Psychiatry Flashcards
Physical signs of anxiety
- Tachycardia
- Palpitations
- Hypertension
- SOB/tachypnoea
- chest pain
- choking sensation
- tremors/shaking
- muscle tension
- dry mouth
- sweating
- cold skin
- nausea/vomiting
- diarrhoea
- ‘butterflies in the stomach’
- dizziness, lightheadedness
- mydriasis
Risk factors and triggers for Hyperventilation Syndrome
- Female
- Age 15-55
- Emotional distress
- Sodium lactate
- Caffeine
Clinical features of hyperventilation syndrome
- agitation
- confusion
- dizziness
- weakness
- depersonalisation
- visual hallucinations
- syncope
- parasthesia: usually bilateral upper limbs
- peri-oral numbness
- atypical chest pain
- tachypnoea
- hyperpnoea
- dyspnoea
- wheeze
- bloating
- belching
- flatus
- epigastic pressure
- dry mouth
- acute hypocalcaemia
- acute hypokalemia
- acute hypophosphatemia
Investigations to rule out an organic cause of hyperventilation syndrome
- FBC
- U&Es
- TFTs
- glucose
- calcium
- ABG: normal pH, normal CO2, low bicarb
- Toxicology
- ELISA
- D-dimer
- ECG
- CXR
- V/Q scan
Acute management of hyperventilation syndrome
- Reassurance
- alleviation of anxiety e.g. benzos
- establishment of normal breathing pattern
Long-term management of hyperventilation syndrome
- Education
- Formal breathing retraining
- B-blockers and benzos
- Treatment of any underlying medical disorder
Prevalence of GAD
3%
Risk factors for GAD
- family history
- female
- age 35-54
- divorced/separated
- living alone
- single parents
- unemployment
- childhood phobias
Description of GAD
Long-standing, free-floating excessive anxiety - excessive worries about minor matters on most days for 6 months, not limited to specific situations
Symptoms of GAD
- Edginess/restlessness
- difficulty concentrating
- irritability
- GI upset
- muscle aches/tension
- difficulty sleeping and chronic fatigue/easy fatiguability
ICD-10 criteria for diagnosis of GAD
Key elements:
1) Apprehension
2) Motor tension
3) Autonomic overactivity
Diagnosis requires at least 4 of the following criteria (with at least 1 from autonomic arousal):
- symptoms of autonomic arousal
- physical symptoms of anxiety
- mental state symptoms
- generalised symptoms
- symptoms of tension
- other: exaggerated response to minor startles
- concentration difficulties
Management of GAD
- CBT
- SSRIs
- beta-blockers for symptomatic relief
- benzos
Prevalence of panic attacks
8%
Describe a panic attack
A sudden period of intense fear or discomfort that something bad is going to happen and there is some imminent threat or danger, often accompanied by physical symptoms. Symptoms peak in the first 10-20 minutes.
Physical symptoms of a panic attack
- Pounding heart/tachycardia
- chest pain
- sweating
- trembling
- SOB
- nausea
- dizziness
- chills or hot flushes
- numbness/tingling
- feelings of choking
- derealisation or depersonalisation
- fear of losing control
- fears of dying
Acute management of a panic attack
- Reassurance
- Consider benzos if symptoms are severe and distressing
- Exclusion of medical causes if first presentaiton
Describe a panic disorder
Recurrent panic attacks that occur unpredictably and are not restricted to any particular situation or objective danger.
Not secondary to substance misuse, a medical condition or other psychiatric disorder.
Prevalence of panic disorders
2%
Risk factors for panic disorder
- Female sex
- Family history
- Age: 15-24, 45-54
- Widowed
- Divorced/separated
- Living in a city
- Limited education
- Early parental loss
- Physical/sexual abuse
Investigations to rule out a organic cause in panic disorder
- FBC
- U&Es
- glucose
- TFTs
- ECG
- Toxicology
- Calcium
- Echo
- EEG
Describe anticipatory anxiety
When patients get anxious about the possibility of having a panic attack
Management of panic disorder
- CBT
- SSRIs
- Benzodiazepines
- continue treatment for 12-18 months before trial discontinuation with tapering doses
Poor prognostic factors for panic disorder
- very severe initial symptoms
- marked agoraphobia
- low SES
- low education level
- long duration of untreated symptoms
- restricted social networks
- personality disorder
Prevalence of phobic disorders
10%
Describe a phobia
Intense unreasonable irrational fear of an object, activity or situation.
Patients recognise this fear as irrational but will go to extreme lengths to avoid the trigger
Management of a phobia
- Gradual exposure therapy
- SSRIs
Prevalence of a specific phobia
6%
Describe agoraphobia
A fear of entering crowded spaces where an immediate escape is difficult or embarrassing, or in which help may not be available in the event of a panic attack
Prevalence of agoraphobia
2%
Risk factors for agoraphobia
- Female
- Family history
- Age: 15-35
Describe social anxiety/social phobia
> 6 months of anxiety causing individuals to fear acting in a certain way which might make them get judged and can cause anxiety which interferes with their normal routine and relationships.
Prevalence of social anxiety
2.3%
Management of social anxiety
- CBT
- SSRIs
- Beta-blockers for symptomatic relief
- SNRIs
- MAOIs
Prevalence of Bipolar disorder
1%
Risk factors for bipolar disorder
- Age
- Family history
- Childbirth
Clinical features of bipolar disorder
- hypomanic/manic episodes
- increased energy
- decreased need for sleep
- elevated sense of self-esteem or grandiosity
- poor concentration
- accelerated thinking and speech
- impaired judgement and insight
- disordered thought form
- abnormal beliefs
- perceptual disturbance
Investigations to rule out organic causes of mania
- FBC & inflammatory markers
- TFTs
- HIV screen
- blood glucose
- Infection screen
- Vitamin B12
- Urine drug screen
- Brain CT/MRI
Indications for hospitalisation in a manic episode
- Impaired judgement endangering the patient or others around them
- Significant psychotic symptoms
- Excessive psychomotor agitation with risk for self-harm, dehydration or exhaustion
- thoughts of harming self or others
Treatment of acute mania
- Discontinuation of any antidepressants
- Short-term benzodiazepines
- Antiemetic agents
- Antipsychotics
- Continue any current mood stabilisers
Treatment of acute depression in bipolar disorder
- Co-prescription of antidepressants and anti-manic agents e.g. quetiapine OR fluoxetine + olanzapine
- Ensure doses of lithium or valproate are at a high level
Maintenance treatment in bipolar disorder
Maintenance treatment recommended for at least 2 years
- Lithium
- Augmentation with valproate
- Lamotrigine or carbamazepine
- Physical health monitoring due to increased CVD risk: annual weight, pulse, glucose, HbA1c, lipids, LFTs
- Family therapy, CBT/interpersonal therapy/avoidance of stimulation
- ECT
Indications for maintenance treatment in bipolar disorder
- Manic episode associated with severe adverse risk or consequences
- manic episodes and another disordered mood episode
- repeated hypomanic and depressive episodes with significant functional impairment or risk
Monitoring required for patients on lithium
- Baseline ECG and bloods
- 3 monthly lithium levels
- Annual U&Es, TFTs, calcium
Risk factors for suicide
- Male
- Depression
- Bipolar disorder
- Alcohol misuse e.g. intoxication
- Eating disorders
- Schizophrenia
- Adjustment disorder
- Personality disorders
Overall prevalence of dementia
1%
Risk factors for dementia
- Age
- Sex: AD is more common in women, vascular dementia more common in men
- Previous cognitive impairment
- family history
- previous stroke
- AF
- smoking
- hypertension
- diabetes
- hypercholesterolaemia
- previous MI
- obesity
- late onset depression
- head injury
- low educational attainment
- Down syndrome
Causes of dementia
- AD
- Frontotemporal dementia
- Lewy body dementia
- Parkinson disease
- Huntington disease
- Progressive supranuclear palsy
- Vascular dementia
- Space-occupying lesions
- Trauma
- Infection
- Metabolic disturbance
- Endocrine disease
- Nutritional deficiencies
- Drugs and toxins
- Chronic hypoxia
- Inflammatory disease
- Normal pressure hydrocephalus
Characteristic pathological changes in AD
beta amyloid plaques and neurofibrillary tangles of hyperphosphorylated tau protein
Clinical features of dementia
- Symptoms present for 6 months
- Normal conscious levels
- Progressive functional impairment
- Progressive memory impairment
- Aphasia
- Apraxia
- Agnosia
- Impaired executive functioning
- Behavioural changes
- Mood changes
- Psychosis
- Neurological symptoms
Distinguishing features of AD
- Gradual, insidious onset of progressive cognitive decline with early memory loss
- Personality changes
- Langauge difficulties
Distinguishing features of vascular dementia
- Focal neurological changes
- Evidence of cerebrovascular disease or risk factors
- May be uneven or stepwise deterioration
Distinguishing features of Lewy Body dementia
- Day to day fluctuations in cognitive performance
- Recurrent visual hallucinations
- Motor signs of Parkinsonism
- REM sleep behaviour disturbance
- Recurrent falls and syncope
Distinguishing features of frontotemporal dementia
- early decline in social and personal conduct
- dietary changes
- early emotional blunting and loss of insight
- attenuated speech output, echolalia, preservation, mutism
- loss of semantic knowledge and naming
- relative sparing of other cognitive function
Investigations to exclude reversible causes of dementia
- Vitamin B12/folate
- TFTs
- Calcium
- Glucose
- U&Es
- CT/MRI head
Management of dementia
Mild/moderate AD:
Lewy Body dementia: Cholinesterase inhibitors
Moderate/severe AD: NMDA receptor antagonists
Contraindications for cholinesterase inhibitors
- bradycardia
- caution in PUD
- COPD
- hepatic impairment
- arrhythmias
Prevalence of depression
- 20% in women
- 12% in men
Risk factors for depression
- Family history
- Early life stressors
- Acute or chronic stress
- Age: late 20s
- Female sex
- Neurotic personality traits
- Personality disorders
- Separation or divorce
- Unemployment
- Illness
Clinical features of depression
- Early morning waking
- Difficulty falling asleep
- Frequent awakening
- Hypersomnia
- Dramatic reduction in appetite with weight loss >5% of body weight in last month
- Psychomotor retardation or agitation
- loss of libido
- reduced concentration and memory
- poor self esteem
- guilt
- hopelessness
- suicide/self harm
- psychotic symptoms
- loss of emotional reactivity
- diurnal mood variation
Investigations to rule out organic causes of depression
- FBC
- ESR
- B12/folate
- U&Es
- LFTs
- TFTs
- Glucose
- Calcium
ICD-10 criteria for depressive episodes
Episodes must last >2 weeks and represent a change from normal
Must have at least 2/3 of:
- depressed mood
- loss of interest or pleasure
- reduced energy or increased fatiguability
Must have at least 2 of the following symptoms:
- disturbed sleep
- diminished appetite
- psychomotor retardation or agitation
- reduced concentration and attention
- reduced self-esteem and self-confidence
- ideas of guilt
- bleak and pessimistic views of the future
- ideas of self harm or suicide
Management of depression
Lifestyle advice
- physical activity
- diet
- avoidance of alcohol and drugs
- good sleeping habits
Psychotherapy
- CBT
- Interpersonal therapy
- Psychodynamic therapy
- Family counselling
- Mindfulness
Antidepressants (in moderate/severe depression) for at least 6 months after remission of symptoms is achieved e.g. SSRIs
ECT
Indications for ECT
- Poor response to adequate trials of antidepressants
- Intolerance of antidepressants due to side effects
- Depression with severe suicidal ideation
- Depression with psychotic features, severe psychomotor retardation or stupor
- Depression with severe self neglect
- Previous good response to ECT
Poor prognostic factors for depression include
- Insidious onset
- Neurotic depression
- Elderly patient
- Residual symptoms
- Low self-confidence
- Comorbidity
- Lack of social supports
Prevalence of eating disorders
6.4%
Risk factors for eating disorders
- Female
- Age
- Family history
- Familial habits
- Premature birth
- Perinatal complications
- Childhood adversity
- Relationship difficulties
- Certain personality traits
- OCD, depression, anxiety
- Increased exposure to media
- certain careers e.g. dancers
Clinical features of anorexia nervosa
- Self imposed low body weight
- Preoccupation with being thin
- Restrictive food behaviours and food rituals
- Amenorrhoea
- Loss of libido, impotence
- Impaired growth spurt during puberty or arrested or delayed pubertal changes
- Generalised endocrine abnormalities
- Physical symptoms e.g. palpitations, syncope, fatigue, cold sensitivity, muscle weakness
- Overvalued ideas concerning body, intrusive dread of fatness
- Anxiety
- Purging behaviours
- Abnormal weighing behaviours
Clinical features of bulimia nervosa
- Normal/slightly above normal weight
- Preoccupation with eating and irresistible craving for food
- Binge eating followed by a sense of control and feelings of shame and disgust
- Overvalued ideas around body image
- Anxiety
- Purging behaviours
- Abnormal weighing behaviour
Examinations to undertake in a person with an eating disorder
- BMI
- Presence of lanugo hair
- Loss of head hair
- Russell’s signs (callouses on hands from frequent vomiting)
- Dental abrasions or tooth decay
- lying and standing BP and pulse
- Muscle wasting
- SUSS test
- Temperature
- Mucous membranes for signs of dehydration
- Facial glands (swollen parotids in frequent vomiting)
Red flag signs in an eating disorder
- Extreme weight loss (>30% expected weigh or BMI <14)
- Bradycardia (<40 bpm)
- Marked postural hypotension (>20mmHg systolic) or postural tachycardia (>30bpm)
- Prolonged QT
- Severe dehydration
- Hypothermia (<35.5)
- Unable to get up form squatting or lying flat without using hands
- Confusion
Investigations to consider in a patient with an eating disorder
- FBC
- U&Es
- LFTs and amylase
- Glucose
- Cholesterol levels
- Endocrine screen: GH, cortisol, TFTs, LH and FSH
- ECG
- DEXA scan
Biochemical profile in a person with an eating disorder
- Normocytic anaemia
- Leukopenia
- Hypokalemia
- Hypochloraemia
- Acidosis
- Hyponatremia
- Hypomagnesaemia
- Hyophosphatemia
- Raised transaminases
- Hypoglycaemia
- Low creatinine
- Hypercholesterolaemia
- Raised amylase
- Raised GH
- Raised cortisol
- Low T3
- Low FSH an LH
- Long QT
ICD-10 criteria for anorexia nervosa
A patient must have ALL of the following:
- Low BMI
- Self-induced weight loss
- Overvalued idease
- Endocrine disturbances
- Failure to make expected weight gains, delayed or arrested pubertal events (in pre-pubertal patients)
ICD-10 criteria for bulimia nervosa
A patient must have ALL of the following:
- Regularly occurring episodes of binge eating
- Pre-occupation with and strong cravings for food
- Methods to counteract weight gain
- Overvalued ideas
Management of anorexia nervosa
Psychotherapy
1) Family therapy in children OR CBT-ED or MANTRA or SSCM in adults
2) CBT-ED or focussed psychotherapy in children OR trial of a different first line therapy
Multivitamin supplementation
Monitoring of weight and physical complications
Treatment of co-morbid anxiety/depression
Management of bulimia nervosa
Psychotherapy
1) Family therapy in children OR Guided self help in adults
2) CBT-ED
Indications for hospital inpatient treatment in anorexia nervosa
- BMI <13.5
- Rapid weight loss
- Severe electrolyte abnormalities
- Syncope
- Suicide risk
- Social crisis
Indications for hospital inpatient treatment in bulimia nervosa
- Electrolyte disturbances from purging
- Suicide risk
Electrolyte abnormalities seen in refeeding syndrome
- Hyophosphatemia
- Hypokalemia
- Hypomagnesamia
- Hyponatremia
- Metabolic acidosis
- Thiamine deficiency
Clinical manifestations of refeeding syndrome
- Muscle weakness
- Seizures
- Peripheral oedema
- Cardiac arrhythmias
- Hypotension
- Delirium
Poor prognostic indicators in anorexia nervosa
- Long duration of illness
- Age of onset before puberty or after 17
- Male sex
- Very low weight
- Binge-purge symptoms
- Personality difficulties
- Difficult family relationships
Poor prognostic indicators in bulimia nervosa
- Severe binge-purge behaviour
- Low weight
- Comorbid depression
Complications of eating disorders
- Emaciation
- Cold intolerance
- Lethargy
- Amenorrhoea
- Infertility
- Reproductive tract atrophy
- Cardiomyopathy
- Bradycardia
- Hypotension
- Cardiac arrhythmias
- Heart failure
- Constipation
- Abdominal pain
- Oesophageal tears
- Gastric rupture
- Lanugo hair
- Loss of head hair
- Russell’s sign
- Proximal muscle weakness
- Osteoporosis
- Peripheral oedema
- Seizures
- Impaired concentration
- Depression
- Dental problems
- Deranged blood chemistry
Describe somatoform disorders
A class of disorders where patients are unduly concerned about physical symptoms or illness, despite examinations and investigations showing no detectable structural or physiological abnormalities
Describe conversion disorders
A term which describes the hypothetical process where psychic conflict or pain undergoes ‘conversion’ into somatic or physical form to produce physical symptoms
Describe somatisation disorder
Multiple, recurrent and frequently changing physical symptoms with the absence of an identifiable physiological explanation
Describe hypochondriacal disorders
Misinterpretation of normal bodily sensations, leading patients to believe they have a serious and progressive physical disease, despite normal examinations and investigations and frequent reassurance.
Describe body dysmorphic disorder
A variant of hypochondriacal disease in which patients are preoccupied with an imagined or minor defect in their physical appearance, causing significant distress or impairment in functioning
Describe Munchausen disorder
Physical or psychological symptoms are produced intentionally or feigned for primary gain.
Munchausen by proxy is when a carer will seek help for fabricated or induced symptoms in a dependent
Describe malingering
Physical or psychological symptoms are produced intentionally or feigned for secondary gain e.g. benefits, illicit drugs
Risk factors for medically unexplained symptoms
- Age
- Female sex
- Childhood sexual abuse
- Growing up in environments where physical distress is more readily acknowledged than psychological distress
- Stressor
- Minor physical injury
Examples of medically unexplained symptoms
- Atypical chest pain
- Hyperventilation syndrome
- IBS
- Dissociative seizures
- Weakness and sensory symptoms
- Fibromyalgia
- Chronic fatigue syndrome
Risk factors for PMS
- Significant psychosocial stress
- History of trauma
- Obesity
- Family history
- History of depression or anxiety
Clinical features of PMS
Symptoms occur in the 10 days prior to menstruation, peaking 2 days before menses begin and remit in the 2 weeks following
- Low mood
- Labile mood/irritability
- Concentration difficulties
- Anxiety
- Fatigue
- Headaches
- Abdominal bloating
- Breast tenderness
Management of mild PMS
- Healthy eating
- Stress reduction
- Regular sleep
- Regular exercise
Management of moderate/severe PMS
- COCP
- Analgesia
- CBT
- SSRI
- GnRH analogues with HRT
- Surgical treatment with add-back HRT
Prevalence of psychiatric disorders in pregnant women
10%
Indications for referral to the perinatal psychiatric services
- Preconception counselling for women with mental illness
- Pregnant women who are severely psychiatrically unwell
- Pregnant women at high risk of puerperal mental illness
- Women expressing ideas of self-harm, suicide or homocide
- Women with a history of puerperal psychosis
- Psychiatrically unwell women who are the main carer for babies <6 months old
- Pregnant women with harmful or dependent substance use
Risks of SSRI use in pregnancy and breastfeeding
- Withdrawal symptoms in the neonate
- Small risk of congenital heart disease if used in 1st trimester
- Rarely associated with persistent pulmonary hypertension when given after 1st trimester
Fluoxetine and sertraline considered safest in pregnancy
Sertraline considered safest in breast-feeding but all are considered safe. Breastfeeding should NOT be discouraged.
Risks of tricyclics use in pregnancy and breastfeeding
- Withdrawal symptoms in the neonate
- Risk of toxicity in overdose
Considered safe in breastfeeding (except doxepin)
Risks of mood stabilisers use in pregnancy and breastfeeding
ALL ARE ASSOCIATED WITH TERATOGENICITY:
- Valproate and carbamazepine increase risk of neural tube defects
- Valproate also increases the risk of congenital abnormalities and developmental disorders
- Lithium increases risk of cardiac defects and Epstein’s anomaly, but CAN be used in pregnancy
Lithium is NOT advised in breastfeeding - risk of neonatal toxicity
Valproate and carbamazepine may be associated with neonatal hepatotoxicity
Risks of antipsychotic use in pregnancy and breastfeeding
- May cause EPSE in neonates
- Olanzapine increases risk of gestational diabetes
- AVOID large doses in infants due to risk of lethargy
Risks of benzodiazepines use in pregnancy and breastfeeding
Associated with floppy infant syndrome (hypotonia, breathing and feeding difficulties)
Neonatal withdrawal syndrome
Use benzos with a short half life in breastfeeding if necessary
Prevalence of ‘postnatal blues’
50-80% of pregnant women
Symptoms of the baby blues
Presents within 10 days post delivery and symptoms peak between days 3-4
- Episodes of tearfulness
- Mild depression or anxiety
- Emotional lability and irritability
- Feeling exhausted or overwhelmed
Management of baby blues
Reassurance - symptoms resolve spontaneously in 2 weeks
Prevalence of postnatal depression
12% of pregnant women
Risk factors for postnatal depression
- Lack of a close confiding relationship
- Intimate partner violence
- Low income
- Young maternal age
- Previous history of depression
- History of antenatal depression
- Discontinuation of antidepressants
- Obstetric complications during delivery
Clinical features of postnatal depression
Symptoms onset within 3 months of delivery and peak at 3-4 weeks
- Low mood
- Anhedonia
- Fatiguability, sleep disturbance
- Low self confidence/low self esteem
- Suicidal ideation
- Anxious preoccupation with the baby’s health, often associated with feelings of guilt and inadequacy
- Reduced affection for the baby with possible impaired bonding/loss of interest
- Difficulty coping with care of the baby
- Obsessional phenomena: typically recurrent intrusive thoughts of harming the baby
- Infanticidal ideas
Management of postnatal depression
Mild:
- facilitated self help
Moderate:
- High intensity psychotherapy e.g. CBT
- Antidepressant e.g. SSRI
Severe:
- Hospital admission to mother and baby unit
- Consider ECT
Prevalence of postpartum psychosis
1 in 500
Risk factors for postpartum psychosis
- Primiparity
- Personal history of bipolar of postpartum psychosis
- Family history of bipolar or postpartum psychosis
- Obstetric complications
Clinical features of postpartum psychosis
Episodes onset rapidly and deteriorate quickly. Usually occur within 2 weeks of delivery, often within a few days. Symptoms often fluctuate dramatically over a short space of time.
- Insomnia
- Restlessness
- Perplexity
- Suspiciousness
- Psychotic symptoms (often related to the baby)
- Mood symptoms e.g. depression, elation, mood instability, overactivity
- Rambling, disordered speech
- Retained degree of insight
Red flag symptoms in postpartum psychosis
- Thoughts of self harm or harming the baby
- Severe depressive delusions e.g. belief that the baby is/should be dead
- Command hallucinations instructing the mother to harm herself or the baby
Management of postpartum psychosis
PSYCHIATRIC EMERGENCY
- Hospitalisation in a mother and baby unit
- Urgent referral to psychiatry
- DO NOT leave the mother alone with the baby
- Antidepressants/antipsychotics/mood stabilisers depending on presentation
- Benzodiazepines in severe behavioural disturbance
- ECT in severe or treatment resistant cases
Which law are compulsory measures in mental health covered in Scotland?
Mental Health (Care and Treatment) (Scotland) Act 2003
5 criteria for the use of MHA
1) Patient is suffering from a confirmed or suspected psychiatric disorder
2) Patient’s ability to make decisions about treatment of their mental disorder is significantly impaired by this disorder
3) Treatment is available for said psychiatric disorder
4) There would be considerable risk to the health, safety and welfare of the individual or others without treatment
5) Use of compulsory powers is deemed necessary and lesser restrictive options are deemed inappropriate
Conditions of the EDC
- Patient can be detained for 72 hours (must be reviewed with 24 hours)
- Can be completed by ONE doctor (post-FY1), but a MHO should be consulted if possible, and the patient reviewed by a psychiatrist ASAP
- Permits life saving medical treatment
- DOES NOT permit management of the psychiatric disorder or physical disease
Conditions of the STDC
- Patient can be detained for 28 days
- Completed by a psychiatrist but also requires MHO consultation
- Permits treatment of the psychiatric disorder or underlying cause of the disorder
- DOES NOT permit artificial feeding, ECT, or drugs controlling sex drive
Conditions of the CTO
- Patients detained indefinitely, but should be reviewed each 6 months
- Completed by a mental health tribunal (psychiatrist and another doctor) submitted by the MHO
- Permits treatment of the psychiatric illness/underlying cause, community care and drugs given for >2 months
- DOES NOT permit artificial feeding, ECT, or drugs controlling sex drive
Criteria for capacity
1) Understands information given to make a particular decision
2) Can retain the information given
3) Can balance or weigh up information to make a decision
4) Can communicate their decision
5) Is over 16 years old
Describe an advanced directive
A statement of an individual’s wishes regarding health care and medical treatment they would wish/not wish to have if they were to become incapable of making decisions in the future.
An individual must be over 18 and have capacity in order to make this.
Describe power of attorney
A legal document which enables an individual (who has capacity and is over 18) to nominate another person to make decisions on their behalf in the event that they become incapable of doing so.
Prevalence of OCD
0.5-3%
Risk factors for OCD
- Age
- Family history
- Avoidant, dependent or histrionic personality traits
- Anankastic/OC personality traits
- Schizophrenia
- Sydenham’s chorea
- Other basal ganglionic disorders
ICD-10 criteria for OCD
- Obsessions or compulsions must be present for at least 2 successive weeks and are a source of distress or interferes with the patient’s functioning
- Obsessions/compulsions are acknowledged as coming from the patient’s own mind
- Obsessions are unpleasantly repetitive
- At least one thought or act is resisted unsuccessfully
- A compulsive act is not in itself pleasurable
Management of OCD
Pyschotherapy:
- CBT, exposure and response therapy
- Behavioural therapy
- Support groups
Medications
- SSRIs at high dose for at least 12 weeks
- Clomipramine
- Antipsychotics
- ECT
- Psychosurgery
- DBS
Poor prognostic indicators in OCD
- Giving in to compulsions
- Longer duration
- Early onset
- Male sex
- Presence of tics
- Bizarre compulsions
- Hoarding
- Symmetry
- Comorbid depression
- Delusional beliefs/overvalued idease
- Personality disorder
Good prognostic indicators for OCD
- Good premorbid social and occupational adjustment
- Precipitating event
- Episodic symptoms
- Less avoidance behaviour
Prevalence of PTSD
3%
Risk factors for PTSD
- Previous trauma
- Interpersonal trauma
- Family history of mood or anxiety disorders
- Personal history of mood or anxiety disorders
- Female
- Low education
- Lower social class
- Ethnicity: Afro-Caribbean, Hispanic
- Low self esteem
- Neurotic traits
- Increased trauma severity
- Peri-traumatic emotions or dissociation
Protective factors for PTSD
- Effective coping strategies
- High IQ
- High social class
- Caucasian ethnicity
- Male
- Psychopathic traits
- Chance to view the body of a dead person
ICD-10 criteria for PTSD
Symptoms onset between 1 and 6 months, present for at least 1 month, after exposure to a stressor.
2 or more persistent symptoms of increased psychological sensitivity and arousal:
- Difficulty falling or staying asleep
- Irritability or outbursts of anger
- Difficulty in concentrating
- Hyper-vigilance
- Exaggerated startle response
Persistent remembering/reliving of the stressor in intrusive flashbacks, vivid memories or recurring dreams, and distress when exposed to circumstances resembling or associated with the stressor
Actual/preferred avoidance of circumstances resembling/associated with the stressor
Inability to recall some important aspects of the period of exposure to the stressor
Management of PTSD
- 8-12 sessions of EMDR or trauma-focussed CBT or exposure therapy
- SSRIs, continued long term with trial reduction after 12 months
Good prognostic indicators in PTSD
- Good social support
- Lack of negative responses from others
- Absence of maladaptive coping mechanisms
- No further traumatic life events
Definition of circumstantiality
Over-inclusive speech that is delayed in reaching its final goal, due to excessive detail and diversion.
Definition of compulsion
Repetitive mental operations or physical acts that a parent feels compelled to perform in response to their own obsessions.
Definition of a delusion
The most severe abnormal idea - a fixed, false belief arrived at illogically and is not amenable to reason, which is not accepted in the patient’s cultural background
Definition of delusions of persecution
False belief that one is being harmed, threatened, cheated, harassed or is a victim of a conspiracy
Definition of delusions of reference
The belief that normal perceptions have a special meaning to you
Definition of delusional perception
Experiencing a normal perception but interpreting it with delusional meaning
Definition of dyspraxia
Impairment of the ability to carry out skilled motor movements despite intact motor function
Definition of dysgnosia
Impairment in the ability to interpret sensory information despite intact sensory organ function
Definition of echolalia
When a patient senselessly repeats words or phrases that have been spoken near them/to them
Definition of echopraxia
When a patient mimics the movements of another person
Definition of flight of ideas
Thinking that is markedly accelerated and results in a stream of loosely connected concepts - the links between concepts can be normal, tenuous or through puns and clanging
Definition of hallucination
Perceptions that occur in the absence of external stimuli and are indistinguishable from normal perception
Definition of illusion
Misperceptions of real external stimuli
Definition of neologism
New word created by the patient, often combining syllables
Definition of obsession
Involuntary thought, image or impulse which is recurrent, intrusive, unpleasant and enters the mind against conscious resistance
Definition of overvalued idea
Incorrect belief that is not impossible which is held with marked emotional investment but not unshakable conviction, but which takes precedence over all other ideas and maintains this precedence for a long period of time
Definition of preservation
When a patient inappropriately repeats an initially correct action
Definition of Pseudo-hallucination
Perceptions that occur in the absence of external stimuli but are experienced in the internal world rather than the external world
Definition of psychosis
Presence of hallucinations, delusions or thought disorders
Definition of rumination
Repeatedly thinking about the causes and experience of previous distress and difficulties, voluntary thinking which is not resisted
Definition of Knight’s move thinking/derailment/loosening of association
When the patient’s train of thinking shifts very suddenly from one very loosely or unrelated idea to the next
Definition of thought blocking
Patients experience a sudden cessation in their flow of thought, often mid-sentence, and then continue talking about a different topic
Definition of grandiose delusions
False belief that one is exceptionally powerful, talented or important
Definition of erotomania
False belief that another person is in love with them
Definition of delusions of infidelity (morbid jealousy, Othello syndrome)
False belief that one’s lover has been unfaithful
Definition of Capgras syndrome
Belief that a familiar person has been replaced by an exact double
Definition of Fregoli syndrome
Belief that a complete stranger is actually a familiar person
Definition of Ekborn syndrome
False belief that one is infested with small but visible organisms
Definition of delusions of control/passivity
False beliefs that one’s thoughts, feelings, actions or impulses are controlled or made by external agency, including thought insertion, withdrawal and broadcast
Definition of elementary auditory hallucinations
Simple unstructured sounds
Definition of first person auditory hallucinations
Patients hearing their own thoughts spoken out loud as they think them
Definition of second person auditory hallucinations
Patients hear voices talking directly to them
Definition of third person auditory hallucinations
Patients hear voices talking about them
Definition of autoscopic visual hallucinations
Experience of seeing oneself in external space
Definition of Charles Bonnet syndrome
Condition where patients experience complex visual hallucinations associated with no other psychiatric symptoms or impairment in consciousness, often associated with a loss of vision
Definition of Lilliputian hallucinations
Hallucinations of miniature people or animals
Definition of reflex hallucinations
False perception which occurs when a normal sensory stimulus in one modality triggers a hallucination in another
Definition of stereotypics
A complex identical movement that does not appear to be goal-directed
Definition of mannerisms
Apparently goal directed movements that are performed repeatedly or at socially inappropriate times
Prevalence of schizophrenia
1%
Risk factors for schizophrenia
- Age
- Higher incidence in men
- Family history: 13% risk if one parent affected, 50% if two parents, 10% if a sibling is affected
- Complications in pregnancy and birth
- Prenatal malnutrition
- Childhood trauma
- Chronic cannabis use
- Lower SES
- Urban areas
- Migrants
ICD-10 diagnostic criteria for schizophrenia
One of more of the following symptoms:
- Thought echo, insertion, withdrawal or broadcast
- Delusions of control or passivity, delusional perception
- 3rd person auditory hallucinatory voices
OR two or more of the following symptoms
- other hallucinations that occur every day for weeks or are associated with fleeting delusions or sustained overvalued ideas
- Thought disorganisation
- Catatonic symptoms
- Negative symptoms
- Change in personal behaviour
Symptoms present most of the time during at least 1 month
No organic brain disease present, and symptoms not due to drug intoxication or withdrawal
Investigations to consider in schizophrenia
- FBC
- ESR
- U&Es
- TFTs
- LFTs
- Glucose
- Lipids
- Serum calcium
- Infection screen
- Urine drug screen
Indications for an ECG in patients commencing an antipsychotic
- Hospital admission
- History of CVD
- Family history of sudden cardiac death
- Evidence of CVD on examination
- Risk of QT prolongation
Management of schizophrenia
- Antipsychotics for at least 1-2 years
- Benzodiazepines for short-term relief of behavioural disturbance, insomnia, aggression, agitation
- Antidepressants or lithium to augment antipsychotics
- Baseline health screen and annual CV risk factor screen
- Regular weight, lipids, glucose, pulse and BP monitoring
- CBT
- Family interventions
- Social support
Treatment for treatment resistant schizophrenia
Clozapine
Definition of treatment resistant schizophrenia
Patients whose schizophrenia, despite at least 2 adequate trials of antipsychotics (one of which is second generation) is still not adequately controlled.
Monitoring for clozapine
- Weekly WCC for 18 weeks, then fortnightly for up to one year, then monthly
Risk factors for suicide in schizophrenic patients
- Young male
- High education level
- Some level of insight
- Periods of time soon after illness onset or following hospital discharge
Good prognostic factors in schizophrenia
- Low income countries
- Female sex
- Married
- Older age of onset
- Abrupt onset of illness
- Onset precipitated by life stress
- Short duration of illness prior to treatment
- Good response to medication
- Paranoid schizophrenic subtype
- Absence of negative symptoms
- Illness characterised by prominent mood symptoms or family history of mood disorders
- Good premorbid functioning
Reasons for reduced life expectancy in schizophrenia
- Suicide
- Smoking
- Socioeconomic deprivation
- CVD
- Respiratory disease
- Accidents
Risk factors for substance abuse
- Male sex
- Young age
- Social deprivation
- Childhood adversity
- Family history
- Conduct disorder in childhood
- Antisocial personality disorder
- Severe mental illness
- Chronic pain
- Head injuries
- Operant conditioning
- Lack of access to appropriate medical services
- Pressure from peers/partner/environment
Clinical features of opioid intoxicity
- Euphoria
- drowsiness
- Apathy
- Personality changes
- Miosis
- Conjunctival injection
- Nausea
- Pruritus
- Constipation
- Bradycardia
- Respiratory depression
- Coma
- Death
Opioid withdrawal symptoms
Lasts around a week, onset between 12-24 hours
- Muscle/bone aches
- Nausea and vomiting
- Diarrhoea
- Insomnia
- Sneezing
- Yawning
- Piloerection
- Sweating
- Mydriasis
- Lacrimation
- Rhinorrhoea
- Tachycardia
- Tremor
- Anxiety, irritability, restlessness
- Goosebumps
Clinical features of sedative intoxication
- Drowsiness
- Disinhibition
- Confusion
- Poor concentration
- Reduced anxiety
- Feeling of wellbeing
- Hypotension
- Impaired coordination
- Respiratory depression
Sedative withdrawal symptoms
- Seizures
- Hallucinations
- Sweating
- Tachycardia
- Nausea
- Tremor
Clinical features of stimulant intoxication
- Alertness
- Hyperactivity
- Euphoria
- Irritability
- Aggression
- Paranoid ideas
- Hallucinations (fornication)
- Psychosis
- Hyperthermia
- Hypertension
- Mydriasis
- Tremor
- Tachycardia
- Arrhythmia
- Perspiration
- Fever
- Convulsions
- Perforated nasal septum
Stimulant withdrawal symptoms
Within a few hours to days of stopping heavy use
- dysphoria
- Fatigue
- Hyperphagia
- Nightmares
- Insomnia or hypersomnia
- Psychomotor retardation or agitation
Clinical features of hallucinogen intoxication
- Marked perceptual disturbances
- Mydriasis
- Conjunctival injection
- Hypertension
- Tachycardia
- Perspiration
- Fever
- Loss of appetite
- Weakness
- Tremor
Clinical features of cannabinoid intoxication
- Euphoria
- Relaxation
- Altered time perception
- Psychosis
- Impaired coordination and reaction time
- conjunctival injection
- nystagmus
- dry mouth
Cannabinoid withdrawal symptoms
Generally mild/moderate symptoms lasting 2-4 weeks
- Irritability/anxiety
- Low mood
- Restlessness
- Insomnia
- Tremors
- Headaches
Clinical features of dissociative anaesthetic intoxication
- Hallucinations
- Paranoid ideas
- Thought disorganisation
- Aggression
- Mydriasis
- Tachycardia
- Hypertension
- Ulcerative cystitis
Clinical features of inhalants intoxication
- disinhibition
- confusion
- euphoria
- hallucinations
- stupor
- headache
- nausea
- slurred speech
- loss of motor coordination
- muscle weakness
- nystagmus
- arrhythmia
- pneumonitis
Inhalant withdrawal symptoms
- Hypersomnia
- Low mood
- Nausea
Investigations to consider in substance misuse
- Urine or saliva drug screening test
- Hair testing
- Breath alcohol level
- FBC and MCV
- U&Es
- LFTs
- ECG
- BBV serology after most recent injection
- Brain imaging
Signs of opioid overdose
- Dilated pupils
- Diarrhoea
- Tachycardia
- Hypertension
- Yawning
- Runny nose
- Fine tremor
- Cool, clammy skin
- Nausea
Side effects of methadone
- Constipation
- Sedation
- Euphoria
- Nausea
- QT prolongation
Management of substance misuse
- Psycho-education
- Substitution prescription
- Child protection
- Take home naloxone kit
- Needle exchange
- BBV screening
- Group support
Prevalence of alcohol misuse
1.4%
Risk factors/triggers/causes for alcohol misuse
- genetic influence
- epigenetic changes
- combination of positive and negative reinforcement
- learned behaviours
- associated psychiatric or physical illness
- cultural influence
- occupational associations
- stressful event
Diseases which alcohol increases the risk of
- Cancer
- Stroke
- Heart disease
- Liver disease
- Death through accidents
Investigations to consider in a patient with alcohol misuse
- Breathalyser/blood alcohol use
- FBC: raised MCV, decreased Hb, decreased neutrophils, decreased platelets
- U&Es: decreased magnesium, potassium and sodium
- LFTs: increased GGT, transaminases
- Clotting screen: increased PT
- ECG
- CT head
Lifestyle advice for keeping health risks from alcohol use to a minimum
- No more than 14 units per week
- Spread out weekly consumption over 3 or more days
- Limit the total amount consumed on one single occasion
- Drink slowly, with food, or alternate with water
- Plan ahead to protect yourself from problems while intoxicated
Factors which influence blood alcohol concentration
- Amount of ethanol consumed
- Person’s blood volume
- How much they’ve had to eat/drink
- Other substance use/medications
- How well the body is prepared for alcohol
Features of alcohol intoxication
- Enhanced sense of wellbeing
- Improved confidence/relief of anxiety
- Disinhibition
- Inappropriate sexual or aggressive behaviour
- Sullen behaviour/withdrawn
- Incoordination
- Slurred speech
- Ataxia, difficulty with balance
- Amnesia, memory impairment
- Impaired reaction time
Consequences of harmful alcohol use
- Substance-related disorders
- Self-harm or suicidal behaviour
- Absenteeism or poor behaviour at work
- Victim of theft
- Unprotected sex e.g. STIs, pregnancy
- Legal problems
- Interpersonal problems
- Financial problems
- Homelessness
- Increased incidence of trauma
- CNS disease: delirium, withdrawal, cerebella degeneration, hemorrhagic stroke, peripheral and optic neuropathy, Wernicke-Korsakoff syndrome
- GI disease: ALD, pancreatitis, PUD, GI cancer
- Cardiac disease: hypertension, arrhythmia,s IHD, alcoholic cardiomyopathy
- Immune disease: immunocompromise
- Metabolic/endocrine disease: hypoglycaemia, gout, hyperlipidaemia, electrolyte imbalance
- Haematological disease: macrocytic anaemia, neutropenia, thrombocytopenia
- MSK disease: myopathy, OP
- Reproductive disease: IUGR, FAS, ED, infertility
ICD-10 criteria for substance dependence
3 or more of the following criteria present together or at some time during the previous year:
- A strong desire or compulsion to take the substance
- Stereotyped pattern of use
- Abstinence/reinstatement
- Difficulties in controlling substance taking behaviour
- Physiological withdrawal state when substance use is ceased/reduced OR continued substance use to relieve or avoid withdrawal symptoms
- Tolerance
- Priority given to the substance with neglect of other interests and activities
- Persistence despite harm
Management of alcohol dependence
Individual and group therapy
- Motivational interviewing
- CBT
- Peer support programmes
Medication
- Naltrexone (blocks euphoric effects of alcohol and feelings of intoxication)
- Acamprosate (aids withdrawal symptoms)
- Disulfiram (prevents breakdown of ethanol, leading to an instant ‘hangover’)
Symptoms of uncomplicated alcohol withdrawal
Symptoms onset within 4-12 hours
- Tremulousness
- Sweating
- Clammy skin
- Nausea and vomiting
- Mood disturbances
- Fatigue
- Headaches
- Hyperacusis
- Autonomic hyperactivity
- Sleep disturbance
- Psychomotor agitation
(can be complicated with illusions or hallucinations, typically visual, auditory or tactile)
Symptoms of withdrawal seizures
Occurs 6-48 hours after cessation
Affects 5-15% of alcohol-dependent drinkers
Generalised tonic clonic seizures
Risk factors for withdrawal seizures
- Previous withdrawal seizures
- Concurrent epilepsy
- Low K+ or Mg2+
Symptoms of delirium tremens
Occurs 1-7 days after cessation, usually ~48 hours.
- Altered consciousness and marked cognitive impairment
- Vivid hallucinations and illusions in any sensory modality e.g. Lilliputian
- Marked tremor
- Autonomic arousal
- Paranoid delusions
- Mortality
Risk factors for delirium tremens
- Hepatitis
- Pancreatitis
- Pneumonia
Management of delirium tremenes
- Benzodiazepines e.g. chlordiazepoxide
- IV Pabrinex
Triad of symptoms of Wernicke’s encephalopathy
1) Ophthalmoplegia
2) ataxia
3) acute cognitive impairment/delirium
Indications for management of alcohol withdrawal in hospital
- Severe dependence
- History of withdrawal seizures or delirium tremens
- Pregnancy
- Older patients
- Poor social support
- Psychiatric or physical comorbidities
Describe a traumatic stressor
A stressor which occurs outside the range of normal human experience, and its magnitude means it would be perceived as traumatic by most people - typically occurs in situations where people feel their own or a loved one’s physical or psychological health is under serious threat
Define an adjustment disorder
Symptoms significant enough to be out of proportion with the original stressor, or causing disturbance of social or occupational function
Prevalence of adjustment disorder
3-12%
Symptoms of adjustment disorder
- Low mood
- Sleep disturbance
- Anxiety
- Anger
- Disturbances of conduct
- Suicidal ideation
Diagnostic criteria of adjustment disorder
Diagnosis should only be made when patients do not meet the criteria for a more specific psychiatric diagnosis or a normal bereavement reaction
Symptoms occur within 1 month of the stressor
Management of adjustment disorder
Symptoms should resolve within 6 months
- Support psychotherapy
- Antidepressants or anxiolytics: if symptoms are persistent and distressing or psychotherapy has failed
Prevalence of acute stress reaction
15-20%
Risk factors for an acute stress reaction
- Physical exhaustion
- Presence of other organic factors
- Elderly age
Define an acute stress reaction
Transient disorder which may occur in an individual as an immediate response to exceptional stress
Symptoms of an acute stress reaction
Develops within a few minutes of a traumatic event (within 48 hours)
- Initial ‘dazed’ state
- Disorientation and a narrowing of attention, inability to process external stimuli
- Diminished responsiveness OR psychomotor agitation and overactivity
- Amnesia
- Depression/anxiety
- Anger
- Despair
Management of acute stress reaction
None usually required
Symptoms usually resolve within a few hours of removal of the stressor. If the stressor persists, symptoms tend to diminish within 24-48 hours and are usually minimal after 3 days
Risk factors for acute stress disorder
- History of a psychiatric disorder
- Previous traumatic events
- Premorbid depression
- Dissociative symptoms
Symptoms of acute stress disorder
Symptoms onset within 4 weeks of trauma
- Dissociative features
- Derealisation or depersonalisation
- Amnesia
- Re-experiencing the event
- Avoidance behaviours
- Negative mood
- Hyperarousal
Management of acute stress disorder
Symptoms typically last 3 days to 4 weeks - if symptoms last longer, patients can be diagnosed with PTSD.
- Simple practical measures e.g. support, advice regarding police procedure
- De-briefing
- CBT
- TCAs, SSRIs, benzodiazpines
Describe dissociation
Disruption in the usually integrated functions of consciousness and cognition with no clear stressor
5 phases of a normal grief reaction
1) Alarm: accompanied by physiological arousal
2) Numbness
3) Pining: hypnagogic and hypnopompic pseudohallucinations and illusions may occur
4) Depression and despair
5) Recovery and reorganisation
Clinical features of a typical grief reaction
- Disbelief, shock, numbness
- Feelings of anger, guilt, sadness, tearfulness
- Low mood
- Change in appetite and weight
- Sleep disturbance
- Psychomotor retardation
- Memory impairment
- Pseudohallucinations/illusions about the deceased
- Suicidal ideation
Gradually reduce in intensity, lasting up to 12 months
Clinical features of an ‘atypical’ grief reaction
- Very intense, prolonged, delayed or absent
- Symptoms outwith normal range
- Prolonged period of not being able to function normally
- Marked slowing of thoughts or movements
- Hallucinatory experiences
Risk factors for depression after a beareavement
- History of depression
- Intense early grief/depressive symptoms
- Lack of social support
- Little experience of death
- Traumatic or unexpected death
Describe personality traits
Enduring patterns of perceiving, thinking about, and relating to both self and the environment, exhibited in a wide range of social and personal concepts
Describe a personality disorder
When an individual has an enduring pattern of traits that are:
- Persistently inflexible and maladaptive
- Stable over time
- Appeared in adolescence or early adulthood
- Cause significant personal distress or functional impairment to the individual or those around them
- Cause disturbance in relationships
- Deviate markedly from the expectation of the individual’s culture
- Often involves problems with cognition, affect and behaviour
Prevalence of personality disorders
4-13%
Risk factors for personality disorders
- Family history of personality disorders of other psychiatric illness: Cluster A type linked to schizophrenia, EUPD linked to depression
- Early adverse social circumstances
- Childhood abuse
- Disordered attachment between infants and their caregivers
- Male sex: RF for paranoid, schizoid, antisocial, narcissistic and OC personality disorders
- Female sex: EUPD
- Lower SES: paranoid
- Offenders: schizoid, antisocial, narcissistic
- Highly educated: OC
- Married: OC
Traits of paranoid personality disorder
- Suspicious, suspects others are exploiting/harming/deceiving them
- Doubts about spouse’s fidelity
- Bears grudges
- Tenacious sense of personal right
- Litigious
- Fear of confiding in orders
- Strong reaction to being lied to
Traits of schizoid personality disorder
- Emotional coldness and detachment - neither enjoys or desires close/sexual relationships
- Prefers solitary activities, enjoys few activities
- Indifferent to praise or critiscism
- Lacks confidence
Traits of schizotypal personality disorder
- Eccentric behaviours
- Odd belief or magical thinking - can lead to overconfidence in their belief
- Unusual perceptual experiences
- Ideas of reference
- Suspicious or paranoid ideas
- Vague or circumstantial thinking
- Social withdrawal
Traits of BPD/EUPD
- Intense unstable relationships (fluctuates between idealisation and devaluation) with repeated emotional crises
- Unstable self image, identity disturbances
- Impulsive behaviour
- Chronic feelings of emptiness
- Repetitive suicidal or self-harm behaviour
- Fluctuations in mood
- Frantic efforts to avoid abandonment
- Transient paranoid ideation
- Pseudohallucinations
- Dissociation
Traits of antisocial personality disorder
- Repeated unlawful/aggressive behaviour
- Deceitfulness/lying
- Reckless irresponsibility
- Lack of remorse or incapacity to experience guilt
- Disregard of other’s rights
- Willing to hurt others to benefit themselves
Traits of histrionic personality disorder
- Dramatic, exaggerated expression of emotions
- Attention seeking
- Seductive behaviour
- Labile, shallow emotions, can’t maintain relationships
- Manipualtive
- Occasional self harm
- Obsessed with physical appearance
Traits of narcissistic personality disorder
- Grandiose sense of self-importance, often pretentious and boastful
- Need for admiration
- Fragile self esteem, vulnerable to criticism
- Only gets involved in activities that benefit themselves
- Callous, little regard for other’s feelings
Traits of dependent personality disorder
- Excessive need to be cared for, needs others to assume responsibility for major life events
- Clingy behaviour
- Forms quick new relationships
- Fear of separation
Traits of avoidant personality disorder
- Hypersensitivity to critical remarks/rejection
- Inhibited in social situations
- Fears of inadequacy
- Avoids contact jobs
Traits of obsessive compulsive personality disorder
- Preoccupation with orderliness, perfectionism and control
- Devoted to work at the expense of leisure
- Pedantic, rigid and stubbon
- Overly cautious
Management options for personality disorders
- Consider detention under MHA if necessary
- Preparation of a crisis plan
- Encourage autonomy
- Dialectical behavioural therapy (or CBT or cognitive analytical therapy)
- Medications for symptomatic relief
- Social assistance
Prevalence of delirium
10-20% of inpatients
Risk factors for delirium
- Pre-existing dementia
- Previous serious head injury
- Alcohol/benzodiazepine misuse
- Age
- Polypharmacy
- Multiple medical problems
- Sensory impairment
- Recent surgery
- Burns victims
- Underlying disease
- Chronic fatigue
Causes of delirium
- Environmental change or stress
- Drugs e.g. anticholinergics, benzos, opiates, anti-Parkinsonian drugs, steroids, alcohol, cannabis, amphetamines
- Posions
- Infection/sepsis
- Hypoxia
- Metabolic/endocrine disturbance e.g. dehydration, anaemia, electrolyte imbalance, renal impairment, thyroid disease
- Nutritional deficiencies
- Trauma
- Intracranial space-occupying lesion
- Head injury
- Brain infection
- Epilepsy
- Cerebrovascular disease
Clinical features of delirium
Acute onset and fluctuating symptoms
- Impaired consciousness
- Impaired attention
- Impaired cognitive function
- Perceptual and thought disturbance
- Sleep-wake cycle disturbance
- Mood disturbances
- Psychomotor agitation
- Emotional lability
4 key diagnostic features of delirium
1) Impaired consciousness
2) Impaired attention
3) Impaired cognition
4) Acute or fluctuating onset of symptoms
Memory test used to identify people with delirium
4AT
Core investigations in a patient with delirium
- General obs
- Bloods: FBC, CRP, U&Es, LFTs, creatinine, TFTs
- Blood glucose
- Blood lactate
- Vitamin B12/folate
- Calcium/phosphate
- Urinalysis, urine culture
- Blood culture
- CXR
- ECG
Prevention methods for delirum
- Identify at risk patients
- Help orientate patients and ensure they are comfortable
- Maintain a good daily routine
- Avoid opiates
- Avoid predisposing medications
- Ensure patient feels in control
- Prevention, early identification and treatment of post-op complications
- Medication review
Management options for delirium
Identification and management of precipitating causes and exacerbating factors
Optimisation of patient’s condition
- Nutrition
- Fluids
- Pain control
Environmental and supportive measures
- Education
- Safe environment
- Stimulating environment
- Reality orientation
- 1 on 1 nursing
Avoid sedation unless severely agitated or is necessary to minimise risk to patient or facilitate investigation/treatment
- Consider oral haloperidol, oral lorazepam or oral risperidone
AVOID BENZOS
Regular clinical review and follow up
Consider capacity
Complications of delirium
- Falls
- Longer hospital stays
- More medical complications
- Development of dementia
- Mortality: 1/3rd
Prevalence of ASD
1%
Risk factors for ASD
- Male
- Family history
Causes of autism
- Tuberous sclerosis
- Fragile X syndrome
- PKU
- Chromosomal micro-deletion syndrome
- Obstetric complications
- Toxic agents
- Pre or postnatal infection
- Autoimmune disease
- Association with neurological disorders
3 characteristic features of autism
Manifest within first 3 years of life:
1) Impairment of social interaction
- Poor use of non-verbal behaviour
- Failure to develop and to share in enjoyment of peer relationships
- Reduced interest in shared enjoyment
- Lack of social or emotional reciprocity and empathy
- Attachment to unusual objects
2) Impairment in communication
- Poor language development
- Extreme difficulty in initiating or sustaining conversation
- Repetitive use of idiosyncratic language
- Lack of imitative or make-believe play
3) Restricted stereotyped interests and behaviours
- Intense preoccupation with interests
- Inflexible adherence to routine and rituals, resistance to change
- Repetitive stereotyped movements
- Unusual interest in parts of hand or moving objects
Clinical features of ASD
- Hyper-reactivity to environmental stimuli
- Delayed/lack of pointing
- Delayed speech
- Lack of response to name
- Poor eye contact
- Delayed and disordered development
- Strong dislike for routine change
- Motor mannerisms
- Regression
- Good memory
- Aggression/irritability/temper tantrums
- Hyperactivity
- Impulsivity
- Self-injurious behaviour
- Seizures
- Motor tics
- Increased head circumference
- Abnormal gaze monitoring
- Ambidexterity
- Unusually intense sensory responsiveness
- Absence of typical response to pain or injury
- Abnormal temperature regulation
- Increased paediatric illness
Define Asperberger’s syndrome
A subtype of autism where there are no significant abnormalities in language acquisition and ability or cognitive development and intelligence
Management of ASD
NO PHARMACOLOGICAL INTERVENTIONS
1) Play-based social communication intervention
- Self-help or support groups
- Social learning programmes
- Implementation of structure, routine and predictability
- Aids to improve communication
- Sleep management
- Supported employment programs
- SALT
- Behavioural intervention
- Structured leisure activity
- Anger management
- Anti-victimisation intervention
- Crisis plan
Good prognostic factors in ASD
- IQ >70
- Communicative language by age 5
- Absence of epilepsy
Prevalence of ADHD
5% in children
2-3% of UK population
Risk factors for ADHD
- Male
- Family history
- Maternal smoking during pregnancy
- Maternal alcohol use during pregnancy
- Prematurity
- LBW
- Perinatal hypoxia
- Emotional neglect
- Brain insult
Diagnostic criteria for ADHD
Symptoms present from childhood, persistent for >6 months and impaired and pervasive symptoms (requires some symptoms from each domain):
1) Inattention (pays more attention to cues and unable to eliminate unnecessary cues)
- Lack of attention to detail
- Difficulty sustaining attention
- Difficulty listening
- Trouble completing tasks
- Problems with organisation
- Avoidance or dislike of sustained mental effort
- Losing things
- Easily distracted
- Forgetful
2) Hyperactivity
- Fidgeting/restlessness
- Leaving seat when not supposed to
- Always on the go
- Talks excessively, can’t engage in quiet activities
- Insomnia
3) Impulsivity
- Blurting out answers in class
- Interrupting or intruding on others
- Difficulty waiting
- Disinhibited behaviours
Severity is based on functional impairment
Management of ADHD
- Psychoeducation
- OT input
- School/work support
- Skills training
- Psychological therapy e.g. family therapy, CBT, social skills training, environmental modification
- Medication
1) Stimulants e.g. methylphenidate, lisdexamfeatime
2) Atomoxetine, guanfacine
Definition of intellectual disability
Diverse afflictions which manifest as significant intellectual impairment associated with an impaired ability to adapt to the normal demands of daily living, with onset before 18 years old
Prevalence of intellectual disabilities
1-2%
Risk factors for intellectual disability
- Male
- Comorbid psychiatric illness
Specific causes of intellectual disability include
- Genetic conditions e.g. Down syndrome, Fragile X, Prader-Willi, PKU, neurofibromatosis,
- Congenital infection
- Substance use during pregnancy
- Pregnancy complications
- Birth trauma
- Prematurity
- Neglect/malnutrition
- Poor linguistic and social stimulation
- Pervasive developmental disorders
- Childhood infections
- Childhood head injury
- Childhood exposure to toxins
Medical conditions associated with intellectual disability
- Epilepsy
- GORD
- Constipation
- Heart abnormalities
- Hearing loss
- Dementia
- Delirium
- Schizophrenia
- Schizo-affective disorders
- Anxiety disorders
- Personality disorders
- Depression (but suicide is LESS common)
Features of mild intellectual disability
- IQ 50-69
- Subtle functional difficulties
- Often identified at a later age
- Difficulties in academic work, greatly helped by educational programmes
- Usually capable of unskilled or semi-skilled manual labour
- May be able to live independently or with minimal support
Features of moderate intellectual disability
- IQ 35-49
- Limited language and comprehension skills
- Self-care and motor skills impaired, may need supervision
- May be able to do simple practical work with supervision
- Rarely able to live completely independently
Features of severe intellectual disability
- IQ 20-34
- Marked degree of motor impairment
- Little/no speech in early childhood, may learn to talk at school
- Capable of elementary self-care skills
- May be able to perform simple tasks under close supervision
Features of profound intellectual disability
- IQ <20
- Severely limited ability to communicate
- Severe motor impairment with restricted mobility and incontinence
- Little or no self care ability
- Often require residential care
Primary prevention of intellectual disability
- Genetic screening and counselling for high risk groups
- Prenatal testing
- Improved perinatal and neonatal care
- Early detection of metabolic abnormalities which may contribute
Management options for intellectual disability
- Family support
- Educational support
- Vocational guidance
- Housing and social support
- Medical care
- Psychiatric care e.g. behavioural therapy
Clinical features of dyslexia
- Slow, inaccurate and effortful reading
- Difficulty spelling
- Difficulty understanding what they’ve read
Clinical features of dysgraphia
- Poor spelling
- Difficulty with grammar
- Poor handwriting
- Mixing of print and cursive writing
- Misuse of capital and lowercase letters
- Slow, laboured writing
- Difficulty putting thoughts down on paper
- Difficulty thinking and writing at the same time
Clinical features of dyscalculia
- Difficulty memorising math formulas and equations
- Difficulty following mathematical reasoning
- Difficulty measuring out ingredients for a recipe
- Difficulty reading graphs/charts
