Psychiatry PTS Flashcards
What things are included in the psychiatric history?
PC
HPC – most important thing to illicit is impact on functioning
Past psychiatric history – any diagnoses or contact with primary care/mental health services
PMH
Medications - including OTC (st johns wort + antidepressants 🡪 serotonin syndrome)
Family history – physical and mental disorders, quality of family relationships
Personal history – timeline from birth to adulthood, educations, employment, relationships and psychosexual history includng sexual orientation
Social history
Use of alcohol and drugs
Forensic history - anything to do with the law, remorse and explanations
Premorbid personality – get POV of patient and someone else if possible
What things are included in the mental state examination?
ASEPTIC
Appearance and behaviour
Speech
Emotions - Mood and affect (patients own view of their mood plus your view)
Perceptions
Thoughts
Insight
Cognition
What things must be considered when making a formulation in psychiatry?
3 P’s:
Pre-disposing factors
Precipitating factors
Perpetuating factors
Explain briefly what these mean and give examples:
Predisposing = family history of a mental disorder
Precipitating = traumatic life event
Perpetuating = lack of support/stable social situation
Define depression
A pervasive lowering of mood
What are the core symptoms of depression?
Low mood
Loss of energy (anergia)
Anhedonia (loss of enjoyment of formerly pleasurable activities)
Name some other symptoms of depression
Early morning waking (quite a classic symptom)
Change in appetite
Change in sex drive
Diurnal variation of mood – lowest in the morning
Agitation
Loss of confidence
Loss of concentration
Guilt
Hopelessness
Suicidal ideation (assess RISK)
Which symptoms must be present in order to diagnose clinical depression?
At least 2 of the 3 core symptoms
Present every day
For at least 2 weeks
🡪 this is the ICD10 diagnostic criteria
Mild depression is categorised as..
Core symptoms + 2-3 others
Moderate depression is classified as…
Core symptoms + 4 others + impact on daily functioning
Severe depression without psychotic symptoms is…
Several symptoms, suicidal, marked loss of functioning
Severe depression with psychotic symptoms…
Severe depression (several symptoms, suicidal, marked loss of function)
With psychotic symptoms – usually mood congruent
Nihilistic and guilty delusions
3rd person auditory hallucinations – derogatory in natur
Name some risk factors for depression
Family history
History of abuse
Drug and alcohol use
Low socioeconomic status
Having a chronic disease
Traumatic life event
Name some medical causes for depression
Hypothyroidism
Physical health problems/chronic disease
Medications - isotretinoin (roaccutane), beta blockers
Childbirth – a lot of women experience post-natal depression
Name some differential diagnoses for depression?
Normal sadness – particularly if in response to a difficult life event such as bereavment
Schizophrenia – flat (unreactive) affect of schizophrenia may appear like depression, but on further questioning they will not have the core symptoms of depression
Alcohol/drug withdrawal may mimic depression
How to investigate someone with depression?
Full history and mental state examination
Blood tests to rule out physical causes – hypothyroidism, chronic disease
PERFORM A RISK ASSESSMENT
Self-neglect
Self-harm
Suicidal thoughts
Name some signs you may expect to see on a MSE of someone with depression
Possible weight loss from reduced appetite
Alteration of motor activity – psychomotor retardation (movement, speech or both)
Emotional reactions may change
Avoids eye contact
Speech - slow and quiet
Describe some non-medical treatments for depression
Self-help groups
Guided self help
Computerised CBT
Individualised CBT or interpersonal therapy
Psychological therapy (however this should be given together with antidepressants)
Name some medical treatments that can be used for depression
Antidepressants – these should be continued for at least 6 months after symptoms stop
Resistant depression can be treated with a combination of antidepressants and
Lithium
An atypical antipsychotic
Another antidepressant
ECT – very effective in severe cases
Name some classes of antidepressants and examples of this class
SSRIs
Sertraline, citalopram, fluoxetine
Inhibits reuptake pumps = more stays in the synapses
SNRIs (serotonin noradrenaline reuptake inhibitors)
Venlafaxine, duloxetine
Inhibits 5HT reuptake pumps and NAd transporter
MAOIs – can lead to hypertensive crisis, can cause migraine
Tricyclics – e.g. Amitriptylline, used more for pain/migraines than depression
What are some disadvantages of antidepressants?
Can take a while to work – so people may stop taking them as they think it’s not working
Can increase suicidal thoughts/make things worse initially
Improves some of the symptoms of depression but not others (apparently be careful with fluoxetine)
What are some side effects of SSRIs?
GI symptoms = most common side effects
Sexual impotence
Weight gain
Increased bowel motility (but this wears off eventually)
Agitation
Increased risk of GI bleed if taking NSAID (so give PPI)
Which drugs do SSRIs interact with?
NSAIDS – add PPI if giving SSRI
Warfarin/heparin – avoid SSRI, consider mirtazapine
Aspirin – give PPI
Triptans – avoid SSRI
NB - fluoxetine and paroextine have higher risk of interaction
Which SSRI is given first line in children and adolescents?
Fluoxetine
Which SSRI is given as a the first line treatment for generalised anxiety disorder?
Sertraline
What are some discontinuation symptoms of SSRIs?
Increased mood change
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
GI symptoms – pain, cramping, diarrhoea, vomiting
Paraesthesia
What are some side effects of tricyclic antidepressants?
Urinary retention (anticholinergic effects)
Dry mouth
Lethargy/drowsiness
Constipation
Name some risk factors for suicide following self harm
Single
Homeless
Unemployed OR in a very stressful job
Poor social support and lack of protective factors in general
Type of self harm – e.g. superficial vs. deep cuts
Whether the regret the self arm or express the desire to do it again
Define bipolar affective disorder
Recurrent episodes of altered mood and activity
Involving both upswings and downswings (hypomania/mania + depression)
What’s the difference between bipolar 1 and 2
Bipolar 1 – mania + depression, sometimes more episodes of mania
Bipolar 2 – more episodes of depression and only mild hypomania - EASY TO MISS so always ask for symptoms of mania in a person presenting with “typical” depression symptoms
Cyclothymia – chronic mood fluctuations over at least 2 years. Episodes of depression and hypomania (not mania). Rapid cycling, episodes only lasting a few days
Risk factors for bipolar disorder?
Strong genetic component – family history of either depression or bipolar is a risk factor
Traumatic life event
History of abuse
Sleep deprivation – can cause mania
What is the peak age of onset of bipolar disorder?
Early 20s
What are the symptoms of hypomania?
LASTING AT LEAST 4 DAYS:
Elevated mood
Increased energy
Increased talkativeness
Poor concentration
Mild reckless behaviour (e.g. overspending)
Sociability/overfamiliarity
Increased libido/sexual disinhibition
Increased confidence
Decreased need to sleep
Change in appetite
What are the symptoms of mania?
LASTING >1 WEEK and more extreme symptoms than hypomania:
Extreme, uncontrollable elation
Over activity
Pressure of speech (as if the words just can’t get out quick enough)
Impaired judgement
Extreme risk taking behaviour - spending sprees, jumping off buildings
Social disinhibition
Inflated self-esteem, grandiosity
Psychotic symptoms can occur – often mood congruent
Insight is often absent in these kind of episodes
What is the main feature that differentiates mania from hypomania?
The presence of psychotic symptoms
For example auditory hallucinations and grandiose delusions
Name some differentials for bipolar disorder
Substance abuse (amphetamines, cocaine)
Endocrine disease – cushings, steroid induced psychosis
Schizophrenia
Schizoaffective disorder – diagnosed when affective and first rank shizophrenic symptoms are equally prominent
Personality disorders – emotionally unstable, histrionic
ADHD in younger people
How would you investigate someone presenting with a manic episode?
Full history
MSE
Physical examination/investigations to rule out physical causes for symptoms
i.e. look out for the purple striae of cushing’s
Name some signs you may see on MSE in someone during a manic episode?
Pressure of speech
Restless and unable to sit still
Flight of ideas – talking about things that are very loosely related
How do you treat an episode of acute mania?
ANTIPSYCHOTICS:
Haloperidol
Olanzipine
Quetiapine
Risperidone
Lithium can be used for acute treatment as well as long-term
BENZOS can also be used for short term acute behavioural disturbance
What are the longer term treatments used for bipolar disorder?
MOOD STABILISERS:
Lithium
Valproate, carbamazepine and other AEDs are used as mood stabilisers
During pregnancy – use antipsychotics instead – they are safe during pregnancy so can be used as mood stabilisers during pregnancy
How are depressive episodes of bipolar disorder treated?
Antidepressants can precipitate mania – so should NOT BE PRESCRIBED WITHOUT A MOOD STABILISER
If the patient is taking an antidepressant at the onset of a manic episode it should be stopped
For episodes of severe depression in bipolar disorder, NICE recommends:
Quetiapine
Olanzipine (+/- fluoextine)
Lamotrigine
Things to be aware of on lithium
L – leukocytosis
I – Insipidus diabetes (nephrogenic)
T – Tremors (if coarse, think toxicty)
H – Hydration (easily dehydrates, need to drink a lot as renally cleared)
I – increased GI motility
U – Underactive thyroid
M – Metallic tastse (warning of toxicity), mums beware – teratogenic
Lithium + diuretics = beware dehydration
Lithium + NSAIDS = beware kidney damage
Name some side effects of lithium
Weight gain
Nephrotoxicity
Tremor
Diabetes insipidus
Hypothyroidism
What are the symptoms of lithium toxicity?
Dry mouth/extreme thirst
Strange movements
Very sleepy
Nausea and vomiting
Diarrhoea
Confusion
They basically act like a drunk person. If someone is in lithium toxicity – stop lithium and rehydrate
Define dysthymia
Chronic, mildly depressed mood and diminished enjoyment
Not severe enough to be considered depressive illness
Presence of low grade depressive symptoms over a long period of time – e.g. >2 years
Treat with SSRIs and CBT
Name some risk factors for post-partum depression
Past psychiatric history
Conflicting feelings about the pregnancy
History of abuse as a child
USS showing fetal abnormalities
Low socioeconomic status
Lack of supportive relationships
What is the first line treatment for post partum depression?
Psychological therapy
Because if breastfeeding – antidepressants can have adverse effect on the baby
Define schizophrenia
A splitting/dissociation of thoughts or loss of contact with reality
Affects a persons thoughts, perceptions (sight, taste, smell, touch, hearing), personality, speech, the power over one’s own will and one’s sense of self
NB – NOT split personality
What is the most common type of schizophrenia?
Paranoid
Delusions and auditory hallicinations are evident in this type
What are the causes/risk factors for schizophrenia?
Family history/genetic link
Insult to brain development in early life (trauma, epilepsy, developmental delay, perinatal infections)
Smoking cannabis in adolescence
Severe childhood bullying or physical abuse
Socioeconomic deprivation
Adverse life events
Briefly describe the pathophysiology behind schizophrenia
Seems to involve dopamine excess
Over activity in mesolimbic dopaminergic pathways
Stimulant drugs which release dopamine can precipitate psychosis
Antipsychotics (which block dopamine) treat psychosis
What is the typical age of onset of schizophrenia?
20-30s
How is a diagnosis of schizophrenia made?
At least 1 first rank symptom
Or at least 2 second rank symptoms
For a duration of at least 1 month
What are the first rank symptoms of schizophrenia?
Delusional perceptions
3rd person auditory hallucinations (running commentary, hears people talking ABOUT them, not to them)
Thought disorder/ alienation (broadcast, withdrawal, insertion, deletion)
Passivity phenomena (made to do or feel things against their will – as if someone is controlling their thoughts, feelings and actions)
I am pretty sure this will be in the exam !! LEARN
What are the second rank symptoms of schizophrenia?
Delusions
2nd person auditory hallucinations (address the person directly)
Any other modality of hallucination
Formal thought disorder (when their words come out wrong because their thoughts are muddled)
Catatonic behaviour
Negative symptoms
What are the positive symptoms of schizophrenia?
Delusions
Persecutory delusions (they think they’re being watched etc.)
Delusions of reference (i.e. they think objects have been placed in certain places to tell them they’re evil)
Hallucinations
Formal thought disorder
What are the negative symptoms of schizophrenia?
Poverty of speech
Flat affect
Poor motivation
Social withdrawal
Lack of concerns for social conventions
What are the cognitive symptoms of schizophrenia?
Poor attention and memory
What investigations would you do for a patient presenting with psychotic symptoms?
Blood tests for organic causes of psychosis – brain tumours, cysts, PD, Huntington’s disease, brain injury, severe systemic infection
Take a collateral history from someone else if needed
Know how to screen for psychotic symptoms in the history (covered next)
MENTAL STATE EXAMINATION
RISK ASSESSMENT
List the differential diagnoses for patients presenting with hallucinations and delusions (psychotic symptoms)
Schizophrenia
Schizoaffective disorder
Delusional disorder
Brief/acute psychotic episodes (lasting < 1 month and therefore cannot be called schizophrenia)
Drug induced psychosis
SOL – brain tumour or abscess
How would you screen for persecutory delusions in a history?
Do you have any enemies?
Do you feel as if anyone is out to get you?
How do you screen for delusions of reference and delusional perceptions in a history?
Do you ever see or hear things that you feel are giving you a message that is specific to you?
How would you screen for thought alienation in a history?
Are your thoughts being interfered with or controlled?
Are they known to others e.g. through telepathy/do they play out loud?
How to screen for passivity phenomena in a history?
Can another person directly control what you do or feel?
How do you screen for 3rd person auditory hallucinations in a history?
Do you hear people talking whom others can’t hear?
What do they say?
How would you screen for 2nd person auditory hallucinations?
Do you ever hear people telling you to do things that other people can’t hear?
How do you screen for hallucinations in general?
Do you ever see/smell/taste things that other people cant?
How do you screen for negative symptoms of schizophrenia in your assessment?
These will be observable in the MSE – apathy, poverty of speech, blunted affect, incongruent emotional response (e.g. laughing when talking about dead family members)
How is schizophrenia treated?
Typical anti-psychotics – work by dopamine blockade (D2 receptors):
Haloperidol
Chlorpromazine
Atypical anti-psychotics – work by blocking dopamine and serotonin:
Quetiapine
Olanzapine
Risperidone
Clozapine (monitor blood for agraunlocytosis)
Aripiprazole
What checks need to be done regularly for people on antipsychotic medications?
ECG – as QTC prolongation can occur
Glucose and lipids – antipsychotics can lead to diabetes and metabolic syndrome
If on CLOZAPINE – regular FBCs to check for AGRANULOCYTOSIS
What are the side effects of antipsychotics?
Diabetes/insulin resistance and dyslipidaemia
QT segment changes on ECG
Agranulocytosis – clozapine
Extra-pyramidal side effects due to the dopamine blockade
Urinary retention
Blurred vision
Weight gain
Hyperprolactinaemia (due to dopamine blockade and dopamine down regulates prolactin)
What are the 4 extra-pyramidal side effects of antipsychotics?
Acute dystonic reaction (hours)
Muscle spasm, acute torticolis, eyes rolling back
Parkinsonism (days)
Tremor, bradykinesia
Akathisia (days to weeks)
“inner restlessness, pacing and agitated, often intolerable. They literally can’t stop moving e.g. shaking legs, touching table
Massive RF for suicide in young males with schizophrenia
Tardive dyskinesia (months to years)
Grimacing, tounge protrusion, lipsmacking
Very difficult/impossible to treat as you’ve upregulated all the D2 receptors
These side effects are worse and more common in the older antipsychotics
How are the EPSEs treated?
Procyclidine
What is the difference between psychosis and neurosis?
Psychosis = severe mental disturbance characterised by a loss of contact with external reality (e.g. schizophrenia, delusional disorders)
Neurosis = relatively mild mental illness in which there is no loss of connection with reality (e.g. depression, anxiety)
What is acute/transient psychosis?
Brief psychotic episodes
Lasting less than the time required for a diagnosis of schizophrenia (1 month – ICD10)
Treat acute episodes with anti-psychotics such as haloperidol
What is schizoaffective disorder?
Where mood symptoms (e.g. depression) and schizophrenic symptoms occur with equal prominence
Treatment – antipsychotics, mood stabilisers, anti-depressants
Who is most at risk for an episode of post-partum psychosis?
Those with a previous episode of psychosis
First time mothers
After instrumental delivery
In those with a family history of an affective disorder
What are the symptoms of post-partum psychosis?
Depressive or manic symptoms
Often associated with first rank symptoms of schizophrenia
Emotional lability
How to treat an episode of post-partum psychosis?
Assess suicide risk and risk to baby
Usually requires hospitalisation – sometimes under section
Whilst hospitalise make sure the BABY STAYS WITH THE MUM
Anti-psychotics
ECT
Short term prognosis good and usually don’t go on to develop schizophrenia
Define generalised anxiety disorder (GAD)
ICD-10:
Generalised, persistent, excessive worry
About a number of events (school, work)
The individual finds the worry difficult to control
For at least 3 weeks (ICD-10) or 6 months (DSM)
No particular stimulus – just anxious in general
Often comorbid with depression, substance misuse etc.
Name some risk factors for GAD?
Alcohol use (always ask about alcohol and drugs even if you don’t suspect it)
Benzodiazepine use
Stimulants – particularly withdrawing from them
Co-existing depression
Family history of any type of anxiety disorder
Childhood abuse, neglect
Excessively PUSHY PARENTS during childhood – can be easy to miss this
Life stresses/events (financial, bereavement etc.)
Physical health problems (someone may be anxious about their health)
Name some physical health conditions that can cause GAD
Hyperthyroidism
Pheochromacytoma
Lung disease – excessive use of salbutamol
Congestive heart failure – heart medications can lead to anxiety
Hypoglycaemia
Who is more likely to get anxiety, boys or girls?
Girls
Particularly young adults and middle aged
What are the symptoms of GAD?
Unpleasant/fearful emotional state
Bodily discomfort
Physical symptoms
Palpitations, tachycardia, sweating and tremor (autonomic hyperactivity), chest pain, nausea and abdominal pain, dizziness, chills and hot flushes, feeling of choking, Often a feeling or impending threat or death (may or may not be in response to a recognisable threat)
Apprehension (fears and worries)
Increased vigilance
Sleeping difficulties (initial/middle insomnia, fatigue on waking)
What questions do you ask someone to screen for symptoms of anxiety?
Over the last 2 weeks, have you been:
Feeling nervous, anxious or on edge?
Not able to stop/control worrying?
Worrying too much about different things?
Having trouble relaxing?
Been so restless that it is hard to sit still?
Becoming easily annoyed or irritable?
Feeling as if something awful might happen?
What are the key symptoms needed for a diagnosis of GAD?
Excessive anxiety and worry about a number of events or activities (i.e. not just one thing bothering them)
Difficulty controlling the worry
For at least 3 weeks
How would you investigate someone presenting with symptoms of GAD?
History – including social situation and interpersonal relationships
MSE – restless, agitated, could have a tremor
Investigations to rule out physical cause – bloods, thyroid function test, blood pressure
RISK ASSESSMENT
How do you treat GAD?
Conservative:
Individual self help/self-help groups
Face to face CBT, applied relaxation therapy
Medical:
SSRIs or SNRIs
Pre-gablin
Benzodiazepines – used in acute situations/crises and not long-term
Beta blockers e.g. bisoprolol for physical symptoms
What is the difference between GAD, panic disorders and phobias?
Generalised anxiety disorder = constant worry without external stimulus
Panic disorder = discreet episodes of anxiety without certain stimulus
Phobias = discreet anxiety attacks about a specific stimulus (e.g. spiders, flying, needles)
What % of the population have GAD at any one time?
2-4% of the population
Cost the NHS >£5bn a year
Name 2 types of phobia and how they are treated
Agoraphobia – fear of crowded places/going outside/into places that are difficult to escape from quickly
Social phobia – fear of social situations in which the individual is exposed to unfamiliar people/possible scrutiny
Mainstay of treatment for phobias = CBT
Phobias can also be treated with exposure therapy
What is a panic disorder?
Attacks that occur unpredictably and not in response to a specific stimulus in the same way as a phobia
Has all the physical symptoms of anxiety
Typically only lasts a few minutes
What are the symptoms of a panic disorder?
Physical:
Tachycardia
Palpitations
Sweating
Dizziness
Choking
Psychological:
Feel like they’re going to die
Impending doom
Depersonalisation – thinking they aren’t real
Derealisaton – thinking the world around them isn’t real
Fear of losing control
What is obsessive compulsive disorder?
A condition characterised by obsessions (intrusive, unwelcome, unpleasant thoughts/images/doubts)
And compulsions (a repetitive, purposeful, physical or mental behaviour performed in response to the obsession)
Examples of obsessions – being followed, everything being dirty etc.
Compulsions – hand washing, cleaning, counting, checking, touching, rearranging, hoarding, repeating thoughts in their head, irresistible habit of seeking explanations by asking endless questions
What are the causes/risk factors for OCD?
Genetics – FH of OCD or tic disorder
Parental over-protection
May occur after streptococcal infection – PANDAS subtype (paediatric neuropsychiatric disorders associated with streptococci)
How does OCD present?
Time consuming (>1 hour/day) obsessions and/or compulsions
Present most days for at least 2 weeks
Distressing and interfering with ADLs
Avoidance of the stimuli that trigger the symptoms
How to investigate someone presenting with obsessive/compulsive symptoms?
History
MSE
How to treat OCD?
Psychoeducation
CBT – exposure followed by response prevention (stopping them doing the compulsion in response to the stimulus - eventually they will stop feeling the need to)
Plus medication e.g. SSRI
SSRIs are effective even if no depressive symptoms
What is a somatisation disorder?
Physical symptoms without physical explanation
Persistent for at least 2 years
More common in women
Usually GI and skin complaints
Refuse to believe there’s no organic cause
Massive impact on daily functioning and family life
Often results in multiple needless operations
Treatment – begin by ruling out all organic illness
What is a conversion disorder?
Presents with neurological SIGNS (rather than symptoms) e.g. paralysis, weakness, amnesia
But the examination is inconsistent
The patient is not faking it consciously, but there is no evidence of underlying pathology
Define alcohol abuse
Regular or binge consumption of alcohol
Sufficient to cause physical, neurological, psychiatric or social damage
How much is a unit of alcohol?
10mL
Or 8g
How many units are recommended per week?
MEN AND WOMEN – 14 units a week
What is alcohol dependence syndrome?
Dependence = the inability to control the intake of a substance to which one is addicted (in this case alcohol)
Characterised by using the substance to avoid withdrawals
What are the 2 components of substance dependence?
Psychological dependence – feelings of loss of control, cravings, pre-occupation with obtaining the substance
Physiological dependence – the physical consequences of withdrawing from the substance
What are some causes/risk factors for alcohol dependence/abuse?
Genetic component (more likely if family history, less likely if someone has acetaldehyde dehydrogenase deficiency)
Occupation (armed forces, doctors, journalists)
Cultural influences (higher rates in scottish and irish, low rates in jews and muslims)
Cost of drinks where you live
Social reinforcement/association between drinking and pleasure
People with chronic illnesses
Traumatic life event
More common in men
What are the signs of alcohol dependence?
CANT STOP
C – compulsion to drink alcohol
A – aware of harms but persists
N – neglect of other activities
T – tolerance to alcohol
S – stopping causes withdrawal
T – time preoccupied with alcohol
O – out of control use
P – persistent, futile wish to cut down
How to investigate someone you suspect has a drinking problem?
Have a high index of suspicion when it comes to alcohol
Screen with CAGE questionnaire
How to treat alcohol dependence?
Acute detoxification
Motivational interviewing
Psychological therapies
Self-help groups
Medication
Prevention measures
How is acute detoxification from alcohol achieved?
Should be in hospital if there is a risk of DT
Usually needs benzos e.g. chlordiazepoxide or diazepam to control withdrawal symptoms and prevent seizures
Rehydrate
Correct electrolyte disturbance
Thiamine (can be given orally or IV)
How is psychological therapy (including group therapy) helpful in the treatment of alcohol abuse?
Sustaining motivation
Learning relapse prevention strategies
Developing social routines not reliant on alcohol
Treating co-existing depression and anxiety
What medical treatments can be used to treat alcohol dependence?
Disulfram – blocks alcohol metabolism resulting in flushing, headaches, anxiety and nausea
Acamprosate - acts on GABA to reduce cravings and risk of relapse
Naltrexone – opioid receptor antagonist
First year PH revision – what are the stages of change steps?
Pre-contemplation
Contemplation
Planning/preparation
Action
Maintenance
Sustained maintenance or potential for relapse
What public health measures can be done to prevent alcohol abuse?
Increasing tax on alcohol
Restricting advertisement on alcohol
Keeping out of site i.e. behind the counter and having to ask for it
School alcohol education – reduces long-term alcohol use and binge drinking
What is delirium tremens?
An acute confusional state secondary to alcohol withdrawal
Medical emergency – requires impatient care
How quickly does DT occur after last drink?
1-7 days
Peak incidence at 48-72 hours after last drink
How does delirium tremens present?
Clouding of consciousness
Disorientation
Amnesia for recent events
Psychomotor agitation
Tremors – their body will shake and tremor
Visual, auditory and tactile hallucinations (characteristically of small people or animals)
Fluctuations in severity hour
Risk of cardiovascular collapse, Paranoid delusions/fear, confabulation and heavy sweating in severe cases
How do you treat delirium tremens?
THIAMINE (Pabrinex)
Lorazepam
Or antipsychotics (haloperidol or olanzapine)
What is Korsakoff’s psychosis?
Short term memory loss and confabulation
That occurs in heavy drinkers due to thiamine deficiency
Underlying pathology - thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus
What else can cause Korsakoff’s (other than alcohol abuse)
Head injury
Post-anaesthesia
Basal/temporal lobe encephalitis
Carbon monoxide posoining
Other causes of thiamine (vitamin B1) deficiency – anorexia, statvation, hyperemesis
How does Korsakoff psychosis present?
Profound short term memory loss – cannot lay down new memories
Confabulation – they start making stuff up and filling in the blanks in their memory with nonsense
How to treat Korsakoff’s psychosis?
Oral thiamine replacement and multivitamin supplementation (for up to 2 years)
Treat psychiatric comorbidities (e.g. depression)
OT assessment
Cognitive rehab
What is Wernicke’s encephalopathy?
TRIAD OF:
Confusion/intellectual impairment
Ataxia
Ophthlamoplegia (eye muscle paralysis) and nystagmus
Due to thiamine deficiency – most commonly seen in those who abuse alcohol
How do you treat Wernicke’s encephalopathy?
IV PABRINEX – high potency thiamine (vit B1) replacement
Treat immediately if diagnosis is made or suspected
Treat high risk patients (alcohol dependents) with prophylactic vitamins
Define delirium
An acute confusional state
Name the categories of things which can cause delirium
Infectious
Toxic
Vascular
Epileptic
Metabolic
Medications
Nutritional/dehydration
Name some infectious causes of delirium
UTI – very common, especially in elderly people
Pneumonia
Septicaemia
Name some toxic causes of delirium
E.g. substance misuse
Intoxication withdrawal (including delirium tremens which is specific to alcohol withdrawal)
Opiods
Name some vascular causes of delirium
CVA (stroke)
Haemorrhage
Head trauma
Name some metabolic causes of delirium
Hyper/hypothyroidism
Hyper/hypoglycaemia
Hypoxia
Hypercortisolaemia
Name some medications which can cause delirium
Anticholinergics
Parkinson’s medications
Benzos
Drug accumulation (i.e. old people don’t clear drugs as effectively as young people, or in someone with hepatic or renal impairment)
Excessive polypharmacy – medication overload
Post surgery (anaesthetics, analgesics, blood loss)
Steroids
Name some nutritional causes for delirium
Thiamine (B1) deficiency
B12 deficiency
Folate deficiency
Dehydration
What kind of people are at high risk and therefore should be screened for delirium on admission to hospital?
> 65 years
People with diffuse brain disease (dementia, PD)
Hip fracture patients
Severely ill (e.g. cancer)
Post-operative
What tool is used to screen for delirium?
4 AT assessment
What are the symptoms of delirium?
Confusion
Disorientation
Agitation
Hallucinations
Aggression
Disinhibtion
Labile mood (mood swings)
“clouding of consciousness”
Worse at night – “sun downing”
What are the 2 subtypes of delirium?
HYPOactive – withdrawn, quiet, sleepy behaviour. Less likely to be recognised so more dangerous for the patient
HYPERactive – restless, agitated and aggressive behaviour
How would you investigate someone presenting with delirium?
LOOK FOR UNDERLYING CAUSE:
Bloods
Urinalysis
Full physical examination – e.g. hip examination for #
CXR if indicated
CT head if worried about CVA/head trauma
How should delirium be managed?
Primarily need to identify the cause and treat it
Nutrition and hydration
Medications that can be used:
short term antipsychotic e.g haloperidol
Short acting benzodiazepine e.g. lorazepam
Long acting benzo if withdrawing from alcohol or drugs (diazepam, chlordiazepoxide)
Make the environment safe and comforting
Photos of family, calendar, big clock for orientation
Side room if bay too stressful
Educate family – not the same as dementia, may be self-limiting
Advanced planning if this is an exacerbation of a terminal illness
Name some steps that can be taken to prevent delirium
Preventing causes:
Reduce polypharmacy, reduce constipation and dehydration, reduce infection (e.g. avoid catheters)
Promote wellbeing:
Encourage mobilisation, healthy diet and sleep, social interaction, activities, visits from family
Maximise orientation:
Treat sensory impairment (glasses, hearing aids), clocks and calendars, staff explaining who they are and what is happening, consistent members of staff
Name some de-escalation techniques that can be used to manage delirium
Talk to the patient and listen to them
Position – quiet room away from busy ward
Put a calendar/clock in their room to help orientate them
Same staff to maximise orientation
Get them to bring in a few personal belongings – family pictures etc.
Get family to come and visit
🡪 Always try CONSERVATIVE de-escalation before using medication or manual restraints
Define dementia
A decline in higher cortical function
With no clouding of consciousness
Chronic, progressive and usually irreversible
Deterioration present for at least 6 months for diagnosis
Which type of dementia can present a lot like delirium and be easy to miss?
Lewy body dementia
Can present like delirium with visual hallucinations and confusion, and it’s course/progression can fluctuate
What is the difference between cortical and subcortical dementia?
Cortical dementias - affect the cerebral cortex
Subcortical dementias – affect the basal ganglia and the thalamus
Name some examples of cortical and subcortical dementia
Cortical – Alzheimer’s disease, Lewy body dementia, frontotemporal dementia
Subcortical – PD dementia, Huntingon’s disease dementia, Lewy body dementia, alcohol-related dementia, AIDS dementia
What are the typical symptoms of cortical dementia?
Memory impairment
Dysphasia – language deficit
Visuospatial impairment (apraxia)
Problem solving and reasoning deficit
What are the typical symptoms of subcortical dementia?
Pscyhomotor slowing
Impaired memory retrieval
Depression
Apathy
Execustive dysfunction
Personality change
Lanuage preserved- unlike in cortical
What is the most common type of dementia?
Alzheimer’s disease
What is Alzheimer’s disease?
Insidious onset of dementia due to generalised deterioration of the brain
It is the most common type of dementia
What causes Alzheimer’s?
Unknown in most cases
Some cases of both early and late onset Alzheimer’s have been linked to a particular gene defect
DOWN’S SYNDROME – most people with Down’s syndrome develop Alzheimer’s disease by about 50 years old
Which are the 3 genes that have been linked to the development of early onset AD?
APP gene
Presenillin 1
Presenillin 2
These account for most cases of familial (early onset) AD which has an AD inheritance pattern
Which gene has been linked to LATE onset AD?
Apolipoprotein E (ApoE)
Describe the macroscopic pathological changes that occur in Alzheimer’s (seen on CT)
Shrunken brain (diffuse cerebral atrophy)
Increased sulcal widening
Enlarged ventricles
Describe the microscopic pathological changes in Alzheimer’s disease
Neuronal loss
Neurofibrillary tangles
Amyloid plaques
LEARN THIS WELL – apparently a favourite in exams
Which neurotransmitters are affected in Alzheimer’s?
Acetylcholine
Noradrenaline
Serotonin
Somatostatin
What age does Alzheimer’s normally present?
More common > 65 year
If < 65 years = early onset = more rapid decline and family history
Name some risk factors for Alzheimer’s
THE CARDIOVASCULAR RISK FACTORS
Hypertension
Diabetes mellitus
Hypercholesterolaemia
Smoking
Family history
How does Alzheimer’s present?
The 4 A’s of Alzheimer’s:
Amnesia – recent memories poor, disorientation about time
Apraxia – unable to button clothes, use cutlery etc.
Agnosia – unable to recognise body parts/objects
Aphasia – later feature, mixture of receptive and expressive loss
Name some signs of Alzheimer’s seen on a CT
Brain atrophy
Enlarged ventricles
Shrinkage of cortex
How would you investigate someone presenting with symptoms of Alzheimer’s disease?
History and COLLATERAL history
Full physical examination to look for reversible causes of memory problems (anaemia, hypothyroidism, B12 deficiency, hyponataemia – common from PPIs, thiazides, antidepressants)
MSE
Mini mental state examination – questionnaire out of 30
Addenbrookes cognitive examination – out of 100, total score < 82 abnormal and need abnormal scores in at least 2 domains for a diagnosis
What are the domains tested in the Addenbrooke’s cognitive assessment?
Attention/orientation
Memory
Language
Visuospatial
Fluency
Name some treatments that can be used for Alzheimer’s?
NOT CURATIVE and do not improve life-expectancy but are thought to slow rate of decline and allow functioning at a higher level
Memantine – NMDA antagonist (blocks action of glutamate)
Acetyl-cholinesterase inhibitors (cognitive enhancers) – Donepezil, Rivastigmine, Galantamine. Works systemically so can cause GI upset (diarrhoea)
What else needs to be done when someone is diagnosed with Alzheimer’s disease/any kind of dementia?
Care plan
OT assessment at home to help them stay independent if that’s what they want
Social activity – keep them busy and around people
Physiotherapy if necessary
Advanced directives need to be considered
What causes vascular dementia?
CVA – 9x increased risk of dementia following a stroke
TIA
Any kind of vascular disease affecting the blood vessels of the brain
What are the risk factors for vascular dementia?
The 4 cardiovascular RF
History of peripheral vascular disease, ischaemic heart disease
What is the characteristic feature in the progression of vascular dementia?
STEPWISE decline
Meaning they are stable for a while, then decline, then stay at this for a while, then decline more etc.
How does vascular dementia present?
Patchier cognitive impairment than in Alzheimer’s
Focal neurological signs and symptoms appear – if cause by CVA
Stepwise rather than continuous deterioration
What would be seen on a CT head in someone with VD?
At least one area of cortical infarction – shows up white on CT
How would you investigate someone presenting with cognitive decline?
History and collateral history
Full physical examination to look for reversible causes of memory problems e.g. B12 deficiency, infections, anaemia
Mental state examination
MMSE
Addenbrookes cognitive assessment
SAME ASSESSMENT FOR EVERYONE PRESENTING W COGNITIVE DECLINE
How can you treat vascular dementia?
Again not reversible
But can prevent further decline by modifying vascular risk factors:
Statins
Anti-hypertensives
Aspirin
Treat diabetes
Smoking cessation
Lifestyle changes if possible
NO ROLE for acetylcholinesterase inhibitors in vascular dementia
What is Lewy body dementia?
A type of dementia in which there is:
Fluctuating cognition and consciousness
Vivid visual hallucinations
Parkinsonism
Sensitivity to neuroleptic medication (DO NOT GIVE ANTIPSYCHOTICS)
Sleep disorder (REM sleep behaviour disorder i.e. sleep walking/aggression)
Often confused with delirium
Associated closely with Parkinson’s disease (25% of PD patients will develop it)
When would you classify it PD dementia rather than Lewy body dementia?
If the dementia signs appear before the movement signs, it’s Lewy Body Dementia
If the movement signs appear before the dementia signs, it’s called Parkinson’s Dementia
But they are essentially exactly the same pathology and often coexist
What is the pathological feature found in the brain of someone with Lewy body dementia?
The presence of Lewy bodies (protein deposits)
In the basal ganglia and cerebral cortex
What age does Lewy body dementia present?
Normally between 50-80 years
What are some symptoms of Lewy body dementia?
Visual hallucinations – small children, animals, complex scenes
Parkinsonian signs – tremor, stooped gait, mask like face
Frequent falls
REM sleep behaviour disorders – supportive feature, commonly precedes the other symptoms
Fluctuating onset and progression
Rapid decline (more so than other types of dementia)
ALWAYS consider LBD if >1 of these features. Massively underdiagnosed and you don’t need all of the features to make diagnosis
How do you treat Lewy body dementia?
No real treatment available
Supportive/palliative/emotional guidance
OT assessment at home to help them stay independent
Advanced directives need to be considered
AVOID antipsychotics – can make it much worse – and can lead to neuroleptic malignant syndrome
What is Pick’s disease?
Frontotemporal dementia
Younger mean age of onset
Early personality changes and relative intellectual sparing
What causes Pick’s disease?
Many cases unknown
Can be due to neurosyphillis (typically causes frontal lobe symptoms – i.e. aggression and personality change)
What are the microscopic pathological features in frontotemporal dementia?
Ubiquitin and tau deposits
How does frontotemporal dementia present?
Insidious onset, poor insight. Amnesia not as severe as in Alzheimer’s
Frontal lobe symptoms:
Euphoria
Disinhibition
Personality changes
Emotional blunting
Temporal lobe symptoms:
Speech disturbances – may end up mute
Expressive dysphasia
How do you treat frontotemporal dementia?
No specific treatments
SSRIs may help behavioural symptoms
OT assessment at home to help them stay independent
Advanced directives need to be considered
Alcohol related dementia?
Accounts for up to 10% of cases of dementia
Generalised brain damage leading to cognitive decline (”a decline in cortical function”)
Caused by excessive alcohol consumption over many years
What are the behavioural and psychological symptoms of dementia (BPSD)?
Anxiety
Depression
Agitation
Psychosis (commonly think the nurses are out to get them etc.)
Disinhibition
Important to rule out treatable causes for these symptoms in people with dementia (such as infection)
What are the treatable causes of BSPD?
PINCH ME:
P - Pain
I - Infection
N – Nutrition (they are hungry)
C – Constipation (check stool charts)
H – Hydration (can get very aggressive if dehydrated)
M – Medication (polypharmacy, codeine can cause aggression)
E – Environment (noisy ward, move to side room if necessary)
How do you manage BPSD?
Address any underlying cause
Educate the family/carer about these symptoms and what may cause them
Occupational therapy
What disease causes a rapidly progressive cognitive decline and what other features would you see?
Creutzfeltd-Jacob disease
Prion infection causing spongiform encephalopathy
Causes rapidly fatal dementia (progresses very quickly and death within 1 year)
Myoclonic jerks and extra-pyramidal signs seen
Causes – sporadic, infected hospital equipment, familial, variant (blood transfusions in 1995)
What is Huntington’s disease?
Autosomal dominant disease with 100% penetrance - trinucleotide expansion repeat of CAG
Symptoms – cognitive decline 🡪 progresses to subcortical dementia, personality change, Choreiform involuntary movements, dysarthria, psychiatric disturbance (depression, suicide risk, psychotic symptoms)
Genetic test available – but cannot give to children, must wait until they are old enough to make that decision
Higher risk of suicide with diagnosis – consider before testing
What is the pathophysiology of HD?
Reduced GABA (reduced inhibition)
Causing dopamine hypersensitivity and increase in dopamine transmission
Increased stimulation at thalamus and cortex leading to involuntary movements
What medications can be used in the treatment of Huntington’s disease?
No curative treatment or to slow progression - purely symptomatic
Antidepressants
Haloperidol – may help reduce chorea by blocking dopamine
PHYSIO AND SALT important
Other diseases that can cause psychiatric symptoms
Neurosyphillis – grandsiosity, euphoria, mania, personality change
Wilson’s disease – copper excess leading to both neuro and psychiatric signs, liver disease and kayser-fleisher rings
Name a potentially reversible cause of dementia?
Normal pressure hydrocephalus
Traid of – ataxia, dementia and urinary incontinence
Causes – idiopathic, SAH, head trauma, meningitis
Treat with ventriculoperitoneal shunt
Name some endocrine disorders that can cause anxiety
Hyperthyroidism
Hyperparathyroidism
Pheochromacytoma (episodic anxiety)
Name some endocrine disorders that can cause depression?
Hypothyroidism
Primary hypoparathyroidism
Hypercortisolaemia (usually iatrogenic – steroids)
Hypocortisolaemia (Addison’s disease)
Hypopituitarism
Name some symptoms of anorexia nervosa
Preoccupation with food (dieting, making elaborate meals for others)
Self-conscious about eating in public
Vigorous exercise
Constipation
Cold intolerance
Depressive and compulsive symptoms
Binging/purging or extreme restriction subtype
Name some physical signs seen in someone with anorexia nervosa?
BMI < 17.5
Emaciation (the state of being abnormally thin or weak) – often disguised by make-up/clothes
Dry and yellow skin
”peach fuzz” hair on face and trunk
Bradycardia and hypotension
Anaemia
Consequences of repeated vomiting – hypokalaemia, alkalosis, pitted teeth, parotid swelling, scarring of the dorsum of the hand (Russel’s sign)
How to approach treatment to an eating disorder?
CBT
Interpersonal therapy
Food diary and regular eating programme – re-establish control of diet, address underlying abnormal cognitions
SSRIs – best one to use is fluoxetine
Define insomnia
Persistent problems with
Falling asleep
Maintaining sleep
Or poor quality of sleep
For at least 3 days a week for 1 month
Can be primary (caused by both intrinsic and extrinsic factors)
Or secondary – to illness or substance misuse
What are some primary causes of insomnia?
Fear/anxiety about falling asleep
Change of environment (adjustment disorder)
Inadequate sleep hygiene
Idiopathic insomnia – rare, lifelong inability to sleep
Behavioural insomnia of childhood
What are some secondary causes of insomnia?
Sleep-related breathing disorders (e.g. sleep apnoea)
Circadian rhythm disorders
Shift work
REM behavioural disorder e.g. Lewy body dementia/PD
Medical conditions causing pain which keeps them awake
Psychiatric disorders – depression (early morning waking), anxiety (early or middle insomnia)
Drugs and alcohol – steroids, antidepressants, stimulants
How common is insomnia?
About 30% of people complain of it
More common in women
More common in the elderly
What are the symptoms of insomnia?
Problems falling asleep or maintaining sleep
Poor quality of sleep
Preoccupation and concern with sleep
Distressed about their sleep problems
Social and/or occupational functioning affected
How do you treat insomnia?
Encourage good sleep hygiene – get rid of noise, light and other distractions, wind-down before bed, avoid caffeine and stimulation before bed
Sleep restriction – don’t allow them to nap during the day to promote sleep at night instead
Medication – once good sleep hygiene proved unsuccessful
The Z drugs are first line – zopiclone, zolpidem, zapeplon
Sedating antidepressants – mirtazapine
Sedating antipsychotics – quetiapine
Melatonin
What is late onset schizophrenia?
Also called paraphrenia
Onset > 45 years
Less emotional blunting and personality decline compared to younger onset
Often does undiagnosed because older patients with the disorder tend to be socially isolated
No evidence of dementia with late onset cases – no memory problems
Brain imaging findings are usually normal
What are the clinical features of late onset schizophrenia?
Delusions and hallucinations – often about neighbours
Paranoid – often about neighbours
“Partition” delusion – leads the patient to believe that people or objects can go through walls
Less negative symptoms (blunting/apathy) and formal thought disorder compared to early onset
What are the risk factors for late onset schizophrenia?
Social isolation
Sensory deficits – poor eyesight/hearing
Reclusive and suspicious pre-morbid personality
More common in women
How to treat late-onset schizophrenia?
Low doses of anti-psychotics
What is a delusional disorder?
A disorder in which the patient experiences strong delusional beliefs and perceptions
But NO hallucinations
2-8% of elderly patients report paranoid symptoms
Name some common features of a delusional disorder in an elderly person
Common delusions in the elderly:
Skin infestation
Illness/cancer
Being spied on/followed/poisoned
Infidelity – morbid jealously leads to spying on their partner
Anger, irritability
Depression
What is psychotic depression?
Common presentation to old age ward – commonly problem in the elderly
Initial presentation – change in mood
More insidious progression to psychosis
The delusions will be nihilistic and mood congruent
A feature of psychotic depression is Cortard’s syndrome – what is this?
A belief that everything inside them is rotting/they’re already dead inside
This is a favourite for exams apparently
What is Charles-Bonnet syndrome?
Complex visual hallucinations in a person with partial or severe blindness (macular degeneration, diabetic retinopathy)
Patients understand that the hallucinations are not really and often have insight compared to other disorders
What are some signs to look out for in someone with Munchausen’s syndrome?
Already diagnosed with personality disorder
Usually physical symptomology – e.g. abdo pain (but will extend to pain rather than flex to pain etc.)
Sometimes psychiatric symptoms – feigned hallucinations, abuse
Multiple A&E presentations to several different hospitals
Frequent admissions
Often multiple surgical procedures
Multiple aliases, no fixed address of regular GP
When discovered – discharge themselves against medical advice
What is the definition of a learning disability?
(Mencap definition)
Learning DISABILITY = A reduced intellectual ability and difficulty with everyday activities – e.g. household tasks, socialising – which affects someone for their whole life
Different to a learning DIFFICULTY (e.g. dyslexia) which does not affect intellect
What can cause a learning disability?
Inherited
Early childhood illness/brain injury
Problems during pregnancy/birth
Smoking/alcohol in pregnancy
Name some examples of learning disabilities
Down’s syndrome
Autism spectrum disorder and Asperger’s syndrome
Williams syndrome
Fragile X syndrome
Global developmental delay
Cerebral palsy
What is the triad of symptoms for autism spectrum disorder?
Impaired social interaction
Speech and language disorder
Imposition of routines – ritualistic and repetitive behaviour
How will someone with ASD present to the doctor?
Poor eye contact
Failure to develop relationships
Abnormal playing/communications
Restricted interests or activities – i.e. they will want to do the same few activities over and over again
Abnormal gazing
Motor tics
What is the difference between ASD and Asperger’s syndrome?
Asperger’s has milder social features
Near normal speech development
What are the main symptoms of ADHD?
Inattentiveness
Hyperactivity
Impulsiveness
Restlessness
Poor concentration
How do you treat ADHD?
Methylphenidate (Ritalin) – important to monitor their growth whilst they’re taking this
Psychotherapy
Name some risk factors for Downs’s syndrome
Increasing maternal age
Previous child with Down’s syndrome
If the mother has Down’s syndrome (although pregnancy is rare)
List the distinguishable facial features of Down’s syndrome
Flat occiput
Oblique palpebral fissures
Small mouth
High arched palate
Broad hands, single transverse palmar crease
List some of the medical issues associated with Down’s syndrome
Learning disability – can be mild, moderate or severe
Autistic traits
High risk of developing Alzheimer’s disease by about 50 years old
Hypothyroidism
Complete atrioventricular septal defect
What is fragile X syndrome?
X linked dominant condition
INHERTIED type of learning disability
More common in men because the females have the “extra protection” from the second X chromosome (women have fewer learning and behavioural problems)
What are the physical characteristics of Fragile X syndrome?
Large head and ears
Poor eye contact
Abnormal speech
Hypersensitivity to touch, auditory and visual stimuli
Hand flapping
Hand biting
Which learning difficulties are associated with fragile X syndrome?
Autism in 15-30%
What is the definition of a personality disorder?
Deeply engrained and enduring patterns of behaviour that are abnormal in a particular culture
Appear to increase distress and risk to self and others
And decrease function
PDs are split into cluster A, B and C (“mad, bad and sad”)
Name some causes/risk factors for personality disorders
Childhood sexual abuse – strongly linked to borderline PD
Adverse events during pregnancy/birth/neonatal period
Poor parenting and adverse childhood
Conduct disorder as a child 🡪 very strong possibility they will have antisocial PD as adult so need to educate the parents
What are the cluster A personality disorders?
”mad”
Paranoid
Schizoid
Schizotypal
What are the cluster B personality disorders?
“bad”
Borderline (emotionally unstable)
Histrionic (want to be centre of attention, make everything a drama)
Narcissist
Antisocial
What are the cluster C PDs?
“sad”
Avoidant/anxious
Dependant
Anankastic (obsessive compulsive)
Define paranoid personality disorder and list some of its features
Definition = pervasive and unwarranted tendency to interpret the actions of others as demeaning or threatening
Thinks the world is – a conspiracy
Think people are – devious
Acts as if – always on guard, suspicious
Commonest behavioural –watchfulness
Least likely to be – trusting
Emotional hot-spot – being discriminated against
Define schizoid personality disorder and list some of its features
Definition = pervasive pattern of indifference to social relationships and a restricted range of emotional experience and expression
Thinks the world is – uncaring
Thinks people are – pointless, replaceable
Thinks they are the only person they can depend on
Commonest behaviour – withdrawal
Least likely to be – emotionally available and close
Emotional hotspot – being over-cared for and smothered by others
Define schizotypal personality disorder and list some of its features
Definition = pervasive pattern of deficits in interpersonal relatedness and peculiarities of ideation, experience, appearance and behaviour
Define borderline personality disorder and list some of its features
Aka emotionally unstable
Most common type
Definition = pervasive pattern of instability of mood, interpersonal relationships and self-image
Thinks the world is – contradictory
Thinks people are – untrustworthy
Ashamed of themselves
Commonest behaviour – self-harm
Least likely to be – able to show self-compassion
Emotional hotspot – abandonment
Patient speak phrase “feel like I have 1000s of emotions coming out of me” – can end up in an emotional crisis which can become psychotic
Define histrionic personality disorder and list some of its features
Definition = pervasive pattern of excessive emotionality and attention seeking
Thinks the world is – their audience
Thinks people are – in competition for attention
Thinks they are vivacious (attractively lively and animated)
Commonest behaviour – exhibitionism
Least likely to be – able to listen to others
Emotional hotspot – being actively or passively side-lined
Define narcissistic personality disorder and list some of its features
Definition = pervasive pattern of grandiosity, lack of empathy and hypersensitivity to the evaluation of others
Thinks the world is – a competition
Thinks people are – inferior
Thinks they are – special
Commonest behaviour – competitiveness
Least likely to be – humble
Emotional hotspot – loss of face/social rank/social status/ being embarrassed
Define antisocial personality disorder and list some of its features
Aka – psychopathic, dissocial, sociopathic
Pscyhopathic when they get in trouble in with the law
And it’s called sociopathic when they have the same traits but without problems with the law
Definition = childhood conduct disorder before the age of 15 and a pattern of irresponsible and antisocial behaviour post 15 years
Thinks the world is – predatory
Thinks people are – weak
Thinks of themselves as autonomous and alone
Commonest behavioural approach – crushing
Least likely to be – gentle and sensitive
Emotional hot spot – perceiving exploitation
Define avoidant/anxious personality disorder and list some of its features
Definition = pervasive pattern of social discomfort, fear of negative evaluation and timidity
Thinks the world is – evaluative
Thinks people are – judgemental
Thinks they are – inept
Commonest behaviour – inhibition
Least likely to be – assertive
Emotional hot spot – exposed ridicule or rejection
Define dependant personality disorder and list some of its features
Definition = pervasive pattern of dependent and submissive behaviour
Thinks the world is – overwhelming
Thinks people are – stronger and more competent than themselves
They are - needy
Commonest behaviour – clinging
Least likely to be – self sufficient
Emotional hot spot – making a decision
Define anankastic/obsessive compulsive personality disorder and list some of its features
Definition = pervasive pattern of perfectionism and inflexibility
Thinks the world is – sloppy
Thinks people are – irresponsible
Thinks they are – responsible
Commonest behaviour – control
Least likely to be – flexible
Emotional hotspot – making a mistake
How do you investigate someone who you think may have a personality disorder?
Important to be assessed more than once
Collateral history
MSE
RISK ASSESSMENT
Treat comorbid psychiatric conditions before a diagnosis of personality disorder is made
How can you treat personality disorders?
General measures – ensure they engage with the services, structure, consistency and clear boundaries. Help them with housing and other social matters
Medications – mood stabilisers, sedatives during borderline PD crises
Adapted CBT for borderline PD
Continuity of care very important – changes in doctors etc. may invoke strong emotional reactions
Psychological therapies
Treatment centres for people with dangerous/severe PDs – prisons and psychiatric units
What is an adjustment disorder?
An abnormal and excessive reaction to an identifiable life stressor
The reaction is more severe than would normally be expected and can result in significant impairment in social, occupational, or academic functioning.
What is Tourette’s syndrome?
A developmental neuropsychiatric disorder
Characterised by tics
Tics = involuntary movement and/or speech
3x more common in boys
What causes Tourette’s?
Genetic association
Environmental factors – stress, gestational/perinatal insults, fatigue, PANDAS (associated with streptococcal infection)
Often comorbid with – OCD, ADHD, depression, anxiety, learning difficulties, ASD, migraines
How to treat Tourette’s?
Education for chid and family
Liaise with school
Lifestyle changes – reduce caffiene intake, reduce stress
Consider medication if tics severe – antipsychotics, alpha-adrenergics
What are the main symptoms of PTSD?
re-experiencing – flashbacks, nightmares
Avoidance – avoiding people, situations or circumstances resembling the traumatic event
Hyperarousal – hypervigilance for threat, startles easily, struggles to sleep
Emotional numbing
What is the definition of an addictive behaviour?
A behaviour which is both rewarding and reinforcing
Name some common addictive behaviours
Gambling
Compulsive eating
Internet addiction
Sex
Shopping
Alcohol use
Drug use
Smoking and nicotine use
Eating disorders
What signs would you see in someone intoxicated with heroin?
Euphoria
Pinpoint pupils (ALWAYS - check for this, can mean overdose)
Drowsiness
Constipation
Respiratory depression (especially in OD)
What signs would you see in someone withdrawing from heroin?
“Goose flesh” (piloerection)
Pupil dilatation
Yawning
Sweating
Abdominal cramps
Insomnia
What signs may you see in someone withdrawing from alcohol?
Tremors
Anxiety
Nausea and vomiting
Headache
Tachycardia
Irritability/aggression
Delirium
What are some causes/risk factors for addictive behaviour?
Stress
Family history
“wrong crowd”/peer pressure
Low self esteem
Anxiety
Coming from a psychologically or physically abusive family
What is the pathophysiology behind addiction?
Related to the mesolimbic reward system - a motivational circuit
What are some common characteristics of addictive behaviours?
Obsession with the substance/activity
Continue even if it’s causing them harm
Finds it difficult to stop
Withdrawal symptoms occur if they do stop
Loss of control
Denial of problem
Tries to hide the behaviour from friends/family
May blackout whilst engaging in behaviour
Depression, low self-esteem, anxiety
Describe an approach to treating addictive behaviour
Aversion therapy – designed to put the patient off the undesirable habit by causing them to associate it with an unpleasant effect
Self-control training
CBT – alcohol, cocaine, gamblers
Relaxation, positive self-talk – smokers
Antidepressants can help, especially in pathological gamblers
Methadone – heroin substitute (don’t get the high, but reduces cravings) – less dangerous than heroin, can even be used in pregnancy
Nicotine patches, gum, inhalers
Motivational interviewing
Define phenomenology
The study of signs and symptoms describing abnormal states of mind
Define delusion
A disorder of thought
A belief that is firmly held, despite rational counter-argument
Ask them – are there ever times where you can reason yourself out of this belief? (to see how much they do think it)
Define hallucination
A disorder of perception
A perception experienced in the absence of an external stimulus
Of similar quality to that of a real perception
What’s the difference between a hallucination and an illusion?
Hallucination = a perception of a stimulus that isn’t actually there
Illusion = misperception of a real external stimulus (i.e. seeing a piece of rope as a snake)
What types of hallucinations can occur?
Auditory
Visual
Olfactory
Gustatory – really bad taste in their mouth with no explanation
Tactile – like feeling it on your skin
Somatic – within a person (i.e. feeling like your insides are moving)
Hypnogogic – when going to sleep (normal)
Hypnopompic – when waking up (normal)
Autoscopic – seeing oneself
Reflex hallucinations –
Extracampine – outside the sensory field
What is the definition of a mental disorder?
Any disorder or disability of the mind
(excluding alcohol and drug use)
What are some of the underlying principles of the mental health act?
Respect for patient’s past and present wishes/feelings
Minimising restrictions on liberty – although they are detained against their will, the patient still has rights to appeal against their detention to a Tribunal
Involvement of patients in planning of care
Avoidance of unlawful discrimination
Effectiveness of treatment
Views of carers and other interested parties
Patient well-being and safety
Public safety – i.e. detaining someone if they are at risk of harming others
What is the role of a doctor approved under section 12 of the mental health act?
Makes recommendations under part 2 and 3 of the mental health act (compulsory admission to hospital)
They are an approved mental health act professional
What is the role of section 2 of the MHA?
Purpose – compulsory admission to hospital for assessment
What is the duration of a section 2?
28 days
Who must be involved in detaining someone under section 2?
2 doctors – one must be section 12 approved (AMHP - approved mental health professional) and one should ideally have previous contact with the patient
Nearest relative can also make an application for someone to be detained under section 2
What evidence is required to admit someone under section 2 of the MHA?
That the patient is suffering from a mental disorder to a degree that warrants detention in hospital for assessment
And the patient ought to be detained for their own health or safety, or the protection of others
Can section 2 of the MHA be renewed?
No
But it can be converted to a section 3
What is the purpose of section 3 of the MHA?
Compulsory admission to hospital for treatment
What is the duration of section 3?
6 months
Can a section 3 be renewed?
Yes
Which professionals must be involved in a section 3?
2 doctors – one must be an approved mental health professional (section 12)
Nearest relative can also apply for a section 3 and must not object to the implication of a section 3
What evidence is required for a section 3 to be applied?
The patient is suffering from a mental disorder of the nature which makes it appropriate for them to receive medical treatment in hospital
The treatment is in the interest of their health and safety, and the protection of others
Appropriate treatment must be available for the patient
What is the purpose of section 4 of the mental health act?
Emergency order
Only in an emergency necessity
When waiting for a second doctor would lead to “undesirable delay”
What is the duration of a section 4?
72 hours
Which professionals are required for a section 4?
1 doctor (who does not need to be section 12 approved)
What evidence is required for a section 4 to be put in place?
The patient is sufferring from a mental disorder to the degree that warrants detention in hospital for assessment
The patient ought to be detained for their own health or safety, or the protection of others
There is not enough time for a 2nd doctor to attend (i.e. due to risk)
What is the purpose of a section 5(4)?
For a patient ALREADY admitted (to psychiatric or general hospital) but wanting to leave
Who can hold a patient on a section 5(4)?
Nurses
This is their holding power until a doctor can attend
How long does a section 5(4) last?
6 hours
What is a section 5(2)?
For a patient already admitted to hospital (general or psychiatric) but wanting to leave
Who can implement a section 5(2) and how long does it last?
Doctors
72 hours
This is a doctors holding power – gives time for section 2 or section 3 to be put in place
NB – has to be a doctor on that specific ward and cannot be done in A&E
Which sections can be put in place by the police?
Section 135 and 136
136 – suspicion of having a mental disorder in public place
135 – needs court order to access patient’s home and remove them
Define illusion
A distorted perception of a normal stimulus (e.g. interpreting a curtain cord as a snake)
Define hallucination
A perception in the absence of an external stimulus
Believed to be true and has similar quality to an actual perception
Define pseudohallucination
A perception in the absence of an external stimulus, experienced in ones own head
With preserved insight
Define over-valued idea
An acceptable, comprehensible idea pursued by the patient beyond normal reason
Causes distress to the patient and those around him/her
Different to a delusion – will accept counter arguments, but this idea is central to their life
Define delusion
An unshakeable belief
Out of keeping with the patient’s cultural/religious norms
Unaltered by reasonable counter arguments
Define delusional perception
A delusion that arises in response to a normal perception
E.g. they see a CCTV camera and think they are being recorded/followed
Define thought alienation
The belief that the persons thoughts are being interfered with in one way or another
Insertion – external source putting thoughts into their head
Withdrawal – external source taking thoughts out of their head
Broadcast – belief that their thoughts are available to others (e.g. by radio/telepathy)
Echo – hears their own thoughts out loud
Thought block – thoughts suddenly disappear
Define concrete thinking
Literal thinking that is focussed on the physical world
Define loosening of association
Speech in which there is no discernible link between statements
Define circumstantial speech
Speech that takes a long time to get to a point (goes round in circles)
Define confabulation
A falsified memory
Patients with memory loss often confabulate to fill in gaps because they cannot remember what has really happened
Seen in Korsakoff’s phenomenon
Define passivity phenomena
A delusion that someone/something is making them perform actions against their will
i.e. making them say or do things
One of the first rank symptoms of schizophrenia
Define psychomotor retardation
A decrease in overall motor activity
A sign of severe depression
Opposite = psychomotor agitation
Define flight of ideas
Speech in which there is an abnormal connection between statements
Define formal thought disorder
When the patients speech indicates that the links between consecutive thoughts are not meaningful
Includes loosening of association
Define pressure of speech
Speech in which the rate and volume are increased
Usually difficult to interpret
Opposite = poverty of speech
Define incongruity of affect
Emotional expressed by a patient differs markedly from the expected emotion for the situation
i.e. laughing when talking about bereavement
Define blunting of affect
Limited range of emotional responsiveness
Define depersonalisation
The person doesn’t believe themselves to be real
Define realisation
The person doesn’t believe the world/people around them are real
Define obsession
Recurrent thoughts, feelings, images or impulses that are intrusive and persistent
But are recognised as the patients own
Define compulsion
Repetitive, purposeful, physical or mental behaviours performed in repsonse to an obsession
Define akathisia
Complete, unpleasant restlessness
Results in inability to sit still/need to pace
Side effect of antipsychotic medication
What is the mechanism of action of benzodiazepines?
Enchange the effect of GABA, the main inhibitory neurotransmitter
What is neuroleptic malignant syndrome?
Psychiatric emergency caused by excess of neuroleptic medication or acute withdrawal from Parkinson’s medication
What are the features of NMS?
Can come on over hours to days
Hyper pyrexia
Hyporeflexia
Sweating
Normal pupils
Tachycardia
Rigidity
Raised CK
How to manage NMS?
Stop the offending agent or give L-dopa in dopamine withdrawal
IV fluids
Benzodiazepines
Bromocriptine
Dantrolene
(Dantrolene also used to prevent and treat malignant hyperthermia)
What is serotonin syndrome?
A disorder caused by excess in serotonin
Caused by
SSRIs
MAO inhibitors
Ecstasy
Amphetamines (cocaine, mcat)
Antiemetics (e.g. metoclopramide)
St. John’s Wort
Features of serotonin syndrome?
Can come on over minutes/hours
Hyperthermia/ hyperpyrexia
Sweating
Hyperreflexia
Clonus
Rigidity
Altered mental state
Dilated pupils
How to manage serotonin syndrome?
IV fluids
Benzos
Stop the offending agent
