Psychiatry Flashcards
Define ‘psychosis’
Mental health problem that causes people to perceive or interpret things differently from those around them, which might involve hallucinations or delusions
Give 3 causes of psychosis
Schizophrenia Bipolar affective disorder Delusional disorder Schizoaffective disorder Drugs Medical illness
Give 2 physical illnesses presenting with psychotic symptoms
Temporal lobe epilepsy Hyper/hypothyroidism Paraneoplastic syndrome Sensory impairment Brain tumours AVMs Delirium Drug induced/withdrawal
Give 3 acute features of psychosis
Lack of insight Auditory hallucination Ideas of reference Suspiciousness Thought disorder Flat affect Voices speaking to patient Delusional mood Delusions of persecution Thought alienation Thoughts spoken aloud
Give 3 chronic features of psychosis
Social withdrawal Under activity Lack of conversation Few leisure interests Slowness Over activity Odd ideas Depression Odd behaviour Neglect of appearance Odd postures and movements Threats or violence
Define ‘illusion’
A misinterpretation of an external stimuli; no diagnostic significance
Define ‘delusion’
A belief that is firmly held on inadequate and irrational grounds
It is not a conventional belief to that person given their educational, cultural and religious background
It significantly affects the way a person behaves and how they feel
Give 2 types of delusion
Persecutory Grandiose Guilt Bizarre Reference
Define ‘hallucination’
An experience that occurs without the presence of an external stimuli
Can occur in healthy people, but generally are a sign of major mental illness
Give 2 types of hallucination
Auditory Visual Olfactory Gustatory Somatic
What is the difference between 2nd and 3rd person auditory hallucination?
2nd person - when the voice is talking to the patient
3rd person - when the voice is talking about the patient
What are the 3 predominant features of acute schizophrenia?
Delusions
Hallucinations
Disordered thoughts
What are the first rank symptoms of schizophrenia?
Hallucinations (3rd person auditory, running commentary, thoughts spoken aloud)
Thought disturbance (insertion, withdrawal, broadcast)
Affective (violation, mood, affect)
How common is lack of insight in schizophrenia?
Very - 97%
How is schizophrenia diagnosed?
Emphasis on first rank symptoms
Symptoms must be present for at least 1 month
What patient population are at highest risk of schizophrenia?
Males in 20s
What is the aetiology of schizophrenia?
Biological - genetic, obstetric, neurochemical
Psychological - personality, cognitive deficit
Social - lower SE class, migration, isolation, trauma
What is the role of vulnerability in schizophrenia?
Combination of biological, psychological and social factors increase vulnerability
How is schizophrenia treated?
Pharmacological - antipsychotics (e.g. olanzapine)
Psychological - CBT, psychotherapy
Social - skills training, employment and housing help
Give 2 types of schizophrenia
Paranoid (delusions and hallucinations) Hebephrenic (thoughts and affect) Catatonic Undifferentiated Residual (negative)
Give 2 brain changes in schizophrenia
Enlarged ventricles
Overall weight reduction
Loss of asymmetry
Redution in cortex and hippocampus
What is the prognosis of schizophrenia?
1/2 will experience relapsing and remitting with some persistent deficits
1/4 will have chronic with persistent functional disability
1/5 will experience 1-2 episodes will full recovery
Small fraction will result in suicide
Give 3 factors which contribute to a worse outcome in schizophrenia
Male Drug misuse Low IQ Long duration untreated Severe symptoms Prominent negative symptoms Poor response to antipsychotics
Give 3 types of mood disorder
Manic episode Bipolar affective disorder Depressive episode Recurrent depressive disorder Cyclothymia/dysthymia Schizoaffective disorder Seasonal affective disorder
Define ‘mood’
Pervasive and sustained; what the patient describes
Define ‘affect’
Variable in response to changing emotional states; what the observer sees
Give 4 symptoms of depression
Markedly depressed mood Loss of interest or enjoyment Reduced self-esteem and self-confidence Feelings of guilt and worthlessness Bleak and pessimistic views of the future Ideas or acts of self-harm or suicide Disturbed sleep Disturbed appetite Decreased libido Reduced energy leading to fatigue and diminished activity Reduced concentration and attention
How is depression defined?
At least 2 of low mood, loss of interest/enjoyment, reduced energy/fatigue plus at least 2 other symptoms present for at least 2 weeks
3 grades of severity
Give 4 symptoms of mania
Irritability Grandiose ideas Inflated self-esteem Increased energy and activity Flight of ideas Rapid pressured speech (may be unintelligible) Enhanced libido (often leading to disinhibition and inappropriate sexual activity) Impaired judgement and impulsive behaviour (including gross over-spending and poor decision making) Decreased need for sleep Increased sociability Impaired concentration and attention Psychotic symptoms
What are the 3 degrees of severity of a manic episode?
Hypomania
Mania without psychotic symptoms
Mania with psychotic symptoms
How is depression treated?
SSRI
How is a manic episode treated?
Lithium
What are cyclothymia and dysthymia?
Cyclothymia - persistent instability of mood, not meeting criteria for BPAD
Dysthymia - long-standing depression of mood, not meeting criteria for depressive episode
What are mood congruent and non-mood congruent symptoms?
Mood congruent - concerned with the same themes as non-delusional thinking in moderate affective disorders
Non-mood congruent – if present with prominent affective symptoms, consider alternative diagnosis i.e. schizophrenia or schizoaffective disorder
What is post-schizophrenic depression?
Depressive symptoms can appear after psychotic symptoms begin to recede in schizophrenia
What is the lifetime risk of a depressive episode?
Men 12%
Women 25%
What are the treatment options for mood disorders?
Biological – antidepressants (augment monoamine neurotransmission), antipsychotics (psychotic symptoms and mania), ECT (severe psychotic depression), mood stabilisers (prevent fluctuations in BPAD and augment antidepressant)
Psychological – CBT, psychodynamic psychotherapy, family therapy, supportive psychotherapy/counselling
Social – help with debt/housing issues, increased socialisation
What does the Yerkes-Dodson curve show?
Performance increases with physiological/mental arousal until level of arousal becomes too high and performance decreases; intellectually demanding tasks require a lower level of arousal (to facilitate concentration), whereas tasks demanding stamina/persistence require higher levels of arousal (to increase motivation)
Define ‘neurosis’
Class of functional mental disorders involving chronic distress
Give 3 physical symptoms of anxiety disorder
Sweating Chest pain Tremors Dizziness Decreased sex drive Irritability Increased muscle tension Tachypnoea Breathlessness Increased BP Numbness Diarrhoea Chills/hot flashes Weakness Dry mouth Palpitations Light headedness
Give 3 psychological symptoms of anxiety disorder
Restlessness Sense of dread Feeling on edge Difficulty concentrating Easily distracted Detachment Fear of losing control Fear of dying
What is the 5 areas model of cognitive behavioural therapy?
Situations, thoughts, emotions, physical feelings, actions
CBT is based on the concept of these 5 areas being interconnected and affecting each other
What factors are involved in the aetiology of anxiety disorder?
Biological - genetic, illness, injury, CNS changes
Psychological - childhood, vulnerable personality, stress, depressed mood, avoidance
Social - lack of support, stress
Give 3 types of anxiety bases disorders
Specific phobias Generalised anxiety disorder Panic disorder OCD PTSD Somatoform and dissociative disorders
What are specific phobias?
Anxiety provoked by specific situations or objects which are perceived to be more dangerous than they actually are, causing anticipatory anxiety and avoidance (e.g. animals, blood, heights)
How are specific phobias treated?
Exposure therapy
What is social phobia?
Shyness, fear of performance failure and negative evaluation (e.g. public speaking, eating in public, general social interactions)
Give 3 symptoms of social phobia
Blushing Muscle twitching Anxiety about scrutiny Self-focused attention Avoidance
How is social phobia treated?
CBT
Short term benzo/propranolol
SSRIs
MAOIs
What is generalised anxiety disorder?
Free floating anxiety often with panic disorder
Give 2 features of GAD
Anxiety is free floating (not restricted to any circumstance)
Irrational worries
Motor tension
Autonomic overactivity
How is GAD treated?
Pharmacological - benzo, SSRI, beta-blocker, mirtazepine, duloxetine
Non-pharmacological - relaxation training, exposure therapy, CBT, physical exercise
What is the bimodal onset of panic disorder?
Late adolescence and mid-30s
How does panic disorder present?
Several severe attacks of autonomic anxiety within a month, fear of death/suffocating, urgent desire to flee
How is panic disorder treated?
SSRI
CBT
Relaxation training
What is agoraphobia?
Fear and avoidance of places/situations that might cause panic (e.g. crowds, public places, travelling away from home)
How is agoraphobia treated?
SSRI
Anxiolytic
CBT
What is PTSD?
Delayed (within 6 months of trauma) and protracted response to a stressful event/situation of exceptionally threatening/catastrophic nature
What are the symptoms of PTSD?
Episodes of repeated reliving of trauma in intrusive memories/flashbacks
Nightmares
Numbness and emotional detachment
Avoidance of activities/situations reminiscent of trauma
Autonomic hyper-arousal (may manifest as persistent anxiety, irritability, insomnia, poor concentration)
Hyper-vigilance
Give 2 associations of PTSD
Aggressive behaviour
Substance misuse
Deliberate self-harm
How is PTSD treated?
CBT
Eye movement desensitisation and reprocessing
High dose SSRI and TCA
What are the 3 main features of OCD?
Obsessions – recurrent, intrusive thoughts/images/ruminations/impulses
Compulsions – ritualistic motor acts
Ego-dystonic – acknowledged as unreasonable/excessive, attempts to resist
How is OCD treated?
CBT
High dose SSRI
Clomipramine
Define ‘somatoform’ disorder
Mental disorder characterised by physical symptoms which cannot be explained by a medical condition (not consciously fabricated)
Define ‘dissociative’ disorder
Break down in memory, awareness, identity and/or perception
How is somatoform and dissociative disorder treated?
Difficult to treat
Spontaneous over time
Psychotherapy
Medication unhelpful
Outline how to carry out a psychiatric history
PC HPC Past psychiatric history PMH DH FH SH Personal history Forensic history Premorbid personality MSE
Outline how to carry out a MSE
Appearance and behaviour Speech Mood Thought - content, form Perception Cognition Insight (Risk)
Give 2 advantages of ECT
Improves mood and psychotic symptoms
Few side effects
Fast acting
Life saving
Give 2 indications for ECT
Severe depression (suicidal ideation, psychomotor retardation)
Catatonia
Treatment resistant psychosis
How often is ECT delivered?
Twice a week for up to 12 sessions
Give 2 side effects of ECT
Anaesthetic risk Dental issues Headache Muscle pain Vomiting Memory loss (long-term)
Give 3 types of psychosurgery
Lobotomy (no longer carried out)
Anterior cingulotomy
Transcranial magnetic stimulation
Vagal nerve stimulation
What is an anterior cingulotomy used for?
Treatment resistant mood disorder or OCD
Give 3 types of dementia
Alzheimer's Vascular Lewy body Parkinson's Pick's disease
How is dementia diagnosed?
History
Examination
Neuropsychiatric tests
What areas of the brain are primarily affected in Alzheimer’s dementia?
Medial temporal lobes
Hippocampi
In terms of signs/symptoms of Alzheimer’s dementia, what are the ‘5 As’?
Amnesia Aphasia Apraxia Agnosia Associated non-cognitive (e.g. mood problem, hallucination, delusions)
Give 2 genes implicated in Alzheimer’s dementia aetiology
APP
APOE
PS1
How is Alzheimer’s managed?
Cholinesterase inhibitors (e.g. donepezil, rivastigmine) to slow decline/reduce non-cognitive symptoms Glutaminergic agent (e.g. memantine) Education, support, OT, PT
Give 2 characteristics of vascular dementia
Patchy cognitive impairment
Stepwise deterioration
Localised neurological deficits
Cerebrovascular disease
How is vascular dementia managed?
Supportive - smoking cessation, aspirin, statin
Give 2 features of Lewy body dementia
Parkinsonism
Hallucinations
Fluctuating course
Give 2 associations of Lewy body dementia
Neuroleptic sensitivity REM sleep disorder Low dopamine transmitter uptake in SPECT/DAT scan Syncope Repeated falls Autonomic disturbance
How is Lewy body dementia managed?
Cholinesterase inhibitor (e.g. rivastigmine)
Supportive
Melatonin/clonazepam for REM sleep disorder
What type of medications should be avoided in Lewy body dementia?
Anticholinergics
Antipsychotics
Give 2 features of Pick’s disease/frontotemporal dementia
Slow steady decline from middle age Frontal lobe dysfunction mainly Blunting of behaviours Disinhibition Apathy Restlessness Aphasia
Give 3 differential diagnoses for dementia
Depression Malnutrition Vitamin deficiencies Alcohol/substance misuse Delirium Polypharmacy
What treatment is recommended for mild cognitive impairment?
None
Give 2 features of delirium
Acute onset Fluctuating course Inattention Disorganised thinking Altered level of consciousness
Give 3 possible causes of delirium
Infection Pain Nutrition Constipation Hydration Medications Environment
How is delirium managed?
Reorientation Involving carers Limit sensory deprivation Correcting reversible causes Consider stopping anti-cholinergic or contributory medications Mobilisation
What is risk?
Probability of a negative event (e.g. suicide, violence)
What is the most powerful predictor of risk?
Past behaviour
What are the most common methods of suicide?
Hanging Strangulation and suffocation Poisoning Drowning Jumping from height
Give 2 risk factors for suicide
Mental health problems Self harm Substance misuse Chronic illness Personality issues/coping style Work and employment Poverty
Give 2 protective factors for suicide
Problem solving ability Self control of thoughts/emotions Hopefulness Participating in sport Family/marriage/social relationships Religious faith Employment Social values
Give 2 correlates of suicide in major depression
Severe illness Self neglect Impaired concentration and memory Hopelessness Alcohol abuse Mood cycling
Give 2 correlates of suicide in schizophrenia
Young male Relapsing pattern Depression Recent discharge from inpatient care Social isolation Insight
What are the 2 vulnerability points in an episode of psychiatric illness?
Initial acute phase
Period of recovery
What are the most common methods of deliberate self harm?
Poisoning
Self-cutting
Give 2 risk factors for DSH
Alcohol
Trauma in childhood
Chaotic personal life
Give 2 circumstances which indicate serious intent to DSH
Final acts/premeditation (e.g. will, saying bye)
Measures to prevent interruption (e.g. isolated spot, knowing others will not be around)
Choosing method perceived to be most successful (e.g. hanging, pills)
Give 2 factors from the history which indicate serious intent to DSH
Active mental illness Absence of intoxicants Regret over failure/indifference to being alive Specific suicidal plans Hopelessness Ongoing intent
How can DSH/suicide be prevented?
No specific management
Teach problem solving skills, admission for mental illness, treat underlying substance misuse/mental illness, population approach
Give 2 population approaches to preventing DSH/suicide
Reducing availability of methods (e.g. catalytic converters, limit on tablet number)
Economic (e.g. increasing employment)
Educating GPs (e.g. better management of depression)
Educating public (e.g. anti-stigma towards mental illness)
How is risk of violence assessed?
Difficult to predict
Increased risk in schizophrenia and substance misuse
Which Act protects patients and society, and allows treatment of patients with a mental disorder?
The Mental Health (Care and Treatment) (Scotland) Act 2003
Which Act deals with capacity?
Adults with Incapacity (Scotland) Act 2000
What 3 Acts may be relevant in patients with a mental disorder?
Mental Health Act 2003
Criminal Procedures Act 1995
Criminal Justice and Licensing Act 2010
What are the Millan principles?
All treatment under the Mental Health Act must follow 10 principles, known as the Millan principles
What does the Detention and Mental Health (Scotland) Act 2003 cover?
Mental illness
Learning disability
Personality disorder
Give 3 types of detention used in psychiatry
Emergency (EDC)
Short-term detention (STDC)
Compulsory treatment order (CTO)
Give 3 features of an emergency detention certificate (EDC)
Keeps/brings patient in hospital for assessment
Any doctor FY2+
Lasts 72 hours
Best to have consent from mental health officer (MHO)
Must be reviewed by senior psychiatrist ASAP
Treatment is not covered
Cannot be appealed
Give 3 features of a short term detention certificate (STDC)
To keep/bring patient in hospital for assessment and treatment
Approved medical practitioner (AMP) only (Section 22) e.g. psychiatrist
Lasts up to 28 days
MHO consent essential
Can be appealed
Must be reviewed and revoked timeously
Give 3 features of a compulsory treatment order (CTO)
To bring/keep patient in hospital for treatment, or to continue treatment in the community
Two medical recommendations (one must be AMP)
Lasts up to six months and is renewable
MHO is the applicant
Can be appealed
Must be reviewed and revoked timeously
What are the criteria for detention of patients under the Mental Health Act?
Mental disorder Significant risk Treatment Significantly impaired decision making ability Necessity
What is the dopamine hypothesis of schizophrenia?
Hyperactivity of the mesolimbic dopamine pathways - accounts for positive symptoms
Deficiency of dopamine in the mesocortical dopamine pathway - accounts for negative and cognitive symptoms
Give 2 typical antipsychotics
Haloperidol Flupentixol Chlorpromazine Sulpride Clopixol
Give 2 atypical antipsychotics
Aripiprazole
Clozapine
Olanzapine
Risperidone
Give 2 indications for antipsychotic medications in psychiatry
Schizophrenia (and related disorders)
Bipolar affective disorder
Give 3 side effects of antipsychotics
Movement disorders (e.g. dystonia, akathisia) Autonomic effects (e.g. anti adrenergic/cholinergic) Neuroleptic malignant syndrome Convulsant activity Pigmentation Metabolic effects (e.g. weight gain) Endocrine effects Hypersensitivity reactions (e.g. skin)
What is acute dystonia and who is most likely to suffer from it as a result of antipsychotic use?
Involuntary skeletal muscle contraction
Young males naive to medication
What is tardive dyskinesia and when is it seen in psychiatry?
Late onset hyperkinetic involuntary movements
Side effect of antipsychotics
What anti-adrenergic effects can be caused by antipsychotics?
Postural hypotension QTc prolongation and arrhythmias (e.g. Torsade des pointes) Sexual dysfunction (e.g. ejaculatory failure)
What anti-cholinergic effects can be caused by antipsychotics?
Dry mouth Blurred vision Constipation Difficulty micturating Urinary retention
What is neuroleptic malignant syndrome?
Life-threatening reaction that can occur in response to antipsychotic medication
What are the signs/symptoms of neuroleptic malignant syndrome?
Muscle rigidity Extreme extrapyramidal symptoms Severe hyperthermia Hypertension Tachycardia
Which antipsychotic can lower the seizure threshold?
Chlorpromazine
Which antipsychotics cause weight gain?
Clozapine
Olanzapine
What endocrine effect can antipsychotics have?
Hyperprolactinaemia
Causes reduced libido, sexual dysfunction (impotence), menstrual irregularities, lactation (non-pregnant females)
What is clozapine used for?
Treatment resistant schizophrenia
What is the method of action of clozapine?
Serotonin and dopamine antagonist
What important side effect is clozapine associated with and what should be done to prevent this?
Agranulocytosis
Regular differential WBC monitoring
What lifestyle factor needs to be taken into account for patients on clozapine?
Smoking induces hepatic enzymes which will cause a reduced plasma level of clozapine (which will increase if smoking stops)
Define bipolar affective disorder
Repeated (i.e. at least two) episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (mania or hypomania), and on others of a lowering of mood and decreased energy and activity (depression)
Give 3 signs/symptoms of BAD
Elevated mood Increased motor activity Increased sexual interest Sleep disturbance Irritability Aggression Fast speech
How is BAD managed?
Mood stabilisers
Antipsychotics
Benzodiazepines
ECT
Name 2 mood stabilising drugs
Lithium
Carbamazepine
Valproate
Give 2 indications for lithium
Acute treatment of mania/hypomania
Prophylaxis in bipolar disorder, schizoaffective disorder and recurrent depressive illness
Augmentation of antidepressants in acute depressive illness
Treatment of depression in bipolar disorder
What investigations should be done before starting a patient on lithium?
Bloods - thyroid and kidney
ECG
What is the main contraindication of lithium and why?
Pregnancy - crosses placenta and causes Epstein’s anomaly and affects thyroid function of baby
Name a drug type which interacts with lithium
NSAIDs
Thiazide diuretics
Give 5 adverse effects of lithium
Nausea/vomiting Diarrhoea Metallic taste in mouth Cognitive dulling Tremor Muscle weakness Weight gain Hypothyroidism Hyperparathyroidism Renal tubular necrosis Kidney failure Nephrogenic diabetes insipidus (thirst, polyuria, sleep disturbance)
How does lithium cause hypothyroidism?
Competes with iodine for absorption into thyroid gland, reducing hormone production
Give 3 signs/symptoms of lithium toxicity
Initially - fine tremor, nausea, vomiting and dizziness
Progressing to - course tremor, ataxia, dysarthria, drowsiness, confusion, fits, coma and death
What is the Care Programme Approach?
Approach used in secondary mental health and learning disability services to; assess, plan, review and co-ordinate care, treatment and support for people with complex needs, relating to their mental health or learning disabilities
Give 3 types of professional involved in the Care Programme Approach and their main duty
Community psychiatry nurse - monitor mental state and medication adherence Housing officer - monitor housing OT - assess ADL GP - review physical health Social work - needs assessment
How would a lithium overdose be managed?
Monitor - serum lithium, renal function, ECG
Reduce absorption and increase clearance to below 1 mmol/L - IV fluids, gastric lavage, whole bowel irrigation, national poisons information service
How long should antidepressants be continued for a single episode?
4-6 months after resolution of symptoms
Name a TCA
Amitriptyline
Imipramine
Name an SSRI
Sertraline
Fluoxetine
Name a selective noradrenaline and serotonin re-uptake inhibitor
Venlafaxine
Name a MAOI
Phenalzine
Moclobemide
What is the basic mechanism of action of antidepressants?
Enhance the functional activity of noradrenaline and/or dopamine in the brain
How long should a patient be newly on antidepressants before reviewing?
6 weeks
What drug is first line for depression?
Sertraline
Give 3 side effects of SSRIs
Nausea Loss of appetite Dry mouth Diarrhoea Constipation Dyspepsia Vomiting Weight loss Insomnia Dizziness Anxiety Fatigue Tremor Somnolence Extrapyramidal symptoms Seizures Mania Sweating Delayed orgasm/anorgasmia Hyponatraemia Alopecia
What is hypericum perforatum?
St John’s wort
OTC remedy for anxiety and depression
Why is it important to find out if a patient is taking St John’s wort before prescribing an antidepressant?
Co-prescribing with SSRI/dopamine potentiator may cause serotonergic syndrome/neurotoxicity
Give 3 signs/symptoms of serotonin syndrome
Myoclonus Nystagmus Headache Tremor Rigidity Seizures Irritability Confusion Agitation Hypomania Coma Hyperpyrexia Sweating Diarrhoea Cardiac arrhythmias Death
What is the spectrum of substance use?
Recreational
Acute intoxication
Harmful use
Dependence syndrome
What is acute intoxication?
Transient condition following use of alcohol or drugs, closely related to dose and following which recovery is usually complete
What are the symptoms of acute intoxication?
Stimulation, excitement or impaired judgement Disinhibition Reduced (or heightened) consciousness Euphoria/dysphoria Impaired motor co-ordination Sensory disturbances Hyperthermia Respiratory Depression
What is harmful substance use?
A pattern of substance use that causes damage to physical/mental health or social circumstances
What is dependence syndrome?
A cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value
How is dependence syndrome diagnosed?
3 or more of:
A strong desire or sense of compulsion to take the substance
Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use
A physiological withdrawal state when substance use has ceased or been reduced
Evidence of tolerance, such that increased doses of the psychoactive substances are required in order to achieve effects originally produced by lower doses
Progressive neglect of alternative pleasures or interests because of psychoactive substance use
Persisting with substance use despite clear evidence of overtly harmful consequences
What is withdrawal state?
A group of symptoms occurring on withdrawal/reduction of a substance after repeated use; indicates dependence
What are the symptoms of benzodiazepine withdrawal?
Anxiety Agitation Irritability Diaphoresis Confusion Nausea Palpitations Insomnia Seizures Hallucinations Psychosis
What are the symptoms of opioid withdrawal?
Rhinitis Lacrimation Yawning Dilated pupils Diaphoresis Insomnia Diarrhoea Nausea & vomiting Piloerection Abdominal cramps Dysphoria Tachycardia Hypertension
What condition can accompany withdrawal state? Give an example
Delirium
E.g. delirium tremens in alcohol withdrawal
What are the signs/symptoms of delirium tremens?
Confusion with nocturnal worsening Hallucinations Illusions Anxiety/fear Tremor Hypertension Tachycardia Tachypnoea Seizures
What are the signs/symptoms of psychotic disorder caused by substance misuse?
Vivid hallucinations, misidentifications, paranoid delusions, ideas of reference
Psychomotor disturbances
Abnormal affect
What is the timing of psychotic disorder caused by substance misuse?
Symptoms occur during/within 48 hours of psychoactive substance use
Improves within 1 month, resolves within 6 months
What substances can cause psychotic disorder?
Alcohol
Cocaine
Amphetamine
What is amnesic syndrome? What is commonly implicated?
Memory impairment - absence or defect in immediate recall, impairment of consciousness and generalised cognitive impairment
Chronic use of alcohol or drugs
What areas of the brain are involved in the dopamine reward pathway?
Vental tegmental area - dopaminergic neurons
Nucleus accumbens - dopamine sensitive cells
Amygdala and hippocampus - memory and desire
Prefrontal cortex - co-ordination of information, determination of behaviour
Give 4 things which can activate the reward pathway
Natural - food, sex, nurturing, exercise
Chemical - drugs, alcohol, coffee, nicotine
What factors are implicated in addiction?
Social learning/copying
Biological and neurological
Genetics
How are substance use disorders assessed?
Use Problems Physical adaptation Behavioural dependence Medical harm Cognitive impairment Motivation for change
What is the cycle of change?
Pre-contemplation Contemplation Preparation Action Maintenance Relapse
What psychosocial interventions can be useful in addiction?
Motivational interview Brief interventions CBT - relapse prevention, anxiety management and coping skills 12 step programmes Peer support Rehabilitation
What are the advantages of motivational interviewing for addiction?
Works on facilitating & engaging intrinsic motivation to change
Collaborative
Goal-orientated
Client-centred
Guides patient to examine & resolve ambivalence
What brief interventions can be useful for addiction?
F - Feedback of risks R - Responsibility highlighted A - Advice to abstain or cut down M - Menu of alternative options and activities offered E - Empathic interviewing S - Self efficacy enhanced
What empathetic techniques should be used in motivational counselling?
Express empathy
Avoid arguments
Roll with resistance
Support self efficacy
What laws are in place for substance use?
Misuse of Drugs Act (1971)
Psychoactive Substances Act (2016)
What is the strongest single predictor of suicide in substance misuse?
Alcohol
What are the effects of opioids?
Analgesia Respiratory depression Euphoria Drowsiness Constipation
What drugs can be used for opioid detox and replacement?
Detox - lofexidine, buprenorphine
Replace - buprenorphine, methadone
What are the issues with opioid replacement therapy?
Prolonged QT and respiratory depression at higher doses
Rapid loss of tolerance - high risk of OD if missed doses (need for re-titration after 3 days)
What are the symptoms of opioid OD?
Respiratory depression
Pinpoint pupils
Decreased level of consciousness
How is opioid OD treated?
Naloxone (competitive opioid antagonist)
What are the symptoms of benzodiazepine OD?
Sedation Drowsiness Ataxia Slurred speech Coma Respiratory depression
How is benzodiazepine OD treated?
Supportive
Flumazenil
What are the effects of MDMA?
Stimulant
Hallucinogenic
How can harm from MDMA be reduced?
Maintain hydration
Avoid overheating
What are the effects of cocaine?
Increased energy Increased confidence Euphoria Diminished need for sleep Psychological dependence
What is cocaine associated with?
Psychosis
Sudden cardiac death
What are the effects of cannabis?
Impaired cognitive and psychomotor performance
Euphoria, heightened perceptual sensitivity, depersonalisation and derealisation
Vasodilation, suffused sclerae, postural hypotension, syncope
Tolerance
Psychological dependence
What are the symptoms of cannabis withdrawal?
Restlessness Insomnia Anxiety Aggression Anorexia Muscle tremor Autonomic effects
What is cannabis use in teenagers linked with?
Schizophrenia
What are the dangers of volatile gases?
Sudden cardiac death Asphyxiation Accidents whilst intoxicated Rapid intoxication Rashes around nose & mouth Occular or oropharangeal irritation Chronic users may develop diffuse cerebral, cerebellar and brainstem atrophy with white matter changes & leukoencephalopathy Hearing loss, cerebellar signs, peripheral neuropathy, lethargy, memory less
What are the risks of ketamine use?
Cardiac problems
Accidental death
Unprotected sex
Cognitive deficits
What is ketamine associated with?
Ketamine bladder - 30% of users have erosion of urothelium which causes revascularisation and leads to urge incontinence, decreased bladder compliance/volume, detrusor overactivity, painful haematuria, bilateral hydronephrosis and renal papillary necrosis
How are learning disabilities defined?
IQ <70
Reduced ability to understand/learn
Impaired social and adaptive functioning
Onset before 18 years of age
What is the age equivalent of mild, moderate, severe and profound learning disability?
Mild - 9-12 years
Moderate - 6-9 years
Severe - 3-6 years
Profound - <3 years
Give 2 causes of learning disability
Genetic - Down’s syndrome, PKU, fragile X
Infective - rubella, meningitis, encephalitis
Trauma - birth asphyxia, head trauma
What mental health conditions are more common in people with learning disability?
Depression Schizophrenia Anxiety Delirium and dementia ADHD
What effect can pregnancy have on mental illness?
May modify the presentation of illness or alter help-seeking behaviour (e.g. greater motivation to tackle issues before birth)
May alter the outcomes of pregnancy (e.g. poorer engagement with antenatal care, greater use of smoking, alcohol, drugs)
What are the features of postnatal depression?
Onset 6-8 weeks
Varying severity
Symptoms similar to depression
Significant effects on child if left untreated
What are the predictors of postnatal depression?
Past psychiatric history Psychological problems during pregnancy Poor marital relationship Lack of social support Stressful life events Low social status Single Previous miscarriage/termination Ambivalence about baby Lack of female confidante Difficult pregnancy/delivery
How is postnatal depression managed?
Social support and primary care counselling
Psychological therapies
Antidepressants
When should a woman with postnatal depression be referred to psychiatry?
Significantly impaired function
Ideas of self harm/harm to baby
Unresponsive to medication
What are the features of postpartum psychosis?
Onset in first 2 weeks
Dramatic presentation - labile mood, confusion, delusions
Good prognosis but 60% recurrence risk
What are the predictors of postpartum psychosis?
History of postpartum psychosis
History of BAD
Family history of PPP or BAD
What is the main difference between the predictors of postnatal depression and postpartum psychosis?
PD - psychosocial
PPP - biological
What is PPP a variant of?
BAD
How is PPP managed?
Usually require admission
Supervision of mother and baby
Antidepressant and neuroleptic +/- lithium +/- ECT
How can PPP be prevented?
Identify risk
Communicate with GP and refer to mental health services
Lithium prophylaxis in immediate postpartum period
What risks regarding pregnancy are increased in schizophrenia?
Reduced fertility Unplanned/unwanted pregnancies Smoking and drinking during pregnancy Complications during pregnancy and delivery SIDS
How should prescribing in pregnancy be done for women with psychiatric conditions?
Pre-pregnancy decision making - contraception, risk of illness, risk of drugs Clear indication Avoid first trimester if possible Lowest effective dose for shortest time Avoid polypharmacy Individual assessment of risks and benefits Involve partner Acknowledge uncertainty
What are the risks of antidepressants in pregnancy?
Cardiac malformations (2% AR)
Persistent pulmonary hypertension of the newborn (0.5% AR)
Neonatal adaptation syndrome (10% AR)
What are the effects of postnatal depression on the mother and child?
Disturbed mother-infant interaction
Poorer infant interactions and play, decreased sociability, cognitive delay
What sex is more likely to develop depression in childhood and adolescence?
Childhood - equal
Adolescence - females (2:1)
What percentage of adolescents with depression are likely to experience a second episode in early adulthood?
45%
What are the 3 core symptoms of depression?
Low mood
Anhedonia
Lack of energy
How does the presentation of depression in children/adolescents differ from adults?
Mood - irritable, argumentative, defiant, aggressive; may have periods of brightening
Sleep - insomnia and hypersomnia, early morning wakening
Behaviour - poor school performance, refusal to attend school, social withdrawal
Somatic complaints
Slow, insidious onset
How should children/adolescents with depression be assessed?
Collateral history (seek permission from patient)
Speak with patient with and without parents
Focus on social history and protective factors
Consider co-morbidities (e.g. ASD)
How should children/adolescents with depression be assessed for risk?
Same as adults
Ask about suicidal thoughts
Emphasis on - self-harm, risky behaviour, impulsivity, abuse
How should children/adolescents with depression be managed?
Involvement of family/school
Psycho-education
Psychological therapies - CBT, family, art/play
Pharmacotherapy - fluoxetine only
What are the 4 types of factors to consider in psychiatric conditions?
Predisposing
Precipitating
Perpetuating
Protective
Name 2 neurodevelopmental disorders
ADHD ASD Tourette's syndrome Learning difficulties Dyslexia
What are the 3 core components of ADHD?
Inattention
Hyperactivity
Impulsivity
What are the risk factors for ADHD?
Male
Genetics
Family history
How does ADHD change with age?
Improvement is seen with age, but 2/3rds still have symptoms in adulthood
What are the developmental impacts of ADHD?
Behavioural disturbance Academic impairment Poor social interaction Impaired self-esteem Engaging in smoking/alcohol/drugs at young age and then abusing Antisocial behaviour Occupational difficulties/unemployed Injury/accidents Inability to cope with daily tasks Mood instability Relationship difficulties
How does ADHD present in adults?
Chaotic Disorganised Always late Losing things Starts a lot, finishes little Multiple jobs and relationships Careless mistakes Avoid books/films/queues Others organise life Restless Fidgeting Can’t relax or switch off Rude Can’t wait Impatient Conflicts at work Lose train of thought Forget question Unthinking breaching of ‘rules’
How is ADHD diagnosed?
Detailed psychiatric and developmental assessment
Collateral history
Diagnostic criteria (DSM or ICD)
Optional neuropsychiatric assessment
What symptoms of inattention can occur in ADHD?
DADMOMLFC
Difficulty sustaining attention Avoids sustaining attention Distracted easily Misplaces things Organisation problems Mistakes made Listening difficult Forgetful in daily activities Completing tasks or jobs
What symptoms of hyperactivity/impulsivity can occur in ADHD?
LFROST/WIB
Loud in quiet situations Fidgetiness Restless or overactive On the go all the time Seating difficult Talks excessively
Waiting difficult
Interrupts or intrudes
Blurts out prematurely
What are the ICD-10 diagnostic criteria for ADHD?
Hyperkinetic disorder: ≥6 symptoms of inattention, ≥3 of hyperactivity, ≥1 of impulsivity
Started before age 7 Present ≥ 6/12 months Affecting ≥ 2 settings Significant impairment in functioning Symptoms not due to another cause
What are the differential diagnoses for ADHD?
Normal behaviour
Malingering or seeking stimulant medication (mainly students)
Hyperthyroidism, substance abuse, mania, cyclothymia, agitated depression, anxiety disorders, EUPD, ASPD, LD, ASD, Tourette’s syndrome
How can ADHD be managed?
Support groups, psychiatry, CBT, occupational therapy
Stimulants - methylphenidate, dexamfetamine
Non-stimulants - atomoxetine, clonidone, bupropion, modafinil
How is the dose of methylphenidate for ADHD titrated?
Smallest dose at least 2 weekly and increase until adequate response/intolerable side effects or increased BP/HR
What preparations of methylphenidate are available for ADHD?
Immediate release (e.g. ritalin) Slow release (e.g. concerta)
What are the side effects of methylphenidate given for ADHD?
Reduced appetite Insomnia Headache Irritability Tachycardia Tics Seizures
When would atomoxetine be considered for management of ADHD?
Unresponsive/intolerant to stimulant
Abuse/diversion of stimulants is a concern
What are the side effects of atomoxetine?
Acute liver failure Suicidality Reduced appetite Nausea Insomnia Dizziness Constipation Sweating Sexual dysfunction Seizures
When would atomoxetine be contraindicated?
Phaeochromocytoma
How is response to management of ADHD monitored?
Monitor core and associated symptoms
Functioning (WFIRS scale)
Patient report/collateral
In what psychiatric co-morbidities should prescribing for ADHD be done carefully?
Psychosis - non-stimulant preferred
Depression - check if on NA antidepressant
Mania - mood stabiliser/antipsychotic cover
Anxiety - atomoxetine preferred (stimulants can exacerbate)
Addiction - 6 months abstinence
Tourette’s - stimulants worsen tics
What is the duration of drug treatment for ADHD?
6 monthly HR/BP
Drug holidays considered annually to assess if patient has ‘grown out’ of it
Gradual withdrawal with non-stimulants, rapid withdrawal with stimulants
What is Asperger’s syndrome?
Similar to autism but no general delay in language or cognitive development and tend to have normal intelligence
What are the 3 core symptoms of autism?
Abnormal reciprocal social interaction
Impaired communication/language
Restricted and repetitive interests/activities
What are the risk factors for autism?
FH Male Parental age Birth complications Environment
What symptoms of abnormal social interaction may be seen in a patient with ASD?
Indifference Minimal shared enjoyment Reciprocal interaction Functional friendships Only early life friends Attachment to objects Aloof or awkward Egocentric Limited empathy Social rules Insensitive Lack of intuition Emotional recognition
What symptoms of communication/language impairment may be seen in a patient with ASD?
Delayed or lack of speech Prolonged or avoidant eye contact Awkward posture or body language Speech unusual volume Formal, stilted, pedantic Misinterpretation of literal/implied meanings Advanced vocabulary ; poor conversational skills Lack of prosody (monotonous) Talking at rather than to Few nonverbal gestures
What symptoms of restricted/repetitive behaviours may be seen in a patient with ASD?
Obsessive fixed interests Motor mannerism (hand flapping, body rocking) Compulsive / repetitive behaviours Ritualistic daily activities Repetitive self injury Preference for sameness e.g. food Change unsettling Increased sensory responsiveness
What other symptoms may be experienced by a patient with ASD?
Clumsiness
Difficulty expressing emotion
Increased pain threshold
Lack of empathy
How is ASD assessed?
Psychiatry, SLT, OT, psychology
Standardised tools - autism behaviour checklist (ABC), childhood autism rating scale (CARS)
What is the main difference between the ICD-10 and DSM-5 diagnostic criteria for ASD?
ICD-10 - 3 different autism subtypes (childhood autism, Asperger syndrome, pervasive developmental disorder)
DSM-5 - spectrum
How is ASD managed?
Education Adapt environment - routine, reduce interactions Communication aids Social skills training CBT, OT Parenting programmes Medication if symptomatic
How is medication used in ASD?
Antipsychotics for stereotyped or aggressive behaviours
SSRIs for compulsive behaviours
Melatonin for insomnia
What is adjustment disorder?
A group of feelings (e.g. stress, sadness, hopelessness) and physical symptoms in over-reaction to a stressful life event due to difficulty coping
What is Russell’s sign?
Repeated contact of the fingers with teeth during self-induced vomiting (e.g. in bulimia) episodes can lead to characteristic abrasions, small lacerations, and calluses on the back of the hand overlying the knuckles
What are the main characteristics of bulimia nervosa?
Recurrent episodes of overeating (twice a week for three months)
Self perception of being too fat and intrusive dread of fatness
Persistent preoccupation with food
Attempts to counteract the “fattening” aspects of food by one of the following; self induced vomiting, purgative abuse, alternating periods of starvation, or use of drugs
How is bulimia nervosa managed in adults?
Focused self help programme using CBT
What should CBT for bulimia nervosa in adults cover?
20 sessions over 20 weeks Engagement and education Establishing regular eating Providing encouragement, advice and support Address psychopathology Involve significant others
How is bulimia nervosa managed in children/adolescents?
Focused family therapy
What should family therapy for bulimia nervosa in children/adolescents cover?
20 sessions over 6 months
Establish relationship
Information about regulating weight and adverse effects of inducing vomiting
Individual involvement too
How is binge eating disorder characterised?
3/5 of: Eating much more quickly than usual Eating until uncomfortably full Eating a lot when not hungry Eating alone because of embarrassment Feeling very bad or guilty after eating
How is binge eating disorder managed?
Self-help programme (CBT) and brief supportive sessions
How is anorexia nervosa characterised?
Weight loss (or in children lack of weight gain), leading to a body weight at least 15% below the normal or expected weight for age and height Weight loss is self induced by avoidance of fattening foods Self perception of being too fat, which leads to a self imposed low weight threshold Widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifest as amenorrhea or in men, loss of sexual interest and impotency
What is the prognosis of anorexia nervosa?
50% recovery with treatment
What are atypical eating disorders?
An eating disorder is called atypical if they do not fit exactly into the diagnostic categories. For example a person may have most of the symptoms of anorexia or bulimia but not all; or they may have symptoms of both conditions; or they may move from one condition to another.
How are atypical eating disorders managed?
Considers following the guidance on the treatment of the eating problem that most closely resembles the individual patient’s eating disorder
What are the cardiovascular physical complications of anorexia nervosa?
Cardiomyopathy Mitral valve prolapse SVT Long QT syndrome Bradycardia Orthostatic hypotension
What are the hormonal physical complications of anorexia nervosa?
Delayed puberty Amenorrhea Anovulation Increased GH Decreased ADH Hypothermia Hypokalemia Hyponatremia Hypoglycemia Euthyroid sick syndrome Hypercortisolism Arrested growth Osteoporosis
What are the gastrointestinal physical complications of anorexia nervosa?
Constipation
Decreased intestinal mobility
Delayed gastric emptying
Gastric dilation and rupture
What are the renal physical complications of anorexia nervosa?
< eGFR Oedema Acidosis with dehydration Hypokalemia Hypochloremic alkalosis with vomiting
What are the haematological and general physical complications of anorexia nervosa?
Anaemia Leucopenia Thrombocytopenia Dry skin and hair Hair loss Lanugo body hair Infertility Low birth weight infant
What is refeeding syndrome?
Any individual who has had negligible nutrient intake for more than 20 consecutive days is at risk of refeeding syndrome. Refeeding syndrome usually occurs within 10 days of starting to feed. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications.
How is anorexia nervosa managed in adults?
Self-help CBT programme - Aim to reduce the risk to physical health and any other symptoms of eating disorder
Encourage healthy eating and reach a healthy body weight
Consider nutrition, cognitive restructuring, mood regulation, social skills, body image concern, self esteem and relapse prevention, create a personalised treatment plan, explain risks of malnutrition, enhance self efficacy, self monitoring of intake and thoughts and feelings, homework
How is anorexia nervosa managed in children/adolescents?
Family therapy - Emphasise the role of family in helping them recover
Psychoeducation about nutrition and malnutrition
Establish a good therapeutic alliance with the person
Latterly support the person to establish a level of independence
Relapse prevention
What is MARSIPAN?
Management of Really Sick Patients with Anorexia Nervosa
Contains guidance for clinicians looking after MARSIPAN patients on acute medical wards and psychiatric wards, but also includes service recommendations e.g. most MARSIPAN patients should be admitted to a SEDU, treated by local expert physician with interest in nutrition/ nutrition team
How is physical risk assessment carried out for eating disorders?
BMI Rate of weight change CV risk (BP, pulse, ECG) Glucose and albumin Electrolytes and renal function Liver function Bone marrow function (WCC, Hb, platelets)
What are the risk factors for developing refeeding problems in anorexia nervosa?
1 or more of:
BMI less than 16kg/m2
Weight loss greater than 15% within the last 3 – 6 months
Little or no nutritional intake for more than 10 days
Low levels of potassium, phosphate or magnesium prior to feeding
History of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics
The presence of purging behaviours, such as vomiting and /or laxative misuse
How is refeeding managed?
Providing immediately before and during the first 10 days of feeding: oral thiamine 200-300mg daily, vit B Co Strong 1-2 tabs tds and a balanced multivitamin/ trace element eg. Forceval 1tab once daily
For most MARSIPAN patients, a re-feeding plan should be prescribed by a nutrition support team or dietitian (if necessary consulting with AEDS dietitian), starting at 20kcal/ kg/day and gradually increasing the caloric intake dependent on daily bloods (as previously detailed)
What psychiatric issues need to be considered in MARSIPAN patients?
Patients may admit or deny eating disordered behaviours (but have a high index of suspicion)
Falsifying weight by means of drinking water, wearing weights etc.
Excessive exercise (including microexercise)
“Under” dressing to burn calories
Disposing of food/ feed or using purging behaviours
Patients who sabotage their care may be observed 1:1 by experienced nurses.
If staff e.g. agency are inexperienced in management of AN, provide a concise management plan to follow
What additional considerations should there be when planning inpatient care for anorexia nervosa?
Consider bed rest (BMI<13) and DVT prophylaxis, partial bed rest (BMI 13-15)
Supervised washes only (BMI<13), supervised showers (BMI 13-15)
Tissue viability risk assessment, airflow mattress
Fluid input/ output charts
Access to toilets/ taps
Meal and snack supervision and post meal and snack supervision
Leave
Frequency of physical observations
Frequency of BMs
ALERT on Kardex regarding low BMI: For dose reductions for symptomatic relief and cautious use of sedative medication
What is the most common type of patient seen by a forensic psychiatrist?
Male
Psychotic
Alcohol/drug misuse
Personality disorder
How are patients managed in forensic psychiatry?
Medical Education and risk factors Psychology Occupational therapy Emphasis on rehabilitation
What are the symptoms of adjustment disorder?
Feeling sad, hopeless or not enjoying things you used to enjoy
Frequent crying
Worrying or feeling anxious, nervous, jittery or stressed out
Trouble sleeping
Lack of appetite
Difficulty concentrating
Feeling overwhelmed
Difficulty functioning in daily activities
Withdrawing from social supports
Avoiding important things such as going to work or paying bills
Suicidal thoughts or behavior
What is the timing of adjustment disorder?
Occurs within 3 months of the triggering event and lasts no longer than 6 months after it ends (can be persistent/chronic)
What is personality disorder?
A mental disorder in which there is a rigid and unhealthy pattern of thinking, functioning and behaving
A person with a personality disorder has trouble perceiving and relating to situations and people
What are the risk factors for personality disorder?
Family history
Abuse/unstable childhood
Childhood conduct disorder diagnosis
Brain chemistry and structure
What are the diagnostic criteria for personality disorder?
Long-term marked deviation from cultural expectations that leads to significant distress or impairment in at least two of these areas:
The way you perceive and interpret yourself, other people and events
The appropriateness of your emotional responses
How well you function when dealing with other people and in relationships
Whether you can control your impulses
How is personality disorder managed?
Psychotherapy
Medication - antidepressants, mood stabilisers, antipsychotics, anxiolytics
What is CBT?
Cognitive behavioural therapy (CBT) is a talking therapy that can help you manage your problems by changing the way you think and behave
How does CBT work?
CBT is based on the concept that your thoughts, feelings, physical sensations and actions are interconnected, and that negative thoughts and feelings can trap you in a vicious cycle
CBT aims to help you deal with overwhelming problems in a more positive way by breaking them down into smaller parts.
You’re shown how to change these negative patterns to improve the way you feel.
Unlike some other talking treatments, CBT deals with your current problems, rather than focusing on issues from your past.
It looks for practical ways to improve your state of mind on a daily basis.
What is psychotherapy?
Psychotherapy is a type of therapy used to treat emotional problems and mental health conditions
It involves talking to a trained therapist, either one-to-one, in a group or with your wife, husband or partner. It allows you to look deeper into your problems and worries, and deal with troublesome habits and a wide range of mental disorders
