Psychiatry - Key Conditions Flashcards
How does schizophrenia present?
Delusions, hallucinations, thought disorder, lack of insight
What are the most common hallucinations in schizophrenia?
Auditory
What thought disorders do you see in schizophrenia?
Thought insertion, removal or interruption - delusions about external control of thought. Thought broadcasting - the delusion that others can hear one's thoughts. Delusional perceptions (ie abnormal significance for a normal event) - eg, 'The rainbow came out and I realised I was the son of God.' External control of emotions.
What are the negative symptoms seen in schizophrenia?
Underactivity (also affects speech), low motivation, social withdrawal, emotional flattening, self-neglect, loss of interests, alogia (poverty of speech)
Give some organic differentials of schizophrenia.
Drug-induced psychosis - amphetamine, LSD, cannabis.
Temporal lobe epilepsy.
Encephalitis.
Alcoholic hallucinosis.
Dementia.
Delirium due to infection, metabolic or toxic disturbance, neurological disease, endocrine cause, etc.
Give psychiatric differentials of schizophrenia.
Mania. Psychotic depression. Some personality disorders. Panic disorders. Dissociative identity disorder.
What investigations would you order for someone first presenting with schizophrenia?
LFTs and FBC. Abnormal LFTs and macrocytosis on FBC are highly suggestive of alcohol abuse.
Screening for AIDS should be preceded by counselling.
Urine screen for drugs of abuse. Light recreational use of cannabis can produce a positive test for the subsequent fortnight. Heavy and chronic use can produce a positive result for months after the last use.
What is the first-line pharmacological treatment of schizophrenia?
First-line treatment in newly diagnosed schizophrenia now involves the use of the newer atypical antipsychotics - eg, risperidone or olanzapine.
What positive symptoms do you see in schizophrenia?
Delusions, hallucinations, disorganised speech (e.g. word salad), disorganised behaviour (bizarre, no purpose), catatonic behaviour
What are the three phases of schizophrenia?
Prodromal (withdrawn), active (severe symptoms), residual (cognitive symptoms)
How do we diagnose schizophrenia?
Two of the following: delusions, hallucinations, disorganised speech, disorganised/catatonic behaviour, negative symptoms; with one of the first three. Must be ongoing for 6 months, with at least one month in the active phase.
Describe the epidemiology behind schizophrenia.
M > F, mid 20’s for men late 20’s for women, ? due to oestrogen regulation in women
What is bipolar disorder?
A disease characterised by episodes of mania (or hypomania) and depression.
What is bipolar I?
This type presents with manic episodes (most commonly interspersed with major depressive episodes). The manic episodes are severe and result in impaired functioning and frequent hospital admissions.
What is bipolar II?
Here, patients do not meet the criteria for full mania and are described as hypomanic. Hypomania in comparison to mania has no psychotic symptoms and results in less associated dysfunction. This type is often interspersed with depressive episodes.
How does the manic phase of bipolar present?
Grandiose ideas, pressure of speech, excessive amounts of energy, racing thoughts and flight of ideas, overactivity, needing little sleep, or an altered sleep pattern, easily distracted - starting many activities and leaving them unfinished, bright clothes or unkempt, increased appetite, sexual disinhibition, recklessness with money.
What is hypomania?
Hypomania is a lesser degree of mania with persistent mild elevation of mood and increased activity and energy but without hallucinations or delusions. There is also no significant effect on functional ability.
What must you ask a pt who is ? bipolar?
Any previous episodes of mania or depression.
Any suicidal or homicidal thoughts.
Any self-neglect.
Family history.
Substance misuse, smoking and alcohol intake.
General physical health.
How do we manage an acute manic episode?
If pt is already on an antipsychotic, increase to maximum dose. Drugs commonly used are haloperidol, olanzapine, quetiapine and risperidone. If one antipsychotic is ineffective it is worth changing to a different one. If the second one is ineffective, start lithium. If not permitted, use valproate.
Which patients should we not use valproate in?
Valproate should not be used routinely in females of child-bearing potential and if it is used then patients need to be counselled about alternative forms of contraception.
How do we manage an acute depressive episode?
Usually refer to secondary care. If depression develops rapidly in a patient with a previous manic episode who is not on treatment then an anti-manic drug should be started. Patients with moderate-to-severe depression should be offered fluoxetine combined with olanzapine or quetiapine on its own.
Why should you be careful about antidepressant use in bipolar?
Antidepressants may be less effective in bipolar disorder, even if depression is the main feature. They should be used carefully, as they may induce mania or hypomania or rapid cycling. If antidepressants are required then they should be prescribed with anti-manic medication.
How do we manage an acute mixed episode?
During an acute mixed episode antidepressants should be avoided and the aim should be to try to stabilise patients on anti-manic medication.
How often do we review manic patients?
Once patients begin treatment they should be reviewed at least weekly and then annually once they are stable.
What is depression?
Depression refers to both negative affect (low mood) and/or absence of positive affect (loss of interest and pleasure in most activities) and is usually accompanied by a variety of emotional, cognitive, physical and behavioural symptoms.
How do we diagnose depression?
At least one of the core symptoms:
Persistent sadness or low mood nearly every day.
Loss of interest or pleasure in most activities.
Plus at least three or four of the following symptoms to a minimum total of 5 depressive symptoms:
Fatigue or loss of energy.
Worthlessness, excessive or inappropriate guilt.
Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts.
Diminished ability to think/concentrate or increased indecision.
Psychomotor agitation or retardation.
Insomnia/hypersomnia.
Changes in appetite and/or weight loss.
Give five RFs for depression.
Female gender, PMH of depression, significant physical illnesses, other mental health problems, psychosocial problems, childhood factors
What are the two screening questions for depression?
During the past month, have you:
Felt low, depressed or hopeless?
Had little interest or pleasure in doing things?
Give a screening tool for depression.
The Patient Health Questionnaire (PHQ-9)
Why do we use SSRIs as a first line treatment?
Selective serotonin reuptake inhibitors (SSRIs) are used as first-line antidepressants in routine care because they are as effective as tricyclic antidepressants and less likely to be discontinued because of side-effects; also because they are less toxic in overdose.
Which SSRI should you start with?
At the moment escitalopram has the highest probability of remission and may be the most effective and cost-effective. Use sertraline if other comorbidities due to lower risk of drug interactions. Use fluoxetine if young.
Why might you consider prescribing omeprazole with an SSRI?
Increased risk of bleeding with SSRIs, and consider co-prescribing a gastric protection agent, particularly in older people who are on aspirin or other NSAIDs
When should you consider reviewing a pt who has just started antidepressant medication?
After 2 weeks. See patients who are considered to be at increased risk of suicide or who are younger than 30 years old, within one week of starting treatment. Regularly review (every 2-4 weeks) in the first three months or until the risk is no longer significant.
Give RFs for postnatal depression
Previous history of mental health problems.
Psychological disturbance during pregnancy.
Poor social support.
Poor relationship with partner.
Baby blues.
Recent major life events.
How would you treat a pt with mild postpartum depression but a history of severe depression?
Give an antidepressant
How would you treat moderate-severe postpartum depression?
High-intensity psychological intervention such as cognitive behavioural therapy (CBT).
Antidepressant treatment if:
Risks are understood and accepted, particularly if breastfeeding.
The woman declines psychological therapy.
Psychological therapies have failed.
How would you manage a woman who has ideas of either suicide or of harming her newborn child?
Immediate referral to psychiatric services, ? involve social services
What is postpartum psychosis?
A severe mental illness which develops acutely in the early postnatal period, usually within the first month following delivery. It is a psychiatric emergency.
When are women most likely to suffer from psychosis?
In the month after giving birth
Which women are more likely to suffer from postpartum psychosis?
Those with:
A past history of postpartum psychosis.
A past history of bipolar disorder.
A family history of postpartum psychosis or bipolar disorder.
How do we manage postpartum psychosis?
Immediate admission to psych unit, and pharmacologically similar to psychosis.
How do we treat anxiety pharmacologically?
Short term: The sedative antihistamines may be effective or the benzodiazepines. The latter should not be used beyond four weeks.
Long term: NICE recommends a selective serotonin reuptake inhibitor (SSRI) or venlafaxine as the first choice.
Name some SSRIs
Citalopram, escitalopram, sertraline, fluoxetine,
