Psychiatry - Level 2 Flashcards
Definition of adjustment disorder?
- Adjustment disorders are states of emotional distress and disturbance, usually interfering with social functioning, arising in period of adaptation to a significant life event (bereavement/separation)
- Must occur within 1 month of stressor and most do not occur after 6 months
Risk factors of adjustment disorder?
o Younger age
o Increased suicidal behaviour
Aetiology of adjustment disorder?
o The integrity of an individual’s social network (bereavement, separation experiences)
o The wider system of social supports and values (migration, refugee status)
o Major developmental transition or crisis (going to school, becoming a parent, failure to attain a cherished personal goal, retirement)
Symptoms of adjustment disorder?
o Sadness o Hopelessness o Lack of enjoyment o Crying spells o Nervousness o Anxiety o Desperation o Trouble sleeping o Difficulty concentrating o Performing poorly at work/school
Subtypes of adjustment disorder?
o Brief/Prolonged (>6m) depressive disorder
o Mixed anxiety and depressive disorder
o Disturbance of affect, conduct
o Grief/Bereavement reactions
Types of grief reaction?
Normal grief
• Typical disbelief, sadness, shock, numbness, anger, guilt, disturbed sleep, appetite
• Symptoms gradually reduce which usually lasts less than 12 months
Abnormal Grief
• Very intense, prolonged, delayed or where symptoms outside of normal
• Worthlessness, excessive guilty, marked slowing of thoughts and movements, not functioning normally
Management of adjustment disorder - psychological?
o Supportive psychotherapy
o Talking therapy
o Counselling
o Verbalization
Management of adjustment disorder - pharmacological?
o SSRIs
o Anxiolytics
Management of adjustment disorder - bereavement?
o Groups such as CRUSE for counselling
Prognosis of adjustment disorder?
- 20% develop major psychiatric illness within 5 years
- Most recover within 5 years
Definition of neurosis?
- Neurosis is abnormal psychogenic reactions with two components:
o Vulnerable personality
o Stress factors triggering the reaction
What is normal anxiety?
o Anxiety is a common, normal mood
o An evolutionary response to threatening situation due to adrenaline release which causes physical symptoms
o Fight or flight response
o It becomes problematic when it starts to interfere with daily life/out of proportion to the threat
What is generalised anxiety disorder?
o Persistent free-floating worry and feelings of apprehension about everyday events causing significant functional impairment
o Most days for 6 months
o Comorbidity with panic disorder, social phobias, depression and substance misuse
Epidemiology of generalised anxiety disorder?
- Lifetime prevalence 1 in 5
- Females 2:1 Males
Risk factors of generalised anxiety disorder?
o Unemployed
o Single
o Stressful events in childhood
Aetiology of generalised anxiety disorder?
o Genetic
o ANS hyperresponsiveness
o Experience of unexpected negative stressors (death of parent, rape, war, family dysfunction)
ICD-10 criteria of generalised anxiety disorder?
At least 4 symptoms (with at least 1 from autonomic arousal):
o Autonomic Arousal
Palpitations, tachycardia, sweating, trembling, dry mouth
o Physical symptoms
Breathing difficulties, choking sensation, chest pain, nausea, abdominal pain
o Mental state
Feeling dizzy, unsteady, faint, derealisation, fear of losing control, passing out, dying
o General symptoms
Hot/Cold flushes, numbness or tingling
o Tension
Muscle aches/tension, restlestness, feeling on edge
o Other
Exaggerated response to minor surprises, concentration difficulties, sleep problems
Assessment of generalised anxiety disorder?
- History and MSE
- Diagnosis made on clinical symptoms (ICD-10)
- Assess severity using GAD-7 questionnaire
- Enquire about:
o Comorbid depressive, anxiety, medical conditions
o Substance misuse
o Environmental stressors
Management of generalised anxiety disorder - general advice?
o Sleep problems
Use sleep hygiene advice - avoid caffeine, alcohol, bedtime routines
o Regular exercise
o Counselling
o Self-help books on relaxation and leaflets
Management of generalised anxiety disorder - psychological 1st line ?
o CBT
Based on idea that thoughts and feelings are maintaining problems
Individual recognises thoughts and finds more helpful ways to view them, also replaces automatic morbid anticipatory thoughts with realistic cognition
o Applied relaxation
Management of generalised anxiety disorder - pharmacological 2nd line?
o SSRIs/SNRIs
Start at low dose and increase
o Beta-blockers
For palpitations and tremor
o Benzodiazepines
Avoid if possible
Only short-term use, best to avoid – risk of dependence
Management of generalised anxiety disorder - if severe or risk to harm self or others?
o Admission, acute CRISIS assessment, CMHT
Prognosis of generalised anxiety disorder?
- The more chronic, the worse the prognosis
- 1 in 3 remits after 3 years with treatment
- In 6 years, 1 in 10 have severe persistent impairment
Definition of panic disorder?
o Recurrent panic attacks which are not secondary to substance misuse, medical conditions or another psychiatric disorder
o Frequency may be attacks every day to a few a year
o Persistent worry about having attacks and persistent behaviour changes due to this
o Can be with or without agoraphobia
Definition of panic attack?
o A period of intense fear characterised by panic symptoms that develop rapidly, reach a peak in about 10 mins and do not last longer than 20-30 minutes
o Attacks may be spontaneous or situational
ICD-10 diagnosis of panic disorder?
o Recurrent panic attacks, not restricted to any situation or set of circumstances
o 4 panic attacks in 4 weeks, sudden onset
Epidemiology of panic disorder?
- Occurs in 1-2% of population
- Female 3:1 Males
- Peak incidence 15-25 and 45-55
Aetiology of panic disorder?
o Genetic
o Neurotransmitters
Increased serotonin, noradrenaline lactate or decreased GABA
o Fear Network
Increased stimulation of amygdala, hypothalamus and brainstem centres
Symptoms of panic disorder?
Autonomic Arousal o Tremor o Tachycardia o Tachypnoea o Hypertension o Sweating o GI upset o Globus hystericus o Chest pain o Dizzy o Light-headed o Derealisation o Numbness
Concerns of death from cardiac and respiratory problems
Thoughts of suicide
Investigations of panic disorder?
o FBC, U&Es, glucose, TFTs, Ca
o ECG
o Toxicology
Management of panic disorder - general advice?
- Allow understanding of panic disorders
- Avoid anxiety-producing substances – caffeine, alcohol, drugs
- Exercise
Management of panic disorder - psychological 1st line?
- Behavioural methods
o Phobic avoidance treated by exposure, relaxation techniques - CBT
- Emotion-focussed psychotherapy
Management of panic disorder - pharmacological 2nd line?
- SSRIs
- TCAs
- Benzodiazepines
o Used short-term for severe anxiety - If ineffective, change AD or if >2 unsuccessful then consider referral to secondary services for combination with SSRI+TCAs, TCA + lithium
- Continue treatment for 1 year and then tapering down
Definition of bipolar affective disorder?
- Bipolar disorder is characterized by both episodes of depressed mood and episodes of elated mood and increased activity
- Mixed is occurrence of both mania and depression symptoms in a single episode, present every day for at least 2 weeks
What is cyclothymia?
- Cyclothymia is mild chronic BAD
Epidemiology of bipolar affective disorder?
- Peak age 21
- Up to 1% life-time risk
- Males = Females
Aetiology of bipolar affective disorder?
o Genetic
o 1st degree relative, you have 10% lifetime risk of BAD
o Dysfunction of hypothalamic-pituitary-adrenal axis
o Cyclothymic personality
Persistent instability of mood
o Psychosocial
Child maltreatment, traumatic events, social exclusion
Lack of confiding relationship
o Neurotransmitters
o Monoamine hypothesis
Excess noradrenaline, serotonin,dopamine for mania, depletion for depression
ICD-10 diagnosis of bipolar affective disorder?
o >2 episodes of mood disturbance, one of which must be hypomanic, manic or mixed with recovery usually complete between episodes
o Depressed episodes need to meet criteria for depression
Symptoms of manic episodes of bipolar affective disorder?
o Abnormally elevated mood, extreme irritability, aggression
o Increased energy or activity, restlessness, and a decreased need for sleep (for example the person feels rested after only 3 hours of sleep).
o Pressure of speech or incomprehensible speech.
o Flight of ideas or racing thoughts.
o Distractibility, poor concentration.
o Increased libido, disinhibition, and sexual indiscretions
o Extravagant or impractical plans
o Psychotic symptoms: delusions (usually grandiose) or hallucinations (usually voices)
o At least 7 days
Symptoms of depression of bipolar affective disorder?
o Feelings of persistent sadness or low mood, loss of interest or pleasure, and low energy
Investigations of bipolar affective disorder?
o FBCs, ESR, glucose, U&Es, LFTs, Ca, TFTs, drug screen
o ECG
o Other tests if indicated
Management of bipolar affective disorder - referral?
Refer to CMHT or CAMHS
Management of bipolar affective disorder - if danger to themselves or others?
o Urgent referral, hospital admission
Management of bipolar affective disorder - pharmacological - acute manic episode?
Stop antidepressant medication
Oral antipsychotic (haloperidol, olanzapine, quetiapine, risperidone)
Try another if ineffective
Add lithium/sodium valproate if 2nd ineffective
Benzodiazepines if agitated (lorazepam)
Management of bipolar affective disorder - pharmacological - acute depressive episode?
Antidepressant and mood stabiliser (lithium, lamotrigine)
Management of bipolar affective disorder - pharmacological - long term treatment?
Lithium (1st line)
Sodium valproate, lamotrigine, carbamazepine if ineffective/not tolerated
Management of bipolar affective disorder - severe, treatment refractory cases?
o ECT (in severe cases where medication does not work)
Management of bipolar affective disorder - psychological?
o Education
o Psychological interventions for BAD
CBT, IPT, Family therapy
o High-intensity psychological treatment for depression
Management of bipolar affective disorder - social care?
o Written care plan
o Support groups
o Crisis plan
o Encourage lasting power of attorney
Management of bipolar affective disorder - General advice?
o Stop driving during acute illness – inform DVLA
o Lifestyle advice
Prognosis of bipolar affective disorder?
- Often delay between age of onset of symptoms and medical help
- Chronic, life-long with patients suffering on average 10 episodes over a lifetime
- Deliberate self-harm and suicide (25-50% try)
- High morbidity in lost work, lost productivity, suicide in (10%)
- Drug and alcohol misuse
Definition of manic episode?
Period of abnormally and persistently elevated, expansive or irritable mood with >3 characteristic symptoms of mania
At least 1 week, or until admissions to hospital
Impairs occupational and social functioning
Definition of hypomania?
A disorder characterized by a persistent mild elevation of mood; a smaller degree of mania
The disturbances of mood and behaviour are not accompanied by hallucinations or delusions
Lasts at least 4 days and clearly different from normal mood
Definition of mania with psychosis?
Clinical picture of mania but with delusions (usually grandiose) or hallucinations (usually voices speaking directly to patient), flight of ideas an extreme
Definition of manic stupor?
Unresponsive, akinetic, mute and fully conscious
Facies indicate elation and flight of ideas common
Medications inducing mania?
o Antidepressants o Benzodiazepines o Antipsychotics o Anti-Parkinsonian medications o Steroids o Analgesics o Antibiotics
Psychotic symptoms in mania?
o May be mood congruent/incongruent o Grandiouse ideas – may be delusional to role, power, religion o Persecutory delusions o Thought disorder and speech incomprehensible o Violent behaviour o Self-neglect o Catatonic behaviour o Total loss of insight
Manic symptoms in acute mania?
o Elevated mood (usually out of keeping with circumstances)
o Increased energy
Overactive, flight of ideas (pressured speech), racing thoughts, reduced need for sleep
o Increased self-esteem
Overoptimistic ideation, grandiosity, reduced social inhibitions, overfamiliarity, facetiousness
o Reduced attention
o Dangerous behaviour
Extravagant, impracticable schemes, reckless spending, inappropriate sexual encounters
o Excitement, Irritability, Aggressiveness, Suspiciousness
o Disruption of work, usual social activity and family life
Definition of depression?
- Depression is characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms
Definition of dysthymia?
- Dysthymia is persistent subthreshold depressive symptoms for more than 2 years
Monoamine hypothesis of depression?
o Depression results from the depletion/change in function of MA neurotransmitters: NA, serotonin and dopamine in limbic system of brain
o Antidepressants inhibit uptake or breakdown of MA causing an increase in levels of the MA neurotransmitters
Other types of depression?
o Atypical, postnatal, seasonal affective disorder
Epidemiology of depression?
- Lifetime risk of depressive disorders= 15%
- Prevalence 1 in 5 people
- Females 2:1 Males
Risk factors of depression - biological?
Genetics Physical illness • Especially severe, chronic or painful Organic Causes • Endocrine o Cushing’s, Addisons, Hypothyroidism • Neurological o Stroke, Alzheimer’s disease, dementia, Huntingtons, MS, epilepsy • Metabolic o Fe, B12, Folate, hypercalcaemia, hypomagnesaemia • Infection • Neoplasms • Drugs o L-dopa, steroids, B-blockers, digoxin, cocaine, amphetamines, opioids, alcohol
Risk factors of depression - psychological?
Childhood experiences • Loss of a parent, lack of parental care, parental alcoholism, childhood sexual abuse Personality traits • Neuroticism, impulsivity, obsessional Vulnerability factors in women • 3 or more children under 14 • No work outside the home • No confiding relationship
Risk factors of depression - social?
Social classes 4 and 5
Urban areas
Unemployment
Core symptoms of depression?
o Anhedonia
o Low mood (diurnal variation, usually worse in morning)
o Reduced energy (anenergia)
For >2 weeks
Other ICD features of depression?
Sleep disturbance
Insomnia (early morning waking 2-3 hours before should)
Hypersomnia (esp. atypical depression, bipolar)
Change in appetite and weight
Reduced concentration
Agitation/Slow Movements
Guilt/worthlessness feelings
Suicidal thoughts
Additional symptoms of depression?
o Psychomotor retardation/agitation
o Constipation
o Pessimistic future
Psychotic symptoms of depression?
o Delusions
o Hallucinations
MSE of depression?
o Downturned eyes o Poor eye contact o Frown, expressionless o Knitted brow o Unkempt o Weight loss o Slow speech o Psychomotor retardation o Low mood o Pessimistic
Classing severity of depression?
o Mild = 2 core + 2 other
o Moderate = 2 core + 3 other
o Severe = 3 core + 4 other
Investigations of depression?
- Investigations
o Not routinely needed but if organic cause suspected then think about:
FBC, ESR, B12/Folate, U&Es, LFTs, TFTs, glucose, Ca2+ - Primary Care Questionnaire
o PHQ-9
Diagnosis of depression according to ICD-10?
If 4 or more of the 10 symptoms of depression
o Mild = 2 core + 2 other
o Moderate = 2 core + 3 other
o Severe = 3 core + 4 other
Management of depression - if risk of suicide?
o Consider CRISIS if urgent
Management of depression - mild depression?
o Active Monitoring and follow-up in 2 weeks
Management of depression - mild-to-moderate depression 1st line?
o Psychological intervention
IAPT
Low-intensity psychological interventions
• Individual self-help guides
• Computerised Cognitive Behavioural Therapy (CBT)
• Structured group-based physical activity
o Consider antidepressant if not reacting, or severely affecting life
Management of depression - moderate-to-severe 1st line?
High-intensity psychological therapy
• Group/Individual CBT
• Interpersonal therapy (difficulties in relating to others and helping relationships)
• Behavioural therapy (getting people to act according to a plan rather than how they feel and involves doing things)
• Couples therapy
Management of depression - medications 2nd line?
Antidepressant
• Explain symptoms may get worse initially, take time to work (4-6 weeks) and should be continued for at least 6-9 months
• If multiple episodes then at least 2 years
• Choice
o Person’s preference, adverse effect profile, toxicity in
overdose
• MARIs 1st Line – SSRIs (Citalopram, Fluoxetine)
o Others
Tricyclics (Amitryptiline, Lofepramine) – avoid in overdose risk
NARIs (Reboxetine)
SNRIs (Venlafaxine)
NaSSa (Mirtazipine)
• MAOIs
o Phenelzine, moclobemide
o Rarely used – only for treatment resistant depression
• If it doesn’t work: o Switch AD or augment Lithium Antipsychotic Drug • If psychotic episodes
Management of depression - ECT?
For severe or life-threatening treatment resistant depression
2x weekly treatment for 6 weeks
Short general anaesthesia and muscle relaxant given
S/E of the anaesthesia, headaches, M. aches, nausea, confusion, temporary anterograde memory impairment
Management of depression - social?
Information leaflet Inform DVLA Sleep hygiene Support at home Isolation
Management of depression - follow up?
o Within 1 week in people <30
o Within 2 weeks for other people
o Review every 2-4 weeks for first 3 months
Management of depression - prognosis?
- Average length of depression episode= 6M,
- After 1st episode, 80% have further depressive episodes
Definition of anorexia nervosa?
o Characterized by deliberate weight loss, induced and sustained by the patient
o A specific psychopathology whereby a dread of fatness and flabbiness of body contour persists as an intrusive overvalued idea, and the patients impose a low weight threshold on themselves
Definition of bulimia nervosa?
o Characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading to a pattern of overeating followed by vomiting or use of purgatives
o Shares many psychological features with anorexia nervosa, including an overconcern with body shape and weight
o Repeated vomiting gives rise to disturbances of body electrolytes and physical complications
Epidemiology of eating disorders?
- Girls 7:1 Boys
- Mortality 5-20%
- Bulimia more common (40%), Anorexia (10%), ED-NOS (50%)
Aetiology of eating disorders?
o No single cause
o Biological
Genetics (twin studies), malnourishment
o Psychological
Perfectionism, reaction to stress, tendency to anxiety and depression, worry
o Environmental
Puberty, stressful life event, bereavement, abuse, stresses
Diagnostic criteria of anorexia nervosa?
- Dietary restriction (may be accompanied by vomiting, exercise, laxative abuse, or other weight control methods)
- Significant and unhealthy self-induced weight loss - BMI of <17.5
- Intense fear of gaining weight even when severely underweight
- Body image distortion with dread of fatness
- Amenorrhoea, reduced sexual impotence
- Arrested puberty
Symptoms through all systems of anorexia nervosa?
o CNS - Can’t think right, depression, dizziness, fear of gaining weight, sad, moody, irritable
o Hair – thin and brittle
o Heart – Hypotension, bradycardia, palpitations, heart failure, prolonged QT
o Blood – Anaemia, leukopenia, thrombocytopenia
o Muscles and Joints – Weakness, swollen joints, fractures, osteoporosis
o Kidneys – Stones, failure
o Electrolytes – Low potassium, magnesium, sodium
o GI – Constipation, bloating
o Hormones – Amenorrhoea, bone loss, growing problems
o Skin – bruise easily, dry skin, fine hair all over body, cold easily, brittle nails
o Reproductive – infertility, low birth-weight infant
Diagnostic criteria of bulimia nervosa?
Recurrent episodes of overeating (binges). ≥ 2 per week for 3 months
Strong desire or compulsion to eat (craving)
Attempts to counteract the “fattening” effects of food by one or more of:
• Self-induced vomiting
• Self-induced purging
• Alternating periods of starvation
• Use of drugs such as appetite suppressants, diuretics or thyroid preparations
Self-perception of being too fat, with fear of fatness
• NB can be normal or overweight – atypical bulimia nervosa
Symptoms through all systems of bulimia nervosa?
o CNS – depression, fear of gaining weight, anxiety, dizziness
o Cheeks – Swelling, soreness
o Mouth – Cavities, tooth erosion, sensitivity
o Throat – Sore, irritated, torn
o Muscles – Fatigue
o Stomach – Ulcers, pain
o Skin – Abrasion of knuckles (Russell’s sign), dry skin
o Hormones – Irregular periods
o GI – Constipation, bloating, diarrhoea, cramps
o Electrolytes – Dehydration, low K, Mg, Na
o Heart – Arrhythmias, heart failure, low BP, HR
o Blood - Anaemia
What is scoff questionnaire and what does score mean?
o Do you make yourself Sick because you’re uncomfortably full?
o Do you worry you’ve lost Control over how much you eat?
o Have you recently lost more than One stone in a 3-month period?
o Do you believe yourself to be Fat when others say you are too thin?
o Would you say that Food dominates your life?
o Score of 2 or more suggests likely AN or BN
Diagnostic criteria of anorexia nervosa?
Dietary restriction (may be accompanied by vomiting, exercise, laxative abuse, or other weight control methods) significant and unhealthy self-induced weight loss. BMI of <17.5)
Intense fear of gaining weight even when severely underweight
Body image distortion with dread of fatness
Arrested puberty
Amenorrhoea, reduced sexual impotence
Diagnostic criteria of bulimia nervosa?
o Recurrent episodes of overeating (binges). ≥ 2 per week for 3 months
o Strong desire or compulsion to eat (craving)
o Attempts to counteract the “fattening” effects of food by one or more of:
Self-induced vomiting
Self-induced purging
Alternating periods of starvation
Use of drugs such as appetite suppressants, diuretics or thyroid preparations
o Self-perception of being too fat, with fear of fatness
NB can be normal or overweight – atypical bulimia nervosa
Tests to perform in eating disorders?
- Sits to stand test
- Squat to stand test
- ECG, blood tests (FBC, ESR, LFTs, U&Es, TFTs, glucose, albumin, cholesterol)
- Risk assessment
Management of eating disorders - nutrition?
o Weight gain – 0.5kg/week in community (Anorexia Nervosa) o May need NG tubes o Multivitamin supplementation o Admission if need to feed to prevent death Rapid weight loss Electrolyte imbalance Bradycardia, postural drop in BP Poor mental state, psychosis
Management of eating disorders - psychological?
o CBT, Motivational enhancement therapy (MET)
o Family therapy
o IPT (bullaemia)
Management of eating disorders - pharmacological?
o Osteopenia – Vit D supplements (cholecalciferol), exercise
o Depression – Fluoxetine (clear obsessional ideas)
Prognosis of eating disorders?
o 50% recover
o 30% improve
o 20% chronic illness
Guiding principles of MHA 1983?
- Least restrictive option and maximising independence
- Empowerment and involvement
- Respect and dignity
- Purpose and effectiveness
- Efficiency and equity
Process of detaining patient under MHA 1983?
• Assessed by 2 Dr’s and 1 AMHP (ideally all attend to see the patient at the same time)
o 1 Dr MUST be Section 12 approved
o 1 Dr should “have prior knowledge” of the patient (eg: GP)
• Each Dr must determine their own opinion regarding whether the person meets the criteria for detention
• AMHP is always responsible for making the application to the receiving hospital (and can disagree)
• Rarely, nearest relative can also make final decision
Criteria for detention under MHA?
- Suffering from MENTAL HEALTH disorder, or nature or degree, which warrants detention in hospital
- Must be at risk to own health AND/OR own safety AND/OR risk to others
- Must be unwilling to go to hospital voluntarily
Important points of MHA?
- Willing patients who lack capacity to consent to admission can no longer be admitted voluntarily (e.g. cognitive impairment, severely depressed mood)
- Learning disability for treatment must also be “associated with abnormally aggressive or seriously irresponsible conduct”
Section 2 of MHA?
o For assessment (or assessment followed by medical treatment)
Of mental disorder
• Antidepressant, antipsychotic, mood stabilizer
Of cause of mental disorder
• Treat underlying cause
Of consequences of mental disorder
• DSH, self-neglect, weight loss
o For interests of patients own health/Interest of patients own safety/a view to the protection of others
o Requires AMHP + 2 Doctors, (1 must be Section 12 approved)
o Lasts for UP TO 28 days, can be appealed (within the first 14 days)
Section 3 of MHA?
o Patient needs to receive medical treatment in hospital
Of mental disorder
• Antidepressant, antipsychotic, mood stabilizer
Of cause of mental disorder
• Treat underlying cause
Of consequences of mental disorder
• DSH, self-neglect, weight loss
o Interests of patients own health/Interest of patients own safety/view to the protection of others
o Requires AMHP + 2 Doctors, (1 must be approved)
o Lasts for UP TO 6 months, can be appealed (twice within the first 6 months and then yearly after)
Section 5(2) of MHA?
o Doctor’s Holding Power
o In-patients only
o Must demonstrate mental disorder, identify risks to self or other, state why continued informal admission is not possible (refusal to stay/lack capacity to make decision)
o Therefore, the person needs assessment under the MHA
o Holding power so that a MHA assessment can be carried out
o Lasts up to 72 hours
o No rights to treat, cannot be used to treat physical health problems
o Application by consultant in charge of care or nominated deputy (must be a registered medical practitioner – FY2 and above)
Section 5(4) of MHA?
o 6-hour duration
o RGN cannot use this
o Must see a Dr. who can either rescind or complete 5(2) within the 6 hours
Police powers - Section 135 of MHA?
o Warrant to search for and remove patient
o To remove them to place of safety for assessment
o Last for up to 24 hours (or 36 if exceptional circumstances)
Police powers - Section 136 of MHA?
o Mentally disordered persons found in public place (not private dwellings)
o If a police officer thinks a person is suffering from a mental disorder and is in immediate need of care
o Can take them to a place of safety to be assessed after discussing the case with a mental health professional
o Last for up to 24 hours (or 36 if exceptional circumstances)
Principles of MCA 2005?
- A person is assumed to have capacity
- All practicable steps must be taken to help the person to decide
- Do not treat people as unable to make decisions if they make an unwise decision
- Any actions or decisions made on behalf of a person who lacks capacity must be in that person’s best interests
- Before acting in a person’s best interest, it must be established there is no other less restrictive way to achieve the outcome
Process of MCA ?
• 1. Diagnostic Test
o At the time of the decision the person has an impairment of, or disturbance in functioning of, the mind or brain
• 2. Functional Test
o Understand the information relevant to the decision
o Retain that information
o Use or weigh that information as part of the process of making the decision
o Communicate his decision
What to consider when determining best interests in MCA?
o The person’s past and present wishes and feelings
o Beliefs and values
o Views of anyone named by the person
o Anyone engaged in caring for the person or interested in
o their welfare
o Any done of a lasting power of attorney
o Any deputy appointed for the person by the court
What is an advanced decision to refuse treatment?
o To have legal weight must be specific refusals of particular (specific) treatment
What is an LPA?
o Allows a person to stipulate who they would wish to manage their health and welfare decisions, and/or decisions about their property and finances
What is an independent mental capacity advocate?
o If the person who lacks capacity does not have anyone else to advocate for them, an IMCA must become involved if the decision is about ‘serious medical treatment’ or DoLS
What is a DOLS?
Deprivation of Liberty Safeguards (DoLS)
• Apply to any person who lacks capacity and is deprived of their liberty in their best interests (regardless of whether they object or not)
• Occurs in care homes, general hospital wards, mental health wards.
• Capacity as defined in the MCA.
• Deprivation legally defined:
o “If the acid test is whether a person is under the complete supervision and control of those caring for her and is not free to leave the place where she lives”
• Urgent (up to 7 days) or standard application (up to 1 year)
Definition of OCD?
- Recurrent obsessional thoughts or compulsive acts.
- Obsessional thoughts are ideas, images, or impulses that enter the patient’s mind again and again in a stereotyped form
- Can cause distress and interfere with social and individual functioning
Epidemiology of OCD?
- 90% of people experience obsessions
- Mean age 20 years, most before 35
- Prevalence between 1-3%
Risk factors of OCD?
o Family history o Emotional, physical, sexual abuse o Bullying o Social isolation Pregnancy
Aetiology of OCD?
o Neurochemical – 5-HT
o Genetic
Examples of OCD behaviour?
Checking, washing, contamination, doubting, bodily fears, counting
Symptoms of OCD?
- Obsessive thoughts
o The patient often tries, unsuccessfully, to resist them.
o They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant - Compulsive acts
o Stereotyped behaviours that are repeated.
o Not inherently enjoyable, nor do they result in the completion of inherently useful tasks.
o Function is to prevent some objectively unlikely event, often involving harm or danger to or caused by the patient
o Repeated attempts are made to resist but if acts are resisted the anxiety gets worse
Management of OCD - psychological?
o CBT
Response prevention to ritualistic behaviour
Exposure techniques for obsession
Management of OCD - pharmacological?
o SSRIs (first line)
o Clomipramine
o MAOIs
o Augmentation – antipsychotics, lithium
Management of OCD - physical?
o ECT
o Psychosurgery – stereotactic cingulotomy
Prognosis of OCD?
- Effective in up to 70% of cases
- Poor prognostic factors
o Early age of onset
o Co-existence of obsessions and rituals
o Low social functioning
Definition of psychosis?
Is an umbrella term
Defined as experience of being out of touch with reality
Describes the experience of hallucinations, delusions and/or thought disorder
Presents in dementia, delirium, DTs, substance misuse, schizophrenia, affective disorders, sleep deprivation, bereavement
Definition of delusions?
A false unshakeable belief, despite evidence to the contrary, not held by others in the same culture and held with intense conviction
Definition of hallucinations?
Auditory, visual, olfactory, tactile, gustatory, somatic
A perceptual experience without an object or stimulus, that appears subjectively real but uncontrollable by patient
Definition of thought disorder?
An abnormality in mechanism of thinking such that to the observer the person does not make sense
Definition of schizophrenia?
o Fundamental and characteristic distortions of thinking and perception
o Affects that are inappropriate and blunted
o Due to increased dopamine in mesolimbic-mesocortical systems
o Glutamate, GABA implicated
Definition of schizoaffective disorder?
o Episodic disorder where both affective and schizophrenic symptoms are prominent with same episode of illness
o Can be manic, depressive types
o Treat like schizophrenia with either manic or depressive treatment according to bipolar management
Epidemiology of schizophrenia?
- Male>Female
- Peak onset 20-30
- Incidence up to 1% in UK
Aetiology of schizophrenia?
o Genetic
o Environment
Winter births, viral infections
Neurosyphilis, encephalitis, TL epilepsy
o Life Events
Social exclusion, economic adversity, childhood trauma, migration, urban environment
o Substance misuse (cannabis, amphetamines)
o Peri-natal trauma
Types of schizophrenia?
o Paranoid o Hebephrenic o Catatonic o Simple o Undifferentiated
Description of types of schizophrenia - paranoid?
Relatively stable, often paranoid delusions with hallucinations and perceptual disturbances
Description of types of schizophrenia - hebephrenic?
Affective changes are prominent (mood is shallow, flat), delusions and hallucinations fleeting
Behaviour irresponsible and unpredictable
Thought disorganised, speech incoherent
Tendency for social isolation
Description of types of schizophrenia - catatonic?
Prominent psychomotor disturbances – hyperkinesia and stupor to negativism
Episodes of violence striking feature
Dream-like state with vivid scenic hallucinations
Description of types of schizophrenia - simple?
Insidious, progressive development of odd conduct, inability to meet demands of society
Characteristic negative symptoms develop mostly
Description of types of schizophrenia - undifferentiated?
One that does not conform to any subtype
Positive symptoms of schizophrenia?
o Hallucinations
o Delusions
o Thought Disorder
Negative symptoms of schizophrenia?
o Avolition – Lack of motivation o Anhedonia o Alogia – poverty of speech o Asociality – lack of desire for relationships o Affect blunt
Is capacity maintained in schizophrenia?
- Clear consciousness and intellectual capacity are usually maintained
ICD-10 diagnosis of schizophrenia?
o Fundamental and characteristic distortions of thinking and perception
Thought echo, insertion, withdrawal, broadcast
Delusional perception, control, passivity
Hallucinatory voices (3rd person) commenting or discussing patient
Persistent delusions
Thought disorders
Negative symptoms
Catatonic behaviour
Affects that are inappropriate or blunted
o 1 FRS or >1 less clear symptoms
o >1/12 months
o Absence of:
Extensive depressive or manic symptoms unless schizophrenic disorder pre-dates affective disturbances
Brain disease (epilepsy)
States of drug intoxication, substance abuse or withdrawal
Investigations to consider in schizophrenia?
o Full physical and neurological exam o Bloods FBC, U&Es, LFT, Ca, glucose o Imaging if suspected organic cause o Urine drugs screen o ECG – QT interval prolongation due to antipsychotics
Management of schizophrenia - first episode of psychosis?
o Early intervention in psychosis team
o CRISIS team
o Hospital admission (voluntarily or Section 2)
Management of schizophrenia - care plan approach?
o Crisis plan
o Advanced Statement
o Key clinical contacts
Management of schizophrenia - antipsychotic drugs - what to offer?
Block dopamine D2 receptors – FGA and SGA
Offer oral, provide benefits and side effects of each one and discuss
Management of schizophrenia - antipsychotic drugs - SGA (1st line)?
• Starting dose= small to min S/E and inc according to response to min effective dose
• Continue for 6-8 weeks
• SE
o Nigro-striatal (EPSE)
Acute – Parkinsonism, dystonia, akathisia
Chronic – Tardive dyskinesia
o Tubero-infundibular (prolactin secretion)
Amenorrhoea, gynaecomastia, impotence, weight gain
o Anti-cholinergic (dry mouth, blurred vision, constipation, urinary retention)
o Anti-adrenergic (postural hypotension, sexual dysfunction)
o Sedative
Management of schizophrenia - antipsychotic drugs - tests to do before starting AP?
• Before starting
o FBC, U&Es, LFTs, HbA1c, prolactin, lipids
o Weight, BP, pulse, ECG (risk of prolonged QT
Management of schizophrenia - antipsychotic drugs - when to give clozapine??
- Offer when two different antipsychotics have failed to treat illness (>1 should be non-clozapine SGA)
- SE: agranulocytosis, myocarditis, weight gain, salivation, sedation, seizures
Management of schizophrenia - other drug treatment?
o Benzodiazepines Lorazepam given acutely to manage anxiety related symptoms Diazepam long-acting o Procyclidine For treatment of AP EPSEs o ECT possible
Management of schizophrenia - psychosocial therapy?
o CBT o Family therapy o Supported employment o Reduced expressed emotions o Relapse signature o Art therapy o MIND self-help groups o Housing options, disability living allowance, employment support o Inform DVLA
Management of schizophrenia - follow up?
o Secondary care team for first 12 months, or until their condition has stabilized (whichever is longer)
Routine review annually by GP
Prognosis of schizophrenia?
- 1 in 4 make good clinical and social recovery
- Suicide is most likely cause of death
- Good prognostic factors
o Older, female, married, no FHx, acute onset positive symptoms - Poor prognostic factors
o Young, single, male, FHx, insidious negative symptom onset
Definition of delusional disorder?
- A delusion is a false belief which is firmly sustained and based on incorrect inference about reality. This belief is held despite evidence to the contrary and is not accounted for by the person’s culture or religion
ICD-10 criteria of delusional disorder?
- Development of a delusion usually persistent, sometimes lifelong and no identifiable organic basis
o Persist for >1 month
o Not due to schizophrenia or a mood disorder – does not display symptoms of either
o Occasional auditory or transitory hallucinations can occur
Epidemiology of delusional disorder?
- Lifetime risk of 0.05
- Mean onset between 40-55 years old
- Slightly more common in females
Risk factors of delusional disorder?
o Advanced age o Social isolation o Group delusions o Low socio-economic status o Premorbid personality disorders o Immigration o Family history o Substance Abuse
Features of persecutory delusions?
o Most common
o Patients convinced that others are attempting to do harm
o Being persecuted such as defrauded or plotted against
o Often lodge complaints and may engage in legal actions
Features of delusions of guilt?
o One has committed a serious crime…deserves punishment
o Hands themselves into police for a crime they didn’t do
Features of grandiose delusions?
o Patients believes they fill some special role, have special relationship or possess special ability
o May be religious or social organisations
Features of delusions of control?
o Subject believes their thoughts, feelings and/or actions are not their own but being controlled by outside force
Features of delusional perception?
o Patient receives normal perception which is then interpreted with delusional meaning and has immense personal meaning
Features of Othello syndrome (delusional or morbid jealousy)?
o Fixed belief that spouse or partner has been unfaithful
o Try to collect evidence or restrict partners activities
o Based on incorrect inference about external reality
o Risk of stalking and violence to partner
o Associated with excessive substance/alcohol use, sexual dysfunction, paranoid schizophrenia, depression
Features of De Clerambault’s syndrome?
o Females more common
o Belief some important person is secretly in love with them and use secret signs and communication
o Makes repeated attempts to contact the person
o The rejections may lead to animosity and bitterness
Features of Capgras syndrome?
o Person that is close to the patient (relative) is believed to have been replaced by a double
o Females predominantly
Features of Fregoli’s syndrome?
o Patient believes familiar person, often a persecutor, takes on appearance of different people
o Recognises that person in people who look nothing like the person
Features of Cotard’s syndrome?
o Nihilistic delusions, patient believes for example; wealth has gone, relatives no longer exist
o Somatic form – feels like being dead, dying, non-existent, rotting of body/organs
o Associated with depression
Features of Folie A Deux?
o Delusion shared by more than one person
o One person has psychotic disorder and the other is often less intelligent or dependent on the other
Features of Ekbom’s syndrome?
o Delusion infested with parasites although no evidence
o Risks of self-harm trying to get rid of parasites
o Can present to dermatologists
Definition of somatisation disorder?
o Multiple, recurrent and frequently changing physical symptoms of at least two years duration
o Long and complicated history of contact with medical care, during which many negative investigations or fruitless exploratory operations may have been carried out
o Chronic and fluctuating, often associated with disruption of social, interpersonal, and family behaviour
Definition of hypochondrial disorder?
o Persistent preoccupation with the possibility of having one or more serious and progressive physical disorders
o Patients manifest persistent somatic complaints or a persistent preoccupation with their physical appearance
o Normal or commonplace sensations and appearances are often interpreted by patients as abnormal and distressing
Definition of persistent pain disorder?
o Persistent, severe, and distressing pain, which cannot be explained fully by a physiological process or a physical disorder
o Occurs in association with emotional conflict or psychosocial problems concluding that they are the main causative influences
Epidemiology of somatisation?
o Women mostly
o Prevalence up to 2%
o Usually between 20-30
Epidemiology of hypochondrial disorder?
o Equal sex incidence
o Most commonly between 20-30 years
Aetiology of somatisation?
Genetic Poor childhood School difficulties Disturbed adolescents Menstruation difficulties Interpersonal discord, unstable relationships
Symptoms of somatisation?
o Symptoms frequently atypical and non-specific
o Long and complex medical histories
o Unable to function and work
o Associated features:
Anxiety, depression, threats of suicide
Alcohol and drug abuse
Symptoms of hypochondrial disease?
o Somatic symptoms without medical explanations
o Disease conviction
o Disease fear
o Bodily preoccupation
o Over-valued belief which can be severe enough to be called delusional disorder
Symptoms of persistent pain disorder?
o All pain is subjective sensation
o Mix of factors – may lead to depressive illness
o A lot present to pain clinics
Management of somatisation disorder - general advice?
o Communicate diagnosis
o Allow patients to vent their concerns and accept that symptoms are real
o Explain negative tests and no need for further investigations
o Attempt to reframe symptoms as emotions
Management of somatisation disorder -ongoing management?
o Regular review by single doctor
o Antidepressants if needed
Management of somatisation disorder - psychological?
o Behavioural therapy
o CBT
Management of hypochondrial disorder -general advice?
o Allow patients to vent their concerns and accept that symptoms are real
o Explain negative tests and no need for further investigations
o Aim to improve function
Management of hypochondrial disorder -pharmacological?
o Antidepressants (Fluoxetine)
Management of hypochondrial disorder -psychological?
o Behavioural therapy
o CBT
