Psychiatry Flashcards
What is the crisis resolution team?
Managed severely unwell/ suicidal psychiatric patients in the community (psychiatric emergencies)
Aim: short term interventions (<6wks) with people at home, to prevent admission to hospital
What is the outreach team?
Provides intensive support and treatment in the community for chronically unwell psychiatric patients and those who have a history of disengagement from mainstream psychiatric services
Patients are usually high risk of causing harm to themselves or others
Community nurses can visit several times a week over a longer period of time than crisis resolution team
Community mental health team (CMHT)
MDT: psychiatrists, community psychiatric nurses, occupational therapists, psychologists, social workers and secretaries
CPNs may visit the patients in their homes every two weeks and then patients are managed in outpatient clinics
What is a care programme approach? (CPA)
A system of care which aims to meet a patients psychiatric and social needs once they are back in the community after significant contact with psychiatric services (eg. inpatient)
CMHT + medical + social services work together
These patients often have complex needs, of require multiple services which requires coordination
Components of psychiatric history taking
- Introduce and identify patient
- Reason for referral
- Presenting complaint
- ICE
- Past psychiatric history
- Past medical history
- Drug history
- Family history
- Personal history
- Social history
- Premorbid personality (what they were like before, maybe get collateral Hx)
What to discuss when asking about ‘personal history’ during a psychiatric history taking
Antenatal and birth complications Developmental milestones Childhood illness/psych illness Family dynamics Home atmosphere Childhood abuse
Did they attend and enjoy school
Were they bullied
Did they finish school
Did they get qualifications
Chronological list of jobs
Duration of work
Redundancy or personal choice
Work environment
Sexual orientation
Chronological account of major relationships
Current relationship
Children
Forensic history
Women: menstrual patterns, previous miscarriages, still births, terminations
What to discuss when asking about ‘social history’ in psych history taking
Accommodation Social support Financial circumstances Hobbies and leisure activities Alcohol and substance misuse
Components of a mental state examination
ASEPTIC:
Appearance and behaviour: clothing, accessories, personal hygiene, eye contact, facial expression, body language, movements, level of arousal, ability to build rapport, disinhibition
Speech: rate, rhythm, vol, content, quantity, tone, dysarthria
Emotion (mood and affect): subjective mood (patients own words), objective mood (euthymic, elated, depressed), affect (blunted, flat, restricted, appropraite, inappropriate, labile, inconguous). Affect is reactive if no abnormality.
Perception: hallucinations
Thoughts: content (delusions, obsessional thoughts, overvalued ideas), form (loosening of associations, circumstantiality, neologism, perseveration), flow (speed of thinking), thoughts of suicide and self harm
Insight: the extent to which the patient understands the nature of their problem
Cognition: consciousness, orientation, attention, concentration, memory
Delusions
- definition
- types of delusions
Definition: fixed false beliefs, which are firmly held despite evidence to the contrary and go against the individuals normal social and cultural belief system
- Grandiose: patient has special powers, is talented, wealthy and important, may be chosen by god
- Persecutory: other people are conspiring against them in order to inflict harm
- Reference: random events/objects/behaviours of other have a special significance on them
- Guilt
- Hypochondrial
- Nihilistic: they are worthless or dying. In severe cases (Cotards syndrome) they claim that everything is non-existent including themselves
- Infestation: one is infested by small organisms
- Folie à deux: a syndrome in which a delusional belief is shared between two people
- Erotomania (De Clérambaults syndrome): someone is inlove with them
- Othello syndrome (morbid jealousy): a patients spouse/partner is being unfaithful without their being proof
- Capgras syndrome: a familiar person or place has been replaced with an exact duplicate
Types of formal thought disorder
- Loosening of association: usually in schizophrenia. three types:
1. Derailment of thought (knights move thinking): thoughts are unrelated or only remotely related
2. Tangential thinking: patient diverts from original train of thought and never returns to it
3. Word salad: speech that is reduced to a senseless repetition of sounds and phrases - Circumstantiality: thinking proceeds slowly with many unnecessary details and digressions before returning to the original point
- Neologisms: words/phrases devised by the patient or a new meaning to an already known word
- Perseveration: uncontrollable and inappropriate repetition of a particular word/ phrase/ gesture
Different types of abnormalities seen in flow of thinking
Acceleration:
- Pressure thought
- Flight of ideas (difficult to understand, switches quickly from one loosely connected idea to another)
Retardation: slow speed of thinking
Thought blocking: sudden cessation of flow of thoughts. The previous idea may the be taken up again or replaced by another thought
Schneiders first rank symptoms
Symptoms, which if 1+ present, suggests diagnosis of schizophrenia:
Delusional perception
Third person auditory hallucinations
Thought interference
Passivity phenomenon
Thought interference
Thought insertion: the thoughts inside their mind do not belong to them and have been put there by an external agent
Thought withdrawal: own thoughts are being taken away from them
Thought broadcast: their thoughts are being broadcasted/ heard out loud
Definition of a hallucination
Types of hallucinations
A perception in the absence of an external stimulus
May be visual, auditory, olfactory, gustatory or somatic. Auditory most common.
Auditory may be second person (voice directly addressing the patient), third person (voices talking amongst themselves, or about the patient), running commentary (voice giving account of what the patient is doing)
Illusion vs. hallucination
Hallucination is a perception in the absence of an external stimulus
Illusion is a false mental image produced by misinterpretation of an external stimulus
Definition of depressive disorder
Affective mood disorder characterised by a persistent low mood, loss of pleasure and/or lack of energy accompanied by emotional, cognitive and biological symptoms
Biopsychosocial model for predisposing, precipitating and perpetutating factors causing depressive disorder
Predisposing:
- BIO: female, postnatal period, genetics, reduced serotonin, reduced NA, reduced dopamine, increased endocrine activity, physical co-morbidities, past history of depression
- PSYCHO: personality type, failure of effective stress control, poor coping strategies, other mental health comorbidities
- SOCIAL: stress, lack of social support
Precipitating:
- BIO: poor compliance with medication, corticosteroids
- PSYCHO: acute stressful life events
- SOCIAL: unemployment, poverty, divorce
Perpetuating:
- BIO: chronic health problems
- PSYCHO: poor insight, negative thoughts about self or world, and the future
- SOCIAL: alcohol and substance misuse, poor social support, reduced social status
Risk factors of depressive illness
FF ΑA PP SS Female Family history Alcohol Adverse events Past depression Physical comorbidities Social support lacking Socioeconomic status (low)
Core symptoms of depressive disorder
Cognitive symptoms of depressive disorder
Biological symptoms of depressive disorder
Psychotic symptoms of depressive disorder
CORE: anhedonia, low mood, lack of energy
COGNITIVE: lack of concentration, negative thoughts (self, world, future), excessive guilt, suicidal ideation
BIOLOGICAL: diurnal variation in mood (worst in the morning), early morning awakening, loss of libido, psychomotor retardation, weight loss and appetite loss
PSYCHOTIC: hallucinations, delusions
ICD-10 classification of depression
Mild: 2 core symptoms + 2 other symptoms
Moderate: 2 core symptoms + 3/4 other symptoms
Severe: 3 core symptoms + 4 or more other symptoms
Severe depression with psychosis: 3 core symptoms + 4 or more other symptoms + psychosis
Differential diagnoses for depressive disorder
Other mood disorders: bipolar affective disorder, other depressive disorders (seasonal, recurrent, cyclothymia, postnatal, baby blues, etc)
Secondary to physical condition: (eg. hypothyroidism)
Secondary to psychoactive substance abuse
Secondary to psychiatric disorders: psychotic disorders, anxiety disorders, adjustment disorder, personality disorder, eating disorder, dementia
Normal bereavement
Investigations for depressive disorder
Used to exclude organic cause.
Diagnostic questionnaires: PHQ-9, HADS, etc
Bloods: FBC (anaemia), TFTs (hypothyroidism), U+E, LFT, calcium, glucose
Imaging: MRI or CT head if ?space occupying lesion
Management of depressive disorder
Mild-Moderate:
- Watchful waiting for 2 weeks
- Antidepressants (not first line for mild depression unless: long duration, past history of mod/severe depression, other complications of physical health)
- Self help programmes
- CBT
- Social support groups
- Physical activity programme
- Psychotherapies
Moderate-Severe:
- Suicide risk assessment
- Psychiatry referral if: high suicidal risk, severe depression, recurrent depression, or unresponsive to initial therapy
- MHA if necessary
- Antidepressants (SSRIs first line) for at least 6 months after resolution of symptoms
- Adjuvants (lithium, antipsychotics)
- Psychotherapy (CBT, interpersonal therapy)
- Social support
- ECT
Definition of bipolar affective disorder
Chronic episodic mood disorder, characterised by at least one episode of mania or hypomania and a further episode of mania or depression
Risk factors for bipolar affective disorder
AAA SSS Age (early 20s) Anxiety disorders After depression Strong family history Substance misuse Stressful life events
Clinical features of bipolar affective disorder
I DIG FASTER Irritability Distractibility/ disinhibition Insight impaired/ increased libido Grandiose delusions Flight of ideas Activity increased/ appetite increased Sleep decreased Talkative (pressure of speech) Elevated mood/ energy increased Reduced concentration/ reckless
Hypomania vs. mania without psychosis vs. mania with psychosis
Hypomania: mildly elevated mood or irritable mood for >=4 days. Mania to a lesser extent. Considerable disruption with life, but not severe. Partial insight may be preserved.
Mania without psychosis: hypomania to a greater extent. Symptoms for >1 weeks with complete disruption of life. May have grandiose ideas and excessive spending. Sexual disinhibition and reduced sleep leading to exhaustion.
Mania with psychosis: severely elevated moor with addition of psychotic features such as grandiose or persecutory delusions and auditory hallucinations. Patient may be aggressive
Classification of bipolar affective disorder
Bipolar I: periods of severe mood episodes from mania to depression
Bipolar II: milder episodes of hypomania that alternate with periods of severe depression
Rapid cycling: more than four mood swings in a 12 month period with no intervening asymptomatic periods. Poor prognosis
ICD-10 criteria for mania and bipolar affective disorder
Mania: at least 3/9 symptoms to be present:
- Grandiosity/ inflated self-esteem
- Decreased sleep
- Pressure of speech
- Flight of ideas
- Distractibility
- Psychomotor agitation (restlessness)
- Reckless behaviour (spending sprees, reckless driving)
- Loss of social inhibitions
- Marked sexual energy
Investigations for bipolar affective disorder
Self-rating scales (moor disorder questionnaire)
Blood tests: FBC (routine), TFTs (both hypo and hyper are differentials), U+Es (baseline for lithium), LFTs (baseline for drugs), glucose, calcium (biochemical disturbance alters mood)
Urine drug test
CT head to rule out space occupying lesion
Differential diagnoses for bipolar affective disorder
Mood disorders: hypomania, mania, mixed episode, cyclothymia
Psychotic disorders: schizophrenia, schizoaffective disorder
Secondary to medical condition: hyper/hypothyroidism, Cushings disease, cerebral tumour, stroke
Drug related: illicit drug ingestion, acute drug withdrawal, side effect of corticosteroid use
Personality disorders: histrionic, emotionally unstable
Management of bipolar affective disorder
Risk assessment
DVLA guidelines when manic, hypomanic or severely depressed
MHA if patient is as risk of causing harm to themselves or others
Patients with an acute episode should be followed up once a week initially, and then 2-6 weeks for the first few months
BIO: mood stabilisers, benzodiazepines, antipsychotics, ECT (if drugs ineffective)
PSYCHO: psychoeducation, CBT
SOCIAL: social support group, self-help group, encourage carming activities
Pharmacological management of bipolar affective disorder
Acute manic episode/mixed episode:
- First line: antipsychotic (olanzapine, risperidone, quetiapine). Rapid onset compared to mood stabilisers. Monotherapy -> if ineffective add another.
- Mood stabilisers (lithium first line, add valproate as second line)
- Benzodiazepines
- Rapid tranquillisation (haloperidol and/or lorazepam)
Bipolar depressive episode:
- Atypical antipsychotic (olanzapine with fluoxetine, or olanzapine alone, or quetiapine alone)
- Mood stabilisers (lamotrigine, or lithium)
- Antidepressants alone are usually avoided as they could cause mania
Long term management:
- Lithium (mood stabiliser) is first-line to prevent relapses
- If lithium is ineffective, add valproate, olanzapine, or quetiapine
Lithium
- monitoring (beforehand and during)
- side effects
- toxicity features
- severe toxicity features
Check U+Es, TFTs, pregnancy status and baseline ECG before treatment is started
Monitor during treatment: lithium levels (12hrs following first dose, then weekly until therapeutic level (0.5-1.0) has been stable for 4 weeks, then every 3 months
Check U+Es every 6 months
Check TFTs every 12 months
Side effects: polydipsia, polyuria, fine tremor, weight gain, oedema, hypothyroidism, impaired renal function, memory problems, teratogenicity
Toxicity features (1.5-2.0): N+V, coarse tremor, ataxia, muscle weakness, apathy
Severe toxicity (>2.0): nystagmus, dysarthria, hyperreflexia, oliguria, hypotension, convulsions, coma
Definition and typical features of psychosis
A mental state in which reality is greatly distorted
Features:
- Delusions
- Hallucinations
- Thought disorder
Causes of psychosis
Non-organic: schizophrenia, shizotypal disorder, schizoaffective disorder, acute psychotic episode, mood disorder with psychosis, drug-induced psychosis, delusional disorder, induced delusional disorder, puerperal psychosis
Organic: drug-induced psychosis, iatrogenic, complex partial epilepsy, delirium, dementia, Huntington’s, SLE, syphilis, endocrine disturbance, cushings syndrome, metabolic disorders (vit B12 deficiency, porphyria)
Schizophrenia predisposing, precipitating, and perpetuating causes (using biopsychosocial model)
Predisposing:
- BIO: genetics, age 15-35, extremes of parental age, high dopamine, reduced glutamate, reduced serotonin, reduced GABA, intrauterine infection, premature birth, foetal brain injury, obstetric complications
- PSYCHO: family history, child abuse
- SOCIAL: substance misuse, low socioeconomic status, migrants
Precipitating:
- BIO: smoking cannabis, psychostimulatnts
- PSYCHO: adverse life events, poor coping style
- SOCIAL: adverse life events
Perpetuating:
- BIO: substance misuse, poor compliance to medication
- PSYCHO: adverse life events
- SOCIAL: reduced social support, expressed emotion
Positive symptoms of schizophrenia
Positive symptoms = acute syndrome
‘Delusions Held Firmly Think Psychosis’:
- Delusions
- Hallucination (usually third person auditory)
- Formal thought disorder
- Thought interference (insertion, withdrawal, broadcast)
- Passivity phenomenon (actions, feelings or emotions being controlled by an external force)
Negative symptoms of schizophrenia
Negative symptoms = chronic syndrome (‘loss of function’)
‘The A factor’:
- Avolition (reduced motivation)
- Asocial behaviour
- Anhedonia
- Alogia (poverty of speech)
- Affect blunted
- Attention deficits
ICD-10 criteria for schizophrenia
Group A:
- Thought echo/ insertion/ withdrawal/ broadcast
- Passivity phenomenon
- Running commentary auditory hallucinations
- Bizarre persistent delusions
Group B:
- Hallucinations in other modalities that are persistent
- Thought disorganisation (loosening of associations, neologisms, incoherence)
- Catatonic symptoms
- Negative symptoms
ICD-10: at least one very clear symptom from group A or two or more from group B for at least 1 month or more. Must be in the absence of organic brain disease
Investigations for schizophrenia
Bloods: FBC (anaemia, infection), TFTs (thyroid dysfunction may cause psychosis), glucose, HbA1c, serum calcium (hypercalcaemia may cause psychosis), U+Es, LFTs, cholesterol, vit B12 and folate (deficiencies can cause psychosis)
Urine drug test
ECG (antipsychotics cause prolonged QT)
CT scan (rule out organic causes, eg. space occupying lesions)
EEG (rule out temporal lobe epilepsy)
Management of schizophrenia
MHA risk assessment
MDT and care programme approach (CPA)
BIO: antipsychotics, adjuvants (benzodiazepines, antidepressents, lithium), ECT (if catatonic schizophrenia)
PSYCHO: CBT, family intervention, art therapy, social skills training
SOCIAL: support groups, peer support, supported employment programmes
Antipsychotics in schizophrenia
Atypical antipsychotics are first line: risperidone, olanzapine
Depot formulations should be considered if there is problem with non-compliance
Clozapine is most effective and is used for treatment-resistant schizophrenia (failure to respond to two other antipsychotics)
Poor prognostic factors of schizophrenia
Strong family history Gradual onset Reduced IQ Premorbid history of social withdrawal No obvious precipitant
Common symptoms of anxiety/neurotic disorders
PSYCH: anticipatory fear of impending doom, worrying thoughts, exaggerated startle response, restlessness, poor concentration and attention, irritability, depersonalisation, derealisation
CARDIO: palpitations, chest pain
RESP: hyperventilation, cough, chest tightness
GI: abdo pain (‘butterflies’), loose stools, N+V, dysphagia, dry mouth
GU: increased frequency, failure of erection, menstrual discomfort
NEURO: tremor, myalgia, headache, paraesthesia, tinnitus
Classification of anxiety disorders
CONTINUOUS: generalised anxiety disorder
PAROXYSMAL:
- Situation dependent: phobic anxiety disorder (specific phobia, agoraphobia, social phobia)
- Situation independent: panic disorder
Conditions associated with anxiety
Medical: hyperthyroidism, hypoglycaemia, anaemia, phaechromocytoma, CUshings, COPD, CCF, malignancies
Substance related: intoxication (alcohol, cannabis, caffeine), withdrawal (alcohol, benzodiazepines, caffeine), side effects (thyroxine, steroids, adrenaline)
Psychiatric: eating disorders, somatoform disorders, depression, schizophrenia, OCD, PTSD, adjustment disorder, anxious/avoidant personality disorder
Generalised anxiety disorder
-definition
Ongoing, uncontrollable, widespread worry about many thoughts or events that the patient recognises as excessive and inappropriate
Symptoms must be present on most days for at least 6 months
Causes of generalised anxiety disorder (biological and environmental)
Biological:
- Genetic: genetics, family history
- Neuro: dysfunction of autonomic nervous system, exaggerated response int he amygdala and hippocampus, alterations in GABA/ serotonin/ noradrenaline
Environmental:
- Stressful life events
- Substance dependence or exposure to organic solvents
Risk factors for generalised anxiety disorder
- predisposing
- precipitating
- maintaining
Predisposing: genetics, childhood upbringing, personality type and demands for high achievement, being divorced, living alone or as a single parent, low socioeconomic status
Precipitating: stressful life events such as domestic violence, unemployment, relationship problems, personal illness
Maintaining: continuous stressful events, marital status, living alone and ways of thinking which perpetuate anxiety
Clinical features specific to GAD
WATCHERS:
- Worry (excessive, uncontrollable)
- Autonomic hyperactivity (sweating, increased pupil size, increased HR)
- Tremor/ tension in muscles
- Concentration difficulty/ chronic aches
- Headache/ hyperventilation
- Energy loss
- Restlessness
- Startled easily/ sleep disturbance
ICD-10 criteria for GAD
A period of at least 6 months with prominent tension, worry and feelings of apprehension about everyday events and problems
At least four of the following symptoms with at least one symptom of autonomic arousal:
- Autonomic arousal: sweating, palpitations, tremor, dry mouth
- Other symptoms: difficulty breathing, feeling of choking, chest pain, nausea, abdo pain, loose motions, feeling dizzy, fear of dying, fear of losing control, derealisation, hot flushes, cold chills, numbness or tingling, headache, muscle tension/ ache/ pain, restlessness, feeling on edge, difficulty swallowing, sensation of lump in throat, being startled, concentration difficulty and mind blanks, persistent irritability, sleep problems
Investigations for GAD
Bloods: FBC (infection, anaemia), TFTs (hyperthyroidism), glucose (hypoglycaemia)
ECG (sinus tachycardia)
Questionnaires (GAD-7, Hospital Anxiety and Depression Scale)
Drug management of GAD
- First line drug treatment is SSRI (sertraline)
- SNRI second line
- Pregabalin third line
- Continue medication for at least 1 year
- Benzodiazepines should only be offered as short-term measures during crises
Stepped care model for the management of GAD
1: identify and assess GAD. Psychoeducation about GAD and active monitoring.
2. Low intensity psychological interventions (self-help methods, psychoeducational group therapy)
3. High intensity psychological interventions (CBT, applied relaxation), or drug treatment (first line SSRI)
4. Highly specialist input (eg. MDT), crisis team, etc.
Specific phobia vs. agoraphobia vs. social phobia
A phobia is an intense, irrational fear of something that is recognised as excessive or unreasonable
- Specific phobia: a fear restricted to a specific object or situation (eg. snakes)
- Agoraphobia: fear of the marketplace. Fear of public spaces or fear of entering a public space from which immediate escape would be difficult in the event of a panic attack. Maintained by avoidance which prevents deconditioning and sets up a vicious cycle of anxiety
- Social phobia: a fear of social situations which may lead to humiliation, criticism, or embarrassment
Risk factors for phobias
Aversive experiences (prior experiences with specific objects or situations) Stress and negative life events Other anxiety disorders Mood disorders Substance misuse disorders Family history
ICD-10 criteria for agoraphobia
A. Marked and consistently manifest fear in, or avoidance of, at least two of the following: crowds, public spaces, travelling alone, travelling away from home.
B. Symptoms of anxiety in the feared situation with at least two symptoms present together (and at least one symptom of autonomic arousal)
C. Significant emotional distress due to avoidance, or anxiety symptoms. Recognised as excessive or unreasonable
D. Symptoms restricted to feared situation
ICD-10 criteria of social phobia
A. Marked fear (or marked avoidance) of being the focus of attention, or fear of acting in a way that will be embarrassing or humiliating
B. At least two symptoms of anxiety in the feared situation plus one of the following: blushing, fear of vomiting, urgency/fear of micturition/defaecation
C. Significant emotional distress due to the avoidance or anxiety symptoms
D. Recognised as excessive or unreasonable
E. Symptoms restricted to feared situation
ICD-10 criteria for specific phobia
A. Marked fear or avoidance to a specific object or situation that is not agoraphobia or social phobia
B. Symptoms of anxiety in the feared situation
C. Significant emotional distress due to the avoidance or anxiety symptoms. recognised as excessive or unreasonable.
D. Symptoms restricted to the feared situation
Management of phobic anxiety disorders
Agoraphobia:
- CBT is the psychological intervention of choice. This includes graduated exposure and desensitisation.
- SSRIs are first line pharmacological agents
Social phobia:
- CBT specifically designed for social phobia. Graduated exposure to feared situations.
- Pharmacological interventions: SSRIs, SNRIs, MAOI
- Psychodynamic psychotherapy
- Specific phobia:
- Exposure (either using self-help methods or more formally through CBT)
- Benzodiazepines may be used short-term (eg. if patient needs CT and they are claustrophobic)
Risk factors for panic disorder
Family history, major life events, age (20-30), recent trauma, females, other mental disorders, white ethnicity, asthma, cigarette smoking, medication (eg. benzo withdrawal)
ICD-10 criteria for panic disorder
A. Recurrent panic attacks that are not consistently associated with a specific situation or object, and often occur spontaneously.
The panic attacks are not associated with marked exertion or with exposure to dangerous or life-threatening situations.
B. Characterised by ALL of the following: discrete episode of intense fear or discomfort, starts abruptly, reaches a crescendo within a few minutes and lasts at least some minutes, at least one symptoms of autonomic arousal, and other symptoms of GAD present
