Pyschiatry Flashcards
1
Q
What are the risk factors for depression?
A
- Female sex
- Past Hx of depression
- FHx of depression/mental illness
- Chronic/severe illness
- Other mental health Dx
- Ethnicity (afro-carribean, asian, refugee)
- Significant life stressors
2
Q
What investigations would you do to exclude physical causes when screening for depression?
A
- Blood tests:
- FBC, ferritin, B12 (anaemia)
- Blood glucose (DM)
- U&Es (electolyte imbalanace)
- Calcium levels (Vit D deficiency)
- TFTs (hypothyroidism)
- LFTs (liver pathology)
- CRP (infection)
- Other tests:
- magnesium levels
- HIV/syphillis serology
- drug screening (urine dip)
- Imaging:
- MRI/CT scan (if intracranial lesion suspected e.g. new onset headache or personality changes)
3
Q
What screening tools are used for depression?
A
Patient Health Questionnaire-9 (PHQ-9). /27
- minimal (1 - 4)
- mild (5 - 9)
- moderate (10 - 14)
- moderately severe (15-19)
- severe (20-27)
Hospital Anxiety and Depression scale. [Each section: 7Q, /21]
- normal (1 - 7)
- mild (8 - 10)
- moderate (11 - 14)
- severe (15 - 21)
4
Q
What screening tool is used for suspected Postnatal depression?
A
Edinburgh Postnatal Depression questionnaire
5
Q
What is the ICD-10 criteria for depression?
A
The depressive episode must last >2 wks and represent a change from normal.
This must not be secondary to other causes such as drugs, alcohol misuse, medication etc.
- CORE SYMPTOMS*
1. Low mood
2. Anhedonia
3. Reduced energy/fatigue
OTHER SYMPTOMS:
- Reduced concentration and attention
- Reduced self-esteem/self-confidence
- Ideas of Guilt and worthlessness
- Bleak and pessimistic views of the future
- Ideas or acts of self harm or suicide
- Sleep disturbance
- Diminished appetite
6
Q
What are the psychotic symptoms associated with depression?
A
*Delusions:
are usually mood congruent and therefore usually nihilistic; poverty, over bearing guilt for misdeeds, responsible for world events, deserving of punishment.
*Hallucinations:
can occur in a range of modalities however 2nd person auditory hallucinations are most common;
- Auditory: derogatory voices, cries for help or screaming
- Olfactory: usually bad smells such as rotting flesh and faeces.
- Visual: demons, the devil, torturers, dead bodies etc.
*Catatonic symptoms:
marked psychomotor retardation aka depressive stupor.
7
Q
How do we measure the severity of depression?
A
- Mild:
2 core + 2 other symptoms - Moderarte:
2 core + 3+ other symptoms - Severe:
3 core symptoms + 4+ other symptoms - Severe depression with psychosis:
Severe depression (as above + psychotic symptoms (delusions +/- hallucinations)
8
Q
What is the role of 5HT and NA in mental and physical processes?
A
- Anxiety
- Pain perception
- Vasoconstiction
- Urethral sphincter contraction
- Bladder wall relaxation
- GI motility
- Pilomotor contraction
9
Q
DDx for depression
A
- Medications:
- Anti-hypertensives: BB, CCB, methyldopa
- steroids
- histamine H2 blockers
- sedatives
- muscle relaxants
- retinoids
- chemotherapy agents
- sex hormones e.g. oestrogen etc.
- psychiatric medications
- Substance misuse:
alcohol, benzodiazepines, opiates, marijuana, cocain, amphetamines etc.
- Psychiatric illness:
bipolar, dysthmia, anxiety disorder, schizoaffective disorder, schizophrenia (negative symptoms), personality disorder
- Neurological:
dementia, Parkinson’s disease, tumours, stroke etc.
- Endocrine:
hyper/hypothyroidism, Addison’s disease, Cushing’s disease, menopause, hyperparathyroidism
- Metabolic:
hypoglycaemia, hypercalcaemia, porphyria
- Others:
anaemia, infections (syphillis, lyme disease, HIV encephalopathy), sleep apnoea
10
Q
What is the treatment for mild-to-moderate depression?
A
- Bio:
- watchful waiting, assess in 2 weeks
- Psycho:
- Guided self-help based on CBT principles (books, internet resources)
- Computerised CBT
- Brief psychological interventions (6-8 sessions) including problem-solving, brief CBT and counselling.
- Social:
- reduce stressors
- establish support network
- enhance protective factors
11
Q
What is the treatment for moderate-severe depression?
A
Bio:
- antidepressant
- ECT
- v. severe symptoms, treatment resistant or life-threatening
Psycho:
- high-intensity psychological treatment (CBT or interpersonal therapy)
Social:
- establish support network
- enhanced protective factors
12
Q
What factors necessitate admission in depression?
A
- self-neglect
- risk of suicide/self-harm
- risk to others
- poor social support
- psychotic symptoms
- lack of insight
- treatment resistant depression
13
Q
What are the pharmacological treatments for depression?
A
- Selective Serotonin Re-uptake Inhibitors
e,g, Sertraline, Citalopram/Esciralopram, Fluoxetine, Paroxetine
NB: As effective as TCAs and less likely to cause side effects and safer in overdose.
- Tricyclic Antidepressants
e. g. Amitriptyline, Imipramine - Serotonin-Noradrenaline re-uptake inhibitors
e. g. Venifaxine/Duloxetine - Monoamine-oxidase inhibitors
e. g. Moclobemide - Noradrenergic and specific adrenergic antidepressant (NaSSA)
e. g. Mirtazapine - Agomelatine: melatonin receptor agonist
- Combination/augmentation therapies
- Atypical antipyschotics.
14
Q
What are the SE of SSRIs?
A
- Increased suicidality <25
- Serotonin syndrome
- Discontinuation
15
Q
What are the psychological treatment options for depression?
A
- CBT**
- Interpersonal therapy
- Psychodynamic psychotherapy
- Pyschoeducation
16
Q
What are the social interventions in depression?
A
Very dependent on the specific social needs
- counselling (supportive/relationship/grief)
- improving social circumstances e.g. vocational training, supported accommodation, benefits.
- address safe-guarding concerns
17
Q
What are the clinical features of atypical depression?
A
- Mood: mood is depressed but remains active i.e. can still enjoy activities.
- Extreme fatigue
- Reversed diurnal variation in mood
- Hypersomnia: excessive sleeping which can be defined as >10hours/day, at least 3 days a week for at least 3 months.
- Hyperphagia: excessive eating with weight gain (>3Kgs in 3 months).
- Interpersonal rejection sensitivity
- Leaden paralysis: feelings of heaviness in the limbs (1hr/day, 3 days/week for at least 3months).
18
Q
What are the clinical features of dsythmia?
A
- Depressed mood (>2 years)
- Reduced energy and fatigue
- Appetite may be increased/reduced
- Insomnia/hypersomnia
- Low self esteem
- Poor concentration
- Difficulties making decisions
- Thoughts of hopelessness
19
Q
What is dysthmia?
A
This is the presence of chronic low grade depressive symptoms.
These are usually long standing e.g. years but there is a time when the person did feel ‘well’. It is possible to experience a depressive episode i.e. double depression in which case need to be aware that the baseline is dysthymic rather than euthymic.
20
Q
What are the risk factors for post-natal depression?
A
- FH
- single mum
- older age mum
- unwanted pregnancy
- poor social support
- poor relationship with own mother
21
Q
What is Seasonal affective disorder (SAD)?
A
This is low mood which occurs with a change in season i.e. depression in winter and remission in spring.
The underlying pathology is believed to involve melatonin synthesis; sunlight hits the pineal gland which decreases melatonin synthesis (↑5HT synthesis).
22
Q
What is the management of Seasonal affective disorder?
A
- Light therapy (go outside, specialised SAD lights)
2. Pharmacological: antidepressants (SSRIs), propranolol
23
Q
You are an F1 doctor working on a psychiatric ward.
Mr Steven Jones is a 31yr old man who is admitted under S2 MHA.
The handover you are given is that he is suffering from mania.
When you try to speak to him, Mr Jones is pacing around the ward, he is continually speaking and can’t remain on a topic.
When you ask ‘how are you?’ he replies ‘fine…. Like a biro pen….they have ink…….I really want a tattoo….I wonder what its like in prison…are you the police?’
Identify the thought disorder?
A
Flight of ideas.
24
Q
What is the ICD-10 criteria for Bipolar affective disorder?
A
“at least two episodes one of which must be hypomanic/manic or mixed, with recovery usually complete between the episodes”.
The criteria for the depressive episode being the same as for unipolar depression, and the criteria for the hypomanic/manic episodes being the same as unipolar hypomania/mania.
*NB Mixed affective episodes is when there is the occurrence of both hypomanic/manic and depressive symptoms in a single episode present everyday for at least 2 weeks.
25
Aetiology of BAD?
- Genetic predisposition
- Greater in upper social classes
- Age of onset peaks at 15-24; mean age of onset 21
NB: no difference in sex/ethnicity
26
How do you Dx a manic episode?
A. Mood must be predominantly elevated, expansive or irritable, and definitely abnormal for the individual concerned. The mood change must be prominent and sustained for at least 1 week (unless it is severe enough to require hospital admission)
B. At least three of the following signs must be present (four if the mood is merely irritable), leading to severe interference with personal functioning in daily living :
➢ Increased activity or physical restlessness
➢ Increased talkativeness
➢ Flight of ideas or the subjective experience of thoughts racing
➢ Loss of normal social inhibitions, resulting in behaviour that is inappropriate
to the circumstances
➢ Decreased need for sleep
➢ Inflated self-esteem or grandiosity
➢ Distractibility or constant changes in activity or plans
➢ Behaviour that is foolhardy or reckless and whose risks the individual does
not recognize, e.g. spending sprees, foolish enterprises, reckless driving
➢ Marked sexual energy or sexual indiscretions
27
What are the psychotic features of mania?
1. Delusions
• Grandiose Delusions: grandiose ideas become delusions and are usually related to some form of identity or role e.g. special powers or religious content.
• Persecutory delusions: suspicion may develop into well formed persecutory delusions
2. Incomprehensible speech: pressured speech is so great that the clear associations are lost hence cannot understand the resulting speech.
3. Self neglect: preoccupation with their own thoughts and extravagant themes and their distractability may lead to self neglect, so patients may not eat or drink and results in poor living conditions.
4. Catatonic behaviour- manic stupor
5. Total loss of insight
28
What investigations would you do to Dx mania?
```
• Bloods:
FBC, U&Es, LFTs, Glucose, Calcium, TFTs, CRP
• Urine dipstick
• Urine drug screen
• CT head
```
* Physical cause?
* Medications- Steroids, *Antidepressants, Levodopa Drugs
* Thyroid disease, Chronic kidney disease
* Neuro- encephalitis, stroke
29
How do you Dx a hypomanic episode?
A. The mood is elevated or irritable to a degree that is definitely abnormal for the individual concerned and sustained for at least 4 consecutive days
B.At least three of the following signs must be present, leading to some interference with personal functioning in daily living :
➢ Increased activity or physical restlessness
➢ Increased talkativeness
➢ Difficulty in concentration or distractability
➢ Decreased need for sleep
➢ Increased sexual energy
➢ Mild overspending, or other types of reckless or
irresponsible behaviour
➢ Increased sociability or overfamiliarity
30
How do you distinguish mania from hypomania?
- Degree of functional impairment: hospitalisation is a proxy of functional deterioration.
NB: DSM: The duration criteria of 4 days for hypomania and 7 days for mania in DSM is arbitrary; follow-up studies have shown that most hypomanic episodes in bipolar 2 lasts for less than 4 days.
31
What is rapid cycling?
Patient’s who are experiencing ≥4 episodes/year this includes both depression and mania.
32
What are the risk factors for rapid cycling?
- female
- early onset of illness
- hypothyroidism
- poor response to lithium
33
What is the treatment of acute de novo mania?
* Antipsychotics:
e. g. Olanzapine, Aripiprazole, Risperidone
OR
* Lithium
OR
* Antiepileptics (NB: NOT in women of childbearing ag)
NB: Do not offer lamotrigine to treat mania (New recommendation).
+/- Adjunctive benzodiazepine
e.g. Clonazepam or lorazepam (for agitation/ and insomnia)
34
How do you manage manic relapse in a known bipolar patient?
1. Increasing the dose of mood stabiliser must be the first option.
- Lithium: check serum lithium levels and consider establishing a higher serum level if compliance is good. If the person is already on lithium, optimise plasma levels first.
2. Antipsychotic augmentation: consider adding olanzapine, quetiapine, or risperidone to lithium.
Antipsychotic augmentation can also be done for patients on valproate.
3. Antipsychotic for psychosis: For psychosis during a manic or mixed episode that is not congruent with severe affective symptoms, antipsychotics must be used.
```
4. ECT may be considered for:
❖ Severely ill manic patients with lifethreatening severity e.g.
exhaustion
❖ Treatment-resistant mania
❖ Preference for ECT and patients
❖ Severe mania during pregnancy.
```
35
What type of drug is Lithium?
Mood stabiliser
36
What is Lithium used to treat?
treatment/prophylaxis of:
Bipolar, Schizoaffective disorder, depression (recurrent and treatment resistant)
37
What is the benefit of lithium?
- most effective drug at preventing manic episodes
| - 'anti-suicidal effects'
38
What are the side effects of Lithium?
Narrow therapeutic range 0.4-1mmol/L hence its one of the reasons why patients need monitoring to ensure they are not at a sub-clinical/toxic dose
• Common: polyuria, polydipsia, tremor, sedation, Gi disturbance (nausea,
diarrhoea, weight gain),
* Signs of intoxication: course tremor, severe vomiting, impairement of consciousness, severe neurological complications
* Complications of use: Teratogen, arrthymia
* Long term effects: chronic renal failure, hypothyroidism
39
Name 3 mood stabilisers:
1. Lithium
2. Antipyschotic medication
3. Sodium valproate
A highly protein bound drug NOT to be used in women of child-bearing age (risk of neural tube defects)
4. Carbamazepine: CYP450 inducer
5. Lamotrigine: protein bound (55%), not affected by food.
40
What are the SE of Sodium valproate?
- GI upset (nausea, vomiting, dyspepsia, diarrhoea),
- tremor
- sedation
- curly/loss hair
41
What are the SE of Carbamazepine?
- dizziness
- drowsiness
- ataxia
- nausea
- headaches
- rash
42
What are the SE of lamotrigine?
- Rash (Steven Johnson syndrome in 0.04%)
- dizziness
- headache
- GI disturbance
- blurred vision
- sedation
- insomnia
43
What class of anti-depressant do Lofepramine and Imipramine belong to?
A. Tricyclic antidepressant
B. Selective serotonin re-uptake inhibitors (SSRIs)
C. Monoamine Oxidase Inhibitors (MAOIs)
D. Atypical antidepressants
C. TCA
44
What is the NICE recommended first-line treatment for a mild depressive episode?
A. Anti-depressant medication
B. Pyschotherapy
C. Watch and wait
D. St. John's wort
C. Watch and wait
This pt should be reviewed in 2 wks time at GP.
45
What complication is associated with MAOIs?
A. Neuroleptic malignant syndrome
B. Catalepsy
C. Hypertensive crisis
D. Tardive dyskinesia
C. Hypertensive Crisis
46
Which is the only antidepressant licensed for children?
A. Fluoxetine
B. Esitalopram
D. Sertraline
D. Citalopram
C. Sertraline
47
Which of the following is NOT true regarding SSRIs and TCAs?
A. SSRIs produce fewer side effects
B. SSRIs are more effective than TCAs
C. SSRIs are less dangerous in overdose
D. SSRIs are recommended as first line
B. SSRI are more effective than TCAs.
**SSRIs are equally effective to TCAs, but produce less side effects**
48
Which of the following is the superior mood stabilizer?
A. Sodium Valproate
B. Antipyschotic
C. Lithium
D. Agomelatine
C. Lithium
Lithium is the gold standard of mood stabilisers
49
Which of the following is NOT a symptom associated with mania?
A. Reduced need for sleep
B. Inflated self-esteem
C. Early-morning wakening
D. Grandiose ideas
C. Early-morning wakening
In mania, there is reduced sleep, however this does not manifest as early-morning wakening. The pt may sleep very late at night for short periods of time or not at all.
50
Through which 5 pathways can a pt come under the care of the mental health team?
- GP
- Police
- A&E
- Social services
- General hospital
51
What is the hierarchy of psych Dx?
In descending order:
```
Organic
Psychosis
Affective (mood)
Neurosis (anxiety etc)
Personality
No mental illness (including lying)
```
52
What is psychosis?
"loss of connection with reality"
- hallucinations
- delusions
53
What is a hallucination?
abnormal perception in the absence of an external stimulus
e.g. hearing voices
- not subject to conscious control
- elementary/complex
54
What is an illusion?
distorted perception in the presence of an external stimulus
i.e. mistaking a tree for a person
55
What is a delusion?
a false, unshakeable belief
- held in the face of evidence to the contrary
- outside of cultural norms for that individual
- the nature/content of belief
- often bizarre (esp. in schizophrenia)
- can be negative/nihilistic (in context of depression)
- can be grandiose (in context of mania)
56
What are the psychotic illnesses?
1. Organic psychosis
- drug induced
- delirium
- dementia
2. schizophrenia
3. delusional disorders
4. affective disorders
- depressive psychosis
- manic psychosis
57
What is schizophrenia?
- disorder of thinking, perceiving and motivation
| - psychotic disorder with positive and negative symptoms
58
What is the epidemiology of schizophrenia?
```
Lifetime prevalence ~1%
Male = female
age of onset:
- late 20s men, early 30s women
- urban > rural; immigrants . nationals
```
59
What is the aetiology of schizophrenia?
* genetic component
* Neuro-chemical
* neurological structural abnormalities
- reduced brain mass
- increased ventricular size
- EEG changes, soft neurological sings
* developmental factors
* substance abuse esp. cannabis
* stressful/life events
* high expressed emotion
60
What are the positive symptoms of schizophrenia?
- delusions
- hallucinations
- thought disorder
(insertion, withdrawal, broadcast)
- sense of being controlled
(passivity)
61
What are the negative symptoms of schizophrenia?
- loss of motivation
- loss of affect variation ("blunting")
- paucity of thought
- loosening of association
62
What are the affective disorders?
1. Depression +/- psychosis (or unipolar affective disorder)
| 2. Bipolar affective disorder (manic depression) +/- pyschosis
63
What is Beck's triad?
1. Worthlessness
"I am a bad person"
2. Helplessness
" My life is terrible"
3. Hopelessness
" Things will not improve"
64
How is Bipolar affective disorder diagnosed?
A manic episode, with a Hx of at least 1 depressive episode
- oscillated between the two
- can be 1/2 per annum or rapid cycling (>4/yr)
65
What are the neurotic disorders?
* Somatisation and conversion disorders
* Obsessive compulsive disorder
* Generalised anxiety disorder
* Panic disorder
* Post traumatic stress disorder
* Phobias
66
What is a somatisation/conversion disorder?
expression of psychological distress through physical means
- often known as medically unexplained symptoms
67
What is somatisation?
the process of converting psychological into physical symptoms
e.g. atypical cardiac pain, atypical pelvic pain
68
What is a conversion disorder?
loss of function as a result of extreme psychological distress
e. g. loss of:
- memory
- power
- sensory function
- speech
69
What is anxiety?
- impending sense of doom
- persistent sense of fear, anxiety, apprehension
- motor tension
- autonomic hyperactivity
70
What are obsessions?
ruminating, circular thoughts/ideas/images
- intrusive, recurrent and persistent
- recognised as own thoughts
- ego dystonic: recognised as absurd, repugnant
71
What are compulsions?
rituals (compulsive voluntary actions) with desire to resist
** there is a belief that carrying out the compulsions will avert disaster**
72
What is a personality disorder?
a collection of personality traits, that cause problems in most spheres of the person's life
- this creates marked difficulties with interpersonal relationships.
73
What are the postpartum mental disorders?
1. Maternity blues:
3rd - 4th day
2. Postnatal depression
3. Postpartum psychosis
74
How do you assess for postpartum mental disorders?
1. How do you feel about the pregnancy/birth?
2. Support?
3. How are you managing?
4. How do you feel about the baby?
- any abnormalities?
5. Any previous psych Hx
6. Family Hx
7. RISK RISK RISK!!! To baby (death and neglect)/mother/others
75
What are the organic causes of psychiatric presentations?
Surgical sieve:
- tumours
- infection
- inflammation
- metabolic
- drugs (prescribed and recreational)
- cognitive and developmental delay disorders
76
What is dementia?
Chronic, progressive cognitive impairment and/or disturbance of higher cortical functions. There is no clouding of consciousness.
77
What are the primary causes of dementia?
1. Alzheimers (most common)
2. Lewy-Body Dementia (2nd most common)
* characterised by hallucinations
3. Fronto-temporal Dementia
* characterised by loss of inhibition and personality changes
78
What are the secondary causes of dementia?
1. Vascular (3nd most common)
*characterised by step-wise changes
Dx: CT head
2. infective
Dx: VDRL (venereal disease research laboratory) test for Syphillis etc.
3. Metabolic
e. g. B12 and folate
4. Endocrine
e. g. TFTs
79
What are the clinical features of Alzheimers?
Memory loss and personality changes.
- insidious onset
80
What are the risk factors for Alzheimers?
- Female > male (2:1)
- genetic factors
* beta-amyloid plaques, neurofibrillary tangles
- age
- dialysis
- HI
- Down's syndrome
81
What are the clinical features of Lewy Body Dementia?
* Fluctuations in alertness
* Visual hallucinations
* Parkinson's dementia
* Falls, faints
82
What is vascular dementia?
one of more thrombotic or embolic infarcts leading to focal/diffuse neurological signs of dementia.
**step-wise deterioration**
83
What are the risk factors for Vascular dementia?
1. male
2. older age
3. CVS or cerebrovascular disease
4. DM
5. Hypertension
6. Increased cholesterol
7. Smoking
8. alcohol
84
What are the clinical features of Vascular dementia?
1. Mood, personality and behaviour changes (depending on sit)
2. Insight lost (late sign)
COURSE
- Acute onset
- Stepwise progression
85
What is delirium?
Acute fluctuating confusional state with clouding of consciousness, psychotic symptoms and disturbed behaviour
86
What is the aetiology of delirium?
1. Prescribed drugs (esp. steroids)
2. Recreational drugs/alcohol (intoxication/withdrawal)
3. Infective
4. Inflammatory
5. Metabolic
6. Neurological
7. Endocrine
87
What are the clinical features of delirium?
* *fluctuating**
- sundowning (worse at night)
- can be hypoactive, hyperactive or mixed
- can have paranoid ideas
- can have hallucinations (esp. visual)
- can be very frightening for patient and staff
88
What are the features of the psychiatric Hx?
1. Presenting complaint (PC)
2. Hx of PC
3. Past psych Hx
4. Past Medical Hx
5. Medication
6. Family Hx
7. Personal Hx
8. Premorbid personality
9. Substance misuse
10. Social
11. Forensic
12. Collateral
89
How should you begin a pysch Hx presentation?
1. Name, age, gender and ethnicty of pt
2. occupation, marital status
3. IP or OP
4. Referral
5. Mental Health Act status
90
How should you explore the HPC of a pysch pt?
“How have you been feeling recently”
1. Begin with patient’s own narrative and explore
2. Clarify terms e.g. patient says she is “depressed”
3. Timing - onset, triggers, progression,
4. Severity, frequency, duration eg hallucinations • 5. Screen for other possible associated symptoms
6. Treatments initiated, changes and effects
7. Impact of illness
91
How should you explore the past Pysch Hx of a psych pt?
“Have you had any mental health problems in the past?”
1. nature /duration of illness 2. treatments – all types
3. admissions / MHA
4. suicide attempts or self harm
92
How should you explore the past Medical Hx of a psych pt?
“How has your general health been?”
```
1. full medical history including medications
– endocrine
– neurological
– head injury
– infections
```
93
How should you explore the Medication Hx of a psych pt?
* Current
+ doses
* Allergies
94
How should you explore the Family Hx of a psych pt?
"What about your family"
1. ages
2. occupations
3. general health
4. relationship w/ pt
5. divorces/separations/conflicts
6. psych Hx
95
How should you explore the Personal Hx of a psych pt?
"Tell me about you; your background and upbringing"
1. birth details
2. early childhood development
3. childhood health
4. earl emotional stresses
5. education
6. occupational Hx
7. history of abuse
8. key relationships and psychosexual Hx
96
How should you explore the premorbid personality of a psych pt?
"How would other describe you?"
1. relationships
2. predominant mood
3. moral religious beliefs
4. activities and interests
5. reaction to stressors
97
How should you explore the substance misuse of a psych pt?
1. Alcohol
2. Illicit drugs
- first use, progression, dependence
```
TRAP:
Type
Route
Amount
Pattern
```
98
How should you explore the social Hx of a psych pt?
1. current occupation
2. finances
3. residence
4. social contacts
5. interest and hobbies
99
How should you explore the forensic Hx of a psych pt?
"Have you ever been in trouble with the police?"
1. arrests
2. charges
3. convictions
4. crimes of violence
5. associated factors?
6. links with episodes of psychiatric illness
100
How should you take a collateral Hx for a psych pt?
at least one collateral Hx is mandatory/
- if possible see separately?
Informants view on:
1. symptoms and progress
2. causes
3. social issues
4. risks
5. premorbid personality
101
What do you assess in an MSE?
1. Appearance and behaviour
2. Mood
3. Speech
(pressured? appropriate?)
4. Thought content
(formal thought disorder/delusions?)
5. Perception
(hallucinations/illusions?)
6. Cognitive function
(OTTPAP?)
7. Insight
8. Risk
(to self/to others/from others)
9. Capacity
102
How do you assess appearance and behaviour?
Describe a ‘picture of patient’
* assess self care /clothing
* eye contact
* posture and movement /s
* level of activity
* appropriateness of behaviour
* responsiveness -distractibility
* rapport
103
How do you assess speech?
1. spontaneity
2. rate
3. quantity
4. tone
5. flow
6. retardation
7. pressure and flight of ideas
8. Formal thought disorder
104
What type of speech might you find in severe depression?
psychomotor retardation and poverty of thought
105
What type of speech might you find in mania?
marked pressure and flight of ideas
106
Identify the thought disorder?
Do rabbits have tails? Maybe it’s just the males...Ha ha
you could cut them off and send the male’s tails by mail!
Clang
rhyming, punning; links between ideas are understandable
107
Identify the thought disorder?
Totally new word with completely new meaning
or ordinary words used in a special way
eg “The only problem I have is my frustionating!”
Neologism
108
Identify the thought disorder?
Loosening of associations
109
Identify the thought disorder?
Derailment
110
Identify the thought disorder?
Knight's move thinking
111
Identify the thought disorder?
Word salad
112
Identify the thought disorder?
Flight of ideas
113
What are the organic causes of thought disorder?
- dysarthia
- dysphasia
- perseveration
114
How do you assess mood?
1. subjective assessment
2. objective assessment
3. guilt/worthlessness
4. suicidal ideation
115
What are the types of mood?
1. Depression
2. Elation
3. Anxiety
4. Depersonalisation
5. Derealisation
116
What is affect?
Objective expression of mood?
117
How do you assess affect?
1. range
2. appropriateness/incongruity
3. reactivity
118
How do you assess range of affect?
* restricted = reduction
* blunted = severe restriction in emotional expression
* flattened = absence/near absence of any sign of emotional expression
119
How can you ask about suicidal ideation?
Have you ever felt hopeless?
Do you ever feel life is not worth living?
Have you had any thoughts about taking your own life?
Have you any plans to end your life?
120
How do you assess thought content?
1. Preoccupations - worries and concerns
2. Overvalued ideas
3. Obsessional thoughts and compulsions
4. Delusions
121
Identify the type of thought content?
‘A solitary belief that is neither delusional nor obsessional, but which is preoccupying to the extent of dominating the sufferer’s life’
Overvalued Idea
122
Identify the type of overvalued idea?
Body image
Dysmorphia/anorexia nervosa
123
Identify the type of overvalued idea?
Serious illness
Hypochondriasis
124
What is a delusion?
Fixed, false belief held in spite of evidence
- not in keeping with social/cultural background
- usually of great personal significance
125
What are primary delusions?
Delusional mood or delusional perception
126
What is delusional perception?
Two stage process:
1. Normal perception
2. Object becomes invested w/ delusional significance
Eg When the red bus appeared from round the corner I suddenly knew right then that I was destined to be crowned King
127
What are secondary delusions?
Arising form some other morbid experience
e. g. in severe depression:
- guilt, poverty, worthlessness, nihilism
128
What are the types of secondary delusions?
* Reference
* Paranoid
* Grandiose
* Hypochondriasis
* Jealousy
- Morbid jealousy, Otherllo syndrome
* Love
- De Clerambaults
* Infestation
- Ekbom's syndrome
129
What are the types of abnormal perceptions?
1. Illusions
2. Depersonalisation/derealisation
3. Hallucinations
- auditory
- visual
- tactile
- olfactory
- gustatory
130
What are the 5 types of hallucination?
- auditory
- visual
- tactile
- olfactory
- gustatory
131
How to assess auditory hallucinations?
1. content
2. First/Second person
3. Spatial origin
4. Frequency and duration
5. Recognition
6. Commanding
7. Resistance
8. Insight
132
Match the description to the hallucination:
Hears the voice of God as the clock ticked
Functional
Hallucination in the same sensory modality to stimulus (e.g. hearing ==> hearing)
133
Match the description to the hallucination:
Gets a head pain whenever she hears a sneeze and is
convinced the sneezing causes the pain
Reflex
| Hallucination in a different sensory modality to stimulus
e.g. hearing ==> feeling
134
Match the description to the hallucination:
Hears voices talking in London when he is in Birmingham
Extracampine
Hallucination that arises from outside of the sensory field or range e.g. in a different location
135
Match the description to the hallucination:
The patient sees himself and knows it is he
Autoscopy
Hallucination of self.
Can be negative e.g. phantom mirror image
136
Which tests can you use to determine cognition?
MOCA
AMST
MMSE
137
How do you assess cognition?
1. orientation
- time
- place
2. attention and concentration
3. memory
- registration
- recall
138
What is insight?
an individual's perception of their condition
139
What are Schneider's First Rank Symptoms?
1. Auditory hallucinations
- voices arguing/discussing
- voices commenting
2. Passivity of thought
- withdrawal
- insertion
- broadcasting
3. Passivity of:
i. affect
ii. impulse
iii. volition
4. Somatic passivity
5. Delusional perception
140
What is the significance of Schneider's First Rank Symptoms?
Relative to other symptoms of psychosis, the presence of a single FRS is considered sufficient to reach a diagnosis of schizophrenia
141
Which of the following is an example of formal thought disorder:
– Auditory hallucination
– Delusional mood
– Depersonalisation
– Derailment
Derailment
142
Abnormal affect is:
```
– a first rank symptom of schizophrenia
– an aspect of personality
– assessed objectively
– mainly assessed by patient report
– rarely seen in depression
```
Assessed objectively
143
What psychotic symptom is this?
Have you ever felt as if you were receiving messages
• from television, radio, newspapers?’
ideas of reference
144
What psychotic symptom is this?
‘Do you ever feel that your thoughts are being interfered with?’
Thought interference
145
What psychotic symptom is this?
‘Do you ever feel that people can read your mind or that your thoughts are available to others?’
Thought broadcasting
146
What psychotic symptom is this?
‘Have you ever felt as if thoughts are being taken out of your head?’
Thought withdrawal
147
What psychotic symptom is this?
‘Do you feel that people are putting thoughts into your head?’
Thought insertion
148
What psychotic symptom is this?
‘Do you ever feel that you are being controlled in some way, like a puppet?
Passivity
149
What psychotic symptom is this?
‘Do you ever feel that people are trying to harm you or hurt you?’
Persecutory delusion
150
What psychotic symptom is this?
‘Do you ever feel that you are being watched or followed?
Paranoid delusion
151
How do you assess auditory hallucinationa?
1. content
2. # of voices
3. recognition of voices
4. 2nd voice - directly to pt
3rd voice - talk about pt
5. Where are they from
6. inside/outside of head
7. are they real/part of you
8. How long are they there?
9. triggers?
10. effect?
11. 'Do you ever hear your own thoughts spoken aloud?'
- thought echo
12. ‘Do the voices ever tell you to do things?’ – commanding voice
152
How to assess a command hallucination?
1. Content
‘What do they instruct you to do?’
2. Harm (self/others)
‘Do they ever tell you to do bad things, for example hurt yourself or others?’
3. Resistance
‘Do you feel you have to act on them?’
153
How to assess risk to others?
***previous Hx of violence***
* sociopathic PD
* alcohol/substance misuse
* psychosis
* commanding voices
* persecutory delusions
* morbid jealousy
154
What must be explored in suicidal thoughts?
1. Thoughts?
2. Plans?
3. Action (how close they have come)?
4. Prevention (what stopped them)?
155
What are the two essential questions following an episode of direct self-harm (DSH)?
1. Intent
| 2. How they feel afterwards
156
What are the risk factors for suicide?
| Name 5
1. sex (male)
2. age <25 or >45
3. Depression or other mental health
4. Previous attempt
5. Excessive alcohol or substance misuse
6. Rational thinking loss
7. Lack of social support
8. Organized plan
9. No spouse
10. Sickness - physical health problem (esp. chronic/debilitating illness)
Other:
- unemployed
- homeless
- LGBTQ
- access to harmful means (medication or weapons)
- Bullying
- Losing a friend/family member to suicide
157
How do you conduct a suicide risk assessment?
Enquire about BDA
1. Before
- planning
- mood
- previous DSH/suicide attempts
- isolation
- alcohol/drugs
- finals acts (suicide notes, finances in order)
2. During
- method
- purpose (did they
expect to die?)
3. After
- how did they end up in hospital?
- regret?
- intent/plans for further attempts
