Psychiatry Flashcards
See year 3 for drugs
name the parts of a psychiatric functional inquiry
mood organic anxiety psychosis safety
what would you ask about in PC and HPC in a psych hx
• Reason for seeking help that day
• Current symptoms - onset, duration and course
• Stressors
• Supports
• Functional status
• Relevant associated symptoms
• Current medication use including doses and adherence
• Safety screen
○ Endangering self or others, dependents at home, ability to drive safely, ability to care for self
what would you go into during a developmental hx for psych?
• Prenatal and perinatal hx
○ desired vs unwanted pregnancy, maternal and foetal health, domestic violence, maternal substance use and exposures, complications of pregnancy/delivery
• Early childhood to 3 yrs
○ Developmental milestones, activity/attention level, family stability, attachment figures
• Middle childhood to 11 yrs
○ School performance, peer relationships, fire setting, stealing, incontinence
• Late childhood to adolescence
○ Drugs/alcohol, legal problems, peer and family relationships
• History of physical or sexual abuse
• Adulthood - education, occupations, relationships
• Premorbid personality
• Psychosexual hx
○ Puberty, first sexual encounter, romantic relationships, gender roles, sexual dysfucntion
what additional parts is there to a psych hx?
forensic
developmental
past psych hx
name the components of a mental status exam
appearance behaviour speech mood and affect perception thought content insight cognition
what would you comment on in appearnace of a MSE
• Posture • Gait • Grooming • Hygiene • Clothing • Body habitus • Facial expression • Chronological vs apparent age Relaxed or in distress
what parts are there to behaviour in the MSE?
- Psychomotor activity - agitation, retardation
- Abnormal movements or lack thereof - tremors, akathisia, tardive dyskinesia, paralysis
- Attention level and eye contact
- Attitude towards examiner - ability to interact, level of cooperation
what do you comment on speech in a MSE
rate
rhythm
tone
spontaneity
how can you describe affect?
euthymic, depressed, elevated, anxious, irritable
full, restricted, flat, blunted
fixed, labile
congruencr
how would you describe thought process and form?
coherence
logic
what kind of things would you comment on in thought content?
suicide/homicidal delusions obsessions magical thinking ideas of reference overvalued ideas broadcasting
what is a psychotic condition?
Characterised by a significant impairment in reality testing, delusions or hallucinations (with/without insight into their pathological nature behaving in a disorganised way so that it is reasonable to infer that reality testing is disturbed
list the first
rank symptoms of schizophrenia
auditory hallucinations
broadcasting
controlled thought
delusional perception
age of onset schizophrenia
15-35
positivie symptoms of schizophrenia
hallucinations
delusions
disordered thinking
negative symptoms of schizophrenia
apathy lack of interest lack of emotions amotivation paucity of though
good prognostic factors of schizophrenia
• Absence of family history • Good premorbid function – stable personality, stable relationships • Clear precipitant • Acute onset • Mood disturbance • Prompt treatment Maintenance of initiative, motivation
poor prognostic factors of schizophrenia
• Slow, insidious onset and prominent negative symptoms
• Mortality is 1.6x higher than the general population
• Shorter life expectancy is linked to CV disease, resp disease and cancer
• Suicide risk is 9 x higher
• Death from violent incidents is twice as high
• 36% of patients have substance misuse problems
Childhood onset
ICD10 criteria for schizophrenia
For more than a month in absence of organic or affective disorder:
• At least one of the following:
• Alienation of thought as thought echo, thought insertion or withdrawal, or thought broadcasting (other people have access to thoughts, leaking out).
• Delusions of control, influence or passivity, clearly referred to body or limb movements actions, or sensations; delusional perception.
• Hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing him between themselves, or other types of hallucinatory voices coming from some part of the body.
• Persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. being able to control the weather)
• Or at least two of the following:
• Persistent hallucinations in any modality, when occurring every day for at least one month.
• Neologisms (making up words), breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech.
○ Schizophasia – just words put together, makes no sense
• Catatonic behaviour, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor.
• “Negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses.
common comorbidities in schizophrenia
substance related disorders
anxiety disorders
reduced life expectanc due to: obesity, diabetes, metabolic syndrome, CV/pulmonary disease
management of schizophrenia
- Biological / somatic
- Acute treatment and maintenance: antipsychotics (haloperidol, risperidone, olanzapine, paliperidone; clozapine if refractory); often regiments of IM q2-4 wk used in severe cases to ensure adherence
- Adjunctive: ± mood stabilizers (for aggression/impulsiveness - lithium, valproate, carbamazepine) ± anxiolytics ± ECT
- Treat for at least 1-2 years after the first episode, at least 5 years after multiple episodes (relapse causes severe deterioration)
- Psychosocial
- Psychotherapy (individual, family, group), supportive, CBT (see Table 14, PS41)
- ACT (Assertive Community Treatment): mobile mental health teams that provide individualized treatment in the community and help patients with medication adherence, basic living skills, social support, job placements, resources
- Social skills training, employment programs, disability benefits
- Housing (group home, boarding home, transitional home)
list the psychological symptoms of depression
• Change in mood
○ Depression – may find diurnal variation
○ Anxiety – inability to relax
○ Perplexity – particularly in puerperal illness (post-natal), bewildered or overwhelmed
○ Anhedonia – not being able to experience pleasure in the things you would usually enjoy
• Change in thought content
○ Guilt – unjustified
○ Hopelessness
○ Worthlessness
○ Any neurotic symptomatology e.g. hypochondriasis, agoraphobia, obsessions + compulsions, panic attacks o Ideas of reference – connecting things around you to negative things about you e.g. laughing at
Delusions and hallucinations if severe – psychotic symptoms
list the physical symptoms of depression
• Change in bodily function ○ Energy – fatigue ○ Sleep – often insomnia, not being able to get to sleep, disturbed sleep, early waking ○ Appetite – weight loss ○ Libido ○ Constipation ○ Pain • Change in psychomotor functioning ○ Agitation Retardation – abnormal slowness of thought and action
list the social symptoms of depression
• Loss of interests
• Irritability
• Apathy
• Withdrawal, loss of confidence, indecisive
Loss of concentration, registration and memory
what is the ICD10 criteria for a diagnosis of depression?
• Last for at least 2 weeks
• No hypomanic or manic episodes in lifetime
• Not attributable to psychoactive substance use or organic mental disorder
If psychotic symptoms or stupor then severe depression with psychotic symptoms
what is somatic syndrome?
Somatic syndrome is a marked loss of interest or pleasure in activities that are normally pleasurable. There is a lack emotional reactions to events or activities that normally produce an emotional response. Patients often wake 2 hours before the normal time and find that the depression is worse in the morning. Objective evidence of psychomotor agitation or retardation. Marked loss of appetite with weight loss (5% + of body weight in a month). Often marked loss of libido.
lsit the general criteria for depression
○ Depressed mood that is abnormal for most of the day almost every day for the past two weeks, largely uninfluenced by circumstances
○ Loss of interest or pleasure
Decreased energy or increased fatigability
list the additional criteria for depression
○ Depressed mood that is abnormal for most of the day almost every day for the past two weeks, largely uninfluenced by circumstances
○ Loss of interest or pleasure
Decreased energy or increased fatigability
how many symptoms do you need to be diagnosed with mild depression?
at least 2 general
total 4
how many symptoms do you need to be diagnosed with moderate depression?
2 general
total 6
how many symptoms do you need to be diagnosed with severe depression?
3 general
total 8
name two measurement tools for depression
SCID
SCAN
define bipolar 1
at least 1 manic episode commonly accompanied by at least 1 major depressive episode
define bipolar 2
at least one major depressive
1 hypomanic
no manic
psychological treatment for bipolar
○ Supportive psychotherapy ○ CBT ○ IPT ○ Interpersonal social rhythm therapy Family therapy
social treatment for bipolar
○ Vocational rehab ○ Consider leave of absence ○ Assess capacity to manage finances ○ Drug and alcohol cessation ○ Sleep hygiene ○ Social skills training ○ Education and recruitment of family members
psychological treatments for depression
○ CBT, IPT, individual dynamic psychotherapy, family therapy
what is panic disorder
- A disorder in which an individual experiences recurrent, unexpected panic attacks and persistent concern about having additional panic attacks. Agoraphobia is not a component of this disorder.
- A state of extreme acute, intense anxiety and unreasoning fear accompanied by disorganization of personality function.
treatment of panic disorder
• Psychological ○ CBT ○ Cognitive restructuring ○ Relaxation techniques • Pharmacological ○ SSRIs ○ SNRI ○ Up to 12 weeks for response ○ Treat for 1 yr after symptoms resolve to avoid relapse Other antidepressants - mirtazapine, MAOIs
what is agoraphobia
a type of anxiety disorder in which you fear and avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed
treatment for agoraphobia
SSRI
SNRI
Mirtazapine
what is generalised anxiety disorder?
his is a persistent (several months) presence of symptoms that are not confined to a situation or object. All the symptoms of human anxiety mentioned earlier can occur. Dominant symptoms are variable but include tremor, palpitations, epigastric pain, worried thoughts, fear, trembling.
treatment of GAD
counselling
relaxation training
SSRI, TCA
CBT
what is social phobia
Marked and persistent (>6 mo) fear of social or performance situations in which one is exposed to unfamiliar people or to possible scrutiny by others; fearing he/she will act in a way that may be humiliating or embarrassing (e.g. public speaking, initiating or maintaining conversation, dating, eating in public)
diagnostic criteria for phobic disorders
• Exposure to stimulus almost invariably provokes an immediate anxiety response; may present as a panic attack
• Person recognizes fear as excessive or unreasonable
• Situations are avoided or endured with anxiety/distress
Significant interference with daily routine, occupational/social functioning, and/or marked distress
treatment of phobic disorders
CBT
Exposure therapy
behavioural therapy
fluoxetine, paroxetine, sertraline, venlafaxine, MAOIs
what is OCD?
The core features of OCD are experiences of recurrent obsessional thoughts and or compulsive acts.
Obsessional thoughts:
• Ideas, images or impulses
• Occurring repeatedly not willed
• Unpleasant and distressing (often the antithesis of personality type)
○ Obscene
○ Violent or senseless
• Recognised as the individual’s own thoughts
• Usual key anxiety symptoms arise because of distress of the thoughts or attempts to resist.
Compulsive acts or rituals:
• Stereotypical behaviours repeated again and again
• Not enjoyable
• Not helpful i.e. do not result in useful activity
• Often viewed by the sufferer as:
○ Preventing some harm to self or others “magical undoing”
○ Viewed as pointless and resisted with key anxiety symptoms accompanying resistance
management of OCD
education SSRI Clomipramine CBT psychosurgery
what is PTSD
delayed or protracted reaction to a stressor of exceptional severity
what are the 3 key elements in PTSD
hyperarousal
re-experiencing phenomena
avoidance
features of hyperarousal in PTSD
persistent anxiety
irritability
insomnia
poor concentration
vulnerability factors for PTSD
mood disorders
previous trauma esp children
lack of social support
female
protective factors against PTSD
higher education
social group good paternal relationship
CAGE questionnaire
Ever felt the need to Cut down on drinking?
Ever felt Annoyed at criticism of your drinking?
Ever feel Guilty about your drinking?
Ever need an Eye opener?
alcohol withdrawal: 12-18hrs
shakes tremor sweating agitation anorexia cramps diarrhoea sleep disturbance
alcohol withdrawal: 7-48hrs
seizures usually tonic clonic
alcohol withdrawal: >48hrs
visual, auditory, olfactory, tactile hallucinations
alcohol withdrawal: 3-5 daus
DT confusion delusions hallucinations agitation tremors autonomic overactivity
