Psychiatry Flashcards
Describe the pathophysiology behind depressive disorders.
- likely to be heritable with multiple gene involvement (twin studies)
- monoamine hypothesis: deficiency of noradrenaline, serotonin and dopamine
- over activity of the hypothalamic-pituitary-adrenal axis
- psychosocial input: personality type, life stressors and failure of effective stress control mechanisms increase likelihood of depression
Name biological factors that predispose you to depression
- female gender
- post natal period
- genetics ( fam history)
- neurochemical - low serotonin, dopamine and noradrenaline
- endocrine: increased hypothalamic pituitary adrenal axis activity
- physical co morbidity
Name psychosocial factors that predispose you to depression
- personality type
- failure of effective stress control mechanisms
- poor coping strategy
- mental health co-morbidity e.g dementia
Name social factors that predispose you to depression
- stressful life event
- lack of social support
- social situations e.g asylum seekers
Name biological factors that precipitate depression
- poor compliance with medication
- corticosteroids
Name psychosocial factors that precipitate depression
Acute stressful life events often precede depression eg loss of a loved one, injury, bankruptcy, unemployment, divorce
Non-acute stressful life events: poverty
Name factors that perpetuate (maintain) depression
Biological: chronic health problems
Psychosocial: poor insight, negative thoughts about self, the world and future (becks triad)
Social: alcohol and substance abuse, poor social support and low social status
Name 3 typical (1st generation) antipsychotics
Haloperidol
Chlorpromazine
Sulpiride
Name 4 atypical (2nd gen) antipsychotics
Olanzapine Risperidone Quetiapine Amisulpride Clozapine
What is the difference between typical and atypical antipsychotics
Not much, apart from atypical antipsychotics cause less extrapyramidal (motor) side effects
Which antipsychotic is only used for treatment resistant schizophrenia when two previous antipsychotics have failed?
Clozapine
Name 3 indications for anti psychotic use
- 1st line treatment schizophrenia
- Other conditions with positive psychotic symptoms ( hallucinations / delusions ) such as mania, acute psychotic disorders, depression, dementia
- Violent or dangerously impulsive behaviour and psychomotor agitation
How do antipsychotics work
By blocking dopamine (D2 mainly) in the brain, namely the Mesolimbic and mesocortical pathways
Name extrapyramidal side effects of antipsychotics
Parkinsonism - bradykinesia and tremor
Akanthisia- restlessness
Dystonia - acute painful contractions and spasms of muscles mainly in neck jaw and eyes
Tardive dyskinesia - abnormal involuntary movements (choreoathetoid) mainly looks like a pouting and chewing jaw
Name the anti-muscarinic side effects of antipsychotics
Can’t see can’t wee can’t spit can’t shit
Blurred vision, urinary retention, dry mouth and constipation
Name cardiac side effects of antipsychotics
PROLONGED QT INTERVAL- particularly with pimozide and haloperidol
Postural hypotension
Tachycardia
Name endocrine / metabolic side effects of antipsychotics
HYPERPROLACTINAEMIA:
Causes gallactorhoea, breast enlargement, reduced mineral bone density and sexual dysfunction)
Impaired glucose intolerance
Hypercholesterolaemia
Definition of schizophrenia
A psychotic disorder characterised by hallucinations, delusions and thought disorders.
Must occur in the absence of organic disease or drug or alcohol related disorder
and isn’t secondary to depression or elevation of mood
Name 4 poor prognostic indicators in schizophrenia
Strong family history Low IQ Lack of obvious precipitation Premorbid history of social withdrawal Gradual onset
Describe the pathophysiology behind schizophrenia
Overactivity of the Mesolimbic dopamine pathways
This is why antipsychotics aim to block D2 receptors
Name biological factors that are a risk factor for schizophrenia
Being male
Strong family history
High dopamine in the brain, low GABA glutamate and serotonin
Neurodevelopmental issues eg birth trauma, intrauterine infection, prematurity, fetal brain injury
What is a neologism
Making up and using a new word
Or using a word that we all know but using it in an inappropriate sense
Name the positive symptoms of schizophrenia
Delusions Hallucinations Formal thought disorder Thought interference Passitivity phenomenon
Name 8 risk factors for depression
Female family history of depression alcohol use adverse life event past history of depression physical co-morbidity low socioeconomic status
Name the 3 core symptoms of depression
anhedonia
anergia
low mood
Name 4 cognitive symptoms of depression
lack of concentration
negative thoughts - becks triad
excessive guilt
suicidal ideation
name 5 biological symptoms of depression
early morning wakening loss of libido diurnal variation in mood psychomotor retardation weight loss/loss of appetite
ICD-10 Diagnostic criteria for depression?
2 core symptoms plus 2 other symptoms (mild depression)
2 core + 3-4 others = moderate
3 core + over 4 other symptoms = severe depression
what is becks triad
negitive thoughts about self, the world and the future
what diagnostic questionnaires can be used in depressive disorder
PHQ-9
HADS
becks depression inventory
What tests should you do to rule out organic causes of depression
FBC (anaemia for fatigue) TFT (for hypothyroidism) LFTS Calcium levels Glucose levels (for anergia) CT head if atypical presentation
describe clinical presentation of atypical depression
weight gain, increased appetite
hypersomnia (excessive sleep)
delusions/hallucinations in severe depression
name 3 psychiatric differentials for depression and 2 organic differentials
psych: BPAD, anxiety disorders, secondary to substance use, normal bereavement
organic: hypothyroidism, diabetes, Anaemia, biochemical abnormalities
Define recurrent depressive disorder
when a patient has another depressive episode after their 1st episode
define seasonal affective disorder
depressive episodes recurring annually at the same time each year, usually during the winter months.
Define masked depression
a state in which depressed mood isn’t particularly prominent, but other features are present e.g EMW, diurnal variation
define atypical depression
occurs with mild-moderate depression with reversal of symptoms e.g over eating, weight gain and hypersomnia
define dysthymia
a depressive state that lasts for at least 2 years, which doesn’t meet the criteria for mild, moderate or severe depression and is not the result of a partially treated depressive illness.
what is dysthymia
a chronic depressive state lasting longer than 2 years, where your low mood can fluctuate between mild to severe but characterised by low-self esteem, hopeless feelings, lack of concentration/productivity e.g the non-core symptoms
define cyclothymia
chronic mood fluctuation over at least a 2 year period with episodes of elation and episodes of depression, but the symptoms do not meet the criteria for a hypomanic or depressive disorder
define baby blues
anxious, tearful and irritable mothers typically onset 3-7 days after birth. more common in primiparae women
what is biological management of depression
Mild-moderate: watchful waiting, antidepressants not recommended for mild depression unless it has gone on for months, if they have a past history of severe depression or if other interventions have failed.
Moderate - severe: SSRI’S 1st line, adjuvants include antipsychotics or lithium.
ECT can be considered as a last option if other interventions fail in acute severe depression
psychological management of depression?
CBT, interpersonal therapy, psychoeducation, counselling , behavioural activation, psychodynamic therapy
social management of depression
social support groups
exercise
Management options for mild-moderate depression?
- watch and wait
- self-help programmes
- online CBT
- exercise programmes (social prescribing)
- psychotherapy: counselling, behavioural activation, IPT, psychodynamic therapy
note: antidepressants not recommended unless other options have failed or they have a history of severe depression
Management of moderate-severe depression
- do suicide risk assessment
- consider mental health act
- antidepressants - SSRI first line
- Adjuvants e.g lithium, antipsychotics
- psychotherapies e.g CBT, IPT, counselling, psychodynamic therapy
- social support groups
- exercise groups
- ECT (last option)
give 5 indications for electroconvulsive therapy
- severe depression that is life threatening
- rapid response needed
- depression with psychosis
- psychomotor retardation
- other treatments have failed
how long should you prescribe antidepressants for after 1st depressive episode has ended
6 months
Define bipolar affective disorder
a chronic mood disorder characterised by at least 1 episode of mania and one further episode of depression or mania
pathophysiology of BPAD?
Monoamine hypothesis: elevated mood is a result of increased central monoamines (serotonin, dopamine and noradrenaline) and depressed mood is a result of low monoamines
Hypothalamis pituitary adrenal axis dysfunction
strong heritability
Name precipitating factors for a first mania episode
stressful or significant life event
Name the symptoms of mania
I DIG FASTER
Irritability Disinhibition/distracted Grandiose delusions Flight of ideas Appetite increased sleep decreased talkative elevated mood/energy increased reduced concentration/reckless
define hypomania
mildly irritable/elevated mood lasting for 4+ days. Interferes with work and social life but not severely.
Partial insight
define mania
A state of irritable/elevated mood lasting for more than 1 week with complete disruption of work and social activities.
Likely to have grandiose ideas, excessive spending and sexual disinhibition and lack of sleep
define mania with psychosis
a severely elevated or suspicious mood with the addition of psychotic features e.g grandiose or persecutory delusions, auditory hallucinations that are mood congruent.
may be aggressive
define bipolar type 1 characteristics
periods of severe mood episodes from mania to depression
define bipolar type 2 characteristics
milder form of mood elevation with mild hypomania that alternate with periods of severe depression
define rapid cycling BPAD
more than 4 mood swings in a 12 month periods with no intervening asymptomatic periods.
what is the ICD-10 criteria for a diagnosis of Mania
requires 3/9 symptoms, including: Grandiosity reduced sleep pressure of speech flight of ideas distractibility psychomotor agitation reckless behaviour social disinhibition marked sexual energy
what is the ICD-10 diagnostic criteria for Bipolar Affective disorder diagnosis
need at least TWO episodes in which a persons mood and activity levels are significantly disturbed.
ONE of such episodes must be MANIA or HYPOMANIA
note: for a diagnosis of mania you need 3/9 symptoms
what are the 5 types of bipolar states
currently hypomanic currently manic currently depressed mixed disorder in remission
what questionnaire can you use to aid the diagnosis of BPAD
mood disorder questionnaire
what investigations would you do to rule out organic causes associated with BPAD
FBC (routine) TFT - hypo/hyperthyroidism Do U+E's for a baseline renal function with view to starting lithium Calcium levels Urine drug test CT head for space occupying lesion
Give 4 differential diagnoses for BPAD
depression schizoaffective disorder schizophrenia cyclothymia hyper/hypothyroidism e.g frontal lobe lesion (cerebral) illicit drug use corticosteroid side effect
Describe management of an acute manic/mixed BPAD episode
antipsychotic e.g olanzipine/quetiapine. used bc have a more rapid onset of action than mood stabilisers. Add lithium too. Benzodiazipines can be used to calm agitation/aid sleep.
Sodium valporate can be offered as a 2nd line alternative to lithium as a mood stabiliser.
If the 1st antipsychotic doesn’t work a 2nd will be offered.
what is the 1st line treatment of an acute manic episode
antipsychotic e.g olanzipine/quetiapine plus lithium
what drug can be used as an alternative to lithium as a mood stabilizer
sodium valporate or lamotrigene long term
what drug can be used for calming of agitation/to aid sleep
benzodiazepines e.g diazepam or lorazepam
what drugs are used for a bipolar depressive episode
atypical antipsychotics e.g olanzipine/quetiapine
lithium or lamotrigine as a mood stabiliser
Why should antidepressants be avoided in BPAD patients
because they can induce mania if used alone. should be used carefully if prescribed with an antipsychotic
What tests should you do before starting a patient on lithium
U+E’s -bc lithium is excreted renally
TFT
pregnancy status
Baseline ECG
Name side effects of lithium
polydipsia, polyuria, fine tremor, weight gain, oedema,
HYPOTHYROIDISM
memory problems
impaired renal function
what therapeutic level should you aim for with lithium
between 0.5-1.0mmol/L
How often should you check lithium levels
- 12 hours after 1st dose
- THEN weekly until lithium levels have been stable between 0.5-1.0 for 4 weeks in a row
- once stable check every 6 months
what is the first line treatment for rapid cycling BPAD
a combination of lithium and sodium valporate
Name symptoms of lithium toxicity
Nausea, diarrhoea and vomiting COARSE tremor (not fine) ataxia muscle weakness fasciculations clonus nystagmus dysarthria hyperreflexia oliguria hypotension convulsions coma
Define psychosis
a mental state in which reality is greatly distorted.
Typically presents with delusions, hallucinations and thought disorder.
define a delusion
a fixed, firmly held false belief that deviates from the individuals normal social and cultural beliefs.
define a hallucination
a perception in the absence of an external stimulus
define a pseudohallucination
a perception in the presence of an external stimulus
what is a thought disorder
an inability to form thoughts from logically connected ideas
name 6 non-organic causes of psychosis
schizophrenia schizoaffective disorder acute psychotic episode delusional disorder drug induced psychosis mood disorder with psychosis
name 6 organic causes of psychosis
dementia delirium drug induced complex partial epilepsy SLE cushings syndrome vitamin B12 and folate deficiency huntingtons disease
what is schizotypal disorder
a disorder very similar to schizophrenia whereby the individual acts weird, suspicious, with unusual speech and affect, however there is NO HALLUCINATIONS OR DELUSIONS
what is an acute/transient psychotic disorder
an acute episode of psychosis lasting less than 1 month therefore not meeting the criteria for schizophrenia
what is schizoaffective disorder
characterised by both symptoms of a mood disorder and schizophrenia in an episode of the same illness. e.g mania and schizophrenia or depression and schizophrenia. Mood symptoms should meet the criteria for depressive illness or mania with one or 2 symptoms of schizophrenia
Schizophrenia symptoms persist with the occasional episode of mood disorder
what is persistent delusional disorder
a single or set of delusions held for at least 3 months. This should be the only symptom with other areas of thinking and functioning preserved
What is induced delusional disorder aka Folie a deux
a disorder where 2 or more people share the same delusional belief
a person primarily forms the delusion in a psychotic episode and passes it onto another person
what is puerperal psychosis
the acute onset of manic or psychotic episode shortly after childbirth (usually in the 1st 2 weeks)
what is late paraphrenia
late-onset schizophrenia. not coded for in icd-10
What are schneiders first rank symptoms of schizophrenia
- delusional perception
- third person auditory hallucination (usually running commentary)
- thought interference (e.g withdrawal, boradcast, insertion)
- passivity phenomenon - actions feelings or thoughts are being controlled by an external force
define schizophrenia
psychotic disorder characterised by delusions, hallucinations and thought disorders which lead to functional impairment.
Always in the absence of organic disease, alcohol or drug related disorders and isn’t secondary to mood depression or elevation.
pathophysiology of schizophrenia
dopamine hypothesis: overactivity of mesolimbic dopamine pathways in the brain
factors that interfere with neurodevelopment including low birthweight, obstetric complications, fetal injury.
what is the expressed emotion theory of schizophrenia
people whos relatives who are overly involved in their lives, are overly hostile or critical are more likely to develop schizophrenia
what is the stress-vulnerability model
a model that predicts that schizophrenia occurs due to enviornmental factors (e.g adverse life events, abuse, bullying) interacting with a genetic predisposition (e.g family history of mental illness or brain injuries)
name biological factors that predispose you to schizophrenia
HIGH dopamine LOW gaba, serotonin and glutamate birth injuries prematurity being aged 15-35
name psychological factors that predispose you to schizophrenia
family history of mental illness
childhood abuse
name social factors that predispose you to schizophrenia
substance misuse
low socioeconomic status
birth in late winter
name biological factors that precipitate schizophrenia
smoking cannabis or taking psychoactive drugs
name a psychosocial factor that precipitates schizophrenia
adverse life event/stressful life event
name a biological factor that perpetuates schizophrenia
poor compliance to medication
substance misuse
name a social factor that perpetuates schizophrenia
low social support expressed emotion (within the family)
name a psychological factor that perpetuates schizophrenia
adverse life event
name the positive symptoms of schizophrenia
Delusions Hallucinations Thought disorder thought interference passitivity phenomenon
what is passitivity phenomenon
the thought that your actions feelings or emotions are being controlled by an external force
name the negative symptoms of schizophrenia
Anhedonia Affect blunted Avolition (reduced motivation) Alogia (poverty of speech) Asocial behaviour Attention deficits
what is the ICD-10 criteria for a schizophrenia diagnosis
one symptoms from group A, or two or more symptoms from group B.
Symptoms must have been present for at least 1 month
Only diagnosed in the absence or organic brain disease.
GROUPA:
1 .Thought echo/insertion/withdrawal/broadcast
2. delusions of control, influence or passitivity phenomenon
3. running commentary third person auditory hallucination
4. Bizzare persistent delusions
GROUP B:
- hallucinations in other modalities that are persistent (e.g visual/tactile)
- thought disorganisation e.g loosening of association, incoherence)
- Catatonic symptoms
- negative symptoms
what are the symptoms of catatonia
- Stupor (where person cant move or speak)
- Waxy flexibility - person stays in the same position for an extended period of time.
- echolalia - person responds to conversatino by echoing the question
- catalepsy (muscular rigidity)
- lack of response to external stimulation
- mutism
- echopraxia - mimicing someone elses movements
what are the ICD-10 group A criteria for schizophrenia
- thought insertion/echo/broadcasting/withdrawal
- running commentary hallucinations
- delusions of control, influence of passitivity
- bizzare persistent delusions
what are the ICD-10 group B criteria for schizophrenia
- hallucinations in other modalities (not auditory)
- thought disorganisation
- catatonic symptoms
- negative symptoms
what investigations would you order in a patient with suspected schizophrenia
CT head - rule out space occupying lesion e.g frontal lobe dishinhibition
EEG - to rule out temporal lobe epilepsy
Bloods - B12, folate, cholesterol, U+E, calcium, glucose, TFT, FBC
ECG for QT prolongation
Urine drug anaylsis
biological management of schizophrenia
Atypical antipsychotics (1st line)
can add adjuvants e.g benzodiazepines for behavioural symptom relief
ECT may be appropriate for treatment resistant patients
How do you treat treatment resistant schizophrenia
Clozapine
if clozapine doesn’t work then use ECT
Psychological management of schizophrenia
- CBT
- Family intervention - psychoeducation helps families reduce high levels of expressed emotion
- art therapy helps relieve -ve symptoms
social management of schizophrenia
social support groups
peer support schemes
supported employment programmes
what is the yerkes dodson law
anxiety can be beneficial up to a plateau of optimal functioning. After that point level of performance deteriorates
what is anxiety
an unpleasant emotional state involving subjective fear and somatic symptoms
name common features of neuroses
anticipating/fear of impending doom exaggerated startle response depersonalisation/derealisation palpitations/chest pain hyperventilation/ chest tightness abdo pain, loose stools, nausea vomiting dysphagia dry mouth failure of erection, menstrual discomfort tremor, myalgia, headache, tinnitus
how can you classify neurotic/stress related disorders
split into paroxysmal anxiety and continuous anxiety
can also be situation dependent and situation independent
name 5 medical conditions commonly associated with anxiety
hyperthyroidism hypoglycaemia anaemia malignancy substance misuse eating disorders somatoform disorders depression OCD PTSD
define generalised anxiety disorder
a syndrome of ongoing, uncontrollable widespread worry about many events, or thoughts that the patient recognises as excessive and inappropriate. Symptoms are present most days in a 6 month duration.
Describe the biological pathophysiology behind generalised anxiety disorder
dysfunction of the autonomic nervous system
exaggerated responses in the amygdala and hippocampus
alterations in GABA, serotonin and noradrenaline.
What can antipsychotics treat and what can’t they treat
can treat positive symptoms
cant treat negative symptoms
what are the 3 main actions of antipsychotics
- control psychotic symptoms (within months)
- tranquilisation (within days)
- sedation (within hours)
what are the 3 main anxiety disorders
g.a.d.
phobic anxiety disorders
panic disorder
define PTSD
a delayed, prolonged and intense reaction to a traumatic event
define normal bereavement
a normal reaction to a traumatic event/loss of a loved one that doesnt last longer than 6 months
define abnormal bereavement
an abnormal reaction that occurs in response to an identifiable, non-catastrophic event e.g divorce or loss of a job, that occurs within one month usually but usually doesn’t last longer than 6 months
define acute stress reaction
exposure to an exceptional physical/emotional stressor followed by IMMEDIATE onset of symptoms e.g within one hour. symptoms include anxiety, dissociation, disorientation, anger, uncontrollable/excessive grief.
name risk factors for PTSD
profession eg doctor/fire man more likely to be exposed to trauma,
asylum seekers,
previous trauma,
PMH of mental health issues
low SES/ social support
extremely distressing event exposure with perceived threat to life
concurrent life stressors eg happens when going through a divorce
name the 4 categories of symptoms of PTSD
reliving - flashbacks, nightmares
avoidance - eg excessive rumination, inability to recall
hyperarousal - difficulty sleeping, irritable outbursts
emotional numbing - negative thoughts, detachment from others
icd-10 criteria for PTSD diagnosis
- occurs within 6 months
- persistent remembering/reliving
- exposure to stressful event
- avoidance of similar situations
- inability to recall
- increased arousal
psychological management of PTSD
CBT (trauma focused)
eye movement desensitization and reprocessing
biological management of PTSD
SSRI eg paroxetine
drug therapy used 2nd line after CBT, or in conjunction if evidence of co morbid depression/anxiety is present
define OCD
recurrent obsessional thoughts or compulsive acts
define obsession
an unwanted intrusive thought that enters the pts mind and is distressing cos they know they are unreasonable
is a product of their own mind
define compulsion
a repetitive act that the pt feels driven to carry out
pathophysiology behind ocd
a learned behaviour = operant conditioning
reduced serotonin in basal ganglia ad frontal cortex
icd 10 criteria for ocd
- must be present for most days for at least 2 weeks
- compulsions/obsessions must be characterised by…
- failure to resist
- originate from pts own mind
- repetitive
- distressing
- carrying them out relieves anxiety but isnt enjoyable
what are the 4 components of the ocd cycle
obsession –> anxiety –> compulsion –> relief
psychological management of ocd
CBT including exposure and response prevention
pharmacological management of OCD
SSRI first line e.g paroxetine, citalopram
clomipramine can also be added to citalopram if severe
what should you always screen for in pts with OCD
screen for depression bc highly co-morbid with ocd, also do suicide risk assessment
define agorophobia
fear/anxiety relating to public spaces
define social phobia
fear/anxiety of being in social situations that may cause embarrassment/criticism/humiliation
give examples of specific phobias
claustrophobia arachnophobia needles blood water heights flying
define a phobic anxiety disorder
an intense irrational fear of an object or situation that the individual recognises as irrational or excessive
describe features of a phobic anxiety disorder
autonomic response to feared situation e.g palpitations, vasovagal syncope, sweating, tremors
psych: anticipatory anxiety, inability to relax, avoidance and a fear of dying
ICD 10 criteria for agorophobia
marked consistent fear or avoidance in..
- crowds
- public spaces
- travelling alone
- travelling away from home
AND
has symptoms of anxiety in the feared situation
AND causes significant emotional distress
is recognised as unreasonable
AND symptoms are restricted to the feared situation on ly
ICD 10 criteria for social phobia
marked consistent fear or avoidance of being the focus of attention in a social situation plus two of the following.. - blushing - fear of vomiting - urgency or fear of weeing/pooing
AND causes significant emotional distress
AND is recognised as unreasonable
AND symptoms are restricted to the feared situation
ICD 10 criteria for specific phobia
marked fear or avoidance fo a specific object or situation
plus
symptoms of anxiety in the feared situation
AND causes signitficant emotional distress
AND is recognised as unreasonable
AND symptoms are restricted to the feared situation
how do you distinguish a phobic anxiety disorder from generalised anxiety disorder
phobic anxiety …
- occurs in response to specific stimulus
- there is anticipatory anxiety
- avoidance of stressful situations
in GAD there is no avoidance or anticipatory anxiety bc there is NO TRIGGER
how do you distinguish phobic anxiety disorder from panic disorder
panic disorder = panic attacks occur spontaneously with no trigger + no avoidance
phobic anxiety = avoidance of the situation that triggers the panic attack
how do you distinguish GAD from panic disorder
in GAD the anxiety and worry is always there whereas in panic disorder feelings are normal in between attacks which are spontaneous
icd-10 criteria for GAD
at least 6 months of prominent tension, worry and feeling apprehensive about normal every day life events. must have at least 4 of the following symptoms: - palpitaitons - chest tightening - shaking/tremor -sweating - dry mouth -gi upset -muscle aches - feeling dizzy - derealisation/ depersonalisation - sleep problems -irritable
what investigations would you do in pts that present with GAD to exclude organic cause of the symptom
blood glucose (hypoglycaemia)
FBC - infection/anaemia
TFT hyperthyroidism
ECG for palpitations
biological management of GAD
Sertraline = 1st line bc has anxinolytic effects
SNRI eg venlafaxine or duloxetine can be offered 2nd line
dont offer benzos apart from short term symptomatic relief if severe
psychological management of GAD
psychoeducation = low intensity psych intervention
CBT = high intensity
applied relaxation techniques
describe the steps in treating GAD
- diagnosis + psychoeducation and monitoring
- add low intensity psych intervention eg self help, group therapy
- high intensity psych (CBT or applied relaxation) OR drug treatment
- drug therapy + CBT + crisis team input
define a somatoform disorder
where a pt has symptoms of a physical illness in the absence of psychological illness, but it is presumed the symptoms are caused by psychological factors.
they persistently seek medical attention even though it doesnt help them
define a dissociative (conversion) disorder
symptoms that cant be attributed to a medical disorder but there is a convincing association between onset of symptoms and the presence of a stressful life event
- stressful event/problem = converted into physical symptoms
describe the pathophysiology behind somatoform/dissociative disorders
- pts adopt the sick role = primary or secondary gain
- associated with PTSD and sexual abuse
describe the process behind developing dissociative disorders
- distressing life event
- emotional distress
- dissociation = separates the distressing event from normal consciousness
- converts emotional distress into physical symptoms
- primary gain = stress relief secondary gain = financial rewards eg benefits
risk factors for dissociative/somatoform disorders
childhood abuse reinforcement of illness behaviours anxiety disorders mood disorders personality disorders social stressors
name types of dissociative disorders (eg symptoms that can manifest from conversion)
dissociative amnesia
dissociative fugue - unexpected physical journey away from normal surroundings
dissociative stupor - reduction in speech/movement/ response to stimuli
trance - temporary altered consciousness
possession - thinks theyve been taken over by a spirit
motor disorder = unexpected movements (involuntary) that look like epilepsy
Anaesthesia/sensory loss - loss of normal sensation
what is somatoform disorder aka briquets syndrome
multiple recurrent and frequently changing physical symptoms that dont relate to a physical illness
usually has a long history of contacting medical services.
common presentations include GI upset, dysphagia, chest pain, SOB, dysuria, incontinence, itching, headache, paraesthesia, visual disturbance
what is hypochondriachal disorder
pt misinterprets normal body sensations leading to non-delusional pre occupation that they have a serious physical disease
refusal to accept reassurance from doctors
what is persistent somatoform pain disorder
persistent and severe pain (longer than 6 months) that cant be explained by physical disorder
often emotional in cause
what is malingering
where physical symptoms are intentionally produced = the patient has a motive to produce fake symptoms
the pt seeks advantageous benefits of being diagnosed with a medical condition eg avoiding prison
what is factitious disorder (munchausens syndrome)
pt fakes having a disorder intentionally to adopt the sick role to recieve the care of a patient or for internal emotional gain
mechanism of action for zopiclone
enhances gaba transmission
which drugs can be used to treat insomnia
zopiclone
benzo in short term
give example of short acting benzo
lorazepam
give example of long acting benzo
diazepam or chlordiazepoxide
give two uses for chlordiazepoxide
- sedetive
- alchohol withdrawal/delirium tremens
what are the symptoms of benzo overdose
ataxia
nystagmus
dysarthria
respiratory depression
how do you treat a benzo overdose
ABCDE
iv flumazemil
how does sodium valporate work
inhibits breakdown (catabolism) of GABA
when should sodium valporate be used
can be used in BPAD if lithium is ineffective or can be added to lithium for rapid cycling BPAD
side effects of sodium valporate
hair loss weight gain GI disturbance ataxia tremor tiredness
when can carbamezapine be used in psychiatry
BPAD resistant to lithium
alcohol withdrawal
note: never use in combination with lamotrigene bc neuro toxic
how does carbamezapine work
blocks voltage gated sodium channels to prevent excessive neuronal firing
what can lamotrigene be used for in psychiatry
bipolar depression
can replace lithium
can be used in pregnancy
side effects of lamotrigene
GI disturbance
RASH
give symptoms of lithium toxicity
tremor acute confusion hyperreflexia polyuria seizures coma
management of lithium toxicity
usually iv fluids is fine
if severe = renal dialysis
side effects/complications of lithium
Gi disturbance weight gain impaired renal function thirst weeing more often fluid and weight retention QT prolongation reduces seizure threshold
contraindications to lithium
pregnancy, cardiac issues (long QT), epilepsy, hypothyroidism (destroys thyroid)
side effects of carbamezapine
dizziness, dermatitis, hyponatraemia
normal lithium levels and levels for toxicity
normal = 0.4-1
toxicity =over 1.5
what monitoring should be done when starting lithium
TFT eGFR FBC U+E baseline ECG pregnancy status
mechanism of action for lithium
reduces intracellular sodium and calcium
how often should lithium levels be checked
12 hours after 1st dose
then weekly till stable for 4 weeks
when stable for 4 weeks check 3 monthly
management of neuroleptic malignant syndrome
ABCDE
IV fluids
bromocriptine
symptoms of neuroleptic malignant syndrome
acute onset typically within 10 days of starting treatment or increasing dose irritable confusion PYREXIA MUSCLE RIGIDITY AUTONOMIC INSTABILITY = tachycardia and fluctuating BP fluctuating consciousness
what do blood tests show in neuroleptic malignant syndrome
derranged LFTs
increased creatinine kinase!!!
leukocytosis (sometimes)
name specific clozapine side effects
hypersalavation
agranulocytosis
reduced seizure threshold
how do you manage extrapyramidal side effects of antipsychotics (eg tardive dyskinesia, akanthesia, acute dystona)
procyclidine
give examples of SSRI’s
citalopram, sertraline, fluoxetine, paroxetine
how do SSRI’s work
inhibiting the REuptake of serotonin from the synaptic cleft = increases serotonin levels in the cleft
side effects of SSRI’s
Gi disturbance sweating tremor rashes sexual dysfunction stopping SSRI syndrome
give examples of SNRI
venlafaxine and duloxetine
how to SNRIs work
inhibit the reuptake of serotonin and noradrenaline in the synaptic cleft = increase availability
doesn’t have as many cholinergic effects
give examples of NSSAs (noradrenaline serotonin specific antidepressants)
mirtazapine
how does mirtazapine work
weak noradrenaline reuptake inhibitingeffect and has anti histminergic effects and blocks alpha 1 and 2 receptors
when is mirazapine indicated
2nd line depression where weight gain and sedation is needed for insomnia
side effect of mirtazapine
weight gain, postural hypotension
autism triad
ABC
asocial
behaviour restricted
communication impaired
name characteristics of autism
onset before 3 years of age
asocial: few social gestures, gaze avoidance, lack of interest in others, lack of emotional expression
communication impairment - delayed and distorted speech, echolalia
restricted behaviours e.g upset in change in daily routine, repetitive behaviour eg rocking or twisting, obsessively persued interests
conditions associated with autism
epilepsy
visual impairment
hearing impairment
learning disability
genetic conditions associated with autism
fragile x syndrome
tuberous sclerosis
risk factors for autism
maternal age over 40
birth issues e.g hypoxia, low fetal weight
sodium valporate in pregnancy
prematurity
describe aspergers syndrome
impaired social functioning and repetitive interests/behaviours but no impairment in language, cognition or IQ
describe retts syndrome
severe progressive disorder starting in early life. language impairment repetitive hand movements loss of fine motor skills irregular breathing seizures ONLY GIRLS
main management of autism
social communication based intervention and assisting with ADLs
speech and language therapist input
autism team
modification of environmental factors that initiate challenging behaviour
triad of ADHD symptoms
inattention
hyperactivity
impulsivity
icd 10 criteria for autism diagnosis
- onset at 3 years of age (impaired development)
- communication impairment
- social interaction impairment
- restrictive and repetitive behaviours
icd 10 criteria for ADHD diagnosis
abnormality of attention, activity and impulsivity at home for the age and developmental level of the child.
abnormality and school/nursery
directly observed abnormality
doesnt meet criteria for another disorder
onset before age 7
duration of at least 6 months
iq above 50
1st line management of ADHD
parent training educational program
CBT/social skills training in older children
1st line medical management of severe ADHD
methylphenidate
2nd line is atomoxetine/dexamfetamine
symptoms of opiate use
respiratory depression, low BP, hypoxia, pupillary CONSTRICTION
symptoms of stimulant use
arrythmia, high bp, increased HR, pupillary dilation, psychomotor agitation, muscle weakness
euphoria, grandiose delusions, paranoid ideation, labile
name the components of substance dependence
must have all occurred over 1 month:
- preoccupation with the substance use
- strong desire to take it
- withdrawal state if stops using
- impaired ability to control use
- built up a tolerance
- keeps using despite the harmful effects
what investigations should you undertake in substance abuse
urinalysis for drug levels bloods - FBC, HIV and hep B and C screen LFT and clotting to check hepatic function ECG for arrythmia Echo if suspect endocarditis
management of substance abuse
hep B immunization for needle users
MOTIVATIONAL INTERVIEWING - to help stop
contingency management - changes behaviours
plus bio therapy for the substance
biological management of opioid use
1st line is methadone or buprenorphine for maintenance and detox
management of opioid overdose
IV naloxone
what drug is used for opioid users who have completely abstained to maintain abstinence
naltrexone
describe the edward gross criteria for alcohol dependency
SAW DRINK subjective awareness of need to drink avoidance of withdrawal gets Withdrawal symptoms has drink seeking behaviour reinstates drinking behaviours after abstaining increased tolerance to alcohol narrowing of drinking repetoire
symptoms of alcohol withdrawal
tremor nausea hallucinatios autonomic hyperactivity seizures peak at 72 hours after stopping
what is delirium tremens
coarse tremor delusions confusion auditory and visual hallucinations fever tachycardia seizures
management of delirium tremens
iv chlordiazepoxide (long acting benzo) bc phenytoin not as helpful in seizures in alcohol withdrawal
long term management of alcohol dependency - eg inducing abstinence
inpatient detox recommended for those at risk of suicide or a severe history of withdrawal reactions
give high dose chlordiazepoxide tapered down over 10 days plus iv thiamine to prevent wernickes encephalopathy
Disulfiram - causes unpleasant symptoms when the pt drinks alcohol
acomprosate - reduces cravings by enhancing GABA transmission
Naltrexone - reduces pleasurable effects of alcohol by blocking opioid receptors
describe paranoid personality disorder
suspicious of others
questions partners faithfulness
thinks others are attacking them
no trust
describe schizoid personality disorder
LONER
flat, cold affect, no emotion, no close friends, likes to be alone, no pleasure in anything
describe emotionally unstable personality disorder
unstable relationships unstable mood easily gets angry suicidal impulsive
describe histrionic personality disorder
emily williams
attention seeking, cares about looks, easily influences
describe dissocial personality disorder
gets violent easily
blames others and holds grudges so has no friends
impulsive
remorseless - doesnt care when they do things wrong
describe anxious avoidant personality disorder
needs to be known that they are liked, avoids situations where they could be embarrassed, feels inadequate, restricts lifestyle to feel safe
describe dependant personality disorder
needs constant reassurance fears abandonment no self confidence doesnt like conflict needs a companion all the time needs others to be responaible
describe akanistic personality disorder
DAD workaholic stubborn fussy with minor details ability to complete tasks is compromised due to attention to detail
section 2
for assessment
lasts 72 hours
need 2x doctor and 1 AMHP
evidence = pt has mental health issue that needs assessing + for own/public safety
section 3
for treatment
lasts 6 months and can be renewed
needs 2x dr and 1 AMHP
evidence = pt has mental health issue that needs hospital tx + for own or other safety + treatment must be availanle
section 4
emergency section done when waiting for 2nd doctor to confirm section 2/3
lasts 72hrs
needs 1 dr and 1 AMHP
section 136
in public place police can detain for public safety
section 135
court order needed to remove pt from own home to psych assessment/tx
section 5(4)
nurses holding power for 6 hours whilst a doctor comes to assess
must be on a ward not emergency department
CANNOT TX
section 5(2)
doctors holding power for 72 hours until doctor comes to assess.
must be on a ward not A+E
CANNOT TX
icd-10 criteria for anorexia diagnosis
FEED fear of weight gain endocrine disturbance - e.g amennorhoea emaciated (skinny) deliberate weight loss distorted body image
difference between anorexia and bulimia
anorexia: no binge eating, no compensatory behaviours, usually more skinny and more likely to have endocrine disturbance, usually no food cravings
bulimia = episodes of binge eating followed by compensatory behaviour, usually normal weight or can be over weight, strong cravings for food
complications of having an extremely low BMI
amenorrhoea anaemia impaired immune system pancreatitis metabolic alkalosis from vomiting osteoporosis metabolic acidosis from laxative use arrythmias bradycardia dehydration - constipation hypothyroid
management of anorexia
risk assessment for suicide
6 months of psycholical intervention eg CBT
aim to gain weight of 0.5-1kg per week in hospital to avoid refeeding syndrome
indications for hospitalization of pt with anorexia
severe anorexia with bmi below 14
suicidal ideation
what is refeeding syndrome
causes changes to phosphate and magnesium when feeding after prolonged starvation/malnourishment
causes an insulin surge
causes = hypokalaemia, hypomagnesium, hypophosphataemia, and absnormal glucose metabolism
phosphate depletion can lead to heart failure!
how do you manage/prevent refeeding syndrome
slow feeds increasing by 0.5-1kg per week
monitor blood electrolytes, BP and pulse daily
if electrolytes drop low then need to be replaced intravenously
what is bulimia
repeated episodes of uncontrolled binge eating followed by compensatory weight loss behaviours eg vomiting or laxatives
have overvalued ideas about body shape
icd 10 criteria for bulemia diagnosis
- compensatory behaviours to prevent weight gain
- preoccupation with eating
- fear of being fat
- over eating
complications of bulimia
irregular periods
signs of dehydration eg sunken eyes
depression/low self esteem
hypokalaemia due to repeated vomiting
investigations to do in bulimia
VBG for metabolic alkalosis from vomiting
ECG for hypokalaemia
U+E, FBC, amylase for pancreatitis, glucose etc
management of bulimia
Fluoxetine 1st line psychoeducation CBT food diary to monitor eating habits risk assessment for suicide
indications for admitting a bulimia pt
suspicion of dehydration or electrolyte disturbance
risk of suicide
