Pyschiatry Flashcards
What characterises a PD (personality disorder)
Lifelong, persistent, maladaptive behaviour that - characterises individual, deviates from norm, arises in late childhood/early adolescence
How should a PD manifest?
More than one of:
1) cognition
2) Affectivity
3) Occupational performance
4) Impulse control
5) Interpersonal relationship
What are the class A PDs?
Paranoid/delusional, Schizoid/socially withdrawn, Schizotypical/distorted reality
Sx of paranoid PD?
V sensitive, distrusts loyalty, holds grudges, suspicious, unsubstantiated conspiratorial explanations, will not confide in others, will perceive attacks on their characters
Sx of Schizoid?
No pleasure from any activities, emotionally cold, indifferent to praise, disinterest in sexual activity, few interests, prefers solitary activities
Sx of Schizotypal?
Social deficit, social anxiety, vague, unusual perceptions, inappropriate affect, odd beleiefs and magical thinking, paranoid ideation & suspiciousness, lack of close friends, ideas of reference
Rx for Class A PD?
Not likely to seek, but psychodynamic/group therapy
What are class B PDs?
Histrionic. Borderline, Narcissistic, Antisocial
Sx of Histrionic?
Self dramatization, attention seeking, preoccupied with physical appearance, shallow/liable affectivity, inappropriate sexual seductiveness
Sx of Borderline?
Act without regard, anger outbursts, unstable and intense relationships, quarrelsome, self harm & suicidal behavior, impulsivity eg spending/sex/substance abuse
Sx of Narcissistic?
Grandiosity, ‘special/unique’, requires excess admiration, lack of empathy, sensitive, chronic envy, arrogant & haughty attitude
Sx of Antisocial?
More common in men. unconcern for others’ feelings and social norms, incapacity to experience guilt, prone to blame others, impulsivity, irritability & aggressiveness, irresponsibility, lack of remorse
Rx of class B?
psychodynamic/group therapy/CBT but antisocial often not responsive
What are class C PDs?
Avoidant/anxious, Dependant/asthenic, Anakastic/obsessional
Sx of Avoidant?
Tense, preoccupied with sense of rejection, needs security, avoids social/occupational activities, unwillingness ot get involved, views self as inept & inferior to others
Sx of Dependant?
Allows others to make decisions, preoccupied with worry of inability of self care, needs reassurance, uncomfortable/helpless left alone
Sx of Anakastic/Obsessive-compulsive?
Obsessive doubt, perfectionism, obsessed with rules and order, excessive conscientiousness, stubborn, meticulous, scrupulous & rigid about etiquettes of morality, ethics or values
Rx of Class C PD?
Psychotherapy/CBT with:
- social skills training for anxious
- assertiveness techniques for dependant
- insight orientated
Drugs for PD?
Antipsychotics for impulsivity and intense angry affect
MAOIs for borderline PD to alleviate abnormal mood
What is a delusion?
Disordered thought where a belief is held firmly and cannot be reasoned by rational argument.
- Not within normal educational or cultural or social background held with convivtion - knowledge
self referential and held without insight
- Overvalued idea - false/exaggerated belief sustained beyond logical reason but with less rigidity than a delusion
Delusional perception: delusional belief arising from perception eg traffic lights change - god is talking to me
What are paranoid delusions?
Persecutory: organisation out to get them
Grandiose : Self importance, inflated self esteem, special powers
Self-referential: things are referencing you
Nihilistic: Delusion they are have nothing and are dead inside eg Cotard syndrome - belief they are already dead - associated with major depressive disorder
Religious: To do with God and religion
Misidentification: Family member/friend replaced by imposter (capgras delusion)
Fregoli: Where you think various people you meet are the same people
Intermetamorphasis: 2 People in the environment swap identities with each other whilst maintaining the same appearance
Subjective doubles: Belief that a dopple-ganger is carrying out independent actions
Infestation: skin is infected with parasites causing itching
Unusual delusions?
Egomaniac - man (or woman) of higher social status eg celebrity is in love with them Morbid jealousy (Othello syndrome) - delusion that partner is being unfaithful
What are hallucinations?
False sensory perception in the absence of an external stimulus. Maybe organic, drug-induced or associated with mental disorder.
Describe auditory hallucinations
Hearing voices - 2nd (yourself) or 3rd person, repeating thoughts (thought echo), several voices discussing patient
Other sensory hallucinations?
Visual
Olfactory - bad smell
Gustatory - bad taste
Tactile - objects in contact with skin, bugs crawling over skin
Hallucinations to do with sleep?
Hypnagogic - on going to sleep (normal)
Hypnopompic - on waking up (normal)
Autoscopic - seeing yourself
Pseudohallucination?
a false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating
Describe somatic passivity phenomena
Feeling that actions controlled by others - disorder of thoughts and perception
Describe thought alienation
Jacob Big Bladder.
Thought broadcast: thoughts made available to others
Thought insertion: thoughts placed in head
Thought withdrawal: Thoughts take out of mind
Define concrete thinking
Lack of abstract thinking, normal in childhood - in autism/asperges/schizophrenia
Define circumstantiality
Slow, rambling, convoluted talking but goal directed
Confabulation
Giving false account to fill in gaps
What is flight of ideas and what is it linked to?
Rapid skipping from one thought to distantly/tentatively related. Mania (Knight’s move thinking - illogical leaps from one idea to another - no link)
What is pressure of speech and what is it linked to?
Delivering speech very rapidly with a wealth of associations, pt wanders of topic. In mania
Define anhedonia and what is it linked to?
Inability to experience pleasure from activities once found enjoyable. Depression.
Made acts, feelings and drives
Delusion of organisation removing free will and controlling pts actions and impulses
Clouding of consciousness
Pt is drowsy and does not react to stimuli - disorder of attention, concentration and orientation
Catatonia
High (excitation) muscle tone that is abolished by voluntary movements in absence of organic pathology
Stupor
Patient immobile, mute and unresponsive. (neounconcsiousnes)
Eyes usually open and follow stimuli, reflexes normal and resting posture maintained
Psychomotor retardation
Patient walks/acts/talks slowly with long delay before questions answered in severe deression
What is formal thought disorder and what types are there?
Disorganized thinking as evidenced by disorganised speech - seen in schizophrenia
Derailment/loosening of association: Lack of logical order in conversation leading to incoherent speech and potential thought disorder
Poverty of speech: Lack of content seen in normal speech
Perseveration: Repeating a word, theme or action more than is appropriate
Thought block: pt stops speaking suddenly w/o explanation
Incongruity of effect
Pts mood does not match circumstances/thoughts
Blunting of affect
Absence of emotions in schizophrenia without signs of depression
Belle indifference. What is it a feature of?
Lack of concern about disability and prospect for recovery. Hysterical disorder
Depersonalisation
Pt feels they are not real or altered in some way - detached from body
Derealisation. What is it seen in?
Surroundings do not seem real. Schizophrenia, anxiety, temporal lobe epilepsy
Disassociation
Process whereby psychological processes relating consciousness split - disconnected to themselves/surroundings
Mannerism
Repeated involuntary movements
Stereotyped behaviour
Repeated regular fixed pattern of movement not goal directed
Define Obsession. What disorder?
Repetitive, senseless thoughts - recognised by pt as irrational and unsuccessfully resisted. OCD
Define Compulsion. What disorder?
Repetitive, stereotyped, seemingly purposeful behaviour, often ritualistic. Pt has insight if its uselessness eg cleaning/checking. OCD.
What are the dopaminergic pathways?
Mesocortical/mesolimbic
Structure of and relevance to schizophrenia of mesocortical pathway? Effect of antipsychotics?
Between midbrain and frontal cortex. Negative symptoms of schizophrenia - blunted/apthetic. Dopamine antagonists can worsen symptoms.
Structure of and relevance to schizophrenia of mesolimbic pathway?
Between midbrain and limbic system. Positive symptoms - delusions/hallucinations.
Action and effects of heroin? (tolerance, dependence and SE)
Action: opioid agonist causes euphoria.
Tolerance: builds fast and needs higher doses for same high
Dependence: Psychological - positive reinforcement of euphoria. Physical - aggressive, irritable, autonomic dysfunction, restless on withdrawal, pinpoint pupils, needle track marks
SE: drowsiness, vomiting, depression, mania, psychosis, viral infection (HIV/Hep B), bacterial infection (endocarditis, necritising fasciitis), social problems: crime, prostitution, homelessness
Rx for heroin? - addiction and toxicity
IM/IV Naloxone for acute toxicity (opioid antagonist)
Methadone for addiction (long acting opioid agonist) and buprenorphine titration for maintenance
Clonidine (alpha2 agonist) for detox (symptoms of withdrawal)
psych: CBT/social housing
Harm reduction - needle exchange, testing for HIv/HepB/C
Mechanism and effects of cannabis?
THC and psychomimetic
Effects: relaxing, altered perception, heightened sensual experience increased appetite
Dependence: moderate psychological and physical - anxiety/dysphoria/sleep problems
SE: confusion/hallucination/depression/memory loss/flash backs/demotivational syndrome
Mechanism and effects of amphetamines?
Release of monoamines and inhibition of monoamine reuptake.
Increased motility, euphoria, anorexia, insomnia
Clinical use of amphetamine
Narcolepsy
SE of amphetamines
cardiac arrhythmias, HTN, stroke
Define delirium
Also known as acute confusional state. Acute and fluctuating disturbance of consciousness, attention and global cognition
Causes of delirium?
DELIRIUMS:
Drugs - medical/recreational (opiates, antiepileptics, L-dopa, sedatives, anaesthesia, alcohol withdrawal
Eyes/ears - blindness/deafness
Low O2 - PE, COPD, anaemia. High CO2 will cause drowsiness
Infection - esp UTI (most common)
Retention - urine/faecal
Ictal - seizure or post-ictal
Underhydration or undernutrition - & thiamine, B12
Metabolic - electrolyte disorders, hypoglycaemia
Subdural haematoma, stroke
Signs and symptoms of delirium?
Memory disturbances, reduced consciousness, disorientation in time/place/person, inattention, altered personality, aggression, mood disorder, hyperactivity (withdrawal), lethargy (hepatic encephalopathy), illusion/hallucination, speech problem (aphasic/chaotic), lack insight, SYMPTOMS FLUCTUATE (worse at night) - disturbed sleep, poor attention
Dx of delirium?
History/MMSE/confusion assessment method (CAM): sudden onset, inattention, impaired consciousness that fluctuates (and this different to dementia), psychomotor changes
Examination: Check for infection/focal neurological signs
Bloods: FBC, U&E, LFT, glucose, ABG, infection screen (cultures, CXR, urinalysis)
Rx of delirium?
Treat underlying cause, remove agitating drugs. Haloperidol 1st line Can also use olanzapine Minimise sensory deficits Tranquilise in extreme case
3 different kinds of bipolar?
Bipolar 1: Underlying depression w/ mania/hypomania ratio 1:1
Bipolar 2: Mild mania dispersed w/ mainly depression ratio 5:1
Rapid cyclic bipolar disorder: 4+ episodes of depression and mania in 1 yr
Define mania and hypomania
Both - elevation of mood & irritability
Mania: severe functional impairment/psychotic symptoms for 7 days+
Hypomania: Decreased or increased function for 4 days+, less severe than maniawith no psychotic features
Causes of bipolar
Genetic predisposition if first degree relative - cyclothymia - elevated mood dispersed w/ low mood - esp if 1
Medical conditions: pregnancy, CVA, thyroid disease, antidepressants, steroids, alcohol and CANNABIS
Sx of bipolar?
Euphoria >2 weeks = manic episode
General increased activity, inappropriate behaviour, pressure of speech, recklessness (sexual encounters, dangerous driving), decreased sleep, grandiose delusions
Depression, irritable mood, anger outbursts, hallucinations
Dx of bipolar?
History and mental state exam
Elation or irritable mood- 3+ symptoms and 1+ episode in 1 week
Mania w/ psychotic symptoms lasting 1-2 weeks
DD of bipolar?
Mania from drugs, unipolar depression, schizophrenia, borderline PD (rapid cyclic bipolar episodes)
Components of a mental state exam?
Appearance, Behaviour, Speech, Mood, Thoughts, Perception, Cognition
Rx of Bipolar?
Mania: atypical antipsychotics. (olanzapine, quetiapine), Lithium/mood stabilisers (2nd line = valproate)
Depression - same as above, avoid antidepressants - though can use fluoxetine. (2nd line = lamotrigine)
Cyclic: Clozapine
Maintenance: Education/psychodynamic therapy/mood diary
Primary care referral: if hypomania - routine referral to community mental health team (CMHT)
Mania/severe depression - urgent referral to CMHT
Mechanism of Lithium carbonate?
Inhibits production of cAMP and inositol triphosphate
V narrow therapeutic range (0.4-1.0mmol/L). Excreted by kidneys
SE of Lithium
Level (0.4-1mmol/L) or Leukocytosis
Insipidus - nephrogenic diabetes - increased ADH
Tremor - fine but coarse in toxicity
Hydration - dry mouth, diarrhoea, polydipsia –> AKI (nephrotoxic) - check U&E 6/12. Also Hyperparathyroidism & hypercalcaemia
Increased GIN&V), skin and memory problems
Underactive thyroid - check TFTs 6/12
Metalic taste in mouth/Mums beware - Ebstein’s phenomenon - heart valve defects of foetus in first trimester
Also weight gain, T wave flattening/inversion
Signs of Lithium toxicity and Rx of toxicity?
> 1.5mmol/L: Exacerbated by dehydration, renal failure, diuretics (thiazide), ACE-I, A2RBs, NSAIDs & metronidazole
Features: Oliguria, confusion, vomiting, seizures, coarse tremor, dysarthria, ataxia, hyperreflexia, coma
Rx: Mild -Hydration w/ normal saline. ITU, benzos, haemodialysis if v severe
Risk factors for depression?
Genetic: predisposition
Childhood trauma: abuse, parent alcoholism, neglect, disruption in relationship
Neurobiological: Stress in early life –> cortisol –> high level of serum corticosteroids –> affects neuronal plasticity (HPA axis)
Personality type: anxious, neurotic, low self esteem
Situational: divorce, unemployment, chronic disease, bereavement
Low socioeconomic status
Major/core Sx of depression?
Depressed mood, anhedonia, fatigue
Minor symptoms of depression
weight change, disturbed sleep (waking 2/3 hours before normal)/insomnia/hypersomnia (atypical depression), reduced diet, inability to think/concentrate, psychomotor retardation/agitation, reduced libido, reduced emotional ability (no emotions = melancholia), feelings of worthlessness/guilt, recurrent thoughts of death/suicide, memory problems
Somatic = biological symptoms = more severe
Psychotic Sx of depression
Delusions - personal inadequacy, excess guilt over misdeeds, responsibility of world issues, ned to be punishment
Hallucinations - mood congruent, accusatory auditory
Visual: demons, death
Olfactory: bad smells, rotten food, faeces
Catatonic: psychomotor retardation (depressive stupor)
What are the subtypes of depression?
Mild: 2 major + 2 minor Moderate: 2 major + 3+ minor Severe: 3 major + 4+ minor Somatic: With biological symptoms Psychotic: Severe depression w/ psychotic symptoms
What screening tools are available for depression?
Hospital Anxiety and Depression Score (HADS) - 14qs (7 for depression, 7 for anxiety) - each from 0-3 - score /21 (11+ needed)
Patient Health Questionnaire (PHQ-9) - ‘Over the last month have you been troubled by following problems’
ICD-10 depression inventory
What investigations would you add for depression?
Bloods: FBC, U&E, glucose, calcium, TFTs, LFTs
If indicated: ABG, thyroid antibody, dexamethasone suppression (Cushings), Cosyntropin (Addisons), CT
Depression DD?
Psych: anxiety, bipolar, eating disorder,
Neuro: MS, parkinsons, stroke
Endocrine: menopause, Addisons, Cushings, hypothyroidism
Other medical condition: Anaemia, SLE, substance misuse
Treatment for depression?
Mild: Wait, CBT, self help, short psychological interventions, sleep hyfiene
Moderate/Severe: CBT, antidepressants (SSRI -fluoxetine/citalopram 1st line, then try other SSRI (when switching, stop 1st then change unless it is fluoxetine - have 4-7day gap due to longer half life, then other drugs (SNRI/MAOI), social support
Treatment resistant/atypical/psychotic: Cocktail of antidepressants, complex therapy
High risk: All of above, add ECT, hospital admission
What is the monoamine theory of depression?
reduced monoamines eg tryptophan (precursor of 5-HT) –> less serotonin –> depression
What are SSRI? Mechanism? CI and why? SE?
Selective serotonin reuptake inhibitors - eg fluoxetine/citalopram
Inhibits reuptake of 5-HT from synaptic cleft –> more serotonin. Takes 4-6 weeks to work.
CI: MAOI - can lead to serotonin syndrome - triad of autonomic hyperactivity, neuromuscular excitation (hyperreflexia), altered mental state
Drugs that prolong QT - amiodarone
NSAIDs/aspirin - GI bleeding
warfarin/aspirin - use mirtazapine
Triptans - avoid SSRIs
SE: weight gain, prolonged QT (citalopram), GI symptoms (can give PPI), agitation & anxiety (starting), decreased seizure threshold, hyponatraemia (older people)
GROUPS TO BE CAUTIOUS: older people, young people
Pt should continue for 6 months to achieve good remission if reacting well.
Discontinuation: dose gradually reduced over 4 weeks. Paroxetine = most discontinuation symptoms.
Symptoms: increased mood change, restlessness, unsteadiness, sweating, GI - pain, cramp, diarrhoea, vomiting
paraesthesia
What are SNRIs? Mechanism? CI? SE?
Serotonin Noradrenaline Reuptake Inhibitors - eg Venlafaxine
Potentiates NT release - inhibits reuptake of serotonin and NAd
CI: same as SSRI - MAOI
SE: increases BP, sexual dysfunction, weight gain, agitiation, hyponatraemia
What are MAOI? Mechanism? CI?
Monoamine oxidase inhibitors (inhibits enzyme which prevents breakdown of monoamine) - eg phenelzine, isocarboxazid
CI: dietary restriction: wine, cheese, beer, smoked meat - contains tyramine - not broken down –> NAd release –> hypertensive crisis
When should you use amitriptyline? What is it? What are side effects?
Second line when others fail, used in neuropathic pain
triclyclic - blocks reuptake of NAd/serotonin
Inhibit NAd, serotonin reuptake - acts on Musc, a1/a2, H1, D2
SE: blocks action of histamine, alpha-adrenergic, dopamine –> blurred vision, dry mouth, constipation, urinary retention, insomnia -
“can’t see, can’t pee, can’t spit, can’t shit”.
Anti muscarin: constipation, dry mouth, retention
Anti-cholinergic effect: overflow incontinence
Histmaine: sedation
A1/2: hypotension
DA: Dyskinesias, breast changes
Cadriac: Long QT, arrhythmias
CNS: Seizures, hallucinations
Other important SE of antidepressants?
Serotonin syndrome and
Hyponatraemia: Muscle cramps, drowsiness, confusion
GI bleed - give PPI as stomach protection
Upon sudden withdrawal: insomnia, headaches, flu like symptoms, GI upset –> titrate down slowly esp w/ venlafaxine
Indication of ECT? How is it done? SE?
Treatment resistant depression/mania, catatonia in schizophrenia.
General anaesthetic, electrodes on non dominant tempral lobe and induce tonic clonic seizure
SE: Death, status epilepticus, impaired memory formation (retrograde amnesia most common), post ictal drowsiness, headache, cardiac arrhythmias.
Absolute CI: raised ICP
When to admit to hospital for depression?
Serious risk of suicide/harm to others (esp children), serious self neglect, severe psychotic symptoms, lack of social support
Risk factors and management of post natal depression?
Single mother, PMHx of depression, unwanted pregnancy, poor social support, severe baby blues, previous post-partum psychosis
Manage: Edinburgh post natal depression scale, early identification of high risj mothers, CBT, meds. Social support and r/o risk to child
What is formulation?
Going beyond the dx, creating meaningful narrative and biological/social/psychological explanations to patients condition
Describe CBT
Cognitive behavioural therapy. 6-20 brief sessions.
1st wave: behavioural - thoughts and feelings follow behaviour - work on changing behaviour
2nd: cognitive aspect and behavioural. - work on changing thoughts as feelings follow.
3rd wave: add mindfulness and acceptance techniques
What is exposure therapy used for and how it performed?
Used for phobias, OCD, PTSD. Safe exposure under supervised condition. Works on troubling thoughts/feelings/memories. Techniques to avoid rituals/thoughts. Addresses symptoms as avoidance increases anxiety.
What is counselling?
Short sessions which helps patient cope with recent events and does not aim to change to patient as a person.
What is cognitive analytical therapy?
A therapy to help patients link events in their early life and how this developed into the issues they have today.
What is interpersonal therapy?
Therapy which works on strengthening how patients form interpersonal relationships.
What is dialectic behavioural therapy?
CBT/Behavioural therapy aimed at people with borderline PD. Helps patients manage their emotions, and accept who they are. Group or individual.
What is family therapy?
Therapy given to family as a group often in CAHMS. Helps family members strengthen their relationship with one another and think about different ways of behaving with each other.
What is marital therapy?
Therapy given to couples which deals with issues and stressors the partners are facing.
What section in ICD-10 are psychiatric illnesses in?
F
What is an S12 approved doctor?
A doctor who can make recommendations under part 2 of the Mental Health Act (1983)
What are the underlying principles of the Mental Health act?
Respect patients’ past and present feelings and wishes. Include the pts thoughts when planning treatment. Minimise limitations on liberty. Don’t discriminate unlawfully. Ensure safety and wellbeing of patient and public.
Describe Section 2 of MHA
Patient detained in hospital for up to 28 days for assessment of mental health. 2 drs needed - 1 S12 approved, 1 who knows patient (eg GP) and one approved mental health practitioner (AMHP). Pt needs to be suffering mental health disorder and is risk to owns/public’s health
Describe section 3 of MHA.
Detained for up to 6 months for treatment - can be following S2 or if patient known to services
Describe section 4 of MHA
Detained for up to 72 hours in emergency if needing to wait for 2nd dr. Prevent undesirable delay
Describe section 5(4) of MHA
Already admitted but wanting to leave. Nurse prevents from leaving (holding power) for up to 6 hours because they think you are too unwell to leave. Must be reviewed by dr. Can then undergo section 5(2)
Describe section 5(2) of MHA
Already admitted. Drs have holding power of pt wanting to leave. Detained for up to 72 hours to wait for section 2 or 3 assessment.
Describe section 135 of MHA
Police obtain permission form a court and AMHP to enter home and take you to safe place.
Describe section 136 of MHA
Police can take you to safe place when they suspect you have a mental disorder and are putting yourself/public at risk in a public place. They suspect you need immediate care.
How is CAMHS different from adult mental health services?
Community based as much as possible, few drug rx, more therapies, emphasis on involving family and school
What factors are important for psychological development at different ages?
Pre/post natal: pregnancy smoking/drinking, milestones, parents mental health, post natal depression
Toddler: Main carer? any change in carer when mum went to work, how was separation/attachment? language development, any abuse
School years: how was separating from parent, friends/bullying, academic achievement, how did they find move to secondary school, what was home life like?
Teenage years: Social life? drugs/alcohol/risky behaviour? any LD missed/ any hyperactivity? Any autistic traits eg odd interests/obsessions? Difficulty coping with change?
Significance of childhood maltreatment/abuse?
Higher incidence of medical/psychological diagnoses - depression, schizophrenia, CVD, cancer, allergies
Describe the attachment theory
A child needs to have a relationship with at least primary caregiver for the full psychological and emotional development and to learn how to regulate emotions.
Diagnostic features of general anxiety features?
At least 4 of (including 1+ of autonomic hyperactivity:
Autonomic: palpitations, sweating, shaking, dry mouth
Physical: Breathing difficulty, choking, chest pain, N+V, light headed, abdo distress, hot flushes, muscle tension/aches, on edge
Mental: dizziness, depersonalisation/derealisation, difficulty in concentrating/getting to sleep, fear of going crazy/death
Medical conditions that could cause anxiety?
depression, arrhythmias, COPD, asthma, hyperthyroid, SLE
Management of GAD?
Stepwise approach:
1) Education + active monitoring
2) Low intensity psychological intervention eg self help/psychoeducational groups
3) High intensity psychological interventions eg CBT/drug treatment
4) highly specialist input eg multi-agency teams
Drugs: sertraline is 1st line SSRI, warn about suicidal thinking, weekly follow up in forst month
What are benzodiazepenes (eg lorazepam/diazepam) used for and how do they work?
Anxiety/sedation for surgery
Facilitate GABA binding
What is the CI of benzos and what are side effects?
Bronchopulmonary disease is CI
SE: drowsiness, ataxia, coma.
Withdrawal after dependence can cause rebound anxiety, insomnia
What is a panic attack and what is panic disorder?
Attack: intense fear with rapidly developing symptoms for about 10-30 mins. can be spontaneous (out of blue) or situational (triggered by situation)
Disorder: recurrent panic attacks
What are the Sx of panic disorder?
Autonomic: tremor, tachycardia, tachypnoea, HTN, sweating, GI upset, palpitation, feeling of choking/inability to swallow (globus hystericus)
Death concerns - from cardiac/resp symptoms
unexplained chest/back/GI pain/headache
derealisation/depersonalisation
Check for suicide/homicide thought
Dx of panic disorder?
Elicited in hx. Check bloods to exclude physical cause
Rx for panic disorder?
Stepwise:
1) recognition & diagnosis
2) primary care rx - CBT or SSRI. If CI or no improvement in 12 weeks - offer imipramine or clomipramine
3) Review & consideration of alternative treatments
4) review & referral to specialist mental health services
5) Care in specialist mental health services
What is agoraphobia?
Fear of situations that are hard to escape eg crowds/public places
Rx of phobias?
SSRI, short term benzo
Exposure training and CBT
What is social phobia and how does it present?
Extreme anxiety restricted to social situations
Blushing/trmbling/emabarressment
Avoidance –> difficult to maintain relationships
What is obsessive-compulsive disorder and what is it associated with?
Chronic disorder assicated with depression/anxiety and obsessions - obsessive thought eg contamination
+ Compulsive acts Checking/washing/doubting/counting
Associated with depression, substance misuse, ating disorder
PD esp dependent/anakastic/histrionic
How is OCD managed?
CBT - including exposure & response prevention (ERP)
SSRI, 2nd line is clomipramine (specific anti-obsessional)
ECT if especially incapacitated
Prognosis: 1/3 significantly improve, 1/3 moderately improve, 1/3 chronic course
What is PTSD and what are risk factors?
Post traumatic stress disorder. Severe psychological disturbance following traumatic event, causing involuntary re-experiencing of elements of event and hyper-arousal, avoidance and emotional numbing.
RF: low social/educational class, female, low self esteem, refugees, soldiers
Sx of PTSD?
6 months after event, last for 1 mo
2+ symptoms of HARD:
Hyperarousal -increased pyshcological sensitivity and arousal:
poor sleep, anger
Avoidance: avoidance of circumstances, inability to recall aspects of exposure
persistent
Re-living: remembering/reliving stressor
Dull/numbed emotions - feeling detached from others
How is PTSD managed?
Watchful waiting for milder symptoms <4/52
Trauma focussed CBT, education
Eye movement desensitization and reprocessing, stress management, hyponotherapy
SSRI (sertraline), zopiclone (sleep), benzos for anxiety
olanzapine for psychosis
What is conversion disorder?
Loss/disturbance of normal motor/sensory function due to psychological cause.
Paralysis, loss of speech/sensation
NEA seizures, amnesia
What is somatisation disorder and how is it managed?
Repeated presenation of medically unexplained symptoms lasting longer than 2 yrs associated with severe psychological distress. Pt refuses to accept reassurance or negative results
Excessive use of medical services, anxiety/depression disorders
Rx: clear explanation and reassurance. If ongoing, regular review by single dr, exploring symptoms
Group therapy/CBT
What is hypochrondiarchal disorder and how is it managed?
Preoccupation with fear of having serious medical condition despite negative medical tests. Has ruminations, overvalued ideas and consults medical advice, pt refuses to accept reassurance or negative test results
Rx: Clarify symptoms are real, SSRI, CBT
What is somatoform pain disorder and how is it managed?
Complaint of persistent severe pain with no organic pathology but psychological factors.
Rx: recognise and treat depression, hypnosis and CBT
Pain clinic: anaethetic led, nerve blocks, transcutaneous electrical nerve stimulation (TENS)
What is psychosis?
Major personality disorders marked by gross emotional and mental disruptions, leading to inadequate self-management and adjustment to society.
What is schizophrenia?
A functional psychosis, whereby there is no organic neurological pathology and has cardinal features of hallucinations and delusions.
What percentage of people have at least 1 psychotic episode?
1%
What is the aetiology of schizophrenia?
Childhood eccentricity, clumsiness, socially withdrawn
depression/anxiety, periods of intense stress, drugs (eg hallucinogens, stimulants)
Family history
Perinatal: In utero viral infection, hypoxic birth injury
What are the positive symptoms of schizophrenia?
Hallucinations - visual/auditory (single/multiple voices/critical/commentary/thought echo), olfactory/tactile
Delusions - persecutory, passivity, reference, intereference
Incongruity of affect (inappropriate emotional response), formal thought disorder, word salad (using mixed up words and nonsense sentences), derailment, neologism (making up new words), flight of ideas, pressure of speech, circumstantiality
What are the catatonic symptoms of schizophrenia?
Strange physical symptoms where pt does not respond to external stimuli
Stupor, mutism, strange posture (catalepsy), negativism (pt does opposite of what you ask them - motiveless resisatnce to movement), waxy flexibility (strange muscle tone allowing abnormal posturing), mannerisms, echolalia (imitating speech), echopraxia (mimicking actions), logoclonia (repetition of last syllable of a word), palilalia (repetition of a word over and over again), verbigeration (repetition of one or several sentences)
What are Schneider’s first rank symptoms of schizophrenia?
- Auditory hallucinations - voices argue, thought echo, commentary
- Delusions of organisation controlling body - passivity
- Delusions of thought interference - insertion, withdrawal, broadcast.
- Delusional percept - A primary delusion that is reported by the pt following an abnormal experience of percept eg traffic light turned green so I am king
What are the negative symptoms of schizophrenia?
Similar to depression - impairment of motivation and spontaneous response, loss of awareness of socially appropriate response, flattening of mood, blunting of affect, anhedonia
Guilt/hopelessness/worthlessness/low self esteem
Alogia (impoverished thinking), poverty of speech/thought
What re the diagnostic features of schizophrenia?
At least one of Scheider's first rank symptoms OR at least 2 of: Any hallucination/delusion Derailment/neologism/Thought disorder Catatonic symptoms Negative symptoms
For more than a month
What are the different types of schizophrenia?
Paranoid - delusions/hallucinations, often persecutory about organisation, angry and violent
Heberphrenic - disorganised thinking, word salad, agitated
Residual - mainly negative symptoms
Simple - gradual decline and development of oddities
catatonic - psychomotor disturbance
gradual onset = worse prognosis
Investigations of schizophrenia?
Full psych hx and mental state exam, with systematic review
Drug screening
EEG - r/o epilepsy
fasting glucose - r/o diabetes
Bloods - FBC/U&E, TFT
Full neuro exam including CT/MRI -r/o organic lesion eg encephalitis, space occupying lesion, hydrocephalus
Infection screen: syphilis, HIV
DD of schizophrenia?
Alcoholic hallucinations, bipolar, drug intoxication (cannabis, cocaine, MDMA, psilocybin)
Neurodegenerative: dementia, PD
Structural: SOL, temporal lobe epilepsy, delirium, encephalitis
Endcrine: thyrotoxicosis, post partum pyschosis
Meds: steroids, antimalarials
Describe the management of schizophrenia.
Many managed in community with help of crisis resolution team (CRT), may need to be detained. Bio-psycho-social
PHARMACOLOGICAL: 1st line - atypical antipsychotics eg olanzapine, quetiapine, aripiprazole, respiradone (PO/IM)
2nd line - clozapine (treatment resistant)
PSYCHOLOGICAL: CBT, family therapy, ECT in catatonic cases, art therapy
SOCIAL: structured activities (OT), healthy eating programes, peer supprt
When should a schizophrenic pt be admitted to hospital?
High suicide/homicide risk, endagers relationships, catatonic/negative symtoms which prevents adequate self-management, lack of co-operation with meds and non-complient to treatment plan
Name some typical antipsychotics and how do they work?
Haloperidol, chlorpromazine, prochlorperazine
Anatgonist of post-synaptic D2 receptors
What are the C/I and SE of typical antipsychotics?
CI: drugs which prolong QT interval (amiodarone, macrolides)
SE: Extrapyramidal SE (EPSE):
Acute dystonic reaction (emergency): sustained muscle contractions - muscle spasms, acute torticollis, ocular gyrate crisis (eyes rolling back in upwards gaze) -> mx=procyclidine and benztropine
Parkinsonism: resting tremor, bradykinesia, rigidity (though bilateral rigidity rathe than unilateral in PD)
Akathisia: severe restlessness, irresistible need to move -> mx= propranolol
Tardive dyskinesia: choreoathetoid movements - abnormal, involuntarty chewing/jaw pouting movements - grimacing, tongue protrusion, lip smacking, rapid eye blinking-> mx= tetrabenzine
What are the atypical antipsychotics and what is the mechanism?
Risperidone, quetiapine, olanzapine, clozapine, aripiprazole.
D2 anatognist but increased efficacy as higher affinity for 5-HT2a and looser binding of D2
What are the CI and SE of atypical antipsychotics?
CI: QT prolonging drugs (amiodarone, macrolides)
SE: sedation, EPS, metabolic disturbance, sexual dysfunction, parkinsonism (quetiapine)
Neuroleptic malignancy syndrome
Raised prolactin - galactorrhoea & metabolic syndrome: impaired glucose tolerance, hypercholesterolaemia, increased BMI/central obesity
(aripriprazole most tolerable SE w/ least prolactin elevation)
Antimuscarinic - dry mouth, blurred vision, urinary retention, constipation
Risk of clozapine?
Agranulocytosis, aplastic anaemia and neuroleptic malignancy syndrome
Monitor regularly w/ FBC
SE = constipation/intestinal obstruction
reduces seizure threshold
What is dementia and how should it be managed in general?
A syndrome with progressive, reversible, global cognitive deficits
R/O cause of cognitive decline - PINCH ME
Pain, Infection, nutrition, constipation, hydration, medication, environment
Assessment of cognition (MMSE, Addenbrookes)
AChE inhibitors - donepezil, rivastigmine
Treat depression w/ SSRI, psychosis w/ antipsychotic
Psychological therapies to pt and carer
Functional OT - mobility, self care, toilet, feeding
Social - accommodation, activities, finance
How many people have Alzheimer’s?
700,000 in UK, 30m world wide
Risk factors and protective factors of Alzheimer’s?
RF: Down’s syndrome, head injury, hypothyroidism, Parkinson’s
Protective: smoking, oestrogen, NSAIDs
What are the main pathological features of Alzheimer’s?
Macroscopic: widened cerebral atrophy esp in cortex & hippocampus
Beta amyloid plaques (beta pleated sheets) deposited in cortex, hippocampus and amygdala.
Neurofibrillary tangles - phosphorylated tau protein in cortex, hippocampus and substantia nigra
Biochem: deficit of ACh from damage to ascending forebrain projections
What are the important genes in AD?
amyloid precursor protein (APP) - chrms 21
apolipoprotein E4 - chrms 19 - encodes a cholesterol transport protein
Presenilin 1 (c14) and 2 (chrms 1)
What are the clinical features of AD?
Early: failing memory - esp in recall, disorientation, poor ADLs
Middle: intellectual decline, personality change, aphasia, apraxia, agnosia, acalculia, impaired visuospatial skills, difficulty finding words
Late: Dependent, incontinence, gait abnormality, spasticity, psych (delusions/hallucinations/depression), behavioural (aggression, sexual disinhibition)
What is Gerstmann syndrome?
R parietal dysfunction - finger agnosia, disorientation, acalculia
What is Charles-Bonnet syndrome?
Hallucinations when older person is blind
How can a pt with AD be assessed?
History, MSE (consciousness clouding/depressive symptoms), MMSE, Addenbrookes cognitive exam - <85 suggests impairment
Bloods - r/o causes - FBC, U&E, LFT, Ca, TFT, B12/folate, ferritin, ceruloplasmin, uine dip
What imaging techniques can show AD?
CT - parietal/mesial temporal cortical atrophy, ventricular enlargement
MRI - atrophy of grey matter
Single photon emission tomography (SPECT) - reduced cerebral blood flow (rCBF) in temporal/posterior parietal lobes
Mx of Alzheimer’s> SE?
Non-pharm: range of activities to promote wellbeing, tailored to persons preference, group cognitive stimulation, group reminiscence 2nd gen AChE inhibitors tha enhance ACh at cholinergic synapses eg Donepezil, galantamine and rivastigmine - SE: GI problems, bradycardia insomnia. Donepezil CI for bradycardia 2nd line (not tolerating AChEI or add on for moderate - severe: Memantine - an NMDA receptor partial antagonist - binds glutamate in CNS Antipsychotics if pt at risk of harming themselves/others, or agitation/hallucinations/delusions causing severe distress
Name a first gen AChE inhibitor and why is not used?
Tacrine - causes hepatotoxicity
Name some risk factors for vascular dementia
Hypertension, hyperlipidaemia, coagulopathies, valvular disease, family history
rare: cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)
What pathological processes underpin vascular dementia
Thromboembolic and hypertensive infarction of small medium sized strokes
Cognitive decline after single stroke (esp w/ midbrain and thalamic stroke
Multi-infarct - multiple strokes causing stepwise deterioration
Progressive small vessel disease: multiple microvascular infarcts causing progressive lacunae formation and leukokariosis causing gradual cognitive decline
What are the clinical features of vascular dementia?
Stepwise deterioration, rapid decline in specific fucntion
Depression, affective lability, confusion
Symptoms fluctuate with partial recovery
Focal neurological signs
Relatively preserved personality & insight
How should you manage vascular dementia
Screen with MoCA (Monreal cognitive assessment)
CT head
Establish cause and teat
Daily aspirin, diet change, stop smoking, manage HTN/diabetes, anti platelets
What is the pathological feature of dementia with lewy bodies (DLB)?
Lewy bodies - eosinophilic intracytoplasmic neuronal inclusions of abnormally phosphorylated neurofilament proteins aggregated with ubiquitin and alpha-synuclein
What are the Sx for DLB?
Parkinsonism (bradykinesia, resting tremor, rigidity)
Fluctuating cognition, visual hallucinations, depression, REM sleep disorder, progressive cognitive impairment
What investigations for DLB?
CT/MRI - sparing of medial temporal lobes, periventricular lucencies, deep white matter lesions
Single-photon emission CT (SPECT) - known as DaTscan - dopaminergic iodine-123-radiolabelled 2-carbmethoxy-3-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (123-I FP-CIT_ is radioisotope. V sensitive + specific
Rx for DLB?
AChEIs & memantine AVOID NEUROLEPTICS
Pathological features of Fronto-temporal dementia (FTD)?
Bilateral atrophy of frontal and anterior temporal lobes (Knife blade atrophy)
Spongiform degeration of neurophil, gliosis, (Picks Disease - has tau/ubiquitin inlcusions)
Sx of FTD?
Onset before 65
Insiduous onset
Profound personality change with decline in social conduct followed by cognitive decline
Emotional blunting, perseverative behaviour - eg drinking from empty cup
How is FTD managed?
Imaging - knife blade atrophy
EEG for Dx
No treatment but manage symptoms
What is Creutzfeldt-Jakob disease and what causes it?
A prion disease that is rapidly degenerative, aggressive dementia caused by proteins throughout the brain - induce formation of amyloid folds resulting in tightly packed beta amyloid sheets resistant to proteases.
Pathology is spongy encephalopathy.
Causes: Iatrogenic - corneal grafts.
Features: rapid onset dementia & myloclonus
Ix: CSF is usually normal
EEG: biphasic, high amplitude sharp waves (only in sporadic CJD)
MRI: hyperintense signals in the basal ganglia and thalamus
New variant CJF - younger pts (25) - anxiety, withdrawal symptoms, dysphonia
Describe late onset schizophrenia.
Paraphrenia - later onset (45+). Delusions and hallucinations present but less emotional blunting and negative symptoms.
Partition delusion - people/objects can transgress through walls
Risk factors for late onset schizophrenia?
Social isolation, sensory deficits (visual/auditory), reclusive and suspicious pre morbid personality
Rx for late onset schizophrenia?
Low dose antipsychotics
What is delusional disorder?
Long standing delusions (3/12) in older people about illness, being spied on, infidelity, poisoned
Describe psychotic depression in the elderly
Depression with nihilistic delusion, owing money, burden to others, 2nd person derogatory auditory hallucinations, olfactory hallucinations, somatic delusions of pain and unable to swallow
What is a unit of alcohol?
(ml X ABV%)/1000
Describe alcohol and drug abuse
Maladaptive pattern of use causing health/social/legal problems and establishes a dependence syndrome:
Drug seeking behaviours which take priority over other activities
Inability to control craving to use
Build up of tolerance.
If abstain, likely to reuse in 2-3 days and get withdrawal symptoms (and consume drug to prevent symptoms)
Narrowing of repertoire.
Continued to use despite harm
Classes of alcohol abuse?
Class A: anxious, acute onset
Class B: Long standing problem, family Hx, drug use, personality disorder
Physical effects of alcohol?
CVD: increased BP, arrhythmias (AF/alcoholic cardiomyopathy)
Hepatic: hypoglycaemia –> lactic acidosis –> fatty acids –> fatty liver, cirrhosis, portal hypertension, oesophageal varcises, hepatitis
GI: oesophagitis, gastritis, pancreatic
sexual: increased desire but decreased function and long term loss of libido
Neuropsychiatric effects of alcohol?
from high alcohol, low B12 and low thiamine: peripheral neuropathy, delirium tremens, Wernicke’s encephalopathy, dementia, poor sleep, alcoholic amnesia (blackouts), depression.
alcoholic hallucinosis - hallucinations
morbid jealousy/Othello syndrome
Assessment of alcohol abuse?
CAGE questions, history, breath test, raised gamma GT in blood, carbohydrate deficient form of transferrin (v sensitive)
What advice would you give to an alcoholic?
Sensible drinking amounts - 14 units spread over the week
2+ alcohol free days
no safe limit
set limit
do not drink alone or woth heavy drinkers
alternate soft and alcoholic drinks
Non alcoholic activities
What is motivational interviewing?
A process that enables pts to move through stages of change - FRAMES
Feedback of risk of self harm
Responsibility (their own)
Advice to cut down
Menu - different options
Empathy
Self efficacy - build confidence - follow up and review progress
What are the stages of change?
Precontemplation, contemplation, planning, action, maintenance, termination
Why might someone relapse?
Ambivalent motivation, , insufficient support, mental illness, environmental stressors
What is alcohol withdrawal syndrome?
Mechanism: chronic alcohol consumption enhances GABA mediated inhibition in CNS & inhibits NMDA-type glutamate receptors. Withdrawal leads to opposite of this - decreased GABA & increased glutamate.
6-12h from last drink - coarse tremor, sweating, insomnia, tachycardia, N&V, psychomotor agitation, anxiety, muscle cramps, tinnitus, hallucinations and in extreme cases, tonic clonic seizures after 36hrs
What is delirium tremens?
Acute confusional state secondary to alcohol withdrawal.
Medical emergency. 48-72hrs onset from last drink.
Increased risk by severe dependence, infection, liver damage.
Sx: clouding of consciousness, disorientation, amnesia, marked psychomotor agitation, hallucinations, worse at night, heavy sweating, paranoid delusions, raised temperature, cardiovascular collapse, death
Rx: benzodiazepine - chlordiazepoxide
Management of paracetamol overdose?
If within 1 hour - can be given activated charcoal to reduce absorption
N-acetylcysteine - if staggered OD/doubt over timeframe - also if joining line of paracetamol level >100mg/L after 4 hours & 15mg/L after 15 hours
Liver transplant according to Kings College Hospital criteria: arterial pH <7.3 after 24H or all of following:
PT > 100s, creatinine >300umol/L, grade III/IV encephalopathy
Psych team review
Antidepressants and CBT
Describe how patients are managed on alcohol detoxification
In controlled environment - hospital ward with alcohol team
Benzodiazepenes for withdrawal symptoms and preventing seizures (chlordiazepoxide and diazepam)
B12 and thiamine
Fluids
If in DT: potentially add in haloperidol
Carbamazepine can be used
Psychological therapy for detox?
Counselling - relapse prevention
Group therapy - alcoholics anonymous
Apart from benzos, what other drugs can be used for alcohol detox?
Oral thiamine if lacking in diet
Aversive - disulfiram: inhibits acetaldehyde dehydrogenase –> unpleasant flusing, headaches, N&V, tachycardia
Anti craving: Acamprosate (weak NMDA antagonist) and naltrexone
What is Wernicke-Korsakoff syndrome?
Made up of Wernicke’s encephalopathy and Korsakoff’s psychosis secondary to thiamine (B1) deficiency
Describe Wernicke’s encephalopathy and its treatment
Petechial haemorrhages and gliosis in periventricular and periaqueductal grey white matter
Tetrad of acute confusional state, ophthalmoplegia (CN6 palsy), ataxia, peripheral neuropathy, tachycardia
Ix: decreased red cell transketolase, MRI
Rx: IV Pabrinex (thiamine)
Describe Korsakoff’s psychosis and its management
Caused by untreated wernicke’s encephalopathy causing disconnection of mammillothalamic tract and inability to lay down new memories (antero- & retrograde amnesia)
Rx: thiamine, multivitamin replacement
Describe alcohol related brain damage
Cognitive impairment whilst sober - short term memory, long term recall, skills, executive functioning
Caused by cortical and subcortical atrophy
Eventually can get alcoholics dementia - intellectual decline
What is frontal lobe syndrome, cause? Presentation? Treatment?
Impairment of frontal lobe
Cause: Head injury, CVA, Tumour
Sx: disinhibition, irritability, aggression, mood change, speech problem
Rx: Atenolol, speech therapy
What is a complex partial seizure (focal onset impaired awareness)?
A seizure originating in the medial temporal lobe and associated with change in consciousness.
How does a complex partial seizure present? ->now called focal onset impaired awareness
Pre ictal: aura, derealisation/depersonalisation, hallucinations
Ictal: automatism: impaired consciousness, wandering off, aggression
Post ictal: delirium, paranoia, reduced consciousness, psychosis
How are complex partial seizures treated? Now called focal onset impaired awareness
Carbamazepine
What endocrine conditions are associated with psychiatric symptoms?
Cushings, Addisons, Hyper/Hypothyroid, Hyper/hypoparathyroid
How would acute dystonic reaction present and how is it managed?
Sustained muscular spasms - abnormal twisting postures after antipsychotics - torticollis, jaw opening, grimacing, dysphasia, tongue protrusion
Rx: discontinue drugs, IM anticholinergics (procyclidine, benzatropine), switch drug to lower propensity of EPSE
Describe serotonin syndrome and its management
Causes: MAOI, SSRIs, ecstasy, amphetamines
autonomic hyperactivity - hyperthermia, altered mental state, neuromuscular excitement - hyperreflexia, myoclonus, rigidity, confusion, agitation, diarrhoea, coma.
Rx: stop drugs, IV fluids. lorazepam IV, serotonin antagonist - cyrproheptadine/chlorpromazine in severe cases. NaCO3 (against rhabdomyalysis)
What is neuroleptic malignant syndrome and what causes it?
A rare reaction to antipsychotic medication of DA activity in the striatum (causing rigidity) and hypothalamus (causing hyperthermia). Caused by rapid anti-psychotic initiation/dose increase, withdrawal from anti-Parkinson meds
How does neuroleptic malignant syndrome present and how is it managed?
Hyperthermia, rigidity, confusion, altered mental state, tachycardia, tachypnoea, incontinence, retention
Rx: benzodiazepenes, IV fluids and NaCO3 for rhabdomyalsis (could cause renal failure), dantrolene for rigidity in severe cases
Cause of Down’s syndrome?
Trismony of chromosome 21 - from increased maternal age (40+), macaism - mixture of normal and trisomic cell lines
Clinical features of Down’s syndrome?
Low intellect, delayed developmental milestones, short stature, muscular hypotonia, brachycepahy, low anteroposterioir diamteter, underdeveloped bridge of nose, low set ears, Brushfield’s spots on iris, Valve defects, Hirshrungs, single palmar crease, syndactaly (webbed fingers), clinodactyly (curved hands), strabismus, myopia, nystagmuys, sensineural deafness, delayed puberty, depression, autism, risk of Alzheimers
Describe the cause of and presentation of Fragile X syndrome
More common in males due to protective second X chrms in females
CGG repeats at fragile sites in X chrms
Sx: large testicles and ears, mitral valve prolapse, hernias, epilepsy, variable LD, depression and anxiety
Describe an autistic patient
Abnormal social relatedness - global impairment of language & communicatrion. poor eye contact, failure to develop relationships, reduced interest in shared enjoyment, lack of empathy, difficulty with conversation, stereotyped language,
Interests: odd interests, rituals
Neruo: seizures, tics, intense sensory responsiveness, irritability and temper tantrums
How should autism be managed?
MDT of psychiatrists, psychologists, paediatricians, SALT, OT, autism behaviour checklists
Structure, routine, predictability
Special schools, behaviour modification and CBT
Family education, support, advocacy
Drugs for sx management - antipsychotics, SSRIs
What is Asperger’s syndrome?
Severe impairment in reciprocal social interactions with repetitive behaviour patterns and restricted interests with normal IQ and language
What are the diagnostic features of ADHD?
PERSISTENT: Inattention - careless, appears to not listen, poor organisation, easily distracted
Hyperactivity - fidgets, runs, loud
Impulsiveness - excessive talking, interrupts
Symptoms present by 7
Must be major functional disturbance - holds back in 2 settings
Before 16 - needs 6 features, 17+ - needs 5 features
What are the long term and short term problems with ADHD?
Short: Sleep, esteem, relationships,
Long: comorbidity, poor employment/financial, antisocial
How would you assess someone with ADHD?
10 week watch & wait period to observe symptoms
Family and child interviews and assessment by MDT
Observe child in 2 settings - home and school
Collateral info - from school/gp
Connors rating scale, Strengths and Difficulties Questionnaire
What is the management of ADHD?
Psycho-education, behavioural interventions - positive reinforcements, fidget tools, break tasks down at school, counselling/CBT, Treat comorbidity
What pharmacological treatments are available for ADHD?
Drug therapy only if 5+, last resort
Methylphenidate - CNS stimulant (DA/norepinephrine reuptake inhibitor)= Ritalin and longer lasting Equasym XL. (SE anxiety, isomnia, anorexia, growth suppression - thus monitor height & weight every 6/12 - , abdo pain, nausea).
Also - Atomoxetine - non-stimulant NE reuptake inhibitor and stimulant (SE liver dysfunction, suicidality)
Lisdexamfetamine if inadequate response to methylphenidate
Dexamphetamine if started on lisdexamfetamine & benefitted but cannot tolerate SE
Drugs are potentially cardiotoxic - do ECG
What is anorexia nervosa and who is at risk?
A marked distortion of body image and a pathological desire for thinness. Mainly young upper/middle class females
What are the risk factors for anorexia nervosa?
Family - over-protective, lack of conflict resolution, parents pre-occupation with food
Individual - dysmorphia, early life dietary problems, lack of sense of identity
What are the physical consequences of anorexia?
Gs + Cs raised- GH, glucose, glands (salivary), cortisol, cholesterol, carotinaemia. reduced body mass index lanugo hair (fine downy hair), bradycardia hypotension enlarged salivary glands hypokalaemia low FSH, LH, oestrogens and testosterone raised cortisol and growth hormone impaired glucose tolerance hypercholesterolaemia hypercarotinaemia low T3
Dx+ assessment for anorexia nervosa?
DSM 5 criteria: 1) Restriction of energy intake relative to requirments -> significantly low body weight in context to age, sex, developmental trajectory, physical health
2) Intense fear of gaining weight or becoming fat, even though underweight
3) Disturbance in way in body image experience - which has undue influence on self evaluation or denial of the seriousness of current low body weight
Full psych hx - features of depression and obsession with food
Management of anorexia nervosa
Children/young people: anorexia focused family therapy as 1st line, CBT as 2nd
Adults: one of: individual eating-disorder-focussed cognitive behavioural therapy (CBT-ED), Maudsley anorexia nervosa treatment for adults (MANTRA), specialist supportive clinical management (SSCM)
Hospital admission if rapid/excess weight loss, severe electrolyte imbalance/physical implications, suicide risk
Precaution with refeeding - cardiac decompensation (congestive heart failure), bloating and oedema
What is bulimia nervosa & how is it managed?
Recurrent episodes of binge eating, with lack of control & with compensatory behaviours (ie intentional vomiting/other purgative behaviours eg laxatives/diuretics/exercising)and over-valued ideas about the ideal body shape
Occurs at least once a week for 3/12
Mx: bulimia-nervosa-focused guided self help for adults
If ineffective after 4/52 - eating disorder focused CBT
What is insomnia?
Difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality. This is despite adequate time and opportunity for sleep and results in impaired daytime functioning.
Chronic if 3 days per week for 3/12+
Primary causes of insomnia?
Psychophysiological: associated w/ cononcerns of inability to sleep, adjustment sleep disorder - due to change/stress
inadequate hygiene, idiopathic, childhood behavioural
Secondary causes of insomnia?
Medical: pain, resp, parkinsons, anxiety, depression, heart failure
Drugs: alcohol, antidepressants, anti-Parkinson meds, bronchodialtors, stimulants, corticosteroids
Management of insomnia?
Ix: Pt interview, sleep diaries, actigraphy, polysomnography if suspected sleep apnoea
Short term: Education - sleep cycle, age changing sleep, nature of issues (mental/physical health)
Hygiene - winding down, no caffeine, avoid naps, go to bed when sleepy, limit screen time
Relaxation training
Medication - short term Z drugs (zopiclone, zolpidem), benzos, sedating anti-depressants - mirtazapine
What is Munchausen’s syndrome and how should it be managed?
Patients falsify symptoms and past histories to attain medical attention. Sometimes wander between hospitals, associated w/ PD.
By proxy: carers/nursing staff stmulate/prolong illnesses in dependants
Rx: challenge, state if some investigation doesn’t show positive it is fictitious, offer support
What is an extracampine hallucination?
Hallucinations outside the reams of possibilities eg I can see behind me
What is pareidolia?
An ill-defined random stimulus that is given meaning without conscious effort
What is conversion?
An unconscious mechanism of symptom formation - psychological conflict into somatic symptoms
Where is serotonin made? Where does it act? What does it do?
Made in raphe nucleus
Works in the nucleus accumbens, prefrontal cortex, hippocampus
Memory, mood, sleep and cognition
Mirtazapine - how does it work?
Na and serotonergic
Alpha 2 blocker
-> noradrenergic and specific serotonergic antidepressant
Psychological therapies used in moderate dementias?
Cognitive rehabilitation
Cognitive stimulation
Reminiscence
Key principles of Mental Capacity Act?
You must be treated as if you have capacity unless it is proven you do not
You must be supported to make your own decisions including being given information in different ways.
You have a right to make unwise decisions as long as you have capacity
Anything done for you must be in your best interests
Anything done for you must be the least restrictive option available
How is lithium therapy monitored?
NICE & National Patient Safety Agency (NPSA) After starting lithium levels performed weekly & alter dose until stable - once dose changed check 12 hours after & 1 week later
Once established - check every 3/12
Thyroid & renal function checked every 6/12
Pts issued w/ information booklet, alert card & record book
Concerns of SSRIs & pregnancy?
1st trimester - small increased risk of congenital heart defects
3rd trimester - persistent pulmonary hypertension of the newborn
Paroxetine has increased risk of congenital malformations
What is dissociative disorder?
A process of ‘separating off’ certain memories from normal consciousness
Psychiatric symyptoms - amnesia, stupor (not physical symptoms - in conversion disorder)
Dissociative identity disorder (DID) - new term for multiple personality disorder
Types of frontotemporal degeneration?
Pick’s disease - most common type of FTD - personality change & impaired social misconduct, hyperorality, disinhibition, increased appetite, perseveration behaviours - focal gyral atrophy w/ knife-blade appearance (atrophy of frontal & temporal lobes)
Microscopically: pick bodies (spherical aggregations of tau protein), gliosis, neurofibrillary tangles, senile plaques
Chronic progressive aphasia (CPA) - non fluent speech, short utterences which are agrammatic. Comprehension preserved
Semantic dementia - progressive aphasia, fluent speech but with little meaning. memory better for recent events
What is a clang association?
ideas that are linked by rhyme or similarity of word sounds alone. This is sometimes seen in schizophrenia or bipolar disorder.
What is malingering?
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Adverse effects of anti-psychotics in the elderly?
stroke and VTE risk increased
Drugs that cause hyponatraemia?
chlorpropramide, carbamazepine, selective serotonin reuptake inhibitor (SSRI) antidepressants, tricyclic antidepressants, lithium, MDMA/ecstasy, tramadol, haloperidol, vincristine, desmopressin, fluphenazine.
What can cause a rise in blood clozapine levels?
cessation of smoking
Starting/smoking more can reduce levels.
