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
Comparing GAD, panic disorder and phobic anxiety
- Age
- When does it occur
- Associated behaviour
- Cognition
- Associations
AGE: GAD variable (adolescence to late adulthood), panic disorder late adolescence to early adulthood, phobia disorder childhood to late adolescence
WHEN: GAD persistent, panic disorder episodic, phobic disorder situational
ASSOCIATED BEHAVIOUR: GAD agitation, panic disorder escape, phobic disorder avoidance
COGNITION: GAD constant worry, panic disorder fear of symptoms, phobic disorder fear of situation
ASSOCIATIONS: GAD depression, panic disorder depression/ agoraphobia/ substance misuse, phobic disorder substance misuse
Stepped care mode for management of panic disorder
- Recognition and diagnosis. Identifying common co-morbidities such as depression and substance misuse.
- Primary care: psychological therapies, medications, self-help strategies. CBT is the psychological intervention of choice. Self-help methods include bibliotherapy, support groups, and encouraging exercise.
- Consider alternative treatments
- Review and refer to specialist mental health services
- Care in specialist mental health services
Pharmacological management of panic disorder
- SSRIs are first line
- If SSRIs are not suitable, or if there is no improvement in 12 weeks, then a TCA (imipramine, clomipramine) may be considered
- Benzodiazepines should not be prescribed
Post-traumatic stress disorder
Intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event
What classes as abnormal bereavement?
Delayed onset, more intense and prolonged (>6m)
Impact of their loss overwhelms the individuals coping capacity
Risk factors for PTSD
Profession (armed forces, fire services, etc) - exposed to major traumatic events
Groups at risk (refugees, asylum seekers) - exposed to major traumatic event
Pre-trauma: previous trauma, history of mental illness, females, low socioeconomic background, childhood abuse
Peri-trauma: severity of trauma, perceived threat to life, adverse emotional reaction during or immediately after event
Post-trauma: concurrent life stressors, absence of social support
PTSD clinical features
Must occur within 6 months of the event.
Can be divided into 4 categories:
- Reliving the situation (flashbacks, nightmares)
- Avoidance (inability to recall aspects of the trauma, avoiding reminders of the trauma)
- Hyperarousal (irritability, outbursts, low concentration, sleep difficulty, hypervigillance, exaggerated startle response)
- Emotional numbing (negative thoughts about self, difficulty experience emotions, detachment, anhedonia)
ICD-10 criteria for PTSD
A. Exposure to a stressful event
B. Persistent remembering/ reliving of the stressful event
C. Avoidance of similar situations resembling or associated with the event
D. Either:
- Inability to recall some aspects of the event
- Persistent symptoms of increased psychological sensitivity and arousal
E. Criteria B, C and D all occur within 6 months of the stressful event
Stages of grief
DABDA
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Differential diagnoses for PTSD
Adjustment disorder, acute stress reaction, bereavement, dissociative disorder, mood or anxiety disorder, personality disorder
Head injury, alcohol/substance misuse
Management of PTSD
Symptoms within 3 months of a trauma:
- Watchful waiting for mild symptoms lasting <4 weeks
- Trauma focussed CBT
- Short term drug treatment for sleep disturbance (eg. zopiclone)
- Risk assessment
Symptoms >3 months after a trauma:
- Trauma focused psychological intervention
- CBT
- Eye movement desensitisation and reprocessing (EMDR)
- Drug treatment if there is no benefit in psych therapy, if patient doesnt want to engage in psych therapy, or if co-morbid depression or severe hyperarousal
Drug treatment: mirtazapine (most common), paroxetine, amitriptyline, phenelzine
Obsessive compulsive disorder definition
Obsessions definition
Compulsions definition
Recurrent obsessional thoughts or compulsive acts, or commonly both
Obsessions: unwanted intrusive thoughts, images or urges that repeatedly enter the individuals mind. They are distressing for the individual who attempts to resist them and recognises them as absurd and a product of their own mind
Compulsions: repetitive, stereotyped behaviours or mental acts that a person feels drives into performing. they are overt (observable by others) or covert (mental acts not observable)
Risk factors for OCD
Early adulthood
Family history
Carrying out the compulsive act exacerbates the obsession so is a maintaining factor
Developmental factors: neglect, abuse, bullying, social isolation
Clinical features of OCD
The OCD cycle
FORD Car:
- Failure to resist: at least one obsession or compulsion is present which is unsucessfully resisted
- Originate from patients mind
- Repetitive and Distressing
- Carrying out the obsessive thought is not in itself pleasurable but reduces anxiety levels
The OCD cycle:
- Obsession
- Anxiety
- Compulsion
- Relief
Investigation for OCD
Yale-Brown Obsessive-Compulsive scale (Y-BOCS)
Differentials for OCD
Obsessions and compulsions:
- Eating disorders
- Anankastic personality disorder
- Body dysmorphic disorder
Primarily obsessions:
- Anxiety disorder
- Depressive disorder
- Hypochondriacal disorder
- Schizophrenia
Primarily compulsive:
- Tourettes syndrome
- Kleptomania (inability to refrain from stealing things)
Organic:
- Dementia
- Epilepsy
- Head injury
Management of OCD
-CBT (including exposure and response prevention)
-Pharmacological therapy:
SSRIs are first-line (fluoxetrine, sertraline, paroxetine, citalopram)
-Comipramine (TCA) may be used or added to SSRI
-Antipsychotic may be added to an SRI or clomipramine
- Treat any comorbid depression
- Psychoeducation, distracting techniques and self-help books can help
Exposure response prevention
Used to treat OCD
Patients are repeatedly exposed to the situation which causes them anxiety and are prevented from performing the repetitive actions which lessen that anxiety
After initial anxiety on exposure, the levels of anxiety gradually decrease
What are somatoform disorders?
Symptoms suggestive of a physical disorder but in the absence of a physiological illness
Patient adopts the sick role which provides relief from stressful or unachievable interpersonal expectations (primary gain). This offers attention and care from others, and sometimes financial rewards (secondary gain)
(eg. ‘i think i have a serious illness and need to go to hospital for more tests’)
What is dissociative (conversion) disorder?
Distressing event -> emotional distress -> dissociation (separation of the distressing event from normal consciousness) -> conversion (of emotional distress to physical symptoms) -> gain (primary gain = stress relief, or secondary gain = financial rewards or benefits)
(eg. ‘ever since losing my job i have been feeling so unwell’)
Risk factors for somatoform and dissociative disorders
Childhood abuse Reinforcement of illness behaviours Anxiety disorders Mood disorders Personality disorders Social stressors
ICD-10 criteria for somatisation disorder
Requires all four to be present:
- At least 2 years duration of physical symptoms that cannot be explained by any detectable physical disorder
- Preoccupation with symptoms causes physical distress which leads to them seeking repeated medical consultations and requesting investigations
- Continuous refusal by patients to accept reassurance from doctors that there is no physical cause for their symptoms
- A total of six or more symptoms
Common symptoms in somatisation disorder
GI: abdo pain, N+V, bloating, regurgitation, loose bowel motions, swallowing difficulty
CVS: chest pain, SOB, palpitations
GU: dysuria, frequency, incontinence, vaginal discharge, menstrual problems
Others: discolouration and itching of skin, arhtralgia, paraesthesia, headaches, visual disturbance
What is somatisation disorder?
Multiple, recurrent and frequently changing physical symptoms not explained by a physical illness
More common in women
Long history of contact with medical services
Often dependent on analgesics
Malingering vs factitious disorder (Munchausen)
They are both disorders in which physical or psychological symptoms are intentionally produced
The difference is the motive behind mimicking the symptoms
Malingering: patient seeks advantageous consequences of being diagnosed with a medical condition
(eg. ‘if i go to hospital i may receive compensation’)
Factitious disorder (Munchausen syndrome): the individual wishes to adopt the 'sick role' in order to receive internal emotional gain (eg. 'i want to go to hospital to be looked after')
Management of somatoform and dissociative disorders
BIO: antidepressants (SSRI) for underlying mood disorders, physical exercise
PSYCHO: CBT, coping strategies
SOCIAL: encourage pleasurable private time (hobbies), involving family where appropriate
Definition of anorexia
Eating disorder characterised by deliberate weight loss, an intense fear of fatness, distorted body image, and endocrine disturbance
Predisposing, precipitating and perpetuating factors of anorexia nervosa (separate into BIOPSYCHOSOCIAL)
Predisposing:
- BIO: genetics, family history, female, early menarche
- PSYCHO: sexual abuse, preoccupation with slimness, dieting behaviours starting in adolescence, low self-esteem, premorbid anxiety or depressive disorder, perfectionism
- SOCIAL: western society pressures on being beautiful, bullying in school around weight, stressful life events
Precipitating:
- BIO: adolescence and puberty
- PSYCHO: criticism regarding eating, body shape and weight
- SOCIAL: occupational or recreational pressures
Perpetuating:
- BIO: starvation leads to neuroendocrine changes that perpetuate anorexia
- PSYCHO: perfectionism, obsessional/anankastic personality
- SOCIAL: occupation, western society
ICD-10 criteria for anorexia nervosa
‘FEEDD’:
- Fear of weight gain
- Endocrine disturbance (resulting in amenorrhoea in females, and loss of libido and potency in males)
- Emaciated (BMI <17.5)
- Deliberate weight loss (with reduced food intake or increased exercise)
- Distorted body image
These features must be present for >3 months and there must be the ABSENCE of (1) recurrent episodes of binge eating; (2) preoccupation with eating/craving to eat
Clinical features of anorexia nervosa
FEEDD (ICD-10): fear of weight gain, endocrine disturbance, emaciated (BMI<17.5), deliberate weight loss, distorted body image
Other features (PP, SS):
- Physical: lanugo hair, fatigue, hypothermia, bradycardia, arrhythmias, peripheral oedema (hypoalbuminaemia), headache
- Preoccupation with food (dieting, preparing elaborate meals for others)
- Social isolation, sexually feared
- Symptoms of depression and obsession
Anorexia nervosa vs bulimia nervosa
- weight
- endocrine
- cravings
- bingeing
- weight loss behaviours
AN significantly underweight, BN usually normal weight/overweight
AN more likely to have endocrine abnormalities such as amenorrhoea, BN less likely to have endocrine abnormalities
AN do not have strong cravings for food, BN has strong cravings for food
AN do not binge eat, BN have recurrent episodes of binge eating
AN may have compensatory weight loss behaviours (excluding purging), BN have compensatory weight loss behaviours
Investigations for anorexia nervosa
- FBC (anaemia, thrombocytopenia, leukopenia)
- U+Es (high urea and creatinine, low potassium, phosphate, magnesium, chloride)
- TFTs (hypothyroidism)
- LFTs (hypoalbuminaemia)
- Lipids (hypercholesterolaemia)
- Cortisol (high)
- Sex hormones (low LH, FSH, oestrogens, progesterones)
- Glucose (low)
- Amylase (pancreatitis is a complication)
- VBG (metabolic alkalosis due to vomiting, metabolic acidosis due to laxatives)
- DEXA scan (rule out osteoporosis)
- ECG (arrhythmias, such as sinus bradycardia and prolonged QT)
- Questionnaires (eating attitudes test - ‘EAT’)
Differential diagnoses for anorexia nervosa
Bulimia nervosa
Eating disorder not otherwise specified (EDNOS)
Depression
OCD
Schizophrenia
Organic causes of low weight (DM, hyperthyroidism, malignancy)
Alcohol or substance misuse
Complications fo anorexia nervosa
- Metabolic: hypokalaemia, hypercholesterolaemia, hypoglycaemia, deranged LFTs, raised urea and creatinine if dehydrated, low phosphate, low magnesium, low albumin, low chloride
- Endocrine: high cortisol, high growth hormone low T3/T4, low LH/FSH/oestrogens/progesterones (amenorrhoea), low testosterone in males
- GI: enlarged salivary glands, pancreatitis, constipation, peptic ulcers, hepatitis
- CVS: cardiac failure, ECG abnormalities, arrhythmias, hypotension, bradycardia, peripheral oedema
- Renal: renal failure, renal stones
- Neuro: seizures, peripheral neuropathy, autonomic dysfunction
- Haem: iron deficiency anaemia, thrombocytopenia, leucopenia
- MSK: proximal myopathy, osteoporosis
- Others: hypothermia, dry skin, brittle nails, lanugo hair, infections, suicide
Management of anorexia nervosa
Risk assessment for suicide and medical complications
BIO: treat medical complications, SSRIs for co-morbid depression or OCD
PSYCHO: psycho-education, CBT, cognitive analytic therapy, interpersonal psychotherapy, family therapy
SOCIAL: volunteer organisations, self-help groups
Psychological treatments should be for at least 6 months
The aim of treatment as an inpatient is a weight gain of 0.5-1kg/week and as an outpatient of 0.5kg/week
Hospitalisation for medical (severe electrolyte abnormalities, BMI <14) or psychiatric (suicide) reasons
Use MHA if necessary
Patients are at risk of refeeding syndrome and other complications when eating again
What complication do you need to be aware of when treating anorexia nervosa?
Refeeding syndrome (low phosphate, low potassium, low magnesium)
What is refeeding syndrome?
Why does it happen?
How do you prevent?
Life-threatening syndrome that results from food intake after prolonged starvation or malnourishment
Low phosphate, low potassium, low magnesium
Occurs as a result of an insulin surge following increased food intake
Phosphate depletion can cause reduction in cardiac muscle activity which can lead to cardiac failure
Prevention: measure serum electrolytes prior to feeding and monitor refeeding blood daily. Start at 1200kcal/day and gradually increase every 5 days, monitor for signs (eg. tachycardia, oedema)
Bulimia nervosa definition
The cycle of BN
Two types of bulimia nervosa
Eating disorder characterised by repeated episodes of uncontrollable binge eating followed by compensatory weight loss behaviours and overvalued ideas regarding ideal body shape/weight
Cycle of BN: sense of compulsion to eat -> binge eating -> fear of fatness -> compensatory weight loss behaviour -> cycle repeated
Two types:
- Purging: patient uses behaviours to expel food from body (vomiting, laxatives, enemas)
- Non-purging: less common. Patient uses excessive exercise or fasting after a bine
Risk factors for Bulimia nervosa
predisposing, precipitating, perpetuating biopsychosocial
Predisposing:
- BIO: female, FHx of substance abuse or eating disorders or mental health, early onset puberty, T1DM, childhood obesity
- PSYCHO: child abuse, bullying, parental obesity, pre-morbid mental illness, preoccupation with slimness, parents with high expectations, low self esteem
- SOCIAL: living in a developed country, profession, difficulty resolving conflicts
Precipitating:
- BIO: early onset of puberty
- PSYCHO: perceived pressure to be thin from culture, criticism regarding appearance
- SOCIAL: environmental stressors, family dieting
Perpetuating:
- BIO: co-morbid mental health problems
- PSYCHO: low . self-esteem, perfectionism, obsessional personality
- SOCIAL: environmental stressors
ICD-10 criteria for bulimia nervosa
-Plus other features of BN
‘Bulimia Patients Fear Obesity’:
- Behaviours: compensatory weight loss behaviours (vomiting, starvation, laxatives, diuretics, appetite suppressants, excessive exercise)
- Preoccupation with eating: compulsion to eat leading to bingeing, followed by a period of shame
- Fear of fatness: and a self-perception of being too fat
- Overeating: at least 2 episodes per week for a period of 3 months
Other features of BN (not in the ICD-10 criteria):
- Normal weight
- Depression and low self-esteem
- Irregular periods
- Signs of dehydration
- Consequences of repeated vomiting and hypokalaemia
Investigations for bulimia nervosa
- Bloods: FBC, U+Es, amylase, lipids, glucose, TFTs, magnesium, calcium, phosphate
- VBG: may show metabolic alkalosis
- ECG: arrythmias due to hypokalaemia (ventricular arrhythmias are life threatening), classic ECG changes (prolongation of PR interval, flattened or inverted T waves, prominent U waves after T wave)
Physical complications of repeated vomiting (organised into systems)
- CVSL arrhythmias, mitral valve prolapse, peripheral oedema
- GI: mallory weiss tears, increased size of salivary glands especially parotid
- Metabolic/renal: dehydration, hypokalaemia, renal stones, renal failure
- Dental: permanent erosions of dental enamel
- Endocrine: amenorrhoea, irregular menses, hypoglycaemia, osteopenia
- Derm: Russel’s sign (calluses on the back of hand due to abrasion against teeth)
- Pulm: aspiration pneumonitis
- Neurological: cognitive impairment, peripheral neuropathy, seizures
Management of bulimia nervosa
BIO: trial antidepressants (fluoxetine), treat medical complications of repeated vomiting, treat comorbid conditions
PSYCH: psychoeducation, CBT specifically for BN (CBT-BN), interpersonal psychotherapy
SOCIAL: food diary, techniques to avoid bingeing, small regular meals, self-help programmes
Monitor electrolytes carefully
Risk assessment for suicide
Inpatient treatment for suicide risk and severe electrolyte imbalances
MHA not usually required as patients have good insight
Opiates
- examples
- route of administration
- psych effects
- physical effects
- withdrawal state signs
- examples: morphine, diamorphine (heroin), codeine, methadone
- route of administration: morphine (PO, IV), diamorphine (IN, IV, smoked), codeine and methadone (PO)
- psych effects: apathy, disinhibition, psychomotor retardation, impaired judgement, drowsiness, slurred speech
- physical effects: resp depression, coma, pupillary constriction, hypoxia, hypotension, hypothermia
- withdrawal state signs: craving, rhinorrhoea, lacrimation, myalgia, abdo cramps, N+V, diarrhoea, pupillary dilatation, piloerection, tachycardia, hypertension
Cannabinoids
- examples
- route of administration
- psych effects
- physical effects
- withdrawal state signs
- examples: cannabis
- route of administration: PO, smoked
- psych effects: euphoria, disinhibition, agitation, paranoid ideation, temporal slowing, impaired judgement, illusions, hallucinations
- physical effects: increased appetite, dry mouth, conjunctival injection, tachycardia
- withdrawal state signs: anxiety, irritability, tremor of outstretched hands, sweating, myalgia
Sedative hypnotics
- examples
- route of administration
- psych effects
- physical effects
- withdrawal state signs
- examples: benzodiazepines, barbiturates
- route of administration: PO, IV
- psych effects: euphoria, disinhibition, apathy, aggression, anterograde amnesia, labile mood
- physical effects: unsteady gait, difficulty standing, slurred speech, nystagmus, erythematous skin lesions, hypotension, hypothermia, depression of gag reflex, coma
- withdrawal state signs: tremor (tongue, hands, eyelids), N+V, tachycardia, postural hypotension, headache, agitation, malaise, transient illusions, hallucinations, paranoid ideation, grand mal convulsion
Stimulants
- examples
- route of administration
- psych effects
- physical effects
- withdrawal state signs
- examples: cocaine, crack cocaine, ecstasy (MDMA), amphetamine
- route of administration: cocaine and crack cocain (IN, IV, smoked), ecstasy (PO), amphetamine (PO, IV, IN, smoked)
- psych effects: euphoria, increased energy, grandiose beliefs, aggression, illusions, hallucinations, paranoid ideation, labile mood
- physical effects: tachycardia, hypertension, arrhythmias, sweating, N+V, pupillary dilatation, psychomotor agitation, muscular weakness, chest pain, convulsions
- withdrawal state signs: dysphoric mood, lethargy, psychomotor agitation, craving, increased appetite, insomnia, bizarre dreams
Hallucinogens
- examples
- route of administration
- psych effects
- physical effects
- examples: LSD, magic mushrooms
- route of administration: PO
- psych effects: anxiety, illusions, hallucinatinos, depersonalisation, derealisation, paranoia, ideas of reference, hyperactivity, impulsivity, inattention
- physical effects: tachycardia, palpitations, sweating, tremor, blurred vision, pupillary dilatation, incoordination
Complications of substance misuse
Physical: death, HIV, hep A/ B/ C, staphylococcus aureus, grooup A strep, Clostridium, TB, endocarditis, superficial thrombosis, DVT, PE
Psych: cravings, anxiety, cognitive disturbance, drug-induced psychosis
Social: crime, imprisonment, homelessness, prostitution, relationship problems
Investigations for substance misuse
Bloods: HIV screen, hep B, hep C, TB screen, U_Es, LFTs and clotting, drug levels
Urinalysis
ECG for arrhythmias
ECHO if ?endocarditis
Management of substance misuse
Key worker with a therapeutic alliance
Hep B immunisation if at risk
Motivational interviewing and CBT
Contingency management (change behaviours by offering incentives)
Supportive help for housing, finance, employment, etc
Self-help groups
Review DVLA guidelines
Biological therapies for opioid dependence
Treatment of opioid overdose
Methadone (first line) or buprenorphine for detoxification and maintenance
Naloxone IV can be used as an antidote to opioid overdose
Alcohol abuse vs binge drinking vs harmful alcohol use
Alcohol abuse: consumption of alcohol at a level sufficient to cause physical, psychiatric and/or social harm
Binge drinking: drinking over twice the recommended level of alcohol per day, in one session (>8 units for men and >6 units for females)
Harmful alcohol use: drinking above safe levels with evidence of alcohol-related problems (>50 units/week in males, >35 units/week in females)
Effects of alcohol consumption (BIOPSYCHOSOCIAL)
BIO:
- Hepatic: fatty liver, hepatitis, cirrhosis, HCC
- GI: peptic ulcer disease, varices, pancreatitis, oesophageal carcinoma
- CVS: HTN, cardiomyopathy, arrhythmias
- Haem: anaemia, thrombocytopenia
- Neuro: seizures, peripheral neuropathy, Wernickes encephalopathy, Korsakoff syndrome, head injury
- Obstetrics: foetal alcohol syndrome
PSYCHO:
- Morbid jealousy
- Self harm and suicide
- Mood and anxiety disorders
- Alcohol-related dementia
- Alcohol hallucinations
- Delirium tremens
SOCIAL:
- Domestic violence
- Drink driving
- Employment difficulties
- Financial problems
- Homelessness
- Accidents
- Relationship problems
Clinical features of alcohol intoxication
Slurred speech
Labile affect
Impaired judgement
Poor coordination
Hypoglycaemia
Stupor
Comor
Alcohol withdrawal
- clinical features
- when do features occur
- when is peak incidence of seizures
Symptoms: malaise, tremor, nausea insomnia, transient hallucinations, autonomic hyperactivity
Occurs 6-12hrs after abstinence
Peak incidence of seizures at 36 hours
The severe end of the spectrum = delirium tremens and the peak incidence is 72 hours
Delirium tremens
- what is it
- peak incidence
- features
- management
Withdrawal delirium develops between 24hrs and one week after alcohol cessation
Peak incidence is 72 hours
Physical illness is a predisposing factor
Features: dehydration, electrolyte disturbances, cognitive impairment, vivid perceptual abnormalities, paranoid delusions, marked tremor, autonomic arousal
Mx: chlordiazepoxide (benzo), haloperidol for any psychotic features, IV pabrinex
Questionnaire for alcohol dependence
CAGE
- have you ever felt like you should CUT DOWN?
- have people ANNOYED you by criticising your drinking?
- have you ever felt GUILTY about drinking?
- do you ever have a drink early in the morning (EYE OPENER)?
Investigations for alcohol abuse
Bloods: blood alcohol level, FBC and MCV, U+E, LFTs and gamma . GT, blood alcohol concentration, vit B12 and folate, TFTs, amylase, hepatitis serology, glucose
Alcohol questionnaires (AUDIT, FAST)
CT head if ?head injury
ECG
How to calculate alcohol units in a beverage
Examples of 1 unit of alcohol
Alcohol units = [strength (alcohol by vol) x volume (ml)] /1000
1 unit =
1/2 pint ordinary strength beer/lager/cider
1 very small glass of wine
1 single measure of spirit
Management of alcohol abuse
Alcohol withdrawal: chlordiazepoxide detox regime + thiamine
Disulfiram
Treatment of medical and psychiatric complications
Motivational interviewing (and CBT)
Social network and environmental based therapies
Alcoholics anonymous
Social support including family involvement
Definition of personality disorders
Deeply ingrained and enduring pattern of inner experience and behaviour that deviates markedly from expectation in te individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment
Risk factors for personality disorders
Society: both low socioeconomic status and social reinforcement of abnormal behaviour are linked to PDs
Genetics and family history
Dysfunctional family: poor parenting and parental deprivation
Abuse during childhood
The different types of personality disorders
Cluster A ‘weird’ (odd/eccentric):
- Paranoid
- Schizoid
Cluster B ‘wild’ (dramatic, emotional):
- Emotionally unstable (borderline)
- Dissocial (antisocial)
- Histrionic
Cluster C ‘worrier’ (anxious, fearful):
- Dependent
- Avoidant (anxious)
- Anankastic (obsessional)
Cluster A clinical features
- paranoid
- schizoid
Paranoid (SUSPECTS): suspicious, unforgiving, spouse fidelity questioned, perceives attack, envious, criticism not liked, trust in others reduced, self-reference
Schizoid (DISTANT): detached affect, indifferent to praise or criticism, sexual drive reduced, tasks done alone, absence of close friends, no emotion, takes pleasure in few activities
Cluster B clinical features
- emotionally unstable
- dissocial
- histrionic
Emotionally unstable (AM SUICIDE): abandonment feared, mood instability, suicidal behaviour, unstable relationships, intense relationships, control of anger poor, impulsivity, disturbed sense of self, emptiness
Dissocial (CORRUPT): callous, others blamed, reckless disregard for safety, remorseless, underhanded, poor planning, temper/ tendency to violence
Histrionic (PRAISE): prevocative, real concern for physical attractiveness, attention seeking, influenced easily, shallow/seductive, egocentric, exaggerated emotions
Cluster C clinical features
- dependent
- anxious avoidant
- anankastic
Dependent (RELIANCE): reassurance required, expressing disagreement is difficult, lack of self-confidence, initiating projects is difficult, abandonment feared, needs others to assume responsibility, companionship sought, exaggerated fears
Anxious avoidant (CRIES): certainty of being liked needed before becoming involved with people, restriction to lifestyle in order to maintain security, inadequacy felt, embarrassment potential prevents involvement in new activities, social inhibition
Anankastic (LAW FIRMS): loses point of activity, ability to complete tasks compromised, workaholic at the expense of leisure, fussy, inflexible, rigidity, meticulous attention to detail, stubborn
Investigations for personality disorder
Questionnaires: personality diagnostic questionnaire
Psychological testing: Minnesota multiphasic personality inventory
CT head/MRI: rule out organic causes of personality change such as frontal lobe tumours and intracranial bleeds
Differential diagnoses for personality disorders
Mood disorders (mania, depression)
Psychotic disorders (schizophrenia, schizoaffective disorder)
Substance misuse
Management of personality disorders
Recognise and treat psychiatric illness and substance misuse
Risk assessment is crucial, particularly in emotional unstable PD
Psychosocial interventions (CBT, psychodynamic psychotherapy, dialectial behavioural therapy)
Pharmacological management will not resolve PD but may be used to control symptoms (low-dose antipsychotics, antidepressants, mood stabilisers)
Give the patient a written crisis plan. Consider crisis resolution team and MHA in acute situations
Support groups, substance misuse services, social support
Risk factors for deliberate self harm
Divorced, single, living alone Severe life stressors Harmful drug/alcohol use Less than 35y Chronic physical health problems Violence or childhood maltreatment Socioeconomic disadvantage Psychiatric illness
Antidotes for overdose
- Paracetamol
- Opiates
- Benzodiazepines
- Warfarin
- Beta blockers
- TCAs
- Organophosphates
- Paracetamol: N-acetylcysteine
- Opiates: naloxone
- Benzodiazepines: flumazenil
- Warfarin: vit K
- Beta blockers: glucagon
- TCAs: sodium bicarbonate
- Organophosphates: atropine
Risk factors for suicide
IM A SAD PERSON:
Institutionalised, Mental health disorder, Alone, Sex (male), Age (middle aged), Depression, Previous attempts, Ethanol use, Rational thinking lose, Sickness, Occupation, No job
Side effects of SSRIs
Contraindications and cautions of SSRIs
GI: nausea, dyspepsia, bloating, flatulence, diarrhoea, constipation
‘STRESS’: Sweating, Tremor, Rash, Extrapyramidal side effects, Sexual dysfunction, Somnolence
Cautions: history of mania, epilepsy, heart failure, acute angle-close glaucoma, DM, anticoag history, GI bleeding, hepatic/renal impairment, pregnancy and breast-feeding, young adults, suicidal ideation
Contraindicaiton: mania
Serotonin syndrome
Rare, life-threatening complication of increased serotonin activity, usually rapidly occurring within minutes of taking the medication
Most commonly caused by SSRIs but can be caused by TCAs and lithium
Clinical feature:
- Cognitive: headache, agitation, hypomania, coma, confusion, hallucinations
- Autonomic: shivering, sweating, hyperthermia, HTN, tachycardia
- Somatic: myoclonus, hyperreflexia, tremor
Mx: stop the drug, supportive measures
Mirtazapine
- what class of drug
- indication
- side effects
- cautions
Noradrenaline-serotonin specific antidepressant (NASSA)
Often used second line for depression (after SSRI) in patients who would benefit from weight gain and who suffer from insomnia
Side effects: increased appetite, weight gain, dry mouth, postural hypotension, drowsiness, fatigue, confusion, tremor, dizziness, arthralgia, myoclonus, mania, anxiety, etc
Cautions: elderly, cardiac disorders, hypotension, urinary retention, DM, psychoses, renal or liver impairment, pregnancy, etc
SSRI of choice for children and adolescents
Fluoxetine
Be cautious when prescribing SSRIs to young people because of increased risk of suicidal ideation
Reviewing patients on SSRIs
Review after 2 weeks of prescribing
People <30 or high risk of suicidal thoughts should be reviewed after 1 week
Warn patients about GI side effects, and increased anxiety and agitation when starting an SSRI
Warn them that you may feel worse before you feel better. Takes 4-6 weeks to see improvement.
Indications and side effects for TCAs
Amitriptyline, comipramine, imipramine, nortriptyline, etc
Indications: depression, nocturnal enuresis in children, neuropathic pain, migraine prophylaxis
SE:
- Anticholinergic: dry mouth, constipation, urinary retention, blurred vision, confusion
- Cardiovascular: arrhythmias, postural hypotension, tachycardia, syncope, sweating
- Psych: hypomania, mania, confusion, delirium
- Metabolic: increased appetite, weight gain, glucose changes
- Neuro: convulsions, dyskinesia, dysarthria, paraesthesia, taste disturbance, tinnitus
- Headache, sexual dysfunction, tremor, gynaecomastia
Cautions: cardiac disease, epilepsy, elderly, thyroid disease, psychoses, pregnancy
CI: recent MI, arrhythmias (heart block), mania, severe liver disease, agranulocytosis
MAOI
- examples
- indications
- side effects
- cautions
- contraindications
Examples: phenelzine, moclobemide
Indications: third line for depression, social phobia
SE:
- CVS: postural hypotension, arrhythmias
- Neuropsych: drowsiness, insomnia, headache
- GI: increased appetite, weight gain, deranged LFTs
- Anorgasmia
Hypertensive crisis when eating tyramine containing foods (cheese, bovril, marmite): headache, palpitations, fever, convulsions, coma
MAOIs also interact with insulin, opiates, SSRIs, TCAs and AEDs
Cautions: avoid in agitated or excited patients, thyrotoxicosis, hepatic impairment, bipolar, pregnancy
CI: acute confusional states, phaeochromocytoma
Typical vs atypical antipsychotics
Typical (first generation): haloperidol, chlorpromazine, etc. Block dopamine receptors in the brain.
Atypical (second generation): olanzapine, risperidone, quetiapine, aripiprazole, cloazpine). Block specific dopamine D2 receptors and have serotonergic effects.
Atypical are less likely to cause extrapyramidal side effects
Indications for antipsychotics
Atypical antipsychotics are first-line for schizophrenia
Antipsychotics can also be used for conditions when they present with positive psychotic symptoms (eg. depression, mania, delusional disorder, delirium, dementia, etc)
Clozapine is a third-line treatment for schizophrenia as there is evidence that it is more effective than other antipsychotics. Should only be given after failing to respond to two other antipsychotics
Side effects of antipsychotics
Extrapyramidal (more common in typical): parkinsonism, akathisia, dystonia, tardive dyskinesia
Anti-muscarinic (can’t see, can’t wee, can’t spit, can’t shit): blurred vision, urinary retention, dry mouth, constipation
Anti-histaminergic: sedation and weight gain
Anti-adrenergic: postural hypotension, tachycardia, ejaculatory failure
Endocrine: hyperprolactinaemia, impaired glucose tolerance, hypercholesterolaemia
Neuroleptic malignant syndrome
Prolonged QT interval
Clozapine causes hypersalivation and agranulocytosis
Extrapyramidal side effects
Parkinsonism: bradycardia, rigidity, coarse tremor, masked facies, shuffling gait. Takes weeks or months.
Akathisia: unpleasant feeling of restlessness. Occurs in the first few months.
Dystonia: acute painful contraction of muscles in theneck, jaw and eyes (oculogyric crisis). May occur within days.
Tardive dyskinesia: abnormal involuntary movements (chewing, pouting of the jaw). may be irreversible. Late onset (years)
Neuroleptic malignant syndrome
- definition
- features
- ix
- mx
- complications
Rare but life-threatening condition seen in patients taking antipsychotics. May also occur with dopaminergic drugs for Parkinsons disease, usually when the drug is suddenly stopped or the dose reduced
Clinical features: Pyrexia, muscle rigidity, confusion, fluctuating consciousness and autonomic instability, may have delirium
Ix: creatine kinase (high), FBC (leucocytosis), LFTs (deranged)
Mx: stop antipsychotic, monitor vital signs, IV fluids to prevent AKI, cooling, dantrolene (muscle relaxant), bromocriptine (dopamine agonist), consider benzodiazepines
Complications: AKI, PE, shock
Contraindications and cautions for antipsychotics
Cautions: cardiovascular disease (ECG first), parkinsons disease, epilepsy, depression, myaesthenia gravis, glaucoma, severe resp disease, history of jaundice, blood dyscrasias
Contraindications: comatose states, CNS depression, phaeochromocytoma
What monitoring is required for clozapine
Weekly differential FBC for 18 weeks, then fortnightly for up to 1 year, and then monthly
Indications for ECT
Prolonged or severe mania Catatonia Severe depression (treatment-resistant, suicidal ideation, life-threatening)
Short-term and long term side effects of ECT
Short term (PC DAMS): peripheral nerve palsy, cardiac arrhythmia/confusion, dental or oral trauma, anaesthetic risk, muscular aches and headache, short term memory impairment and status epilepticus
Long term: anterograde and retrograde amnesia
Contraindications for ECT
MI <3 months ago) Major unstable fracture Aneurysm (cerebral) Raised ICP Stroke (<1month ago) History of status epilepticus Severe anaesthetic risk
5 key principles of the mental capacity act (2005)
- Assume capacity is present unless it’s proven that its not
- An unwise decision does not mean they lack capacity
- Help the person make their decision (eg. interpreters)
- If they lack capacity, the decision should be made in their best interest
- The decision made should be the least restrictive
Deprivation of Liberty Safeguard (DOLS)
Aim of DoLS is to make sure that people who lack capacity are looked after in a way that does not inappropriately restrict their freedom
Independent mental capacity advocate
Is someone appointed to support a person who lacks capacity but has no one to speak on their behalf
IMCA makes representations about the persons wishes, feelings, beliefs and values while bringing to the attention of the decision maker all factors that are relevant to the decision
Section 2 and section 3 of the MHA (2007)
S2: allows for an admission, for assessment and response to treatment. Lasts up to 28 days.
S3: allows for treatment of a mental disorder. Patients can be detained under s3 if they are well known to mental health services or following an admission under s2. Can be detained for up to 6 months but may be discharged before this. Detention can be renewed for a further 6 months. After that it can be renewed for further periods of one year at a time.
An AMHP (approved mental health professional) usually makes the application on the recommendation of two approved clinicians with at least one section 12 approved doctor
Patients rights and lack of rights during a s2 and s3 MHA
Patients can appeal an s2 to a tribunal during the first 14 days, or to the hospital managers at any time.
Patients can appeal an s3 to a tribunal once in the first 6 months. If s3 is renewed, an appeal can be made once during the second 6 months. then an appeal can be made once during each one-year period
Patients have the right to apply for a discharge to the mental health act managers at any time whilst they are detained
Patients cant refuse treatment under an S2 or S3.
Patients can be treated under their will for 3 months under an s3, and after this time they are seen by a second opinion appointed doctor (SOAD) if they lack capacity to consent or are refusing treatment. A SOAD carries out an assessment to see if they think treatment is needed
ECT is not included as a treatment under MHA
Emergency MHA sections
Section 4: used as an emergency when s2 would cause unacceptable delay. Can be switched to an s2 when they get to the hospital. Can be done by a doctor with an AMHP or nearest relative. Lasts 72 hours, no right to appeal.
Section 5(2): urgent detention of inpatients on any ward (exc A+E). Patients must then be assessed for an S2 or S3 or discharged. Lasts 72 hours, no right to appeal.
Section 5(4): same as 5(2) but can be done by a registered mental health nurse and lasts 6 hours. Happens when a doctor cant attend immediately. No right to appeal.
Section 135: Allows a police officer to enter a person’s premises to take them to a place of safety
Section 136: Allows a police officer to remove a person from a public place to a place of safety
