Psychiatry Flashcards
Give the sections you might ask about in a psychiatric history?
Presenting Complaint, Past Psychiatric History, Family History, Personal History, Past Medical History, Drug History, Forensic History
What types of assessment might you do during or after a psychiatric history?
Mental State Assessment
Physical Examination
Risk Assessment
What might you ask about in family history?
Any relatives had problems similar to this? Mental health problems? Seen psychiatrist? Are parents alive/any medical conditions? What is relationship with parents like?
What might you ask in personal history?
Birth and early development School - social and academic Home environment - childhood and now Qualifications Relationships (including sexual experiences) Children + family Work
What might you ask about past medical history?
Medical conditions Admissions to hospital Surgery Trauma e.g. head injuries, road accidents, self harm Side effects from medication
What might you ask about in drug history?
Current medication + compliance, side effects
Allergies
Illicit drug use - how much/long, what, when, how, why
Alcohol consumption - how much/long, often, dependency?
When would you do the Mental State Exam?
During history, but may need to ask specific questions afterwards to clarify
What are the components of the Mental State Exam?
ASEPTIC A = appearance and behaviour S = speech E = emotions/affect/mood P = perceptions/hallucinations T = thoughts/delusions I = insight C = cognition
What are you looking for in appearance as part of the MSE?
eye contact dress psychomotor agitation/retardation self-care distractibility cooperability
What are you looking for in their speech during MSE?
Speed
Volume
Language
Neologisms, punning, clanging
What is a neologism?
Inventing new words to describe something
What is clanging?
Changing thought pattern through rhyme
What is the difference between mood and affect?
Mood = subjective/patient's own view Affect = objective/professional's opinion
What do you assess for thoughts/delusions in MSE?
Content (obsession, preoccupation, delusion, over-valued idea)
Form (circumstantial, tangential, loosening of association)
Stream (poverty, racing, perseverative, thought insertion/withdrawal/broadcast)
What might you assess about perceptions in MSE?
5 senses: visual, auditory, olfactory, gustatory, tactile
If auditory - content, 2nd or 3rd person, command
How might you assess cognition?
Level of assessment guided by Hx and MSE
MMSE - but does not assess frontal
Formal cognitive assessment e.g. ACE-III
What different things might you look for in a general psychiatric risk assessment?
Harm to self or others Suicide risk Vulnerability to exploitation Risk to children Self-neglect For above: how likely? how soon? how bad?
What are the five Ps in formulation?
1) presenting problem
2) predisposing factors
3) precipitating factors
4) perpetuating factors
5) protective factors
What is the lifetime prevalence of mental illness?
1 in 4
What is the incidence of suicide in the UK? What is the proportion between men and women?
11.2 per 100 000. 75% men, 25% women
What is the point prevalence of mental illness?
1 in 6
What percentage of people with long term conditions in the UK have mental health problems?
30%
List the common affective disorders
Depression
Bipolar
Cyclothymia
What is the prevalence of depressive episodes?
2.6% (slightly higher in females than males)
What is the prevalence of mixed anxiety and depression?
11.4% (slightly higher in females than males)
What proportion still have depressive symptoms a year after first presenting?
50%
What proportion of people with depression have recurrent depression (another episode)?
50%
How much does depression increase mortality risk from physical illness?
50% increased risk (causes include CVD, cancer, metabolic, respiratory disease)
What are the 3 core symptoms of depression?
- Low Mood
- Low energy (anergia)
- Low pleasure/interest (anhedonia)
List non-core symptoms of depression
Change in appetite (decrease/increase)
Change in sleep (classically early morning waking)
Poor concentration
Change in libido
Diurnal mood variation (depression worse in morning)
Agitation
Guilt - past
Worthlessness/lack of confidence - present
Hopelessness - future
Suicidal ideation
Give diagnostic criteria for mild depression in first episode
at least 2 core symptoms + at least 2-3 other symptoms
No symptoms should be present to an intense degree
Minimum duration 2 weeks
Give diagnostic criteria for moderate depression in first episode
At least 2 core symptoms + at least 4 other symptoms
Functioning affected, symptoms to marked degree, but may be mild if wide range of symptoms
Minimum duration 2 weeks
Give the diagnostic criteria for severe depression in first episode
All 3 core symptoms + at least 4 other symptoms (usually several, some of which will be severe intensity)
Somatic syndrome almost always present
Marked loss of functioning, suicidal
Minimum duration 2 weeks (but if rapid onset and particularly severe, may diagnose earlier)
Give diagnostic criteria for severe depression with psychosis
Meets criteria for severe depression +
hallucinations, delusions or depressive stupor (psychomotor retardation can progress to stupor)
Classify psychotic symptoms as mood congruent or incongruent (typically congruent - nihilistic, guilty, derogatory)
Give incidence of post-natal depression in women after childbirth
13% (and is leading cause of mortality for women post-partum)
What is the difference between Bipolar I and Bipolar II and Rapid Cycling?
Bipolar I = both mania and depression (sometimes only mania)
Bipolar II = more episodes depression, only mild hypomania (often misdiagnosed as recurrent depression)
Rapid cycling - each episode only lasts few hours/days
What should you always screen for if someone presents with depressive history?
Mania
Psychosis
Describe the features of cyclothymia
Persistent instability of mood with numerous episodes of depression and mild elation (neither severe enough to be bipolar affective disorder or recurrent depressive disorder)
Describe features of dysthymia
Chronic depression of mood often lasting several years, not sufficiently severe, or episodes not lasting long enough to be depressive disorder
Give the features of hypomania
4+ days duration Elevated mood (euphoric, dysphoric, angry) Increased energy Increased talkativeness Poor concentration Mild reckless behaviour Sociability/overfamiliarity Increased libido/sexual disinhibition Increased confidence Decreased need to sleep Change in appetite
Give the features of mania
>1 week Extreme elation/uncontrollable Over-activity Pressure of speech Impaired judgement Extreme risk-taking Social disinhibition Inflated self-esteem, grandiosity With psychotic symptoms - mood congruent/incongruent
List the common differentials for psychosis
Schizophrenia Delusional disorder Schizotypal disorder Depressive psychosis Manic psychosis Organic psychosis
What is the lifetime risk of having schizophrenia?
1%, equal male and female
When is the common age of onset for schizophrenia?
2nd-3rd decade with 2nd peak in late middle age
Men tend to get earlier, women get another peak post-menopausal
How does schizophrenia affect mortality?
Life expectancy 25 years less
Increased risk of suicide
Increased risk of CVD, resp, infection
What are the first rank symptoms of schizophrenia?
Thought alienation
Passivity phenomena
3rd person auditory hallucinations
Delusional perception
What are the second rank symptoms of schizophrenia?
Delusions 2nd person auditory hallucinations Hallucinations in any other modality Thought disorder Catatonic behaviour Negative symptoms
Give some positive psychotic symptoms
Hallucinations Delusions Passivity phenomena Thought alienation Lack of insight Disturbance in mood
Give some negative psychotic symptoms
Blunting of affect Amotivation Poverty of speech or thought Poor non-verbal communication Clear deterioration in functioning Self-neglect Lack of insight
How many first and second rank symptoms do you need to diagnose schizophrenia?
First rank = >1
Second rank = 2+
What is schizotypal disorder?
Eccentric behaviour, anomalies of thinking like schizohprenia but no definite schizophrenic anomalies
Symptoms only when stressors present
Cold or inappropriate affect
Anhedonia
Tendency to social withdrawal, paranoid or bizarre ideas (not true delusions), obsessive ruminations
Thought disorder
Transient quasi-psychotic episodes
Delusion-like ideas without external provocation
No definite onset/evolution, course like personality disorder
Give some examples of anxiety disorders
Generalised anxiety disorder Phobic disorders Panic disorder Mixed anxiety and depressive disorder Obsessive compulsive disorder Post traumatic stress disorder, acute stress reaction, adjustment disorder Dissociative disorders Somatoform disorders
Give some features of generalised anxiety disorder
Persistent and generalised anxiety, not restricted to certain circumstances
>6 months
Tiredness
Poor concentration
Irritability
Muscle tension, palpitations, epigastric discomfort
Disturbed sleep (usually insomnia rather than EMW)
Give some physical features of panic disorder
Palpitations Chest pain Choking Tachypnoea Dry mouth Urgency of micturition Dizziness Blurred vision Paraesthesiae
Give some psychological features of panic disorder
Feeling of impending doom Fear of dying Fear of losing control Depersonalisation Derealisation
What is depersonalisation?
Feeling outside of one self, observing thoughts and actions from a distance
What is derealisation?
Feeling like the world around you isn’t real or seems “foggy” or “lifeless”
Give some features of OCD
Obsessive/recurrent thoughts, images, compulsions
Often unpleasant, repetitive, intrusive, irrational
Recognised as patient’s own thoughts
Compulsive acts - stereotyped behaviours repeated, not pleasant, not to complete useful task, often to prevent unlikely harmful event
Patient often aware that acts are pointless, but does them to prevent anxiety - if resists acts, anxiety gets worse
Give some criteria to define personality
Enduring pattern inner experience and behaviour Deviates from cultural expectations Pervasive and inflexible Onset adolescence/early adult Stable over time Mode of relating to others
What about a personality makes it a personality disorder?
Leads to distress
Impairments in self and interpersonal functioning
Give the 3 different clusters for personality disorder types
Cluster A - “odd, eccentric”
Cluster B - “emotional, erratic”
Cluster C - “anxious/fearful”
What personality disorders fall under Cluster A?
Schizoid
Paranoid
Schizotypal
What personality disorders fall under Cluster B?
Emotionally unstable (borderline)
Histrionic
Dis-social/antisocial
Narcissistic
What personality disorders fall under Cluster C?
Obsessive-compulsive
Dependent
Avoidant
What is the most common personality disorder and what are its two sub-types?
Emotionally Unstable Personality Disorder (EUPD)
- Impulsive
- Borderline
What are the features of EUPD (impulsive)?
Unstable/capricious mood
Acts without thinking of consequences
What are the features of EUPD (borderline)?
Impulsive attributes (unstable mood, impulsive acts)
chronic feeling emptiness
Feelings of self-harm, suicide
Fears of abandonment
Intense/unstable relationships
Uncertainty regarding self-image, aims, preferences
Transient stress-related paranoia, dissociation, intense anger, PTSD
Give some reasons for self-harm in BPD
To relieve psychic pain, feel concrete pain, inflict punishment, reduce anxiety, feel in control, express anger, feel something when feeling numb, seek help, keep away bad memories
What is the management for EUPD?
- Psychotherapy - Dialectical Behavioural Therapy (DBT), therapeutic community approaches
- Medication for comorbidities if appropriate
- Structured Clinical Management - emphasis problem solving, crisis management
What is the prognosis for EUPD patients?
1 in 10 will commit suicide - worse if comorbidities and substance misuse
Impact and suicide risk greatest in early adulthood
Short-medium term outcome poor, longer term more positive
How is an illusion different from a hallucination
Illusion - misperception of an external stimulus
Hallucination - Perception without the presence of external stimulus
What type of hallucination is a first rank symptom of schizophrenia?
3rd person auditory hallucinations
What is the more common reason for visual hallucinations?
Organic episodes (often acute)
What causes are more common for olfactory, gustatory and tactile hallucinations?
Organic episodes
Olfactory and gustatory common as prodromal symptoms of temporal lobe epilepsy
Tactile sensations - more common in drug and alcohol withdrawal
What is a functional type of hallucination?
When a stimulus in one sensory modality triggers a hallucination in the same modality
What is a reflex type of hallucination?
Stimulus in one sensory modality triggers a hallucination in a different modality
What is an extracampine type of hallucination?
Hallucination outside of sensory field/physically impossible hallucination
What is a hypnagogic hallucination? Is it normal?
Hearing voices when falling asleep, normal and common - 1 in 3 people experience these
What is a hypapompic hallucination?
Hearing voices when waking up - less common than hypnagogic
What are the 4 sub-categories of thought disorders?
Disorders of Stream of Thought
Disorders of Possession of Thought
Disorders of Content of Thought
Disorders of Form of Thought
What is flight of ideas?
Thinking/speaking quickly, jumping from one point to another, but there is logical connectivity between points
What is circumstantiality?
Knows point to make, but goes round and round before getting to the point
What is tangentiality?
Goes off on a tangent in thought and does not make it to final point
What is perseveration?
Answering different questions with the same answer without it making sense
What is thought blocking?
Loses train of thought - which can be normal. May not be able to pick up line of thought once reminded
What is thought insertion?
Believes an external agency is placing thoughts in their head
What is thought withdrawal?
Believes external agency is taking thoughts out of their head
What is thought broadcast?
Believes their thoughts are being broadcasted to everyone
What is a delusion?
Firmly held thought/belief outside of social norm that is unshakeable, not deterred when provided evidence against it
What is an over-valued idea?
Firmly held belief, but is shakeable when given contrary evidence
Give 3 types of primary delusion
- Delusional Mood
- Delusional Perception
- Sudden delusional idea (autochthonous delusion)
What is a delusional mood?
Has strong conviction/feeling that something is not right, but cannot tell what it is, feeling comes out of nowhere
What is a delusional perception?
True perception of a stimulus evokes a delusional interpretation - adds new meaning often of personal significance to patient
What is a sudden delusional idea?
Sudden primary delusion with no stimulus/trigger. Also called autochthonous delusion
List some different types of delusion
Persecutory, Grandiose, Infidelity, Love, Religious, Guilt, Self-referential, Nihilistic, Poverty, Hypochondriacal, Misidentification
What is another name for infidelity delusion? What do they believe?
Othello’s delusion - believes partner is cheating
What is another name for love delusion? What do they believe?
Erotomania/De Clerembault - believes person that is unattainable is in love with them
What is a self-referential delusion?
Believes that actions/words/insinuations are aimed at them when they may not be
What is another name for nihilistic delusion? What does the delusion often involve? When might this delusion present? Prognosis?
Cotard’s syndrome - believes they are non-existent, dying, insides are rotting
Usually in severe depression
Prognosis usually good
Give 3 types of misidentification delusion and briefly describe what they involve
Capgras - believes someone they know has been replaced by imposter
Fregoli - believes different people are the same person in disguise
Intermetamorphosis - believes swapped bodies with someone else “Freaky Friday”
What is loosening of association?
No sense or association between points of thought/speech
What is dissociative amnesia?
Sudden memory loss during episodes of extreme trauma
What is confabulation? What cause is more common?
Short-term memory not good so fills in gaps with false stories that they believe are true
More common in organic pathology e.g. Korsakoff syndrome
What is anhedonia?
Inability to feel pleasure
What is apathy?
Lack of energy/motivation
What is incongruity of affect?
Affect/appearance of mood to others does not fall in line with thoughts or internal emotions
What is blunting of affect?
Reduced ability to express emotions
Can be due to meds, as well as disorders
What is conversion?
Type of somatic disorder involving central nervous system under voluntary control
What is somatic disorder?
Unconscious transposition of psychological conflict into somatic sensory or motor symptoms
What is Belle Indifference?
Lack of concern or feeling indifferent about a physical symptom - often associated with conversion
What is passivity phenomena? Give 3 examples
When the person does not feel in control of their own actions/feelings/drives.
E.g. somatic passivity, made act/feel/drive, catatonia
What is somatic passivity?
Feels as thought somebody has control over their body
What is made act/feel/drive?
Made act - believes someone is in control of their actions
Made feel - believes someone is in control of their feelings
Made drive - believes someone is in control of their drives
What is catatonia?
A state of excited or inhibited motor activity in the absence of a mood disorder or neurological disease
What is waxy flexibility?
Patient’s limbs feel like wax or lead when moved and stay in same position they are left in. Found in catatonic schizophrenia and structural brain disease
What is echolalia?
An automatic repetition of the words heard
What is echopraxia?
An automatic repetition of the movements made by examiner/other person
What is logoclonia?
Repetition of the last syllable of a word
What is negativism?
Motiveless resistance to movement
What is palilalia?
Repetition of a word over and over with increasing frequency
What is verbigeration?
Repetition of one or more sentences/strings of words, often in a monotonous tone
What is concrete thinking?
Taking things literally
What is a mental disorder?
Any disorder/disability of the mind excluding drug and alcohol use
What is a S12 approved doctor?
A medically qualified doctor recognised under section 12 of the MHA with specific expertise in mental disorder and additional training in application of the Act
What is an Approved Mental Health Professional (AMHP)?
From range of professions and authorised by local authority to carry out functions of MHA on their behalf e.g. sectioning
Give some underlying principles of the Mental Health Act 1983
Respect for patient's past and present wishes Respect for diversity Minimising restrictions on liberty Involvement of patients in their own care Avoidance of unlawful discrimination Effectiveness of treatment Parent/carer/relative's wishes Patient wellbeing and safety Public safety
What is Section 2 of the MHA used for?
For Assessment!
treatment can be given without patient’s consent
What is the duration of Section 2?
28 days, non-renewable
Patient can leave after 24 hours if section not approved by relevant professionals within this time
Who is required to complete a Section 2 of MHA?
2 doctors (at least one of which S12 approved) 1 AMHP
What evidence is required for Section 2 of MHA?
- Patient suffering from mental disorder of nature/degree that warrants detention for hospital assessment
- Patient ought to be detained for his/her own safety OR protection of others
What is the purpose of Section 3 of the MHA?
For treatment
What is the duration of Section 3 of MHA?
6 months, renewable
Who is required for Section 3 of MHA?
2 S12 doctors
1 AMHP
What evidence is required for Section 3 of MHA?
- Patient has mental disorder of nature/degree that warrants hospital admission for treatment
- Treatment is in interests of his/her health/safety OR safety of others
- Appropriate treatment must be available for patient
What is the purpose of Section 4 of MHA?
Only for “urgent necessity” when waiting for 2nd doctor would lead to undesirable delay - for patient not already admitted
What is the duration of Section 4 of MHA?
72 hours
Who is required for Section 4 of MHA?
1 doctor
1 AMHP
What evidence is required for Section 4 of MHA?
- Patient has mental disorder of nature/degree that warrants hospital admission for assessment
- Detained for his/her own health and safety OR protection of others
- There is not enough time to wait for second doctor to attend
What is the purpose of Section 5(2) of MHA?
To detain a patient ALREADY admitted in hospital (general or psychiatric) but wanting to leave. Allows time for Section 2 or 3, and if not able to coercively treat
What is the duration of Section 5(2) MHA?
72 hours
Who can carry out Section 5(2) of MHA?
Any registered medical practitioner (F2 or above), responsible for and knows the patient
What is the purpose of Section 5(4) of MHA?
To detain a patient ALREADY admitted in hospital but wanting to leave, cannot be treated coercively, to allow time until doctor can attend
What is the duration of Section 5(4) of MHA?
6 hours
Who carries out Section 5(4) of MHA?
Nurses responsible for/know the patient
What is the purpose of Section 135 of MHA?
To allow police to enter patient’s home and take them to a place of safety until further assessment by doctor and AMHP - requires warrant to enter home from magistrate/court
What is the duration of Section 135 of MHA?
36 hours
Who grants a Section 135 of MHA?
Magistrate - often requested by social worker, healthcare professional or police in emergency
What is the purpose of Section 136 of MHA?
To remove a person from a public place and take them to a place of safety to await further assessment by doctor and AMHP
What is the duration of Section 136 of MHA?
24 hours (but extendable up to another 12 hours for clinical reasons)
Who grants a Section 136 of MHA?
Police
Where can Sections 2, 3 and 4 be done?
anywhere except for prison
What are the 4 components used in CBT?
Thoughts, Emotions, Bodily Sensations, Behaviours
What is the purpose of section 37?
Hospital order - used in forensic psychiatry where crime is thought to be due to mental disorder, to move from prison to hospital for treatment
Who orders a section 37?
Crown court
What section may be given in forensic psychiatry as a restriction order?
Section 41 - Ministry of Justice controls movement
What is section 35?
Crown court order for assessment of prisoners for mental disorder for 28 days
Within what time frame must an appeal against Section 2 be made?
14 days
What is Section 17?
Leave from hospital, with conditions placed by professionals, can be called back to hospital at any time
What is a community treatment order?
Hospital leave under certain conditions, and will be called back or revoked if not taking medications/meeting conditions. Assigned care coordinator. If break conditions, may be detained for up to 72 hours while decision is made
What’s an SOAD service?
Second Opinion Appointed Doctor service
Safeguards rights of patient under MHA, if patient lacks capacity to consent to treatment e.g. 3 months treatment without consent, but still not well enough to consent to further treatment
Where is counselling usually done? What are typical features of counselling?
Usually in primary care
Short duration
Patient comes up with own answers
What is cognitive analytical therapy a combination of?
CBT and psychoanalytical therapy
What form of psychotherapy is often used in personality disorders?
Dialectical Behavioural Therapy (DBT) - for intense emotions, to help you understand and accept difficult feelings
What are the 3 different types of family therapy?
Structural - how they interact
Systemic - therapist observes (unseen behind mirror), then comments
Strategic - therapist forms strategies with clear goals within family context
What are some contraindications for psychotherapy?
Lack of motivation
Lack of psychological insight
Complex mental health needs or learning difficulties
Antisocial characteristics
What is attachment theory?
A person needs stable relationship with at least one primary caregiver for successful social and emotional development + regulation of feelings
How do MAO-Is work as anti-depressants?
Inhibit degradation enzyme (monoamine oxidase) from breaking down noradrenaline and dopamine. NAd and DA increase
Why might dietary restrictions be put in place when taking MAO-Is for depression?
MAO breaks down tyramine in the gut, MAO-Is decrease MAO action, causing build up of tyramine. High tyramine levels can cause a spike in blood pressure requiring emergency treatment. Therefore should avoid eating foods rich in tyramine
Give examples of foods high in tyramine
Aged foods! - encourage fresh food instead Over-ripe or dried fruits Strong or aged cheese Cured, smoked or processed meats Pickled or fermented foods Alcohol Snow peas/broad beans/soybeans Sauces - soysauce, teriyaki, shrimp sauce Improperly stored/spoiled foods
What monitoring might you do for a patient on MAO-Is?
Blood pressure - risk of postural hypotension or hypertensive responses
How quickly should you withdraw MAO-I treatment?
Withdrawal symptoms may occur on cessation so withdraw slowly
Withdraw over 4 weeks (or longer if show withdrawal symptoms)
Withdraw over 6 months if on long-term maintenance treatment
Give some examples of MAO-Is
Tranylcypromine
Phenelzine
Isocarboxazid
What is the monoamine hypothesis?
Depression is caused by reduced monoamines (serotonin, norepinephrine, dopamine) in central nervous system
What is the mechanims of action of tricyclic antidepressants?
Increase monoamines by blocking transporters 5HT.
Also agonises anti-cholinergic receptors and antihistaminergic receptors.
Antagonises a-1 adrenergic receptors
Why are tricyclic antidepressants not first line treatments for depression anymore?
Higher risk if overdose taken (serotonin syndrome)
More side effects - e.g. postural hypotension, drowsiness, urinary retention, hallucinations, tachycardia, arrhythmias, blurred vision, dry mouth
What is the mechanism of action for SSRIs?
Acts on 5HT receptors to reduce reuptake of serotonin, raising serotonin levels
Give some side effects of SSRIs and why
Side effects due to other 5HT receptors in body being blocked e.g.
Nausea, vomiting, GI upset/bleeding
Also monoamines - Agitation, akathisia, anxiety, suicidal thoughts, worse depression
Sexual dysfunction
Insomnia
Hyponatraemia
How long do SSRIs usually take to work?
2-4 weeks. Allow 6 weeks for initial side effects (worsening of depression, suicidal thoughts, anxiety) to wear off
How long should SSRIs be given for?
6-9 months if first episode or uncomplicated
2 years if recurrent depression
Give some contraindications for SSRIs
Caution - Bleeding disorders (especially GI bleeds)
Manic phase of bipolar disorder
Poorly controlled epilepsy
Prolonged QT interval or drugs that cause this
Severe hepatic impairment
What drugs prescribed alongside SSRIs can increase risk of serotonin syndrome?
Other SSRIs SNRIs MAO-Is!!! Lithium Opioids St John's Wort Triptans Vortioxetine
What are the symptoms of serotonin syndrome?
Fever
Tremors - neuromuscular
Diarrhoea - autonomic
Agitation - mental state
What do SNRIs stand for? Give some examples of this medication
Serotonin and Noradrenaline Reuptake Inhibitors
Venlafaxine
Duloxetine
What is the neuroplasticity hypothesis?
BDNF encourages neuronal plasticity
Stress increases cortisol which induces glutamate release that is neurotoxic and decreases plasticity
Antidepressants increase BDNF and decrease glutamate, improving neuroplasticity
What is salience and how does it relate to psychosis?
Salience is choosing the importance of stimuli. Psychosis is the misdistribution of salience.
What is the role of the nucleus accumbens?
Reward, pleasure centre, addictions
What is the action of typical antipsychotics?
Block D2 dopaminergic receptors - blocks mesolimbic pathway which reduces positive symptoms of psychosis - but reduces ability to feel pleasure
What is the action of atypical antipsychotics?
Lower affinity and occupancy of D2 receptors and high degree of occupancy on 5HT2A serotoninergic receptors
What disorders may antipsychotics be used to treat?
Mainly schizophrenia
Bipolar disorder
Anxiety/Depression - if severe or difficult to treat
Give some risk factors for neuroleptic malignant syndrome
Use of neuroleptic drugs - new or increased dose Genetic susceptibility Patient agitation/catatonia Withdrawal dopaminergic drugs (Parkinson's) D2 receptor antagonists Atypical antipsychotics Increased temperature Previous neuroleptic malignant syndrome
Give some symptoms and signs of neuroleptic malignant syndrome
Usually within 10-21 days on changed medication - think Parkinson’s
Rigidity - muscle rigidity leading to Dyspnoea
Difficulty walking/shuffling gait
Tremor/involuntary movements
Seizures, chorea, oculogyric crisis, opisthotonos
Altered mental state
Raised temperature, high or low BP
Incontinence
Raised CK, WCC
How would you manage neuroleptic malignant syndrome?
Protect airway if compromised
Physical restraint or IV benzodiazepines if agitated (only if necessary)
Discontinue neuroleptic agent
IV fluids for dehydration
Kidney management and dopaminergic medications if severe
Give some ways that neuroleptic malignant syndrome might lead to death
cardiovascular collapse respiratory failure myoglobinuric acute kidney injury seizures arrhythmias
What is important to screen for if someone presents with self-harm/suicide attempt?
Psychosis - hallucinations/delusions/intrusive thoughts/voices
Depression - low mood, anergia, anhedonia
If depression, screen for mania (4+ days increased activity, disinhibition)
Anorexia
Alcohol or illicit drug use
Recent change in medication e.g. SSRIs
What are possible organic causes of anxiety?
Hyperthyroidism
Pheochromocytoma - increases serum catecholamines, do 24hr urine test with vanillylmandelic acid
Brain tumour
Delirium due to infection, pain, trauma, medications
How would you manage EUPD?
No meds recommended unless to treat comorbidities - can give clozapine/quetiapine to numb emotions
DBT
MBT - mentalisation-based treatment
Therapeutic communities
How might you distinguish between OCD and OCPD?
OCPD = pervasive, childhood, ego-syntonic but unhappy OCD = not pervasive, ego-dystonic, unhappy
How might you manage OCPD?
Life advice - eat healthy, exercise, mindfulness, reduce workload (if appropriate)
Therapy - CBT or community, IAPT
Anxiety medication - propanolol, benzodiazepines, SSRIs
What are 3 ways of thinking about harm when doing risk assessment in relation to others
- Risk of self-harm/suicide
- Risk of harm to others
- Risk of others causing patient harm
What conditions might have psychotic symptoms?
- Paranoid schizophrenia/schizotypal disorder
- Depressive psychosis
- Manic psychosis
- Drug/alcohol-induced psychosis
What can negative psychotic symptoms suggest?
Depressive psychosis
Bipolar, depressive phase leading to psychosis
Schizophrenia prodrome! - appear before schizophrenic episode
Give the full name and an example of a NASSA. When might these be used?
Noradrenergic and selective Serotonin Antidepressant (aka tetracyclics)
Mirtazapine
Used when people can’t take SSRIs, less sexual symptoms, but may cause drowsiness
What is the mechanism of action of mirtazapine?
Give some side effects
It is a pre-synaptic alpha-2 adrenergic receptor antagonist - increases noradrenaline and serotonin
SE: weight gain, sedation
If someone is being treated for depression and presents with manic or psychotic symptoms, what should you do?
History and MSE, risk assessment
Wean off antidepressant (SSRI, NASSA, SNRI) as could be causing mania
1st line = trial antipsychotic + psychotherapy (cognitive analytical, CBT, interpersonal social rhythm therapy)
2nd line = add lithium or sodium valproate
What is the management for mild depression?
Risk assessment, biopscychosocial formulation, 5Ps
Manage comorbid issues: mania, anxiety, psychosis, alcohol/substance abuse, eating disorders, dementia
2 week follow-up if sub-threshold symptoms
How would you manage mild-moderate depression or persistent sub-threshold symptoms?
Low intensity psychosocial interventions e.g. IAPT. Group CBT if refuse IAPT
Consider antidepressant if:
- subthreshold symptoms persist despite intervention or been present for at least 2 years
- past history moderate-severe depression
- complicating chronic physical health problems
How would you manage moderate-severe depression?
Offer anti-depressant
High intensity psychosocial intervention
Treat comorbidities e.g. sleep hygiene
Follow up within 2 weeks if low suicide risk, if high risk suicide or under 30yrs review within 1 week - crisis team signposting
What might you need to discuss with a patient starting antidepressants?
Be vigilant for worsening depression or suicidal ideas, signpost to seek help
Takes 2-4wks for symptoms to improve
Antidepressants should be taken for at least 6 months after symptoms improve/remission
Risk of discontinuation symptoms but not addictive, should be withdrawn slowly
May have sedating effects - affect driving ability in first few weeks
Not to use St John’s Wort
What antidepressants are first line?
SSRIs - sertraline, citalopram, fluoxetine, paroxetine..
Why might you avoid prescribing tricyclics or venlafaxine?
High risk of toxicity or overdose
If treating recurrent depression, what might you consider in selecting antidepressant?
- choose one that responded to previously
- avoid ones that failed to respond to previously
If chronic health problem, which antidepressant should you consider?
Sertraline has lower risk drug reactions
If bleeding problem/anticoagulation - avoid SSRIs, use mirtazapine as alternative
If SSRI prescribed, but take aspirin/NSAID - consider PPI in older people
Name 3 screening questionnaires for depression
Patient Health Questionnaire-9, PHQ-9
Hospital Anxiety and Depression Score, HADS
BDI-II, Back Depression Inventory-II
Describe the scoring system for PHQ-9
9 symptoms, rated 0 (not at all) to 3 (nearly everyday) Total Score = 27 Mild = 5 Moderate = 10 Moderately Severe = 15 Severe = 20
Describe scoring system for HADS
14 questions (7 depression, 7 anxiety), total score 21 8-10 = mild 11-14 = moderate 15-21 = severe
How would you manage PTSD?
Self-help advice
Trauma-focused CBT, narrative exposure therapy, prolonged exposure therapy
Eye Movement Desensitisation and Reprocessing (EMDR)
Venlafaxine or SSRI (fluoxetine)
Benzodiazepine for crisis moments
If persists or disabling - add antipsychotic (risperidone)
How would you manage mania or mixed episodes in bipolar disorder?
Risk assessment - drugs? anti-depressants?
Mania - oral antipsychotic (haloperidol, olanzapine, quetiapine, risperidone)
Try 2nd line antipsychotic if 1st doesn’t work
Add in lithium or sodium valproate
Taper any antidepressant medication
How would you manage depression within bipolar disorder?
Psychotherapy Quetiapine Olanzapine Fluoxetine and Olanzapine combined Lamotrigine
Give examples of atypical antipsycotics
Clozapine Olanzapine Risperidone Aripiprazole Quetiapine
Which type of antipsychotics cause metabolic syndrome? Give some features of this
ATYPICAL antipsychotics Weight gain Hypertriglyceridaemia Increased insulin + glucose increased LDL cholesterol Clozapine - risk of cardiomyopathy
Which type of antipsychotics are more likely to cause extra-pyramidal effects. Give examples of these side effects
TYPICAL antipsychotics Dystonias Akathisias Seizures Parkinson-like symptoms - rigid, tremor, shuffle Neuroleptic malignant syndrome
Give examples of typical antipsychotics
Haloperidol
Chlorpromazine
Loxapine
Perphenazine…
Give 2 examples of Z drugs for sleep/hypnotic effects. What is their mechanism of action?
Zopiclone, Zolpidem
Bind to GABA-A receptors which mediate inhibitory neurotransmission
(same action as benzodiazepines)
Give examples of hypnotics
Benzodiazepines (e.g. lorazepam, chlordiazepoxide)
Z drugs (zopiclone, zolpidem)
melatonin
Give some side effects of clozapine? When is clozapine often used?
Side effects: weight gain, neutropenia, cardiac myopathy
Used for resistant psychosis not responsive to other antipsychotics
Give diagnostic criteria for anorexia nervosa
Actual body weight <15% expected for height
BMI<17.5 (adults)
Females - amenorrhoea >3 months
Men - loss sexual interest and impotence
Weight loss self-induced: avoidance, excessive exercise, purging, appetite suppressants, laxatives, diuretics
Distorted self-image - persistent over-valued idea of fatness
What must you exclude when considering diagnosing eating disorders in someone with change in weight?
Unintended or organic cause of weight loss or weight gain - infections, diarrhoea, vomiting, cancer, poor sleep, hyper/hypothyroidism
Psychosis
Give some features you may find on physical examination in a patient with anorexia nervosa
Dry skin, thin hair Lollipop head Lanugo - fine body hair Dental marks on fingers/calluses (Russell's sign) Cardiomegaly High temperature Salivary gland enlargement Muscle weakness (sit-up-stand-up-squat test) Angular stomatitis
Give a mnemonic that screens for eating disorders and expand
SCOFF S = sick because full? C = control lost over eating O = one stone or more lost in last 3 months F = fat when others think thin F = food dominates life
What investigations might you do in a patient with anorexia nervosa?
FBC
U+Es - Na, Cl imbalance due to water intake/purging
Calcium
Magnesium
Phosphate
Serum proteins
LFTs - raised liver enzymes due to hypovolaemia
Potassium - hypokalaemia
Urinalysis - diabetes?
ECG - arrhythmias? T wave inversion, bradycardia, high take off, prolonged QT
What are the health risks of anorexia nervosa?
Cardiac arrest/heart failure (breakdown cardiac myocytes and hypokalaemia) Respiratory arrest Gastroparesis Constipation - decreased intake, muscle weakness, laxative-dependency Oesophageal rupture (Mallory-Weiss tear) Pancreatitis Amenorrhoea/Infertility Increased fracture risk/falls risk Hypothyroidism Increased cholesterol Renal failure - prolonged dehydration Anaemia Infection
What is the mortality in anorexia nervosa compared to general population?
6 times higher
What might be immediate management for a patient with anorexia nervosa?
Ask consent to admit, if decline - section
IV fluids + K, offer food/Forsips
If decline, consider NG tube or parenteral
What would be long-term management for a patient with anorexia nervosa?
Psychoeducation Monitor physical weight CBT (family therapy if child) Diet plan Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
What is refeeding syndrome?
Feeding after period of starvation
Body switches from fat to carb metabolism, increases insulin
Causes electrolytes to enter cells
How might you treat refeeding syndrome?
IV thiamine, magnesium, phosphate
What deficiency causes Wernicke’s encephalopathy? What are the triad of symptoms you might see?
Thiamine deficiency
Triad = confusion, ataxia, ophthalmoplegia
What is difference between hypochondriasis and somatisation?
Hypochondriacal delusions - focused on illness
Somatisation - focus on symptom
Which antidepressant can help with neuropathic pain?
Duloxetine
What must you rule out in a patient presenting with confusion before diagnosing dementia?
Organic causes of confusion - delirium
What investigations might you do to rule out organic causes of confusion?
CHECK MEDICATIONS FBC - WCC + Hb U+E - Na, K, eGFR Calcium LFT Clotting factors TFT Vitamin D/Vit B12/Folate Mandatory - CT head or MRI with contrast!! CXR 24 hr ECG Cognitive test - MoCA, AMT, GPCOG, 6CIT, MMSE, ACE-III
What criteria must be met for dementia?
Decline in lots of types of cognition
Duration at least 6 months
Sufficient impairment
What is the definition of delirium? What is its management?
Acute confusional state
Mx: treat underlying cause, improve environment, DoLs if appropriate
Sedatives if aggressive
Would you use DoLS or LPS on a mental health ward?
No, would use Mental Health Act instead. LPS only applies to other hospital wards
What are the characteristic features of vascular dementia?
Step-wise decline in cognition
Previous CVD events - TIAs
Decline in affect first
Vascular RFs - HTN, cholesterol, smoking, DM, previous MI/stroke, AF
How would you manage vascular dementia?
Manage vascular risk factors
Supportive - OT, PT, SLT, memory cafe, cognitive stimulation therapy, aromatherapy, play therapy, art therapy
What are the characteristic features of Lewy Body Dementia?
Parkinsonian features AFTER cognitive decline (rigidity, shuffling, bradykinesia, tremor, dysphagia)
FLUCTUATING COGNITION
Vivid psychotic symptoms
How would you manage Lewy body dementia?
1st line = Rivastigmine Supportive care (can't use anti-psychotics unless minimm dose quetiapine/olanzapine)
What are the characteristic features of Alzheimer’s disease?
Linear cognitive decline
Physical health preserved
Decreased learning ability and new memory formation first
How would you manage Alzheimer’s disease?
1st line = Donepezil
2nd line = Memantine
Supportive
What are the risk factors of Alzheimer’s disease?
family history, genes, age, vascular disease, head injury
What are the characteristic features of Parkinson’s Disease Dementia?
Parkinsonian features BEFORE dementia
Fluctuating cognition
Visual and auditory hallucinations
How might you manage Parkinson’s Disease Dementia?
Rivastigmine
Supportive
What are the characteristic features of FrontoTemporal Dementia?
Personality and behaviour changes
Disregard for others, apathy
Social disinhibition
How would you manage frontotemporal dementia?
Supportive
May use SSRIs to control impulsions and compulsive behaviours, or antipsychotics (rare) if SSRIs not working
If suspect or have diagnosed dementia, what investigations might you do?
SPECT - to detect hypoperfusion
DaT - Parkinson’s, LBD?
Give the 5 principles of the Mental Capacity Act
- Assume capacity until proven otherwise
- Support to make own decision
- Unwise decisions do not mean lack of capacity
- Act in best interests of patient
- Least restrictive option preferred
What is the 2-stage test for assessing capacity?
- Does person have impairment of mind or brain?
2. Does that impairment make them unable to make a specific decision at this time?
What are the 4 stages to assess if a person is able to make a decision when assessing capacity?
- Can they UNDERSTAND?
- Can they RETAIN?
- Can they WEIGH UP information?
- Can they COMMUNICATE back to you?
What is the mechanism of action of Donepezil?
Binds reversibly to acetylcholinesterase to inhibit hydrolysis of acetylcholine. Acetylcholine transmission increases
What is the mechanism of action of Galantamine?
Reversible competitive inhibitor of acetylcholinesterase
What is the mechanism of action of Rivastigmine?
Inhibits acetylcholinesterase and butrylcholinesterase to increase cholinergic transmission
What is the mechanism of action of Memantine?
NMDA receptor antagonist, blocking effect of glutamate which causes neuronal excitement and excessive stimulation in Alzheimer’s disease
What are important things to ask about in someone presenting with generalised anxiety disorder?
Comorbid depression
Other anxiety disorders - OCD, PTSD, phobias
Physical health problems
Substance abuse
Environmental stressors
Suicide risk (if comorbidities or severe)
What would be first interventions offered for people with anxiety without marked functional impairment?
Psychoeducation + Active monitoring
Low intensity psychological intervention: Self-help, guided self-help, psychoeducational groups
What would be interventions for GAD with marked functional impairments or no improvement from Step 1 interventions?
Inform that response to psychological interventions is not immediate and encourage continuing
High intensity individual psychological - CBT /applied relaxation
Or drug treatment - SSRI or SNRI alternative
Pregabalins if SSRI or SNRI not tolerated
When might benzodiazepines be used in treatment of anxiety? Why might they not be used?
Used for short-term anxiolytic effect
Not to be used in GAD unless for crises - long-term use can lead to dependency and withdrawal symptoms (including anxiety)
What might you refer to specialist treatment for GAD?
Not responded to Step 3 interventions (drug treatments, CBT)
Or risk of self harm/suicide/self-neglect
Or significant comorbidity
What self-care advice could you give to someone with GAD?
Sleep hygiene - regular bedtime, no alcohol after 6pm, no caffeine after 3pm
Regular exercise helps mental health
Describe the scoring system that helps to screen for GAD.
GAD-7 7 questions, each with score 0-3 based on frequency of symptoms in last 2wks, total score = 21 Mild = 5 Moderate = 10 Severe = 15
Give some differential diagnoses of anxiety/GAD?
Situational anxiety Adjustment disorder Panic disorder Social phobia OCD PTSD Somatoform Anorexia nervosa Medication-induced anxiety Cardiac disease, hyperthyroidism, pulmonary disease, anaemia, infection, IBS, phaechromocytoma
Give features and test for phaeochromocytoma
Anxiety with hypertension and tachycardia
24 hr vanillylmandelic urine and metanephrines to diagnose
How might you manage PTSD at different levels?
subclinical - active monitoring, follow up within 1mnth
If event occurred in last month - refer for psychotherapy and drug treatment
If symptoms for over a month - refer specialist mental health service
When might you consider drug treatment for PTSD? What drugs would you choose?
Patient preference, declines psychotherapy, referral delayed
Venlafaxine or SSRI
Hypnotic if sleep problems
What psychotherapy would be offered to someone with PTSD?
Trauma-focused CBT
Exposure therapy
EMDR
How might you manage OCD?
Psychotherapy - CBT, Exposure and Response Prevention Therapy (ERPT)
OR
Drug treatment - SSRI
Clomipramine if SSRI not tolerated, preferred
Combine drug and psychotherapy if severe
What scale might be used to assess severity of OCD?
Y-BOCS (Yale Brown Obsessive Compulsive Scale)
How much of day have thoughts/act on compulsions?
How much interfere with life?
How much distress?
How much effort to resist?
How much control over thoughts do you have?
Give features of lithium toxicity and management
Tremor, hypereflexia, ataxia, chorea, muscle weakness, diarrhoea, vomiting, renal impairment, altered consciousness
Management: Stop lithium and supportive care (fluids + electrolytes)
Give features of delirium tremens and management
Tremor, confusion/delirium, sweating, tachycardia. Severe - coma, convulsions
Oral lorazepam or parenteral lorazepam/haloperidol
Treat for WE - IV Pabrinex
