Week 2 Flashcards
Schizophrenia
A form of psychosis, is characterised by distortion to thinking and perception and inappropriate or blunted affect.
Reduced/blunted affect
Reduced emotional reactivity in an individual.
A failure to express feelings either verbally or non-verbally, especially when talking about issues that would normally be expected to engage the emotions.
Strongest risk factor for developing Schizophrenia
Family history
Other risk factors, other than family history for schizophrenia
Black Caribbean ethnicity Migration Urban environment Cannabis use + illicit substances 2nd trimester viral illness Increased parental age Social isolation
Most common form of psychosis
Schizophrenia
Hallucinations
Can be defined as perceptions in the absence of stimuli. Most commonly auditory but may be visual or affect smell, taste, or tactile senses.
Usually third person talking (talking about me) relatively specific to schizophrenia
Type of auditory hallucinations in Schizophrenia
Usually third person talking (talking about me) relatively specific to schizophrenia
2nd order talking
Talking TO me
Third person talking (auditory hallucinations)
Talking ABOUT me
Delusions
a fixed, false belief not in keeping with cultural and educational background.
Symptoms of Schizophrenia
Auditory hallucinations in 3rd person Voices commenting on the patient's behavior Thought insertion, withdrawal, echo & broadcasting Passivity phenomena Delusional perceptions impaired insight Incongruity/blunting of affect Decreased speech Neologisms Catatonia
Passivity phenomena
Bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Neologisms
Made up words
Catatonia
Abnormality of movement and behavior arising from a disturbed mental state. It may involve repetitive or purposeless over activity, or catalepsy, resistance to passive movement, and negativism.
Such as excitement, posturing or waxy flexibility, negativism, alogia, mutism and stupor.
Flight of ideas
Refers to a thought disorder, wherein there are abrupt, rapid shifts in the conversation topics. The affected individual quickly moves from one topic to another
Alogia
Poverty of speech
Avolition
Lack of self-will/ lack of the drive/will to act
What is a risk for an schizophrenic individual?
Increased risk of suicide and cardiovascular disease
Possible theories for developing schizophrenia (pathogenesis)
Include increased size of the ventricles and reduced whole-brain volume.
Increased activity of dopamine in the mesolimbic region is associated with symptoms of psychosis. It is likely numerous other neurotransmitters are involved in the pathogenesis.
What drugs are risk factors for schizophrenia?
Amphetamines (increase Dopamine in brain)
Cocaine
Cannabis
Novel psychoactive substances (e.g. Ivory Wave, Spice)
Diagnosis of Schizophrenia by ICD-10 - Criteria 1
Psychotic episode lasting for at least one month & one (or more) of the following is present:
- Thought echo, insertion, withdrawal, or broadcasting.
- Delusions of control, influence or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations, delusional perception.
- Hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing him between themselves, third person hallucinations (talking about me)
- Persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. being able to control the weather or being in communication with aliens from another world).
Diagnosis of Schizophrenia by ICD-10 - Criteria 2
Psychotic episode lasting for at least one month if two (or more) of the following are present:
- Persistent hallucinations in any modality (auditory, taste, smell and touch) when accompanied by delusions, or when accompanied by persistent over-valued ideas.
- Neologisms,
- Catatonic behavior
- “Negative” symptoms such as marked apathy (complete lack of emotion), paucity of speech, and blunting or incongruity of emotional responses
Different types of hallucinations
Auditory, taste, smell and touch
Mutism
Inability to speech
Stupor
Daze/state of unconsciousness
The different sub-types of schizophrenia
Paranoid schizophrenia
Hebephrenic schizophrenia
Catatonic schizophrenia
Undifferentiated schizophrenia
Paranoid schizophrenia
Predominant symptom is that of what are stable, normally paranoid delusions. These are often accompanied by hallucinations (often auditory) but catatonic symptoms and those of abnormal affect, volition and speech are normally absent.
Hebephrenic schizophrenia
Affective (mood) symptoms are prominent with abnormal behaviour, such as depression, anxiety, lethargy, feelings of guilt etc. Negative symptoms are significant and social isolation may result.
Catatonic schizophrenia
Predominant symptoms are those of psychomotor disturbance and may exhibit both hyperkinesis (extreme or excessive activity of a part of the body, especially the muscles) and stupor as well as automatic obedience and negativism. Other features may include episodes of violent excitement.
Undifferentiated schizophrenia
Those that meet the diagnostic threshold but do not fit into one of the above categories.
Hyperkinesis
Extreme or excessive activity of a part of the body, especially the muscles
Investigations for schizophrenia
Other conditions excluded especially autoimmune encephalitis (in particular anti–NMDA receptor encephalitis).
Screen for Illicit drugs and alcohol if necessary
Trauma investigations
Prior to starting an antipsychotics; what investigations should be done?
- Weight
- Height
- Waist circumference
- Pulse and blood pressure
What assessments should be recorded prior to starting to anti psychotic medications?
- Assessment of any movement disorders
2. Assessment of nutritional status, diet and level of physical activity
Two generations of antipsychotics
Typical
Atypical
What is a serious side effect of anti-psychotic drugs?
Close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
Dystonia
Uncontrolled and sometimes painful muscle movements (spasms) and tremor. Basically muscles contract involuntarily, causing repetitive or twisting movements
Tardive dyskinesia
Which refers to uncontrolled repetitive movements such as smacking lips together
Side effects of typical anti-psychotics drugs
Dystonia
Tardive dyskinesia
Agranulocytosis and bone marrow suppression
Examples of typical anti-psychotics drugs
chlorpromazine flupentixol haloperidol levomepromazine perphenazine prochlorperazine
Examples of Atypical anti-psychotics drugs
Risperidone quetiapine olanzapine ziprasidone clozapine
Side effects of Atypical anti-psychotics drugs
Significant weight gain and insulin resistance. Agranulocytosis & Bone marrow suppression
Extrapyrimidal side effects e.g. dystonia and tardive dyskinesia less common (unlike typical anti-psychotics)
Management of schizophrenia
- Oral atypical antipsychotics are first-line
- Cognitive behavioural therapy should be offered to all patients
- Cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients
Difference between children and adult disorders
Children less likely to manage individual psychological therapy and lack verbal abilities to talk about emotions
Children may have less insight into the difficulties (they are identified by others) and may not engage
Some adolescent psychological therapies have variable evidence based
Medications are commonly unlicensed for under 16s
Children tend to have less predictable medication responses (+/- more side effects
Compliance with medication is less consistent
Presentations mainly seen in Children and Adolescents (0 – 18 years)
- Oppositional defiant disorder in under 12s
- Conduct disorder (CD) diagnosed in over 12s
- ADHD and ASD
- Separation anxiety (SAD) and school refusal
- Trauma and Attachment Disorders
Oppositional defiant disorder (ODD)
Uncooperative, defiant, and hostile toward peers, parents, teachers, and other authority figures. They are more troubling to others than they are to themselves.
Conduct disorder (CD)
Children show an ongoing pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These rule violations may involve breaking the law and result in arrest.
Presentations mainly seen in adults (18 - 65 years)
Puerperal psychosis
Postnatal depression
Puerperal psychosis
Characterized by acute sudden onset of psychotic symptoms, manic symptoms/disinhibition, confusion
It is a psychiatric emergency due to safeguarding risks
Disorders of the puerperium such as Puerperal psychosis
The period of about six weeks after childbirth during which the mother’s reproductive organs return to their original nonpregnant condition
Postnatal depression
o 1 in 10 women (same as depression); as opposed to postnatal blues that are present in 50-75% of women
o Usual onset 1-4 weeks postpartum
Risk factors for Postnatal depression
Family/personal history of depression or anxiety, Complicated pregnancy
Traumatic birth,
Relationship difficulties
History of abuse or trauma,
Lack of support and financial difficulties
Risk factors for Puerperal psychosis
Previous thyroid disorder Previous episode, Family history, Being unmarried First pregnancy, c-section, and perinatal death
Presentations mainly seen in Old Age (>65 years)
- Dementia
- Delirium
- Pseudo-dementia
Pseudo-dementia
Appears similar to dementia but does not have its root in neurological degeneration. The term “pseudo” refers to the actual lack of the neurodegenerative dementia
Delirium
As Dementia, it is linked to aging brain - A disturbed state of mind or consciousness, especially an acute, transient condition associated with fever, intoxication, and certain other physical disorders, characterized by symptoms such as confusion, disorientation, agitation, and hallucinations.
Anxiety disorders
A type of mental health condition and makes it difficult to get through your day. Symptoms include feelings of nervousness, panic and fear as well as sweating and a rapid heartbeat.
Genetic factors that predispose to anxiety disorders
> Biological vulnerability to inherit a fearful disposition
Abnormal function of serotonin, norepinephrine, dopamine, and GABA
Irritable, shy, cautious, and quiet temperament
Limbic system can be overactive
Cognitive factors that predispose to anxiety disorders
o Attentional biases (failure to consider alternatives)
o Selective attention (focusing on one thing)
o Distorted judgments of risk
o Negative spin on non-threatening situations
o Select avoidant solutions
o Selective memory processing
o Tendency to remember anxiety-provoking cues/experiences
o Perfectionistic beliefs
o Inflated sense of responsibility
Management of mild anxiety
CBT
Management of unresponsive/moderate-severe anxiety
o SSRIs (sertraline, fluoxetine, fluvoxamine, citalopram)
o Up to 12 weeks to effect
o Continue for 1 year
Medical management of depression
o SSRIs are first line o Consider augmentation with low dose antipsychotic if poor response to at least 2 SSRIs– (Quetiapine, Risperidone, Aripiprazole or Olanzapine) o Venlafaxine (SSNRI), Mirtazapine (tetracyclic) in older group can be considered as alternatives to SSRIs
Functions of self harming
o Coping with intense emotions
o Communicating distress
o Re-connecting with self (feel again) and others
o An attempt to end one’s life (i.e. suicide intent)
o A lifesaving act
Biological basis of self harming
o Self-harm promotes the release of endorphins
o Because it brings temporary distress reduction - through negative reinforcement, these behaviours tend to be repeated
Non-suicidal self-injury
Periods of optimism and some sense of control
Successful decrease in discomfort
Frequently chronic and repetitive
Intent to relief from unpleasant emotions
Uncomfortable but intermittent psychological pain
Choices available – ‘temporary solution’
Suicidal self-injury
Hopeless and helplessness central
No release of discomfort after self-injury
Generally not chronic or repetitive
Intent to escape pain or end consciousness
Unendurable, persistent psychological pain
Tunnel vision – ‘one way out’
Initial management of self harming patients
o Educate about signs of distress in themselves and others
o Use of positive coping skills
o Learn about the difference between self-injury and suicide and normalise the experiences
o Some people will just want to be heard and empathised with
o Refer to specialist mental health professional for assessment of risk and underlying causes
Autism spectrum disorder (ASD)
It refers to five different disorders that are all under the umbrella - All have different degree of severity, but they all have in common is the qualitative impairment in social interaction and communication as well as repetitive stereotyped behaviour, interests, and activities.
The 5 different disorders under the Autism spectrum disorders classification
o Asperge’s Syndrome o Rett’s Syndrome o Childhood Autism o Pervasive Developmental Disorder o Pervasive Developmental Disorder NOS
Kanner’s syndrome + childhood disintegrative disorder?
Different impairements of ASD
o Social communication
o Social interaction
o Social imagination
o Repetitive behaviours
Other medical associations of ASD
o fragile X syndrome
o tuberous sclerosis
o seizure disorders (epilepsy)
o and hearing and visual impairments
Social communication symptoms of ASD
o Generally good language skills but find it hard to grasp the underlying meaning of conversation
o Difficulties understanding jokes, idioms, metaphors and sarcasm
o Voices often sound monotonous
o Language can be pedantic and idiosyncratic
o They often have narrow interests which dominate their conversations (lack of reciprocity)
o Difficulty sharing thoughts and feelings
Social Interaction symptoms of ASD
o Difficulties picking up non-verbal cues
o Appear self-focused and lacking in empathy, when in fact, they are simply trying to figure out social situations
o Continually struggle to make and sustain personal and social relationships
Causes of ASD
In some cases, autistic behaviour can be caused by:
o Rubella (German measles) in the pregnant mother
o Tuberous sclerosis
o Fragile X syndrome
o Encephalitis (brain inflammation)
o Untreated phenylketonuria (PKU)
Neurobiology of ASD
- Frontal lobes, amygdala and cerebellum appear pathological in autism
- The amygdala in boys with autism appears 13-16% larger, which is associated with more severe anxiety and worse social and communication skills
- No clear and consistent pathology emerged for autism.
Sensory impairment symptoms in ASD
~ Finds some flavours and foods too strong and overpowering because of very sensitive taste buds
~ Smells can be intense and overpowering. This can cause toileting problems
~ Noise can be magnified, and sounds become distorted and muddled
~ Inability to cut out sounds – notably background noise, leading to difficulties concentrating
~ Touch can be painful and uncomfortable. Dislikes having anything on hands or feet
~ Difficulties brushing and washing hair
~ Only tolerates certain types of clothing or textures.
~ Poor depth perception, problems with throwing and catching, clumsiness
~ Easier to focus on a detail rather than the whole object
~ Has difficulty getting to sleep as sensitive to the light
Management of ASD
- Learning and development, improved social skills, and improved communication
- Decreased disability and comorbidity
- Aid to families
ADHD diagnosis by DSM-V
Defines ADHD as a condition incorporating features relating to inattention and/or hyperactivity/impulsivity that are persistent. For children up to the age of 16 years, six of these features have to be present; in those aged 17 or over, the threshold is five features
Adult ADHD impacts
- Increase in frequency of psychiatric comorbidity as compared to children
- Higher levels of criminality, antisocial behaviour
- Higher level of substance misuse (self-medication?)
- Significant impairments in occupational function
Childhood ADHD impacts
- Significant difficulties parenting ADHD children
- Increased level of home stress
- Emotional dysregulation leads to difficulties in peer relationships and reckless and dangerous behaviour
- Poor problem-solving ability leading to developmentally inappropriate decision making
- Significant barrier to learning and potentially exclusion from education
- Higher likelihood of antisocial behaviours
Epidemiology of ADHD
More common in boys than in girls (M:F 4:1);
Most diagnosed between the ages of 3 and 7;
There is a possible genetic component
Genetic factors in ADHD
- Studies found hyperactivity tends to aggregate in families
- ADHD shows familial clustering both within and across generations
- There is strongly increased risks for ADHD among the offspring of adults with ADHD
- There is about a 15% increased risk of ADHD in siblings of children with ADHD
- Mainly dopamine and serotonin transporter genes involved
Management of ADHD
Following presentation, a ten-week ‘watch and wait’ period should follow to observe whether symptoms change or resolve.
If they persist then referral to secondary care is required.
Drug therapy should be seen as a last resort and is only available to those aged 5 years or more. Methylphenidate is first line in children
Why do investigations need to be carried out before giving ADHD medications?
Methylphenidate or lisdexamfetamine are first line options.
All of these drugs are potentially cardiotoxic. Perform a baseline ECG before starting treatment and refer to a cardiologist if there is any significant past medical history or family history, or any doubt or ambiguity.
What is the Mental Health Act for?
Protects rights of people with a mental disorder
Ensures those with a mental disorder receive effective care & treatment
The 5 Criteria for Detention under the Mental Health Act
- (Likely) Mental Disorder
- Significantly Impaired Decision-Making Ability
- Determining treatment required
- Significant risk
- Informal/voluntary care not appropriate
Significantly Impaired Decision-Making Ability (SIDMA)
As a result of a mental disorder, the patient’s ability to make decisions about medical treatment is significantly impaired
Emergency Detention Order
72 hours assessment – temporary doctor holding power – section 5 (2)
> Does NOT authorize treatment
> Fully registered doctor (FY2 and above)
> Where possible, a mental health officer (social worker with training in mental health act) should also agree to it
Short Term Detention Order
Up to 28 days for assessment/treatment – section 2
Approved medical practitioner plus a Mental health officer
> Likely mental disorder
> Right of appeal (patient & named person)
> Can be extended by 3 days if extra time is needed to put together an application for a CTO or 5 days once CTO application submitted
When can an emergency detention order be used?
o To save the patient’s life
o To prevent serious deterioration in the patient’s condition
o To alleviate serious suffering
o To prevent the patient from being a danger to themselves or others
What are the exceptions for using detention orders?
- Electroconvulsive Therapy
- Nutrition by artificial means
- Vagus Nerve Stimulation
- Transcranial Magnetic Stimulation
- Medicines for the purpose of reducing sex drive
- Neurosurgery (with patient consent or additional protections)
Compulsory treatment Order
Initially up to 6 months – section 3 - Approved Medical Practitioner plus Mental Health Officer
> Mental disorder present
> Reports from 2 independent doctors
> MHO makes the application to the tribunal service
> Mandatory tribunal
> Treatment authorised (for up to 2 months of detention)
> Renewal at 6 months then yearly
Advance Statements
>
Written statement Signed when the person is well How they would prefer (or prefer not) to be treated if they were to become ill in the future Witnessed and dated Tribunal and medical practitioner must regard this It can be overruled
Named person
This is someone who will look after the person’s interests if he or she has to be treated under the Act. RMO – Responsible Medical Officer; the medical practitioner, usually a consultant psychiatrist, who is responsible for the person’s care and treatment.
Advocacy
Every person with a mental disorder has the right of access to independent advocacy
Advocacy means getting support from another person to help you express your views and wishes, and help you stand up for your rights.
Public support for or recommendation of a particular cause or policy.
Mental health tribunal
Organised by Mental Health Tribunal Service for Scotland
> Decide on CTO applications/appeals
> Panel – a psychiatrist, a convenor (solicitor) and a third person with other experience
> Take place in hospital
What is valid consent?
o Given freely without duress or coercion o Legally capable of consenting o Cover the intervention/procedure o Informed o Enduring
What to Consider when Obtaining Consent
o What the treatment consists of
o The main beneficial effects
o Risks and unwanted side effects
o Consider Written/visual aids, Translators, Friends/relatives and Time to reflect
Capacity
Is the ability to decide
- Understand and retain relevant information
- Use and weigh that information to decide
- Communicate that decision
Power of attorney
- Granted whilst they have capacity
- Powers to act as their continuing (financial) and/or welfare attorney
- In case capacity is lost at some future point
- One or more persons
Guardianship
A guardianship order allows you to make on-going decisions on behalf of a loved one with a mental illness, allowing them to experience a better quality of life outside of the hospital.
Granted by the sheriff
Welfare and/or financial
Person requires someone to make specific decisions on their behalf over the long term
Mental Health (Care and Treatment) (Scotland) Act 2003
Allows for treatment of mental disorder or physical consequences of mental disorder in someone without capacity to consent to treatment.
