Psychiatry Flashcards
Patient - elderly man, inpatient in hospital becomes acutely confused following UTI, hallucinating, w/ sleep wake reversal
Delirium
Delirium Aetiology
- Infection
- Drugs - BZ, opiates, L-Dopa, Digoxin
- Hypoglycaemia
- Dehydration and electrolyte imbalance
- Decreased O2
- Alcohol withdrawal
- Surgery
RF’s
- Age
- Dementia or brain injury
- New environment
- Sleep deprivation
- Immobilization
- Visual or hearing impairment
Delirium Presentation
- Sleep/wake reversal
- Incoherent thought and speech
- Visual hallucinations
- Persecutory delusions
- Hyperactive = agitated and upset
- Hypoactive = Drowsy and withdrawn.
Delirium Ix
1) Hx and Exam to identify underlying cause.
2. Septic screen
Delirium Rx
- Nurse in a quiet and safe area.
- Re-orientate
- Avoid psychoactive drugs (can use haloperidol if severe)
- Treat cause
Patient - Young male, cannabis user, auditory hallucinations, thought echo, though withdrawal and passivity.
SCH
SCH Aetiology
- UK
- Genetics - FHx
- Dopamine excess (only explains positive Sx)
- Daily cannabis use is a RF.
SCH Presentation
First rank Sx; 3rd person auditory hallucinations + thought echo + thought interference + delusional perception + passivity phenomenon.
- Sx must be present for 6 months.
SCH: Paranoid
- Common, hallucinations and delusions are persecutory
SCH: Hebephrenic
- Disorganised SCH w/ fleeting affect, hallucinations and delusions.
SCH: Catatonic
- Stupor, posturing and negativism (withdrawal, self-neglect, blunted affect)
SCH Ix
1) Clinical
2) Rule out brain pathology such as FTD or LBD. Brain scan for mass lesions.
SCH Rx
1) Antipsychotic (neuroleptic drugs)
- Block D1 and D2 receptors.
- Manage acute +’ve Sx.
- Extra-pyramidal SE; parkinsonism due to Dopamine blockade.
- Common SE = Akathisia, parkinsonism, tardive dyskinesia, hypotension, dry mouth, weight gain, urinary retention.
Antipsychotics
1st gen = Chlorpromazine, haloperidol
2nd gen = risperidone, olanzapine, clozapine
Patient - 5 days after first dose of haloperidol, becomes hyperthermic, rigid, w/ increased HR and pallor.
Neuroleptic malignant syndrome
NMS Aetiology
- Due to dopamine blockade, triggers massive glutamate release, neurotoxic and muscle damage.
NMS Presentation
- Pyrexia
- Muscle rigidity
- Antonomic lability, HTN, high HR, high RR.
- Agitated delirium and confusion
- LOC
NMS Ix
1) Clinical w/ Hx of Antipsychotics or levodopa (when stopped)
2) Bloods; CK and FBC (leucocytosis)
NMS Rx
1) Stop offending drug.
2) ITU for nursing
3) Dantrolene to decrease muscle tone
4) Bromocriptine (dopamine agonist) enhances dopaminergic activity.
Patient - Periods of depression and low mood punctuated with periods of elation and psychotic behaviour
Bipolar disorder.
BPD Aetiology
- UK
- Genetics
- Biochemical - increased serotonin
BPD Presentation
- Develops in late teens.
- Type 1 = mania and depression
- Type 2 = Hypomania and depression.
Mania
- Abnormal elevated mood or irritability
- In mania there is severe functional impairment or psychosis for 7 days or more.
- Hypomania is less severe or less prolonged.
- Delusions of grandeur, pressure of speech, flight of ideas etc, sexual promiscuity.
BPD Rx
1) Lithium is the drug of choice. Alternative = valproate.
2) Mania management = stop antidepressant and start antipsychotic therapy - olanzapine or haloperidol.
3) Manage depression w/ talking or fluoxetine.
Lithium;
- TFT, parathyroid and U&E prior to starting.
- Toxicity can occur
- Interacts w/ NSAID’s and diuretics.
- Monitoring week following first dose and 12hrs following last dose. + every 3 months when stable.
- TFT and U&E every 6 months
Lithium toxicity
- Therapeutic range = 0.4-1.0mmol/L
- Toxicity occurs >1.5mmol/L
- May be precipitated by; dehydration, renal failure, NSAID, diuretics and metronidazole.
- Coarse tremor
- Hyperreflexia
- Acute confusion
- Seizure
- Come
Rx
- Mild to mod = volume resus w/ saline
- Dialysis
Patient - No joy, low mood and little energy for 2 weeks or more.
Ya depressed mate
Depression Aetiology
- Genetics; FHx
- Biochemical - Monoamines
- Biopscyhosocial - yeh we don’t fucking know.
Depression Presentation
- Anhedonia
- Low mood
- Anenergia
- All for atleast 2 weeks.
Others include;
Biological - insomnia, decreased libido and appetite
Psychological - decreased motivation, guilt, decreased confidence, worthlessness and hopelessness.
Psychosis.
Depression Ix
1) PHQ9
2) HAD
3) Beck’s depression inventory
4) Bloods (TFT, steroids) to rule out organic illness.
Depression Rx
1) Talking therapies (CBT, IPT) mindfulness.
2) Lifestyle changes (reduce alcohol and drugs)
3) Medications if severe.
Patient - Gave birth to a beautiful baby boy 2 months ago, feels low, feels guilty and like a bad mother. To the point she cant leave the house or function :(
Post-natal depression.
PND Aetiology
- UK
- Related to the removal of pregnancy hormones and the surges etc.
- Any depressive illness occurring in the first post-natal yr. Can be de novo or following a hx of depression.
PND Risks
- Previous mental health issues
- Poor support
- poor partner relationship
- major life events
- baby blues
- not breast feeding
- unemployment
- substance misuse.
PND Presentation
- Same as normal depression
PND Ix
- Assess for Hx
- Alcohol and drug screen
- The pregnancy experience
- Mother baby relationship
- DV at home
PND Rx
1) Reassure - ‘you’re a great mother - gurl you got dis’
2) Mild to mod - CBT
3) Severe - consider CBT + drugs.
SSRI side effects
- GI upset
- Hyponatraemia
- Long QT
SSRI in pregnancy
- Risk Vs benefit
- used in 1st trimester = small risk of heart defects
- Used in 3rd trimester can causes persistent pulmonary hypertension of the newborn.
Antipsychotic side effects
- Parkinsonism
- Acute dystonia (torticollis, oculogyric crisis)
- Akathisia
- Tardive dyskinesia
- NMS
ECT
- indication
- SE
- Severe depression + catatonia
- Headache
- Nausea
- short-term memory loss
- Anterograde amnesia
- arrhythmia
Anorexia presentation
- All things low
- G’s and C’s are raised; Cortisol, growth hormone, glucose, salivary glands, cholesterol.
GAD Rx
- Education
- Low intensity CBT
- high intensity CBT and/or drug (SSRI)
