Psychiatry Flashcards
What are the components of the Mental State Examination (MSE)
- Appearance
- Behaviour
- Cooperation and attitude
- Affect and Mood
- Affect is patients observed emotions
- Congruency - is the emotion appropriate?
- Range - broad (manic), flat, constricted (depressed)
- Reactivity - constricted, flat or blunted
- Mobility - changes to stimuli
- Mood - sustained emotion present over a long time
- Affect is patients observed emotions
- Speech
- Rate, volume, quantity, quality
- Thought form and content
- Form - how is it delivered
- Flow - linear, incoherent, tangential, circumstantial, derailment, flight of ideas
- Content
- Themes, preocuppations, overvalued ideas
- Ideations - self-harm, suicide, violent thoughts
- Delusions
- Posession - thought insertion, withdrawal, broadcasting
- Form - how is it delivered
- Perception
- hallucinations, illusions, derealisation, dissociation
- Cognition
- level of consciousness
- memory, concentration
- orientation
- Insight - awareness of their illness
- Judgement - ability to assess situations and act appropriately
- Risk - suicide, self-harm, homicide, relationships, finance, neglect
Symptoms of Depression (SIG E CAPS)
*Requires >=5 symptoms, for at least 2 weeks, with at least one of the symptoms being depressed mood or anhedonia
- Sleep disorders
- Interest loss
- Guilt/ worthlessness
- Energy depleted
- Concentration diminished
- Appetitie changes
- Psychomotor agitation
- Suicidal thoughts
What is the prevelance of depression in the community
- Lifetime prevelance of 20%
- Females > males (2:1)
- 5% of the population at any one time
- Peak onset in the 20s
What are some screening tools to assess depression
- PHQ-9
- DASS-21
- K-10
- Edinburgh depression score for postnatal depression
- Geriatric depression scale
Treatment for depression
First line
- SSRI’s (Selective Serotonin Reuptake Inhibitor)
- E.g. Sertraline (Zoloft), Citalopram (Clexa), Esclitopram (Lexapro), Paroxetine (paxil), Fluoxetine (Prozac)
- Modulation of the 5-HT transporter SERT
- SE – GI (nausea, diarrhea), Sexual (deceased libido), weight gain, fever
- SNRI’s (Selective Noradrenaline Reuptake Inhibitor)
- Venlafaxine (Effexor), Duoxetine
- Blocking of SERT and NA transporter (NAT)
- SE - Nausea, anorexia, constipation, dizzy, insomnia, dry mouth, sexual dysfunction, hypertension
- NaSSA (Noradrenaline Serotonin Specific Antidepressants)
- Mirtazapine
- Antagonism of inhibitory presynaptic alpha2-adrenoceptors on NA and 5-HT
- SE – weight gain, drowsy, dizzy, dry mouth, constipation
It may take 2-6 weeks to see a clinical response. if there is no initial or only a partial response then consider increasing the dose. If there is no or partial response consider switching to a different first line medication.
Second line
- RIMA (Reversible Inhibitor of Monoamine Oxidase A)
- E.g. Moclobemide
- Decreases interneuronal breakdown of NA and 5-HT
-
NRI (NA Reuptake Inhibitor)
* Reboxetine -
NDRI (NA Dopamine Reuptake Inhibitor)
* Bupropion
Third line
-
MAOI (Monoamine Oxidase Inhibitors)
* E.g. Selegiline (Zelpar), Phenelzine (Nardil), Tranylcypromine (:arnate) - TCA (Tricyclic Antidepressants)
- E.g. Amitryptyline (endep), Nortriptyline (allegron), Imipramine (tofranil)
- Negative allosteric modulators of NA and 5-HT transporters
- Many side effects, can be highly toxic, overdoses lethal
If psychosis is also present, then antipsychotics should be added to Tx
Other
-
Mood Stabilization Augmentation
* Lithium, sodium valproate, lamotrigine + SSRI & TCA -
ECT
* Response rate 50-80%
iii. CBT
What is dysthymia?
Symptoms of depression are present most of the day, for the majority of the days, lasting at least 2 years. It is less severe than MMD
Subtypes
- Pure dysthymia (low-grade chronic depression), without full criteria for major depression during the preceding 2 years
- Persistent Major depressive episode
- Intermittent major depressive episodes with current major depression
- Intermittent major depressive episodes without current major depressive disorder episode
Criteria
- Depressed mood for most of the day, more days than not for > 2 years
- Presence, while depressed of 2 or more of the following:
- Appetite Disorder
- Concentration deficit
- Hopelessness
- Energy deficit
- Worthlessness
- Sleep Disorder
- During 2 years patient hasn’t been without symptoms in criteria A and B for more than 2 months at a time
- Criteria for a major depressive disorder may be continuously present for 2 years
- There has never been a manic episode, a hypomanic episode, or criteria met for cyclothymic disorder
- Disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia
- The symptoms are not attributable to physiological effects of a substance
- Symptoms cause clinically significant distress or impairment in functioning
Difference between Premenstral Syndrome (PMS) and Premenstrual Dystrophic Disorder
PMS is characterized by cyclic, physical and behavioral symptoms occurring in the luteal phase of the normal menstrual cycle. Symptoms must not be present at other times through the cycle, must cause significant impairment and must not represent an exacerbation of another disorder. PMS is not classified as a mental illness.
Premenstrual Dysphoric Disorder (PMDD) is the more severe form of the disorder and classified as a mental illness in the DSM-5. The criteria for PMDD require that the woman experience at least 5 of 11 cognitive-affective, behavioural, and physical symptoms during the final week of the luteal phase that resolve with or near the onset of menses.
Treatment of PMS and Premenstrual Dystrophic Disorder
Fluoxetine (Lovan) - 2 weeks before period
What are the baby blues and how common is it?
Mother typically presents with mood swings ranging from elation to sadness, insomnia, tearfulness, crying spells, irritability, anxiety and decreased concentration. Symptoms develop within 2-3 days postnatal, peak on the fifth day and resolve within 2 weeks
It does NOT impact on the ability of the mother to function in ADLs or care for herself or the baby.
- Occurs in 30-80% of pregnancies (Very common)
- No treatment necessary
Define postpartum depression and risk factors
- Major depressive episode with onset in pregnancy or within 4 weeks of delivery
- 7-19% of women
Risk factors
- Psychosocial - stress, poor support, abuse, low SES
- Psychiatric - Hx depression, FHx, personality disorder
- Other - sleep deprivation, complicaitons of pregnancy, unwanted pregnancy, youn maternal age
Classifications of bipolar affective disorder
- Bipolar I: One or more manic episodes (lasting >=1 week) with or without major depressive episodes
- Bipolar II: One episode of hypomania + one episode of major depressive episode + no episodes of mania
Symptoms of Mania (DIGFAST)
Abnormally persistently elevated or irritable mood & increased goal-directed activity or energy. Lasting most of the day for at least 1 week, nearly every day. Includes greater than 3 of the following:
- Distractibility
- Indiscretion
- Grandiosity
- Flight of ideas
- Activity Increase
- Sleep deficit
- Talkativeness
*If psychotic symptoms are present, the episode is, by definition manic and not hypomanic
What makes an episode hypomanic as opposed to manic
- Most of the day for at least 4 consecutive days
- Same as symptoms for mania
- Episode is not severe enough to cause marked impairment in functioning
- No psychotic symptoms
Risk factors for Suicide attempt (SAD PERSONS)
- Sex (Male)
- Age (Older than 45)
- Depression
- Previous suicide attempt
- Ethanol abuse
- Rational thinking loss
- Sick (chonic disease)
- Organised plan (access to means)
- No spouse
- Social support lacking
5 Important questions regarding suicidal thoughts
- Ideation
- Intent
- Plan
- Access to means
- Previous attempt
Classification of Anxiety Disorders
- Generalized Anxiety Disorder
- Social Anxiety Disorder
- Panic Disorder
- Phobia
- Agoraphobia
- Separation Anxiety Disorder
- Selective Mutism
*PTSD and OCD
Risk factors for developing anxiety disorders
- Female sex
- Family history of mental health conditions
- Personality traits (behavioral inhibition)
- Perfectionist, timid, low self-esteem, inhibited, easily flustered, want to control everything
1. Physical illness - Diabetes, asthma, hypertension, health disease
1. Co-morbid mental health conditions - Mood disorders, substance use disorders
- Substance use
- Environmental and development factors
- Stress
- Smoking (risk for panic disorder and panic attacks)
- Psychological trauma, esp. during childhood
how many Australians have experienced Anxiety disorder in the past 12 months?
14.4%
Anxiety disorder is the most common class of mental disorders
higher rates in females (17.9%) vs males (10.8%)
Whats the difference between normal anxiety (stress) and abnormal anxiety?
Normal Anxiety:
- occurs in response to a stressful event
- can be beneficial to improve performance in stressful events
- goes away when the stimulus is removed
Abnormal anxiety:
- excessive and ongoing worry. Anxiety doesn’t subside when the stressor is removed. Anxiety may occur without an obvious cause, or may be disproportionate to a stressor.
- interferes with daily functioning
- causes significant physical and emotional distress
Symptoms of Generalized Anxiety Disorder
- Excessive anxiety and worry, occuring more days than not forat least 6 months, about a number of events or activites
- the individual finds it difficult to control the worry
- three of the following symptoms
- Worry
- Anxiety
- Tension in muscles
- Concentration difficulty
- Hyperarousal (irritable)
- Energy loss
- Restelessness
- Sleep disturbances
+ significant distress
+ no substance triggers
Screening tool used for generalised anxiety disorder and its questions
GAD-7
Over last 2 weeks, how often have you been bothered by any of the following symptoms
- Feeling nervous, anxious or on edge
- Not being able to stop or control worrying
- Worrying too much about different things
- Trouble relaxing
- Being so restless that it’s hard to sit still
- Becoming easily annoyed or irritable
- Feeling afraid as if something awful might happen
Treatment for GAD (Plus, what is CBT)
First line
-
CBT
* CBT can be used for anxiety or depression. It aims to help a person identify and challenge unhelpful thoughts and to learn practical self-help strategies. These strategies are designed to bring about positive and immediate changes in the person’s quality of life. CBT aims to show people how their thinking affects their mood and to teach them to think in a less negative way about life and themselves. It is based on the understanding that thinking negatively is a habit that, like any other habit, can be broken. - SNRI/ SSRI’s
- Buspirone (anxiolytic)
Benzodiazepines can be used until SSRIs take effect but should never be used for long-term management
What is Social anxiety Disorder and the treatment
-
SAD:
* Fear/anxiety out of proportion to a social situation where one may be scrutinized by others (e.g. meeting new people at a party, eating in public, using public restrooms) -
Performance-only SAD:
* Symptoms of fear/ anxiety restricted only to public speaking or performing in front of crowds - Cognitive Behavioral Therapy
- Pharmacology
- First line pharmacotherapy: SSRI/ SNRI
- No/ partial response to SSRI and no history of a substance - clonazepam (benzo)
- No/ partial response to SSRI and history of substance abuse - phenelzine (MAOI)
- For performance-only SAD: propanalol (beta-blocker)
DSM-5 criteria for Social anxiety disorder
- Marked fear or anxiety in one or more social or performance situations in which the person is exposed to possible scrutiny by others
- Fear that they will act in a way that will be humiliating, embarrassing, or they will be rejected by others
- Exposure to the feared social situation almost invariable provokes anxiety or panic attack
- Anticipatory anxiety
- Avoidance or fear interferes significantly with the person’s normal routine
- The duration of the symptoms must be at least 6 months
- Not due to substance or general medical conditions
What is agoraphobia?
Fear or anxiety about 2 or more of:
- Using public transport
- Being in open spaces
- Being in closed spaces
- Standing in line or being in a crowd
- Being outside the home alone
Patients fear or avoids these situations because escape may be difficult in the event of developing panic like symptoms, where fear and anxiety is out of proportion to the actual damage.
Symptoms of a Panic Disorder
Recurrent unexpected panic attacks with > 4 of the following symptoms:
STUDENTS FEAR THE 3 C’s
- Sweating
- Trembling
- Unsteadiness
- Depersonalisation/ derealisation
- Excessive heart rate/ palpitations
- Nausea
- Tingling
- SOB
- FEAR of dying
- Chest pain, chills, choking
1 months of anxiety about panic attacks with one of the following:
- persistent concern or worry about panic attacks
- significant maladaptive behaviour
Anxiety due to medical conditions
Physical Distress That Have Commonly Appeared Anxious
- Phaeochromocytoma
- Diabetes
- Temporal lobe epilepsy
- Hyperthyroidism
- Carcinoid (neuroendocrine tumours)
- Alcohol withdrawal
- Arrhythmias
DSM-5 classification of Post-traumatic Stress Disorder
- Experienced or observed event
- intrusions (e.g., flashbacks, intrusive images and sensory impressions, dreams/nightmares);
- Avoidance (e.g., avoiding people, situations, or circumstances resembling or associated with the event);
- Negative alterations in mood and cognition (e.g., feeling alienated from others, constricted affect, diminished interest in significant activities, distorted negative beliefs about oneself or the world, and inability to remember key features of the traumatic event);
- Alterations in arousal or reactivity (e.g., hypervigilance for threat, exaggerated startle response, irritability, difficulty concentrating, and sleep problems).
- Symptoms for greater than 1 month
- Significant distress or impaired function
Treatment of PTSD
Psychotherapy
- CBT (trauma focused, exposure therapy)
- Cognitive processing therapy
- Eye movement desensitization and reprocessing – recalling memories whilst watching finger move back and forth
Pharmacotherapy
- SSRI, SNRI (first line)
- Nightmares - Prazosin is effective for improving sleep
- Consider atypical antipsychotics for psychotic symptoms
- Benzodiazepines can be used for hyperarousal and anxiety, but monitored closely
How does acute stress disorder differ from PTSD
Characteristic symptoms same as PTSD, just lasts between 3 days to 1 month
What is adjustment disorder?
A maladaptive emotional or behavioural response to a stressor that lasts < 6 months following termination of the stressor. Symptoms such as stress, feeling sad, physical symptoms that occur because patients is having hard time coping. The reaction is stronger than expected for the type of event that occurred.
What are obsesions and compulsions
- Obsessions
- Recurrent and intrusive thoughts, ideas, impulses or images that are usually resisted by the person and are recognized as the product of their own mind and not imposed from outside
- Compulsions
- Repetitive behaviors in response to an obsession, to prevent discomfort or some dreaded event with which is not connected in a realistic way. The person generally recognizes that their behavior is excessive or unreasonable. Performing the action provides relief from anxiety caused by obsession
DSM-5 criteria for OCD
- Obsessions and/or compulsion
* Obsessions
- Recurrent/ persistent, intrusive thoughts, or urges that cause anxiety or distress
- Attempts to suppress these thoughts or urges
- Compulsions
- Repetitive behaviours or thoughts that the individual feels forced to perform by these obsessions
- Intentions to prevent or reduce anxiety, distress, or a dreaded event; behaviours are excessive or are not linked to the dreaded events at all
- Time-consuming, or resulting in significant distress/ impairment
- Not due to substance-use disorders or another medical condition
- Not due to another mental disorder (anxiety disorders, eating disorders)
Treatment for OCD
A combination of pharmacotherapy and psychotherapy has been proven effective in the treatment of OCD
- Cognitive Behavioural therapy
- Pharmacotherapy
- Antidepressants à SSRI (sertraline, fluoxetine)
- Alternatively, tricyclic antidepressants with serotonergic action (clomipramine)
- Atypical antipsychotics (quetiapine)
Clinical features of Schizophrenia (Including - positive symptoms, negative symptoms, cognitive symptoms and catatonia)
Schizophrenia tends to present initially with prodrome of negative symptoms (classically withdrawal) that precedes the positive psychotic symptoms (hallucinations and bizarre behaviours)
Positive symptoms of psychosis
-
Hallucinations
* A perceptual abnormality, in which sensory experiences occur in the absence of external stimuli - Delusions
Fixed, false beliefs that are not amenable to reason, despite evidence to the contrary
- Bizarre: impossibility of being true
- Non-bizarre: possibility of being true or consistent with patient’s culture
-
Illusions
* A perceptual abnormality, in which real external stimuli are misinterpreted - Disorganised thought and speech processes
- Loose associations – incoherent thinking expressed as illogical, sudden, and frequent topic changes
- Word salad
- Neologisms – creating of new words
- Flight of ideas
- Clang associations – use of words based on rhyme rather than meaning
- Circumstantial speech – non-linear thought expressed as a long-winded manner of explanation
- Tangential speech
- Thought-blocking
- Pressured speech
Negative symptoms of psychosis (the 5 A’s)
-
Flat affect
* Reduced or absent affective expression -
Avolition
* Reduced or absent ability to initiate purposeful activities -
Alogia
* Impoverished thinking that presents as reduced speech output or poverty of speech -
Anhedonia
* Inability to feel pleasure from activities -
Apathy
* Lack of emotion or concern, especially with regards to matters that are normally considered important
Cognitive symptoms
- Inattention
- Impaired memory
- Poor executive functioning
Mood symptoms - Depression
Catatonia – A behavioural syndrome characterized by abnormal movements and reactivity to the environment
- Retarded catatonia – immobility, posturing, negativism
- Excited catatonia – excessive, purposeless movement in both the upper and lower limbs, restlessness, impulsivitiy
- Malignant catatonia – fever, autonomic instability (tachycardia, tachypnea, abnormal BP and sweating), rigidity, and delirium (resembles neuroleptic malignant syndrome)
Criteria for schizophrenia
- >=2 of the following symptoms for >= 1 month (with at least one of the first 3)
- Delusions
- Hallucinations
- Disorganised speech
- Grossly disorganized or catatonic behavior
- Negative symptoms
- Symptoms must cause social, occupational or personal functional impairment
- Some sign of illness must persist for at least 6 months
- Schizoaffective disorder and mood disorder with psychotic features have been ruled out
- Symptoms must not be due to a medical or substance use disorder
- If there is a history of autism spectrum disorder or other communicating disorder beginning in childhood, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month
What are some other causes of depressive symptoms, and what investications would you consider performing?
Investigations
- TFTs – elevated TSH suggests hypothyroidism
- Metabolic panel
- FBC – anaemia can cause fatigue
- Serum B12 and folate
- 24-hour urinary cortisol – elevated levels suggest Cushing’s
- MRI, ANA, syphilis
Causes
- HIV/AIDS
- diabetes
- arthritis
- strokes
- brain disorders such as Parkinson’s disease, Huntington’s disease, multiple sclerosis, and Alzheimer’s disease
- metabolic conditions (e.g. vitamin B12 deficiency)
- autoimmune conditions (e.g., lupus and rheumatoid arthritis)
- viral or other infections (hepatitis, mononucleosis, herpes)
- back pain
- certain cancers (e.g., pancreatic)
- hypothyroidism
- anaemia
Causes and investigations for psychotic symptoms
- CT/ MRI – rule out dementia, brain tumour, traumatic brain injury
- EEG - Temporal lobe epilepsy
- Serum HIV enzyme-linked immunosorbest essay
- Serum rapid plasma regain test – rule out syphilis
- FBC
- WCC - infection (also do CRP): infections such as EBV, rabies, mumps, measles
- volume abnormalities in red cells can suggest vitamin deficiencies or increased alcohol intake
- LP – encephalitis
- Urea and electrolytes – Hypercalcemia
- LFTs – most drugs processed by liver, hepatic encephalopathy
- Urine drug screen and plasma drug level monitoring
- Antihistamine, Dextromethorphan, anticholinergic, dopamine agonist, corticosteroid, adrenergic, thyroid hormones, cocaine, cannabis, amphetamine, alcohol
- Endocrine disorders – TFTs, 24-hour urine cortisol, hyperparathyroidism
- Autoimmune disorders – SLE
- Metabolic disorders – Wilson’s disease – copper
- Chromosomal disorders – Klinefelter’s syndrome
- Prolactin
Causes
- Brain tumors
- Traumatic brain injury
- Epilepsy
- Autoimmune disorders
- Thyroid disease – hyperthyroidism
- Hyperparathyroidism
- Huntington’s disease
- CNS infection
- Multiple sclerosis
- Stroke
- Migraine
- Carbon monoxide poisoning
- Heavy metal poisoning
Treatment for schizophrenia
- Hospitalization if acutely psychotic
- General approach
- Acknowledge the patients emotional state
- Avoid validation of delusions or confronting patients about the delusional nature of their complaints
- Antipsychotic treatment
- Acute psychotic episodes - Short acting antipsychotics (olanzapine) +/- mood stabilizer (lithium, valproate)
- First-line treatment: second-generation antipsychotics (olanzapine, risperidone, quetiapine)
- Alternatively, first-generation antipsychotics (haloperidol, fluphenazine, chlorpromazine)
- Cloazapine for treatment-resistant schizophrenia
- Psychoeducation
- Patient, family and group psychosocial therapy and education
- CBT
- Supportive social measures
What is schizophreniform disorder?
Psychotic and residual symptoms lasting 1-6 months
(Schizophrenia lasts > 6 months)
What is breif psychotic disorder?
- Psychotic symptoms lasting > 1 day but < 1 month
- triggered by stressful symptoms
What is schizoaffective disorder?
- Features of schizophrenia AND a major mood disorder (depression or bipolar)
- psychosis must have been present for at least 2 weeks in the absence of any mood disturbance
- mood symptoms do not appear in the absence of psychosis
DSM-5 criteria for erectile dysfunction
Motivational Interveiwing - Stages of change
