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MSRA Content > Psychiatry - Level 2 > Flashcards

Psychiatry - Level 2 Flashcards

1
Q

Definition of adjustment disorder?

A
  • 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
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2
Q

Risk factors of adjustment disorder?

A

o Younger age

o Increased suicidal behaviour

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3
Q

Aetiology of adjustment disorder?

A

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)

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4
Q

Symptoms of adjustment disorder?

A 
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
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5
Q

Subtypes of adjustment disorder?

A

o Brief/Prolonged (>6m) depressive disorder
o Mixed anxiety and depressive disorder
o Disturbance of affect, conduct
o Grief/Bereavement reactions

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6
Q

Types of grief reaction?

A

 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

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7
Q

Management of adjustment disorder - psychological?

A

o Supportive psychotherapy
o Talking therapy
o Counselling
o Verbalization

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8
Q

Management of adjustment disorder - pharmacological?

A

o SSRIs

o Anxiolytics

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9
Q

Management of adjustment disorder - bereavement?

A

o Groups such as CRUSE for counselling

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10
Q

Prognosis of adjustment disorder?

A
  • 20% develop major psychiatric illness within 5 years

- Most recover within 5 years

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11
Q

Definition of neurosis?

A
  • Neurosis is abnormal psychogenic reactions with two components:
    o Vulnerable personality
    o Stress factors triggering the reaction
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12
Q

What is normal anxiety?

A

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

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13
Q

What is generalised anxiety disorder?

A

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

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14
Q

Epidemiology of generalised anxiety disorder?

A
  • Lifetime prevalence 1 in 5

- Females 2:1 Males

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15
Q

Risk factors of generalised anxiety disorder?

A

o Unemployed
o Single
o Stressful events in childhood

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16
Q

Aetiology of generalised anxiety disorder?

A

o Genetic
o ANS hyperresponsiveness
o Experience of unexpected negative stressors (death of parent, rape, war, family dysfunction)

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17
Q

ICD-10 criteria of generalised anxiety disorder?

A

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

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18
Q

Assessment of generalised anxiety disorder?

A
  • 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
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19
Q

Management of generalised anxiety disorder - general advice?

A

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

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20
Q

Management of generalised anxiety disorder - psychological 1st line ?

A

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

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21
Q

Management of generalised anxiety disorder - pharmacological 2nd line?

A

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

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22
Q

Management of generalised anxiety disorder - if severe or risk to harm self or others?

A

o Admission, acute CRISIS assessment, CMHT

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23
Q

Prognosis of generalised anxiety disorder?

A
  • 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
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24
Q

Definition of panic disorder?

A

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

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25
Q

Definition of panic attack?

A

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

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26
Q

ICD-10 diagnosis of panic disorder?

A

o Recurrent panic attacks, not restricted to any situation or set of circumstances
o 4 panic attacks in 4 weeks, sudden onset

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27
Q

Epidemiology of panic disorder?

A
  • Occurs in 1-2% of population
  • Female 3:1 Males
  • Peak incidence 15-25 and 45-55
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28
Q

Aetiology of panic disorder?

A

o Genetic
o Neurotransmitters
 Increased serotonin, noradrenaline lactate or decreased GABA
o Fear Network
 Increased stimulation of amygdala, hypothalamus and brainstem centres

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29
Q

Symptoms of panic disorder?

A 
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

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30
Q

Investigations of panic disorder?

A

o FBC, U&Es, glucose, TFTs, Ca
o ECG
o Toxicology

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31
Q

Management of panic disorder - general advice?

A
  • Allow understanding of panic disorders
  • Avoid anxiety-producing substances – caffeine, alcohol, drugs
  • Exercise
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32
Q

Management of panic disorder - psychological 1st line?

A
  • Behavioural methods
    o Phobic avoidance treated by exposure, relaxation techniques
  • CBT
  • Emotion-focussed psychotherapy
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33
Q

Management of panic disorder - pharmacological 2nd line?

A
  • 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
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34
Q

Definition of bipolar affective disorder?

A
  • 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
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35
Q

What is cyclothymia?

A
  • Cyclothymia is mild chronic BAD
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36
Q

Epidemiology of bipolar affective disorder?

A
  • Peak age 21
  • Up to 1% life-time risk
  • Males = Females
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37
Q

Aetiology of bipolar affective disorder?

A

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

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38
Q

ICD-10 diagnosis of bipolar affective disorder?

A

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

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39
Q

Symptoms of manic episodes of bipolar affective disorder?

A

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

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40
Q

Symptoms of depression of bipolar affective disorder?

A

o Feelings of persistent sadness or low mood, loss of interest or pleasure, and low energy

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41
Q

Investigations of bipolar affective disorder?

A

o FBCs, ESR, glucose, U&Es, LFTs, Ca, TFTs, drug screen
o ECG
o Other tests if indicated

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42
Q

Management of bipolar affective disorder - referral?

A

Refer to CMHT or CAMHS

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43
Q

Management of bipolar affective disorder - if danger to themselves or others?

A

o Urgent referral, hospital admission

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44
Q

Management of bipolar affective disorder - pharmacological - acute manic episode?

A

 Stop antidepressant medication
 Oral antipsychotic (haloperidol, olanzapine, quetiapine, risperidone)
 Try another if ineffective
 Add lithium/sodium valproate if 2nd ineffective
 Benzodiazepines if agitated (lorazepam)

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45
Q

Management of bipolar affective disorder - pharmacological - acute depressive episode?

A

Antidepressant and mood stabiliser (lithium, lamotrigine)

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46
Q

Management of bipolar affective disorder - pharmacological - long term treatment?

A

 Lithium (1st line)

 Sodium valproate, lamotrigine, carbamazepine if ineffective/not tolerated

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47
Q

Management of bipolar affective disorder - severe, treatment refractory cases?

A

o ECT (in severe cases where medication does not work)

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48
Q

Management of bipolar affective disorder - psychological?

A

o Education
o Psychological interventions for BAD
 CBT, IPT, Family therapy
o High-intensity psychological treatment for depression

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49
Q

Management of bipolar affective disorder - social care?

A

o Written care plan
o Support groups
o Crisis plan
o Encourage lasting power of attorney

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50
Q

Management of bipolar affective disorder - General advice?

A

o Stop driving during acute illness – inform DVLA

o Lifestyle advice

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51
Q

Prognosis of bipolar affective disorder?

A
  • 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
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52
Q

Definition of manic episode?

A

 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

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53
Q

Definition of hypomania?

A

 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

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54
Q

Definition of mania with psychosis?

A

 Clinical picture of mania but with delusions (usually grandiose) or hallucinations (usually voices speaking directly to patient), flight of ideas an extreme

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55
Q

Definition of manic stupor?

A

 Unresponsive, akinetic, mute and fully conscious

 Facies indicate elation and flight of ideas common

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56
Q

Medications inducing mania?

A 
o	Antidepressants
o	Benzodiazepines
o	Antipsychotics
o	Anti-Parkinsonian medications
o	Steroids
o	Analgesics
o	Antibiotics
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57
Q

Psychotic symptoms in mania?

A 
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
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58
Q

Manic symptoms in acute mania?

A

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

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59
Q

Definition of depression?

A
  • 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
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60
Q

Definition of dysthymia?

A
  • Dysthymia is persistent subthreshold depressive symptoms for more than 2 years
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61
Q

Monoamine hypothesis of depression?

A

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

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62
Q

Other types of depression?

A

o Atypical, postnatal, seasonal affective disorder

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63
Q

Epidemiology of depression?

A
  • Lifetime risk of depressive disorders= 15%
  • Prevalence 1 in 5 people
  • Females 2:1 Males
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64
Q

Risk factors of depression - biological?

A 
	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
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65
Q

Risk factors of depression - psychological?

A 
	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
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66
Q

Risk factors of depression - social?

A

 Social classes 4 and 5
 Urban areas
 Unemployment

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67
Q

Core symptoms of depression?

A

o Anhedonia
o Low mood (diurnal variation, usually worse in morning)
o Reduced energy (anenergia)

For >2 weeks

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68
Q

Other ICD features of depression?

A

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

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69
Q

Additional symptoms of depression?

A

o Psychomotor retardation/agitation
o Constipation
o Pessimistic future

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70
Q

Psychotic symptoms of depression?

A

o Delusions

o Hallucinations

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71
Q

MSE of depression?

A 
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
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72
Q

Classing severity of depression?

A

o Mild = 2 core + 2 other
o Moderate = 2 core + 3 other
o Severe = 3 core + 4 other

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73
Q

Investigations of depression?

A
  • 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
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74
Q

Diagnosis of depression according to ICD-10?

A

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

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75
Q

Management of depression - if risk of suicide?

A

o Consider CRISIS if urgent

76
Q

Management of depression - mild depression?

A

o Active Monitoring and follow-up in 2 weeks

77
Q

Management of depression - mild-to-moderate depression 1st line?

A

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

78
Q

Management of depression - moderate-to-severe 1st line?

A

 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

79
Q

Management of depression - medications 2nd line?

A

 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
80
Q

Management of depression - ECT?

A

 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

81
Q

Management of depression - social?

A 
	Information leaflet
	Inform DVLA
	Sleep hygiene
	Support at home
	Isolation
82
Q

Management of depression - follow up?

A

o Within 1 week in people <30
o Within 2 weeks for other people
o Review every 2-4 weeks for first 3 months

83
Q

Management of depression - prognosis?

A
  • Average length of depression episode= 6M,

- After 1st episode, 80% have further depressive episodes

84
Q

Definition of anorexia nervosa?

A

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

85
Q

Definition of bulimia nervosa?

A

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

86
Q

Epidemiology of eating disorders?

A
  • Girls 7:1 Boys
  • Mortality 5-20%
  • Bulimia more common (40%), Anorexia (10%), ED-NOS (50%)
87
Q

Aetiology of eating disorders?

A

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

88
Q

Diagnostic criteria of anorexia nervosa?

A
  • 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
89
Q

Symptoms through all systems of anorexia nervosa?

A

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

90
Q

Diagnostic criteria of bulimia nervosa?

A

 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

91
Q

Symptoms through all systems of bulimia nervosa?

A

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

92
Q

What is scoff questionnaire and what does score mean?

A

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

93
Q

Diagnostic criteria of anorexia nervosa?

A

 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

94
Q

Diagnostic criteria of bulimia nervosa?

A

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

95
Q

Tests to perform in eating disorders?

A
  • Sits to stand test
  • Squat to stand test
  • ECG, blood tests (FBC, ESR, LFTs, U&Es, TFTs, glucose, albumin, cholesterol)
  • Risk assessment
96
Q

Management of eating disorders - nutrition?

A 
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
97
Q

Management of eating disorders - psychological?

A

o CBT, Motivational enhancement therapy (MET)
o Family therapy
o IPT (bullaemia)

98
Q

Management of eating disorders - pharmacological?

A

o Osteopenia – Vit D supplements (cholecalciferol), exercise

o Depression – Fluoxetine (clear obsessional ideas)

99
Q

Prognosis of eating disorders?

A

o 50% recover
o 30% improve
o 20% chronic illness

100
Q

Guiding principles of MHA 1983?

A
  • Least restrictive option and maximising independence
  • Empowerment and involvement
  • Respect and dignity
  • Purpose and effectiveness
  • Efficiency and equity
101
Q

Process of detaining patient under MHA 1983?

A

• 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

102
Q

Criteria for detention under MHA?

A
  • 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
103
Q

Important points of MHA?

A
  • 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”
104
Q

Section 2 of MHA?

A

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)

105
Q

Section 3 of MHA?

A

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)

106
Q

Section 5(2) of MHA?

A

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)

107
Q

Section 5(4) of MHA?

A

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

108
Q

Police powers - Section 135 of MHA?

A

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)

109
Q

Police powers - Section 136 of MHA?

A

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)

110
Q

Principles of MCA 2005?

A
  • 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
111
Q

Process of MCA ?

A

• 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

112
Q

What to consider when determining best interests in MCA?

A

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

113
Q

What is an advanced decision to refuse treatment?

A

o To have legal weight must be specific refusals of particular (specific) treatment

114
Q

What is an LPA?

A

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

115
Q

What is an independent mental capacity advocate?

A

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

116
Q

What is a DOLS?

A

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)

117
Q

Definition of OCD?

A
  • 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
118
Q

Epidemiology of OCD?

A
  • 90% of people experience obsessions
  • Mean age 20 years, most before 35
  • Prevalence between 1-3%
119
Q

Risk factors of OCD?

A 
o	Family history
o	Emotional, physical, sexual abuse
o	Bullying
o	Social isolation
Pregnancy
120
Q

Aetiology of OCD?

A

o Neurochemical – 5-HT

o Genetic

121
Q

Examples of OCD behaviour?

A

Checking, washing, contamination, doubting, bodily fears, counting

122
Q

Symptoms of OCD?

A
  • 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
123
Q

Management of OCD - psychological?

A

o CBT
 Response prevention to ritualistic behaviour
 Exposure techniques for obsession

124
Q

Management of OCD - pharmacological?

A

o SSRIs (first line)
o Clomipramine
o MAOIs
o Augmentation – antipsychotics, lithium

125
Q

Management of OCD - physical?

A

o ECT

o Psychosurgery – stereotactic cingulotomy

126
Q

Prognosis of OCD?

A
  • 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
127
Q

Definition of psychosis?

A

 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

128
Q

Definition of delusions?

A

 A false unshakeable belief, despite evidence to the contrary, not held by others in the same culture and held with intense conviction

129
Q

Definition of hallucinations?

A

 Auditory, visual, olfactory, tactile, gustatory, somatic

 A perceptual experience without an object or stimulus, that appears subjectively real but uncontrollable by patient

130
Q

Definition of thought disorder?

A

 An abnormality in mechanism of thinking such that to the observer the person does not make sense

131
Q

Definition of schizophrenia?

A

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

132
Q

Definition of schizoaffective disorder?

A

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

133
Q

Epidemiology of schizophrenia?

A
  • Male>Female
  • Peak onset 20-30
  • Incidence up to 1% in UK
134
Q

Aetiology of schizophrenia?

A

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

135
Q

Types of schizophrenia?

A 
o	Paranoid
o	Hebephrenic
o	Catatonic
o	Simple
o	Undifferentiated
136
Q

Description of types of schizophrenia - paranoid?

A

 Relatively stable, often paranoid delusions with hallucinations and perceptual disturbances

137
Q

Description of types of schizophrenia - hebephrenic?

A

 Affective changes are prominent (mood is shallow, flat), delusions and hallucinations fleeting
 Behaviour irresponsible and unpredictable
 Thought disorganised, speech incoherent
 Tendency for social isolation

138
Q

Description of types of schizophrenia - catatonic?

A

 Prominent psychomotor disturbances – hyperkinesia and stupor to negativism
 Episodes of violence striking feature
 Dream-like state with vivid scenic hallucinations

139
Q

Description of types of schizophrenia - simple?

A

 Insidious, progressive development of odd conduct, inability to meet demands of society
 Characteristic negative symptoms develop mostly

140
Q

Description of types of schizophrenia - undifferentiated?

A

 One that does not conform to any subtype

141
Q

Positive symptoms of schizophrenia?

A

o Hallucinations
o Delusions
o Thought Disorder

142
Q

Negative symptoms of schizophrenia?

A 
o	Avolition – Lack of motivation
o	Anhedonia
o	Alogia – poverty of speech
o	Asociality – lack of desire for relationships
o	Affect blunt
143
Q

Is capacity maintained in schizophrenia?

A
  • Clear consciousness and intellectual capacity are usually maintained
144
Q

ICD-10 diagnosis of schizophrenia?

A

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

145
Q

Investigations to consider in schizophrenia?

A 
o	Full physical and neurological exam
o	Bloods
	FBC, U&amp;Es, LFT, Ca, glucose
o	Imaging if suspected organic cause
o	Urine drugs screen
o	ECG – QT interval prolongation due to antipsychotics
146
Q

Management of schizophrenia - first episode of psychosis?

A

o Early intervention in psychosis team
o CRISIS team
o Hospital admission (voluntarily or Section 2)

147
Q

Management of schizophrenia - care plan approach?

A

o Crisis plan
o Advanced Statement
o Key clinical contacts

148
Q

Management of schizophrenia - antipsychotic drugs - what to offer?

A

 Block dopamine D2 receptors – FGA and SGA

 Offer oral, provide benefits and side effects of each one and discuss

149
Q

Management of schizophrenia - antipsychotic drugs - SGA (1st line)?

A

• 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

150
Q

Management of schizophrenia - antipsychotic drugs - tests to do before starting AP?

A

• Before starting
o FBC, U&Es, LFTs, HbA1c, prolactin, lipids
o Weight, BP, pulse, ECG (risk of prolonged QT

151
Q

Management of schizophrenia - antipsychotic drugs - when to give clozapine??

A
  • Offer when two different antipsychotics have failed to treat illness (>1 should be non-clozapine SGA)
  • SE: agranulocytosis, myocarditis, weight gain, salivation, sedation, seizures
152
Q

Management of schizophrenia - other drug treatment?

A 
o	Benzodiazepines
	Lorazepam given acutely to manage anxiety related symptoms
	Diazepam long-acting
o	Procyclidine
	For treatment of AP EPSEs
o	ECT possible
153
Q

Management of schizophrenia - psychosocial therapy?

A 
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
154
Q

Management of schizophrenia - follow up?

A

o Secondary care team for first 12 months, or until their condition has stabilized (whichever is longer)
Routine review annually by GP

155
Q

Prognosis of schizophrenia?

A
  • 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
156
Q

Definition of delusional disorder?

A
  • 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
157
Q

ICD-10 criteria of delusional disorder?

A
  • 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
158
Q

Epidemiology of delusional disorder?

A
  • Lifetime risk of 0.05
  • Mean onset between 40-55 years old
  • Slightly more common in females
159
Q

Risk factors of delusional disorder?

A 
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
160
Q

Features of persecutory delusions?

A

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

161
Q

Features of delusions of guilt?

A

o One has committed a serious crime…deserves punishment

o Hands themselves into police for a crime they didn’t do

162
Q

Features of grandiose delusions?

A

o Patients believes they fill some special role, have special relationship or possess special ability
o May be religious or social organisations

163
Q

Features of delusions of control?

A

o Subject believes their thoughts, feelings and/or actions are not their own but being controlled by outside force

164
Q

Features of delusional perception?

A

o Patient receives normal perception which is then interpreted with delusional meaning and has immense personal meaning

165
Q

Features of Othello syndrome (delusional or morbid jealousy)?

A

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

166
Q

Features of De Clerambault’s syndrome?

A

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

167
Q

Features of Capgras syndrome?

A

o Person that is close to the patient (relative) is believed to have been replaced by a double
o Females predominantly

168
Q

Features of Fregoli’s syndrome?

A

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

169
Q

Features of Cotard’s syndrome?

A

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

170
Q

Features of Folie A Deux?

A

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

171
Q

Features of Ekbom’s syndrome?

A

o Delusion infested with parasites although no evidence
o Risks of self-harm trying to get rid of parasites
o Can present to dermatologists

172
Q

Definition of somatisation disorder?

A

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

173
Q

Definition of hypochondrial disorder?

A

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

174
Q

Definition of persistent pain disorder?

A

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

175
Q

Epidemiology of somatisation?

A

o Women mostly
o Prevalence up to 2%
o Usually between 20-30

176
Q

Epidemiology of hypochondrial disorder?

A

o Equal sex incidence

o Most commonly between 20-30 years

177
Q

Aetiology of somatisation?

A 
	Genetic
	Poor childhood
	School difficulties
	Disturbed adolescents
	Menstruation difficulties
	Interpersonal discord, unstable relationships
178
Q

Symptoms of somatisation?

A

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

179
Q

Symptoms of hypochondrial disease?

A

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

180
Q

Symptoms of persistent pain disorder?

A

o All pain is subjective sensation
o Mix of factors – may lead to depressive illness
o A lot present to pain clinics

181
Q

Management of somatisation disorder - general advice?

A

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

182
Q

Management of somatisation disorder -ongoing management?

A

o Regular review by single doctor

o Antidepressants if needed

183
Q

Management of somatisation disorder - psychological?

A

o Behavioural therapy

o CBT

184
Q

Management of hypochondrial disorder -general advice?

A

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

185
Q

Management of hypochondrial disorder -pharmacological?

A

o Antidepressants (Fluoxetine)

186
Q

Management of hypochondrial disorder -psychological?

A

o Behavioural therapy

o CBT

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