Psychiatry Flashcards
1
Q
Things to consider when interviewing?
A
Reviewing the patient’s records noting previous symptomatology and episodes of previous violence
Factors increasing risk of this
Two doors for interview room, remove all potential weapons
Familiarise yourself with the ward’s panic alarm system
Break-away/ aggression management training courses
Use two or more comfortable chairs, same height, orientated at an angle, clipboard for notes
2
Q
Interview structure?
A
Introduce, explain purpose of the interview, put the patient at ease
Look relaxed and interested, make good eye contact
Ask open Qs
Clarify terms you don’t understand/ are vague
Express empathy
Facilitate communication
Mirror the patient’s feelings
Use pauses appropriately
Summarise
Further Qs
Thank the patient
3
Q
Objective details needed for an overdose?
A
What was taken?
Where and when?
Was anyone present?
Were any precautions taken to avoid discovery?
Suicide note?
Act of anticipation of death?
Action taken to alert possible helpers after taking the overdose?
4
Q
Subjective (patient’s perception) of overdose?
A
Patient's stated intent Patient's estimate of lethality of the substances taken Evidence of recent/ psych illness, symptoms of depression/ psychosis Past hx of psych illness/ self-harm Drug/ alcohol abuse? Recent precipitating life event Family hx of mental illness Social support at home Protective factors Risk factors Harm to others Vulnerability to exploitation Self-neglect
5
Q
Things to consider in a psychiatric assessment?
A
Intro, HPC+ clarifying and closed questioning, past psych hx, family hx, personal hx, past medical hx, medication, drugs and alcohol, forensic hx, MSE
6
Q
Things to ask for past psych hx? Family hx? Personal hx?
A
Had anything like this before/ seeked help for this before/ been in hospital?
Anyone else in the family? Tell me more about your family
Birth, early development, school, home, qualifications, relationships
7
Q
Past medical hx? Medication, drugs and alcohol? Forensic hx?
A
Chronic, cancer, COVID, admissions, surgical procedures, head injuries/ accidents, self-harm, side effects from meds
Current, allergies, illicit drug use, alcohol- how much and how often, how long, dependency, time start drinking, every day
Juvenile crime, court appearances, convictions, length of sentence, against person/ property, experience of prison
8
Q
Elements of MSE?
A
1) Appearance and behaviour
2) Speech
3) Affect and mood
4) Thoughts and delusions
5) Perceptions and hallucinations
6) Cognition
7) Insight
9
Q
Appearance features?
A
Distiguishing- scars, tattoos, signs of IV drug use Weight Stigmata of disease Personal hygiene Clothing Objects
Engagement
Eye contact
Facial expression
Body language- close/ withdrawn
Psychomotor activity- retardation= paucity of movement and delayed responses to Qs
Restlessness
Involuntary movements/ postures, tremors, tics, lip-smacking, akathisias, rocking
10
Q
Assessing speech?
A
Rate- pressure, slow–> retardation= major depression
Quantity- minimal= depression
Excessive= mania and schizophrenia
Tone- monotonous= depression, schizophrenia and autism, tremulous= anxiety
Volume
Fluency and rhythm- stammering and stuttering, slurred- major depression
11
Q
Assessing mood and affect?
A
Affect= immediately expressed and observed emotion Mood= subjective internal state at any one time
Mood= how feeling, current mood, been feeling low/ depressed lately?
Affect= apparent emotion, range and mobility: Fixed= remains same Restricted= not demonstrate normal range as expected Labile= exaggerated may/ may not relate to external triggers
Intensity- heightened= mania, blunted/ flat= schizophrenia, depression and PTSD
Incongruency= schizophrenia
12
Q
Assessing thought?
A
Form= processing and organisation of thoughts
Speed
Flow and coherence
13
Q
Abnormalities of thought flow and coherence?
A
Loose associations= moving rapidly from one topic to another with no apparent connection between topics
Circumstantial thoughts= irrelevant and unnecessary details
Tangential thoughts= unrelated thoughts
Flight of ideas= thoughts= so quick, one train of thought not completed before next–> mania
Perseveration= persistent and inappropriate repetition of same thought–> frontal lobe dysfunction
14
Q
Abnormalities of thought content?
A
Delusions- firm, fixed belief based on inadequate grounds, not amenable to a rational argument/ evidence to the contrary
Obsessions= thoughts, images/ impulses out of person’s control, person knows they’re irrational
Compulsions- repetitive behaviours that the patient feels compelled to perform
Overvalued ideas= not delusional/ obsessional, preoccupying to the extent of dominating the sufferer’s life
Suicidal thoughts
Homicidal/ violent thoughts
15
Q
Abnormalities of thought possession?
A
Thought insertion- belief that thoughts can be inserted into the patient’s mind
Thought withdrawal- removed from patient’s mind
Broadcasting- others can hear the patient’s thoughts (x3= Schneiderian first rank symptoms of schizophrenia)
Thought alienation- thoughts are no longer within their control by being removed/ replaced by an outside force/ agency
Thought blocking= mind becomes empty of thoughts–> paranoid schizophrenia
Pressure= rapid, abundant–> mania
Thought echo- hallucination of hearing aloud his/ her own thoughts short after–> psychosis
16
Q
What are confabulations?
A
Gaps in person’s memory= unconsciously filled with fabricated misinterpreted/ distorted information
Somatic passivity- sensation imposed by an outside force
Catatonia- group of symptoms involving lack of movement and communication
Stupor= near-unconsciousness/ insensibility
17
Q
What is delirium? What are persecutory delusions? Delusions of reference? Grandiose? Guilt/ worthlessness? Delusions of control?
A
Abrupt change–> mental confusion and emotional disruption e.g. during alcohol withdrawal, after surgery/ with dementia
People/ organisations trying to inflict harm
Objects/ events/ people= special significance
Exaggerated self-importance
Innocent error= in psychotic depression
Actions, impulses and thoughts= controlled by outside agency
18
Q
Abnormalities of perception? Dissociative symptoms x2?
A
Hallucinations- sensory perception without external stimulation
Pseudo-hallucinations- aware not real
Illusions= misinterpret external stimulus
Depersonalisation- feels no longer their “true” self
Derealisation= sense world around them is not a true reality
19
Q
2nd person auditory hallucinations? 3rd person? Command? Tactile?
A
Voices talk to patient–> affective psychosis and personality disorder
Talking about patient –> paranoid schizophrenia
Telling to do something
Sensations of being touched
20
Q
What is cognition? Formal assessment?
A
The mental action/ process of acquiring knowledge and understanding through thought, experience and the senses
MMSE, AMTS, ACE-III
21
Q
Qs for essential cognitive state exam?
A
Orientation: Day/ time is it? Remember what my job is? Do you know where you are? Registration: Name and address Attention: Spell WORLD backwards Memory: Recent-Recall 3 items/ name and address at 5 mins Remote- WWII dates General- Prime minister
22
Q
Assessing insight into their illness?
A
What do you think the cause of the problem is?
Do you think you have a problem?
Do you feel you need help with your problem?
Willing to seek help, appreciates and accepts need for tx
Appreciates and accepts need for tx and risks with non-compliance, not engaging with follow-up, impact on others
23
Q
What is concrete thinking? Functional hallucination? Reflex hallucination? Extracampine? Hypnagogic and hypnapompic?
A
Reasoning based on the see, hear and feel in the now
Triggered by a stimulus in the same modality
Stimulus in one sensory modality produces a sensory experience in another
the feeling of a silent, emotionally neutral human presence
When falling asleep/ waking up respectively
24
Q
Delusion of infidelity? Secondary? Guilt? Nilhilistic? Poverty?
A
Partner is cheating Arises from another morbid experience They're bad/ evil Denies existence of body, mind, loved ones and world around them Convinced they are impoverished
25
What is dissociative amnesia? Anhedonia? Conversion and Belle indifference? Apathy?
Sudden that occurs during periods of extreme trauma and can last for hours/ days
Symptoms can't be explained by neurological condition/ other medical condition
Absence of psychological indifference despite serious mental illness
Lack of motivation
26
Waxy flexibility? Echolalia? Echopraxia? Logoclonia? Negativism? Palilalia? Verbigeration?
Patient's limbs when moved feel like wax or lead pipe, and remain in the position in which they're left, found rarely in catatonic schizophrenia and structural brain disease
Automatic repetition of words heard
Automatic repetition by patient of movements made by examiner
Repetition of last syllable of a word
Motiveless resistance to movement
Repetition of word with increasing frequency
Repetition of one/ several sentences/ strings of fragmented words, often in a rather monotonous tone
27
Included in a case summary?
Synopsis: basic personal info, previous psych diagnosis, description of presentation, current symptoms, positive features on MSE, suicide risk, attitude to illness
DDx: 2-3, less likely to exclude
Formulation- 3 Ps= predisposing, precipitating and perpetuating
Investigations, initial drug tx, instructions--> nursing staff, and potential risks, detainable under MHA?
28
Screening Qs for psychosis?
Have you been having any strange experiences recently?
Have you been hearing voices? What are they like?
Do you ever seem to see other things other people cannot?
Do you ever think thoughts are being taken out of your mind/ being put into your mind/ not private?
Does it ever seem to be repeated?
Have you ever felt like you are being made to do things by someone else?
Do you feel in danger?
29
MMSE?
Ask the date? Season? Name of this place?
Name 3 objects, ask to repeat
Count backwards from 100 in 7s / spell WORLD backwards
Recall 3 words from earlier
Name a wrist-watch, then pencil
Repeat the sentence after you
Give the patient a piece of plain blank paper and repeat the command
Write 'close your eyes'- ask to read and do
Ask to write sentence themselves= a subject and verb, correct punc and gram not needed
Copy intersecting pentagons
30
E.g. of organic disorders? Other neuroses? Affective disorders? Psychoses?
Delirium, dementia, lobe syndrome, endocrine causes
OCD, phobias, panic disorders, PTSD
Depression, bipolar, cyclothymia
Schizophrenia, delusional disorder, schizotypal disorder, depressive psychosis, manic psychosis, organic psychosis
31
Meaning of organic illness?
Refers to those conditions with demonstrable aetiology in the CNS
32
DDx for dementia? Common causes?
Delirium or depression should be excluded
| Alzheimer's, vascular dementia, Lewy body, fronto-temporal dementia
33
Features of dementia?
Memory impairment- start with short-term and progresses to long-term
Hx of personality change, forgetfullness, social withdrawal, lability of affect, disinhibition, less self-care, apathy
Hallucinations and delusions often paranoid
Anxiety and/ or depression in 50%
Neurological
Catastrophic reaction
Pathological emotion
Sundowner syndrome- confusion increases with evening
34
Tx for dementia?
Diagnostic, functional and social
AChesterase inhibitors, antioxidants, hormonal
Antipsychotics
SSRIs; hypnotics
Psychological support
Maximise mobility, independence with self-care
Social management
35
Presentation of fronto-temporal dementia? Posterior-parietal? Cortical-subcortical dementias? Multifocal?
Personality change- common of early-onset dementia, language impairments
Early memory loss and focal cognitive deficits, personality changes= later manifestations, issues with word-finding
Cortical and subcortical symptoms
Rapid onset and course; cerebellum and subcortical structures
36
Based on what Mental Health Act? One doctor has to be what? Who is responsible for liaising with the individual and relatives?
1983
Section 12 approved
Approved Mental Health Professional- usually AMH
37
Aims of MHA?
Respect for patients' past and present wishes and feelings, diversity, minimising restrictions on liberty, involvement of patients in care/tx, avoidance of unlawful discrimination, effectiveness of tx, views of carers and other interested parties, patient wellbeing and public safety
38
Length of section 2? Tx can be given without what? People involved? Evidence needed?
28 days
Patients' consent
One S12 approved, AMHP
1)Patient is suffering from a mental disorder/ nature or degree that warrants detention in hospital for assessment- don't need a diagnosis; and
2) Patient ought to be detained for his/ her own health of safety/ protection of others
39
Length of section 3? Purpose? People involved? Evidence needed?
6 month
Treatment
2 doctors, 1 AMHP
a) Patient is suffering from mental disorder of a nature/ degree which makes it appropriate for patient to receive medical tx in a hospital; and
b) Tx is in interests of his/ her health and safety of others; and
c) Appropriate tx must be available for the patient
40
Duration of section 4? Used when? People required? Evidence required?
72 hours
In urgent necessity- when waiting for second doctor would lead to "undesirable delay"
1 doctor and 1 AMHP
a) Patient is suffering from a mental disorder of a nature/ degree that warrants detention in hospital for assessment
b) Patient ought to be detained for his/ her own health/ protection of others
c) Not enough time for 2nd doctor to attend
41
What is a section 5(4) for? How long? Cannot be what?
For a patient admitted- psychiatric/ general hospital- wanting to leave
Nurses' holding power until doctor can attend
6 hours
Treated coercively whilst under section
42
What is section 5(2) for? Duration? Allows time for what? Cannot be what?
Patient already admitted but wanting to leave
Doctors' holding power- 72 hours
For Section 2 or 3 assessment
Coercively treated
43
Section 135 and 136 are what? S136 is for who? S135 needs what? Where issued? Need a what?
Police sections
Person suspected of having mental disorder in a public place
Needs court order to access patient's home and remove them to:
Place of safety (local psychiatric unit/ police cell)
Section 2 or 3
44
Core symptoms of depression? Other? Mild depression? Moderate?
Low mood, anergia, anhedonia
Change in sleep, appetite, libido, diurnal mood variation, agitation, loss of confidence, loss of concentration, guilt, hopelessness, suicidal ideation
Core+2-3 others
Core+ 4 others+ functioning affected
45
Severe depression without psychotic? With psychotic symptoms?
Several, suicidal, marked loss of functioning
Mood congruent- nihilistic and guilty delusions, derogatory voices
Can be POST-NATAL, part of recurrent depressive illness, part of BIPOLAR illness
46
Bipolar I? Bipolar II? Symptoms of hypomania (4+ days)? Mania (>1 week)?
Depression+ hypomania/ mania
Mania+ depression
More episodes of depression, only mild hypomania EASY TO MISS
Rapid cycling- episodes= few hours/ days
Cyclothymia
47
Symptoms of hypomania (4+ days)? Mania (>1 week)?
Elevated mood- can euphoric/ dysphoric/ angry
Increased energy, talkativeness, poor concentration, mild reckless behaviour, sociability/ overfamiliarity, increased libido/ sexual disinhibition, increased confidence, decreased need sleep, change in appetite
Extreme elation- uncontrollable, overactivity, pressure of speech, impaired judgement, extreme risk taking behaviour, social disinhibition, inflated self-esteem, grandiosity, psychotic symptoms, mood congruent/ incongruent
48
Typical onset schizophrenia? Increased risk of what? Involves?
2nd- 3rd decade, increased suicide risk, death from CVD, respiratory disease, infection
Die 25 years earlier than general population
Splitting of thoughts/ loss of contract with reality
Affects- thoughts, perceptions, mood, personality, speech, volition, sense of self
49
First rank symptoms of schizophrenia (>1)? Secondary symptoms (2+)?
Thought alienation, passivity phenomena, 3rd person auditory hallucinations, delusional perception
Delusions, 2nd person auditory hallucinations, in any other modality, thought disorder, catatonic behaviour, negative symptoms
50
Positive symptoms (any change in behaviour/ thoughts) of schizophrenia? Negative (disinterest from world) symptoms?
Hallucinations, delusions, passivity phenomena, thought alienation, lack of insight, disturbance in mood
Blunting of affect, amotivation, poverty of speech, poverty of thought, poor non-verbal communication, clear deterioration in functioning, self-neglect, lack of insight
51
Symptoms of generalised anxiety?
```
Excessive across different situations
>6 months
Tiredness
Poor concentration
Irritability
Muscle tension
Disturbed sleep
```
52
Physical and psychological symptoms of panic disorder?
Palpitations, chest pain, choking, tachypnoea, dry mouth, urgency of micturition, dizziness, blurred visions, paraesthesiae
Feeling of impending doom, of dying, of losing control, depersonalisation, derealisation
53
Obsessive thoughts and compulsive acts in OCD?
Often unpleasant, repetitive, intrusive, irrational, recognised as patient's own thoughts
Checking, washing, counting, symmetry, repeating certain words/ phrases
54
What are personality disorders? Manifests as problems in what?
Enduring, persistent and pervasive disorders of inner experience and behaviour that cause distress/ significant impairment in social functioning
Cognition, affect and behaviour
55
Paranoid personality description? Schizoid? Schizotypal?
Suspicious, distrust of others
Emotionally cold, detachment, lack of interest in others
Interpersonal discomfort with peculiar ideas, perceptions, appearance and behaviour
56
Dissocial/ antisocial personality? Emotionally unstable- impulsive and borderline type? Histrionic?
Callous lack of concern for others, irresponsibility, aggression
Inability to control anger or plan
Unclear identity, intense and unstable relationships
Self-dramatization, shallow affect, craving attention+ excitement
57
Narcissistic personality? Anxious/ avoidant?
Grandiosity, lack of empathy, need for admiration
| Tension, self-conscious
58
Anankastic/ obsessive-compulsive personality? Dependent personality?
Doubt, indecisiveness, caution, rigidty, perfectionism
| Clinging, submissive, excess need for care, feels helpless not in a relationship
59
3 clusters DSM-IV uses to organise categories of personality disorder?
A(odd/ eccentric)- paranoid, schizoid, schizotypal;
B(emotional/ dramatic)- antisocial, histrionic, narcissistic, borderline;
C(fearful/ anxious)- avoidant, dependent, obsessive-compulsive
60
Features of personality disorders?
Persistent/ ingrained behaviour patterns, inflexible responses, extreme/ deviant behaviour from cultural norm, problems in social functioning, present from early adult life and persistent
61
Features of paranoid personality disorder in an interview?
```
Miscontruing question
Persecutory belief
Tenacious sense of personal rights
Miscounstruing actions
Misconstruing events
Conspirational explanation
Suspicions of partner's infidelity
```
62
DDx to paranoid personality disorder?
Depression- guilt normally directed inward
Paranoia- usually more intense/ unshakable
Other psychotic- usually one setting/ not generalised, perplexed manner
Organic illness- personality change has a starting point
63
DDx to histrionic disorder?
Depression- talking about themselves, biological/ cognitive symptoms
Cyclothymic disorder-independent mood fluctuations in situations
64
DDx to dissocial disorder?
Alcohol/ drugs, psychotic illness
65
Modifications to a psychiatric assessment?
The patient is distressed, reduced cognitive/ intellectual capacity, non-native speaker, identification of urgent issues, concerns about risk/ safety issues, time, breaks, empathy, carer, language, focus, information sharing, confidentiality limits
66
5 Ps for making a formulation?
Presenting problem, predisposing factors- biological, social
Precipitating factors- specific event/ trigger to onset of current issue
Perpetuation factors- make condition endure e.g. severity, compliance
Protective factors- reduce risk/ impact of mental health morbidity
67
What is psychosocial tx? Who does this?
Help with independent living, money, housing, education, employment, meaningful activities
Social inclusion work
Psychoeducation, family work, psychological therapy and counselling
CMHN/CPN, social worker, occupational therapist, STR worker, psychologist, psychotherapist
68
Care coordinator role described as what? Filled by a who? Targets what as treatment?
'Case manager'
Care programme approach
A CMH nurse/ mental health social workers, can be OT, psychologist/ psychiatrist
5 Ps and uses a biopsychosocial formulation
69
What is psychotherapy?
A type of treatment, based on psychological theory
Treat (mainly) mental and emotional disorders
Generally involves talking, but may also involve art, drama and online delivery
70
What does IAPT involve?
Primary care psychotherapy service- GP/ self referral
Work in GP surgeries
Mainly CBT and guided self-help, range of approaches growing
Sheffield= counselling
71
Freud's original model of psychodynamic (psychoanalytic) therapy focussed on therapy as a process of what? Modern day focuses on what?
Uncovering past trauma to resolve present day symptoms
Making connections between past and present, more aware of unconscious processes, give meaning to symptoms and narrative of their life
72
Psychodynamic therapy involves what? What is seen as part of the focus of the work?
Weekly sessions for around a year
| The therapeutic relationship
73
What are 1st, 2nd and 3rd wave CBT approaches?
Behaviour therapy
Cognitive therapy
Combines mindfulness and acceptance techniques with the above
74
What is CBT and what is it based on?
Generally structured, 12-20 sessions, might be longer
| Focus= here and now, on problems in day to day life
75
Aim of counselling? Used with who?
In primary care- help patient be clearer about their isses and come up with their own answers
In someone to cope with recent events they have found difficult--> coping strategies
76
Cognitive analytical therapy NICE approved for what? Integrates what approaches? Patient does what? Focuses on? The therapist does what?
Depression, personality disorders
Cognitive and psychoanalytic approaches
Describes how issues have developed from events in their life and their personal experiences
On ways of coping and how to improve
Writes a letter at the beginning and end of tx
77
Interpersonal therapy used for what? Aims to what?
Mild-moderate depression
To help the patient understand how problems may be connected to the way their relationships work
Identify how to strengthen relationships and find better ways of coping
78
Dialectical behaviour therapy used for what? Programme includes? Goal is? Combines what?
Borderline personality disorder- repeated self-harming, relationship issues
Individual and group sessions
Regular over 12-18 months
Help patients learn to manage difficult emotions by letting them experience, recognise and accept them
Behavioural and 3rd wave CBT
79
Family therapy often used in what? Sometimes what? What does systemic psychotherapy work with?
CAMHS
Observed by other therapists/ recorded to help therapists and family reflect
A family's strengths to help family members think about+ try different ways of behaving with each other
80
Marital therapy might deal with what?
Problems between the partners/ stresses both are facing e.g. loss of a child
81
How is AMH different to CAMHS?
```
AMH= individual focused, family hx of mental illness
CAMHS= young person as part of the family system, family hx of mental illness and life events, developmental stage essential in process of assessment and diagnosis
```
82
Questions to ask younger person? Even younger? Under 16 y/o start from assumption of what?
Do they know why they're at the appointment?
What would they like help with?
'Talk' through play- puppets/ dolls
Try to understand what matters in their world
That they don't have capacity
83
Some conditions only diagnosable when? Depression may present as what in a young child? Rating scales such as what can be helpful?
At a certain age- below that seen as normal development
Irritable, temper tantrums, refusing to go to school, clingy
CDI
84
Focus on what around a young person as this is needed for what? Interview who? Also do what?
System around the young person
The family together- understand relationships/ environment for the child
Speak to them on their own- crucial information
85
Must get what before contacting the school? 3 main categories of MH disorders in adolescents?
Permission from the young person and family
| Neurodevelopmental, conduct and emotional disorders
86
Triad in ADHD? Over what age? Tx?
| Triad of what in ASD? Assessment? Tx?
Poor concentration, overactivity and inattention
6 y/o
Parenting advice and stimulant medication
Difficulties in social understanding, rituals and preoccupations and language difference
MDT assessment
Support in schools and to parents
87
Conduct disorder? E.g. of emotional disorders?
Description of young person with behavioural presentation, controversial as a medical diagnosis as describes breaking social norms
Eating disorders, PTSD, self-harm, depression, anxiety disorders, OCDs, psychosis
88
Anxiety disorders common to CAMHS and AMH? CAMHS?
Generalised anxiety disorder, panic disorder, phobias
| School phobia and separation anxiety
89
OCD has what and is often what? How does psychoses compare?
Shorter length of illness, hidden
Specific diagnosis= less clear, most common= hallucinations, delusions, idea of reference, thought disorder unusual
Most common onset= late teens, can occur in childhood
90
Causes of emotional dysregulation? Who first described concept of attachment?
Disrupted attachment
Psychological trauma- PTSD
Temporary effect of trauma, life event or stress
Bowlby
91
Attachment functions to protect infant from what? Probable also what gives meaning/ has importance for our functioning? Essential for what? Area of brain mainly involved?
External dangers
Emotional connection
Development of child
Limbic system and right hemisphere
92
Separation leads to what?
Increased pulse and decreased temperature, prolonged/ frequent--> changes in cortisol and reduced response to stress
93
Attachment types? Secure?
Secure, anxious, ambivalent, avoidant
Can internally self regulate the emotional neural systems and response to environment from about 5 years upwards
Develop reciprocal social bonds
94
Anxious attachment? Ambivalent?
Maintaining attachment with a caregiver who is unpredictable
Clingy
Alternate clinging with excessive submissiveness to no trust
Role reversal- parent cared for by child
Dysregulation of fear and anger
95
Avoidant attachment?
Child tries to minimise need for attachment to avoid rebuff
In distant contact with the caregiver
Severe- can 'freeze' when reunited with parent
96
What is PTSD?
Delayed/ protracted response to a stressful event/ situation of an exceptionally threatening/ catastrophic nature, likely to cause pervasive distress in almost anyone
Usually within 6 months
97
PTSD in children?
Often re-live the trauma in their play, may lose interest in things they used to enjoy
Somatic complaints
Regression
3 wish test
98
Therapies for PTSD? Meds?
Trauma focussed therapies- focus on the traumatic experience rather than past life
Group therapy
CBT
EMDR- process flashbacks and make sense of the traumatic experience
SSRIs if associated depression, gradually tapered and stopped
99
Public health approaches to mental health?
```
Population level
Data
Causes of the causes/ social determinants
Prevention
Partnership working
```
100
Health inequalities such as what? Can lead to differences in what? Analysed and addressed by policy across what four factors?
Income, housing, environment, transport, education, work
Health status, access to care, quality and experience of care, behavioural risks to health
Socio-economic factors, geography, specific characteristics, social excluded groups e.g. homelessness
101
Ageing usually starts at the age of what? Type of changes? Why older adult services?
Age of 65 y/o
Cognitive, physical and social changes
Differences in presentation, needs and impact of physical and mental health
102
Impact of physical health on old age psychiatry?
Bidirectional relationship- physical illnesses as aetiological/ risk factors, consequences of mental illness on physical health
Sensory impairments= direct risk factors for MH issues
Considerations for treatment
103
Diagnosing dementia?
Clinical syndrome
Exclude differential diagnoses- bloods (confusion screen)
Imaging- CT/MRI, DaT/ SPECT
Formal cognitive testing- ACE- III
104
ACE-III? Normal score? Doesn't do what? Domains?
Assesses 5 cognitive domains
82/100
Sub-scores= just as important as total score
Change in score= relevant over time
Exclude dementia
Attention, memory, fluency, language, visuospatial
105
Onset, fluctuations, hallucinations, progression, personality changes and insight for Alzheimer's?
Gradual, no fluctuations, sometimes hallucinations, progression, personality changes, insight varies
106
Onset, fluctuations, hallucinations, progression, personality changes and insight for vascular dementia?
Step-wise onset, sometimes fluctuations and hallucinations, progressive, personality changes, insight varies
107
Onset, fluctuations, hallucinations, progression, personality changes and insight for LBD/PDD?
Gradual onset, are fluctuations and hallucinations, progressive, personality changes, insight varies
108
What is pseudodementia? Changes in what lobe? On MRI?
Cognitive impairment secondary to mental illness- most commonly depression
"Don't know answers"
Impairments in executive functioning and attention
Frontal lobe
White matter hyper-intensities
109
What is mild cognitive impairment? Prognosis?
Cognitive impairment without functional impairment
Aetiology similar to dementia
1/3= will improve, 1/3 will remain stable, 1/3 will progress to dementia
110
Tx for dementia? Best for what? SEs? E.g. of NMDA receptor antagonists? Used for what? Can be what? SEs?
Acetylcholinesterase inhibitors e.g. donepezil, galantamine, rivastigmine
Cognitive problems
Bradycardia, diarrhoea, headache
Memantine
Severe impairment/ unable to tolerate AChEI, neuropsychiatric impairment
Added to AChEI
Confusion and dizziness
111
Tx for other dementias?
Vascular- treat RFs
Alcohol-related- stop drinking
Fronto-temporal= no specific tx
112
Other tx for dementia?
Stimulation- mental and physical
| Carer support, support charities, medication for BPSD, future planning- driving/ LPoA
113
Recovery for delirium can take how long? Tx?
3-6 months
Treat the cause, supportive environment
May need benzodiazepines/ antipsychotics
114
Changes in vascular depression? On MRI? Presentation associated with what? Poor response to?
Cortical circulation
White matter hyperintensities
Cognitive impairment, psychomotor retardation and apathy, poor insight
Antidepressants
115
Drugs cause delirium? Metabolic causes? Infective? Intracranial?
Beta-blockers/ nifedipine/ clonidine, opioids/ antipsychotics/ benzodiazepines, methyldopa, digoxin
Anaemic/ B12/ folate deficiency, hypercalcaemia/ hypothyroidism/ hyper or hypokalaemia/ natraemia
Post-viral/ neurosyphilis
Post-stroke/ subdural haematoma/ Parkinson's disease/ SOL/ dementia
116
What is Capgras syndrome? Fragoli syndrome? Cotard syndrome? De Clerambault's syndrome?
Close friends/ pet replaced with identical imposter
One/ more familiar persons repeatedly change their appearance
Patient denies existence of one own's body to the extent of delusions of immortality--> self-starvation because of negation of existence of self
Someone else is in love with them
117
Common psychotic elements in psychotic depression?
Nihilistic delusions
Hypochondriacal delusions
Delusions of poverty
Auditory hallucinations - second person derogatory
118
Onset of late onset schizophrenia? What delusions are classical? What are uncommon?
>60 y/o
Persecutory delusions
Negative symptoms and thought disorder
119
Features of delusional disorders?
Persistent delusions without hallucination s
Often more distressing to other people than the patient
Patients often reluctant to seek/ accept help
120
What is Charles Bonnet syndrome?
Visual hallucinations- simple repeated patterns, complex images of people/ landscapes/ objects
Ass w/ visual impairment
No role for antipsychotics/ tx
Patients usually retains insight
121
Features of high secure hospitals? Medium secure unit? Low secure unit?
High physical, procedural and relational security, issues of public safety
Max security
Less physical, high procedural and relational security, escape must be prevented
Emphasis on rehabilitation
122
People in psychiatric intensive care unit (PICU)? Limit on stay?
Acutely disturbed and may present a risk to others/ to themselves
6 weeks
123
Features of being 'fit to be interviewed'?
In clear consciousness, fully oriented, did not appear to be suggestible/ abnormally acquiescent
124
Features of not being fit to plead? Determined by who? Decision should normally be made when?
Not able to understand the nature and course of proceedings
A judge
As soon as it arises, which would ordinarily be before arraignment, the court may postpone consideration of unfitness until any time before the opening of the defence case
125
Features of being unfit to plead?
Unable to plead to a charge, instruct their legal representative, make a proper defence, challenge a juror, understand the evidence
126
What does insanity mean in relation to legal issues?
Persons did not know the nature and quality of the Act/ did not know what he/ she was doing was wrong/ was unable to refrain from committing the Act
Not guilty by reason of insanity
Murder--> manslaughter on grounds of diminished reponsbility
127
Tests used to tell if you are just trying to use the insanity plea to get away with stuff? When are forensic sections of the MHA used? Numbers?
Polygraph test/ screen
When court/ prison authorities advised by doctors, feel people would benefit from time in hospital to assess/ treat MH problem
37/41
128
Risk domains?
```
Risk to self- further DSH/ suicidal behaviour
Self neglect
Using alcohol and illicit substances
Non compliance with tx/ aftercare
Non engagement
Violence
Other risks- arson, to children/ sexual offending/ reoffending
Of deterioration in physical health
```
129
Methods for risk assessment? Using who and what?
Combination- clinical judgement, actuarial and hybrid- structured clinical judgement
MDT, knowledge of the patient, multiple sources of information, clinical records/ notes, collateral history, victim statements, witness statements, criminal record
130
Include what in risk assessment for violence?
Summarise circumstances of past violence and recent change
Nature and context of past risks
Identify factors that increase risk
Recommend/ prioritise risk management strategies
131
Hx for assessing risk?
H/O violent behaviour, social restlessness, poor compliance with tx, poor engagement, substance abuse, social context, poor impulse control, access to particular victims, clinical diagnosis
Environment- access to victim
Dynamic factors- severe stress
132
Protective factors for risk?
Engagement with team, previous achievements, compliance with care planning, medication, OPD, community visits, family support, preferred future, use of leave, access to community resources, appropriate living/ coping skills
133
Qs in risk assessment?
What risks are present? How often are they present? In what circumstances? The character of the risk?
What can we do with it?
134
Practical approach to risk management? Violence prevention plan?
LEAD: look, examine, adjust, document
Distinguish static and dynamic factors, focus on current status of each dynamic factor, develop a plan to address the combination of factors unique to the individual, determine the setting and parameters necessary to implement plan safely, document this process
135
Positive symptoms of schizophrenia? Negative symptoms?
Hallucinations, delusions, disorganised thinking, abnormal behaviour
Avolition, asociality, blunted affect, anhedonia, alogia
136
Needed for schizophrenia?
1 of for past month:
thought disorder, delusions- control/ reference, hallucinatory voices, culturally inappropriate/ implausible persistent delusions
137
Types of schizophrenia? 2 other subtypes?
Paranoid- delusions+ hallucinations
Catatonic- unusual motor activity
Hebephrenic/ disorganised- disorganised speech, flat affect
Undifferentiated- don't fit neatly into a diagnosis
Residual- at least one episode of schizophrenia experienced in the past, no longer exhibiting signs of the disorder
Post-schizophrenic depression
Simple schizophrenia- progressive development of negative symptoms, no hx of psychosis
138
Aetiological theories of schizophrenia? Epidemiology?
Dopaminergic overactivity
15-35 in males, higher in females
Higher in Afro-Caribbean and socio-economically deprived people
139
Approaching patient with psychotic symptoms?
Psych hx, MSE, physical exam, diagnostic formulation, investigations, management
140
MSE features for psychosis?
Odd/ inappropriate attire, agitated/ defensive, poor eye-contact, odd posturing/ purposeless and repetitive movements
Pressured speech, loud/ low, monotonous speech
Flat affect, inappropriate affect- positive symptoms, depressed/ indifferent mood
Lack of logical idea connection, word salad, repetition of words- echolalia, neologisms
Thought insertion, withdrawal and broadcasting, paranoid ideations, evaluation for suicidal ideations
Illusions/hallucinations
Disoriented/ inattentive secondary to symptoms
Poor recall and lack of insight
141
Psychosocial formulation for schizophrenia? Biological factors?
Stressful life, family cohesion, living conditions, attitude and knowledge of illness
Family hx, substance misuse, comorbidities
142
Schizo investigations?
Blood tests- U&Es, LFT, calcium, FBC, glucose
CT/MRI, CXR- if comorbidities
Urine drug screen, microscopy and culture
EEG- seizures
143
Tx for prodromal schizophrenia? First episode presentations?
Low-dose antipsychotics, CBT, antidepressants
Withdrawn/ bizarre behaviour, failure to achieve educational potential, via criminal justice system
Following self-harm/ suicide attempt
144
SEs of atypical antipsychotics?
Weight gain, cataracts, sexual SEs, hyperlipidaemia, EP symptoms, diabetes mellitus, prolonged QTC interval, myocarditis
145
Time to remission of symptoms of schizophrenia? What has been proven to reduce the rate of relapse in schizophrenic patients living with their families?
3-9 months/ more
| Family psychoeducation
