’s
Memory impairment
Dysphasia
Visuo-spatial impairment
Problem solving/reasoning deficits
Treatment of Alzheimer’s?
Acetylcholinesterase inhibitors compensate for loss of acetylcholine
NMDA (glutamate) receptor antagonist prevents excitatory neurotoxicity
Name 3 acetylcholinesterase inhibitors
Galantamine, donepezil, rivastigmine
Name a NMDA receptor antagonist
Memantine
General management of Alzheimer’s? (4)
Treat other causes such as infection
Manage psychosis, aggression
Social support/nursing care
Group cognitive stimulation or behaviour management
What is vascular dementia?
Focal neurological symptoms appearing in a stepwise manner after strokes, associated with more patchy cognitive impairment than Alzheimer’s
What is mixed dementia?
Vascular and Alzheimer’s
What is the pathophysiology of vascular dementia?
At least one area of the brain infarcted on CT
9 times risk of dementia in year after stroke
Risk factors for vascular dementia? (4)
Hypertension
High cholesterol
Diabetes
Smoking
Symptoms of vascular dementia? (4)
Depends on area of brain affected
Stepwise cognitive impairment, memory decline
Behavioural and affective changes
Motor changes - hemiparesis, bradykinesia, ataxia
What is dementia with Lewy bodies?
Dementia associated with the presence of Lewy bodies and neurites in the basal ganglia and cortex
Symptoms of dementia with Lewy bodies? (5)
Fluctuating cognition and alertness Vivid visual hallucinations Spontaneous Parkinsonism Sensitivity to antipsychotics Sleep disorder
What is the link between dementia and Parkinson’s?
25% of people with Parkinson’s will develop dementia
80% still alive after 20 years will have dementia
How is Parkinsons dementia differentiated from dementia with Lewy bodies?
If Parkinson’s precedes the dementia by >1 year, it is Parkinson’s dementia - i.e. motor symptoms first
What are the two types of Lewy body dementia?
Dementia with Lewy bodies
Parkinson’s dementia
How is dementia with Lewy bodies treated?
Cholinesterase inhibitors (rivastigmine)
Possibly memantine
Caution with antipsychotics as high sensitivity
Social care, therapy
What is frontotemporal dementia?
Characterised by early personality changes and relative intellectual changes, with a younger mean age of onset
Pathological changes in frontotemporal dementia?
Affects frontal and temporal lobes
Loss of spindle neurons
Ubuquitin or tau positive inclusions
Symptoms of frontotemporal dementia? (5)
Changes in behaviour and conduct Loss of social awareness Poor impulse control Impaired comprehension Difficulty with speech production
Treatment of frontotemporal dementia?
Cholinergic systems not affected so can’t use AD drugs
SSRIs may help disinhibition/impulses
Social care/therapy
What is normal pressure hydrocephalus?
Excess fluid accumulation in the ventricles without much increase in pressure overall, but may have local pressure effects
What causes normal pressure hydrocephalus? (4)
Idiopathic Subarachnoid haemorrhage Head injury Meningitis all cause expansion of lateral cerebral ventricles
Symptoms of normal pressure hydrocephalus? (4)
Marked mental slowness
Apathy
Wide based gait
Urinary incontinence
Name a local affect of increased pressure in normal pressure hydrocephalus
Traction on frontal and limbic fibres surrounding the ventricles
Treatment of normal pressure hydrocephalus?
Ventriculoperitoneal shunt to drain fluid into abdomen
May only improve symptoms in some, has complications
What is Creutzfeldt-Jakob disease?
Fatal brain disorder - 90% die in 1 year, onset around 60
What causes Creutzfeldt-Jakob disease?
Prion proteins - misfolded proteins that can disrupt normal proteins, causing cell disruption and death
Mostly spontaneous
What is a non spontaneous cause of Creutzfeldt-Jakob disease?
Eating beef infected with bovine spongiform encephalopathy, mainly affects younger people
Early symptoms of Creutzfeldt-Jakob disease? (3)
Minor lapses of memory
Mood changes
Apathy
Later symptoms of Creutzfeldt-Jakob disease? (8)
Clumsiness Decreased coordination Slurred speech Jerky, involuntary movements Weakness Dementia Incontinence Coma
Treatment for Creutzfeldt-Jakob disease?
None, opioids for pain, clonazepam for movement
What is Huntington’s disease dementia?
Dementia occurring at any stage of the progressive, inherited Huntington’s disease
Symptoms of Huntington’s disease dementia? (7)
Abnormal movements and coordination (Huntington's) Mood problems Cognitive impairment Difficulty with planning/organisation Difficulty concentrating Short term memory loss Obsessive behaviour
How does Huntington’s disease dementia differ from Alzheimer’s dementia?
Recognition of people and places is intact until the very late stages
Treatment for Huntington’s disease dementia?
None for the dementia
Anti-depressants
What is HAND?
HIV Associated Neurocognitive Disorder, affects up to 50% of HIV patients
What causes HAND?
Either by HIV directly damaging the brain or the weakened immune system enabling other infections to damage to brain
(5) Symptoms of HAND?
Difficulties with memory Thinking and reasoning difficulties Decision making difficulties Learning difficulties Mood problems
Treatment of HAND?
At least 3 antiretrovirals, prevents cognitive impairment worsening - may reverse it
Rehabilitation
What is neurosyphilis?
Infection of the brain/spinal cord caused by Treponema pallidum, usually occurs in chronic untreated syphilis 10-20 years after first infection
Symptoms of neurosyphilis? (8)
Blindness Confusion Personality change Memory loss Depression Mood disturbance Psychosis, visual disturbance Seizures
How is neurosyphilis treated?
Penicillin - early diagnosis critical
What is Wilson’s disease?
Genetic disease where copper builds up in the body, symptoms related to liver and brain begin anytime from 5-35
Symptoms of Wilson’s disease? (7)
Itching, vomiting, oedema (liver) Dysarthria Personality changes Tremors Visual/auditory hallucinations KAISER FLEISCHER RINGS - dark rings circling iris Impaired judgement Mild cognitive deterioration - slow thinking, memory loss
What causes Wilson’s disease?
Autosomal recessive disorder caused by mutation in the Wilson disease protein gene (ATP7B)
Treatment of Wilson’s disease? (4)
Low copper diet, avoid copper cookware
Chelating agents - trientine, d-penicillamine
Zinc supplements
Liver transplant if severe
What are the two types of dementia?
Cortical and subcortical
Where to cortical and subcortical dementias affect?
Cortical - cerebral cortex
Subcortical - basal ganglia, thalamus
Types of cortical and subcortical dementias?
Cortical - Alzheimer’s, frontotemporal, possibly vascular
Subcortical - Parkinson’s, Huntington’s, AIDS dementia, alcohol related dementia
Symptoms of cortical dementias? (4)
Memory impairment
Dysphasia
Visuospatial impairment
Problem solving and reasoning deficits
Symptoms of subcortical dementias? (7)
Psychomotor slowing Impaired memory retrieval Depression Apathy Executive dysfunction Personality change
What is delirium?
Acute confusional state characterised by the rapid onset of a global but fluctuating dysfunction of the CNS due to an underlying infectious, vascular, epileptic or metabolic cause
How common is delirium?
Occurs in 1/3 of patients admitted to hospital, increases mortality and morbidity
Diagnosis of delirium? (5)
Impaired consciousness and attention + perceptual disturbance + cognitive disturbance + acute onset and fluctuating + evidence of physical cause
Types of delirium?
Hypo and hyperactive
Symptoms of delirium? (9)
Fluctuating mood Irritability, confusion, distraction Apathy and depression Transient persecutory, self referential delusions Sweating, tachycardia, dilated pupils Visual hallucinations Memory loss Incoherent speech Day drowsiness, evening alertness
Risk factors for delirium? (7)
Over 65 Dementia or Parkinson's Hip fracture Illness Infection Hypoxia Low B12/folate
Differences between delirium and dementia? (4)
Delirium is more rapid onset
Delirium is more fluctuating course
Delirium has clouded consciousness
Delirium has vivid, complex thoughts and hallucinations
Investigations of delirium? (6)
Ask about premorbid personality Drugs/alcohol screen Look for trauma Bloods - FBC, inflammatory markers, U+E, LFT, TFT, calcium, B12/folate MSU CXR, Head CT/MRI
Management of delirium? (5)
Identify and treat underlying pathology Short term antipsychotic or benzodiazepine Maximise orientation and hydration Reduce constipation Reduce polypharmacy
What is frontal lobe syndrome?
Damage to the prefrontal regions of the frontal lobe, characterised by deterioration of behaviour and personality
Cause of frontal lobe syndrome? (6)
Head injury Stroke Infection Tumour Frontotemporal dementia Genetics
Symptoms of frontal lobe syndrome? (6)
Lack of spontaneous activity Trouble with speech Loss of concentration Preserved memory but apathy Loss of abstract thought Perseveration Can be withdrawn or uninhibited - mood change
Investigations of frontal lobe syndrome?
To find cause - e.g. brain imaging, inflammatory markers
Management of frontal lobe syndrome? (4)
Supportive care
Supervision if risky
Respite care
Therapy e.g. speech and language
What are complex partial seizures?
Focal onset seizures, most common type in adult epilepsy, begin in one side of the brain - often frontal or temporal - and may produce impaired awareness
How is depression related to complex partial seizures?
Can occur in pre-ictal and ictal phases
More common post-ictal
Very common inter-ictal
How is psychosis related to complex partial seizures?
Rare pre-ictal
Can occur during a seizure or post ictal
Can develop inter-ictally, especially if temporal lobe
Symptoms of psychosis in complex partial seizures?
Similar to schizophrenia - delusions, depressive/manic psychosis, visual hallucinations
How are psychotic features of epileptic seizures treated?
Antipsychotics with least effect on seizure threshold - haloperidol
How is cognitive impairment related to epileptic seizures?
Common due to medication or persistent abnormal brain supply
What psychiatric symptoms can occur in hyperthyroidism? (3)
Depression and anxiety
Irritability, apathy
Psychotic depression
What psychiatric symptoms can occur in hypercortisolaemia (Cushing’s)? (2)
Depression
Mania
What psychiatric symptoms can occur in hypocortisolaemia (Addison’s)? (2)
Depression
Apathy
What psychiatric symptoms can occur in hypopituitarism? (3)
Depression
Irritability
Impaired memory
What psychiatric symptoms can occur in phaeochromocytoma?
Episodic anxiety
What psychiatric symptoms can occur in hypothyroidism, hyperparathyroidism, and primary hypoparathyroidism? (6)
Depression and anxiety Acute agitation, emotional lability Apathy Hallucinations after parathyroidectomy Dementia Delirium
What is psychosis?
Misinterpretation of thoughts and perceptions that arise from the patient’s mind as reality, including delusions and hallucinations
What are the first rank symptoms of schizophrenia?
Delusional perception
Thought interference (insertion, withdrawal, broadcast)
Passivity phenomena (inc. somatic)
Auditory hallucinations
What are the second rank symptoms of schizophrenia? (5)
Persecutory delusions Delusions of reference Persistent hallucination of any modality Neologisms or other thought disorder/disorganised speech Negative symptoms
How is a diagnosis of schizophrenia made?
One first rank symptom or one of persecutory delusions and delusions of reference
Or two of the other second rank symptoms
Persisting for at least 1 month
When is the peak incidence of schizophrenia?
Late teens/early adulthood
What are positive symptoms of schizophrenia? (3)
Delusions, hallucinations, formal thought disorder
What are negative symptoms of schizophrenia? (5)
Poverty of speech Flat affect Poor motivation Social withdrawal Lack of concern for social conventions
What are cognitive symptoms of schizophrenia? (2)
Poor attention
Memory loss
What is paranoid schizophrenia? 2 symptoms
The most common type of schizophrenia with persecutory delusions and auditory hallucinations prominent
Often lack of negative symptoms
What is hebephrenic schizophrenia? 4 symptoms
Often early onset and poor prognosis
Characterised by irresponsible, unpredictable behaviour, innapropriate mood and incongruous affect - giggling, odd mannerisms
Incoherent thoughts, fleeting delusions and hallucinations
What is residual schizophrenia? 2 symptoms
When there has been a history of another type of schizophrenia and in the current illness, negative and cognitive symptoms predominate
What is catatonic schizophrenia? 4 symptoms
Uncommon
Psychomotor disturbances prominent, often alternating between stupor and excessive activity
Rigidity, posturing, waxy flexibility
Echolalia and echopraxia
What is simple schizophrenia?
Uncommon
Negative symptoms without overt/preceding psychosis
What causes schizophrenia? (4)
Genetics - first degree relative, advanced paternal age
Neurodevelopmental problems
Social factors
Neurochemical changes
What is the neurodevelopmental hypothesis?
Factors interfering with early development of the brain increase schizophrenia risk
Give 5 examples of the neurodevelopmental hypothesis
Winter births (foetus flu exposure) Obstetric complications/perinatal injury Developmental delay/mild neuro symptoms Temporal lobe epilepsy Cannabis use when young Childhood abuse or bullying
What findings (2) on brain imaging in schizophrenia supports the neurodevelopmental hypothesis?
Increased ventricle size
Loss of grey matter
Give 4 examples of social factors predisposing to schizophrenia
Socioeconomic deprivation
Urbanity
Negative life events e.g. bereavement
Family being overbearing
What neurochemical changes are present in schizophrenia?
Final common pathway involves dopamine excess (overactivity in mesolimbic dopaminergic pathways), raised serotonin, decreased glutamate
What is the treatment of schizophrenia? (4)
Antipsychotics for positive symptoms, to prevent relapse
If agitated, IM antipsychotic or benzodiazepine
CBT and family therapy
Social support and rehabilitation
Name 3 typical antipsychotics
Haloperidol
Chlorpromazine
Supiride
What is the major side effect of typical antipsychotics?
Motor problems - extrapyramidal symptoms
Name 5 atypical antipsychotics
Olanzapine Quietapine Risperidone Amisulpiride Clozapine
What are 2 side effect of atypical antipsychotics?
Weight gain and diabetes
How can adherence of antipsychotics be improved?
Monthly depot injections if do not adhere to oral
How long should an antipsychotic be trialled before changing?
4-6 weeks
When can clozapine be used?
When at least one typical and one atypical antipsychotic have been used without success
What side effects of antipsychotics need to be monitored? (2)
Clozapine - blood tests to check for granulomatosis
Monitor ECG for increased QT syndrome in all
How long after a psychotic episode should antipsychotics be continued?
1-2 years
5 years if further episode
High risk of relapse if stopped within 6 months
What is acute and transient psychosis?
Psychosis lasting less time than needed for schizophrenia diagnosis - <1 month, group of disorders
Symptoms of acute/transient psychosis? (5)
Acute onset Delusions Hallucinations Perceptual disturbance Disruption of normal behaviour
How is acute and transient psychosis treated?
Usual spontaneous resolution, may be associated with acute stress
If persists treat as it is schizophrenia
What is persistent delusional disorder?
Fixed, unshakeable delusion with other areas of thinking and function preserved
What are the symptoms of persistent delusional disorder?
Long standing delusion
No hallucinations etc, no evidence of brain disease
Treatment of persistent delusional disorder?
Psychotherapy - challenging beliefs
May be reluctant to medication - try antipsychotics
What is schizoaffective disorder?
Affective and schizophrenic symptoms occur together with equal prominence, doesn’t justify either schizophrenic or depressive/manic diagnosis
What are the types of schizoaffective disorder?
Manic, depressive, mixed
How is schizoaffective disorder treated? (5)
Antipsychotics - paliperidone Mood stabilisers Antidepressants Psychotherapy and group therapy Possible ECT
What is puerperal psychosis?
Psychosis affecting women after childbirth, usually within 2 weeks of birth
Symptoms of puerperal psychosis? (4)
Hallucinations
Delusions
Mania/depression
Confusion
What is the treatment of puerperal psychosis? (CBT)
Antipsychotics
Antidepressants
Mood stabilisers
CBT
Cause of puerperal psychosis? (3)
Traumatic pregnancy or birth
Family history
Previous schizophrenia/mood diagnosis
What is bipolar disorder?
Disorder characterised by recurrent episodes of altered mood and activity, involving both upswings and downswings
What are the 4 types that individual episodes can be in bipolar disorder?
Manic
Hypomanic
Depressive
Mixed
What is hypomania?
Less severe form of mania causing less disruption to life, without psychotic symptoms
What is a mixed episode in bipolar disorder?
Both manic and depressive, rapid cycling
How is bipolar disorder diagnosed?
After at least 2 episodes, at least one of which is hypomanic/manic
What are the 2 main types of bipolar disorder?
I - manic and depressive episodes
II - recurrent depressive episodes and hypomania
What is mania?
Alteration in mood, usually elated and expansive but can also be irritable, with increased energy and activity
Give 5 symptoms of mania
Distractibility
Decreased need for sleep
Disinhibited - risky sexual or financial behaviour, dangerous driving
Heightened senses
Rapid thinking and speech - pressure of speech, flight of ideas
What psychotic symptoms can occur in mania?
Mood congruent delusions
Auditory hallucinations
When does bipolar usually present?
Peak in early 20s and lesser peak around 50
What is the cause of bipolar disorder? (6)
Genetic
Hypothalamic-pituitary-adrenal and thyroid axes implicated
Psychological stress in childhood inc. abuse
Sleep disturbance
Postpartum
Severe physical illness/bereavement - life event
How does psychological stress in childhood increase risk of bipolar?
Psychological stress leads to hypothalamic-pituitary-adrenal dysfunction and hypersensitivity to stress
How is mania treated? (5)
1st line haloperidol, olanzapine, quietapine, risperidone 2nd line lithium - better long term Benzodiazepines short term/rapid tranq. Psychotherapy Physical monitoring - renal for lithium
How is depression in bipolar disorder treated?
Antidepressants but only with a mood stabiliser as may precipitate rapid cycling, stop at start of a manic episode
What is cyclothymia?
Chronic mood fluctuations over at least 2 years, with episodes of depression and hypomania of insufficient severity to meet bipolar diagnosis
May progress to bipolar
How is cyclothymia treated? (2)
Lithium
Psychotherapy
What is dysthymia?
Persistent depressive disorder, lasting for over 2 years interfering with daily life, usually does not go away for more than 2 months at a time
Major depressive episodes may be concurrent
Risk factors for developing dysthymia?
Family history
Life trauma
Negative personality
How is dysthymia treated?
Antidepressants
Psychotherapy
What is depression?
Common illness that negatively affects thoughts, feelings and actions
Characterised commonly by lowering of mood, loss of energy, loss of enjoyment in activity that was previously enjoyable
What is the classic triad of depressive symptoms?
Anhedonia
Low mood
Anergia
How is depression diagnosed?
At least two of anhedonia/anergia/low mood present for 2 weeks
Other symptoms of depression apart from the classic triad? (9)
Reduced concentration Flat affect Low confidence/self esteem Guilt, worthlessness, hopelessness Decreased sleep Decreased appetite Reduced motor activity Thoughts of self harm Low libido
How is depression classified?
Mild/moderate/severe
Depending on how many symptoms, how severe, degree of distress and impact on daily life
Depression with psychosis is always severe
What is Beck’s triad?
Thoughts in depression often include negative thoughts about self, the world and the future
What are the biological symptoms of depression? (3)
Decreased sleep
Decreased appetite
Decreased libido
What is the typical sleep pattern in depression?
Early waking, maximal low mood in morning
What psychotic features occur in depression? (5)
Mood congruent Nihilistic delusions Delusions of guilt Hypochondriacal delusions Auditory, usually 2nd person hallucinations condemning the person or urging them to self harm
Who is most at risk of depression?
Women, onset usually in 20s
Causes of depression? (7)
Possibly genetic Monoamine neurotransmitter loss Dysfunctional limbic system and prefrontal cortex Psychosocial factors Treatment with recombinant interferons Severe illness Medications i.e. isotrenoin
How might antidepressants work on the monoamine neurotransmitters?
Serotonin, noradrenaline levels are reduced in the synaptic cleft in depression
Antidepressants increase availability
This results in secondary neoplastic changes that bring about antidepressant effect i.e. produce more brain derived neurotrophic factor promoting neurogenesis
What are some psychosocial factors implicated in depression? (4)
Recent life trauma
Adverse social circumstances
Low socioeconomic class
Childhood bereavement, abuse
How might psychosocial factors lead to depression?
Stress leads to increased cortisol which may cause low mood due to decreased brain derived neurotrophic factor
How is mild depression managed? (5)
In primary care Treat any physical illness, substance misuse Self help groups Physical activity CBT or IPT if mild
When are patients with depression referred to psychiatric services? (5)
High suicide risk Severe illness Unresponsive to treatment Recurrent depression Bipolar
How is moderate or severe depression treated?
As mild depression but add antidepressants
At least 6 months, tapered when stopped
What are SNRIs? Name 2
Serotonin noradrenergic reuptake inhibitors
Venlafaxine
Duloxetine
What are SSRIs? Name 4
Selective serotonin reuptake inhibitors - most common Gluoxetine Citalopram Sertraline Paroxetine
What is mirtazepine and 3 side effects?
Noradrenergic and specific serotenergic antidepressant
Dry mouth, drowsy, weight gain
Name 2 tricylic antidepressants
Amitriptyline
Imipramine
What are MAOIs? Name 2
Monoamine oxidase inhibitors
Phenelzine
Tranylcypromine
How do antidepressants generally work?
Increasing neural transmission of monoamines - serotonin, noradrenaline
How do SSRIs and SNRIs work?
Inhibit reuptake of neurotransmitters from the synaptic cleft
2nd messengers from monoamine binding to post synapse increase production of BDNF
This increases neuroplasticity and neurogenesis in the hippocampus
How do MAOIs work?
Inhibit breakdown of neurotransmitters
Side effects of tricyclic antidepressants?
Increased CV mortality (arrhythmias) so SSRIs safer in overdose
Side effects of SSRIs and SNRIs? (5)
Initial agitation
Headache, nausea, anxiety
May increase suicidal ideation (except fluoxetine)
Management if resistant to antidepressants? (2)
Augment with lithium, atypical antipsychotic or another antidepressant
ECT if severe especially with psychosis or stupor
Why is effective treatment important in the initial depressive episode?
Recurrent episodes tend to be more severe and shorter disease-free periods if not treated effectively first time
What are post partum blues?
Normal low mood, affect 30-50% of women after childbirth
Symptoms of post partum blues? (4)
Emotional lability
Crying
Irritability
Worried abot coping
Cause of post partum blues?
Elevated prepartum progesterone, big postpartum fall in oestrogen and progesterone implicated
How is post partum blues treated?
Self resolving within a few days usually
Reassure and ensure supported
How common is postpartum depression and when does it occur?
10-15% of new mothers, mainly first week but can be up to the first year after birth
Symptoms of post partum depression? (5)
Similar to depression but also: Guilt/anxiety over the baby Feeling inadequate Unreasonable fears Reluctance to feed or bond Possible feelings of harming the baby
Risk factors for postpartum depression? (5)
History of depression Low socioeconomic class Single mother Lack of support Traumatic birth
How is postpartum depression treated?
Psychotherapy
Antidepressants if needed - risk when breastfeeding to baby
Why is it important to recognise and treat postpartum depression?
Prolonged maternal depression may affect later social and cognitive development of the child
What is suicide?
Intentional self inflicted death
Epidemiology of suicide?
8/100,000 annually
More men than women
Especially middle aged men
What is self harm?
Intentional non fatal self inflicted harm
Epidemiology of self harm?
3/1000 annually
More women than men
Mostly young women
Causes of suicide and self harm? (4)
Availability of means
Lack of social support
Traumatic life events
Mental illness
What mental illnesses predispose to self harm/suicide? (5)
Depression Schizophrenia Substance misuse Emotionally unstable/antisocial PD Eating disorder
3 further causes of suicide?
Chronic painful illnesses
Family history of suicide
Decreased brain derived neurotrophic factor at postmortem
3 further causes of self harm?
Unemployed
Divorce
Socioeconomic deprivation
What are the 3 types of suicide?
Altruistic - for the good of society
Anomic - reflects a society’s disintegration, loss of common values
Egoistic - an individual’s separation from otherwise cohesive social groups
Suicide prevention strategies? (5)
Detect and treat psychiatric disorders Respond to risk Prescribe safely Manage self harm well Reduce availability of means
2 most common types of self harm?
Overdose
Physical self injury - cutting
Management of self harm? (6)
Medical stabilisation Psych assessment Decrease risk of repitition - address psych illness or social problems Prescribe lower lethality drugs Psych therapy, self help groups Dialectical behaviour therapy
4 motivators for self harm?
Interruption of a sequence of events
Attention
Communication attempt
Wish to die
What needs to be established in a psych assessment of self harm/suicide attempt? (6)
Motives Psych illness Planning - leaving a note, will, attempt not to be found Mode of harm Social history History of self harm
What are the 3 categories of psychological therapy?
Supportive therapies
Cognitive and behavioural therapies
Psychodynamic psychotherapies
What is group therapy?
Emphasises interrelationships within the group where problems are shared
What is family therapy?
Systemic or behavioural - improved family functioning will improve patient
What is CBT?
Cognitive behavioural therapy, helps to identify and challenge automatic negative thoughts and to modify underlying core beliefs
When is CBT used? (5)
Depression Anxiety Eating disorders Personality disorders Psychosis
What are behavioural therapies?
Based on operant conditioning - positive reinforcement of desirable behaviours, withholding reinforcement if negative
What are behavioural therapies used for?
Phobias
Tourette’s
Eating disorders
What are psychodynamic therapies?
Unstructured, helps with long standing problems, based on psychoanalytic principles - therapist interprets what the patient says and makes links
What is transference and counter transference?
Transference - patient experiences strong emotions with the therapist
Counter-transference - therapist experiences strong emotions toward the patient
What is interpersonal therapy IPT and used for?
For depression, eating disorders
Focusses on interpersonal - close relationships and problems
What is dialectical behaviour therapy DBT and used for?
Borderline PD! Esp. self harm
Incorporates CBT, and group skills training for alternative coping strategies
What is eye movement desensitisation and reprocessing EMDR and used for?
PTSD
Aims to help patients access and process traumatic memories to resolve them
Recall the trauma while focussing on an external stimulus
What is ECT?
Electroconvulsive therapy, by electric current through electrodes to brain uni or bilaterally temporal
How does ECT work? (5)
Induces a modified cerebral seizure, causing neurotransmitter release, hormone secretion, synapto and neurogenesis, increase in blood brain barrier permeability
Indications for ECT? (3)
Severe depression
Prolonged/severe/unresponsive mania
Catatonia
When all other treatments failed or if high risk
Side effects of ECT?
Cognitive impairment
Dysarrhythmias
Headache
What are the most commonly used anxiolytics?
Benzodiazepines
Indications for anxiolytics? (4)
Insomnia
Short term for anxiety
Alcohol withdrawal
Control of violence
Effects of anxiolytics? (3)
Sleep inducing
Anticonvulsant
Muscle relaxant
Commonly used hypnotics?
Zopiclone, zolpidem
How is benzodiazepine overdose treated?
Flumenazil
What is methylphenidate?
Stimulant, used for ADHD (ritalin)
Other indications for antidepressants? (5)
Phobias PTSD Generalised anxiety Bulimia OCD
