1
Q
Define hallucination.
A
A perception in the absence of a stimulus.
2
Q
What are hypnagogic and hypnopompic hallucinations?
A
Hypnagogic – state before falling asleep
Hypnopompic – state before waking up
3
Q
What are the 4 main kinds of hallucinations?
A
- Auditory
- Visual
- Olfactory
- Gustatiry - taste (often unpleasant)
- Tactile - i.e. sense of bugs crawling all over you
4
Q
Define extracapine hallucinations.
A
A sense of presence/movement in the absence of such a stimulus (i.e. someone is near you)
5
Q
Define elemental hallucinations.
A
Ssimple hallucinations - e.g. flashing lights, noises etc
6
Q
Define Charles de bonnet hallucinations.
A
Recurring hallucinations in someone with impaired vision.
7
Q
Define illusion.
A
An altered perception of a real object
8
Q
Define pareidolic illusion.
A
Perceived meaningful images from vague stimuli (i.e. seeing a face in a fire)
9
Q
Define delusion.
A
A fixed, false belief, held despite evidence to the contrary that is not explained by the patient’s background.
10
Q
Define mood incongruent.
A
Behaviours that are not consistent with a patient’s current mindset or are at conflict with current situational factors.
- Laughing at a funeral/in depressive state
- Manic state patient believing a news disapproves of them
11
Q
Define mood congruent.
A
Behaviours that are consistent with a patient’s current mindset or are at conflict with current situational factors.
12
Q
Define persecutory/paramoid delusions.
A
Patient, or a loved one, are being hunted by the FBI
- most common type of delusion
13
Q
Define passivity/control delusions.
A
Patient belives someone else is controlling them
- somatic passivity = sensations being imposed on them
14
Q
Define grandiose delusions.
A
A delusion in which one believes they are someone of great importance
15
Q
Define reference delusion.
A
Patient thinks they are receiving messages in the dialogue of a TV programme (the reference)
16
Q
Define somatic delusions.
A
Delusion related to the body and functions rather than mind
- Ekbom’s syndrome = a belief that one is infested with parasites
17
Q
Define Ekbom’s syndrome.
A
Belief that one is infested with parasites
18
Q
Define hypochondriasis.
A
Unconsciously pretending they have a medical illness
19
Q
Define Munchausen.
A
Consciously pretending they have a medical illness as they have satisfaction in taking a sick role
20
Q
Define Munchausen by proxy.
A
A person abusing another person to take them in for care
- Mother abuses child to take child in for care
21
Q
Define malingering delusions.
A
Lying or exaggerating symptoms for some gain
- often for financial gain
- can be to get medications
22
Q
Define Othello syndrome.
A
One believes their partner is being unfaithful
23
Q
Define De Clerembault’s syndrome/erotomania
A
Excessive sexual desire
- often believing a VIP is in love with them
24
Q
Define Capgras delusions.
A
Believing a close acquaintance has been replaced by an imposter
25
Define Fregoli syndrome.
Belief that 2 or more people are the same person changing disguises in order to deceive
26
Define Folie á deux.
Shared delusions/hallucinations between people
27
Define Cotard syndrome.
Nihilistic delusion (severe depression)
– Believe your body is rotting away/you are dead
28
Define depersonalisation/derealisation.
Feeling disconnected or detached from one-self
- “I feel as if I’m not real"
29
What is Knight's move thinking?
No clear links between successive thoughts
30
What is flight of ideas?
Jumping thoughts with links between successive thoughts
- feature of mania, not of psychosis
31
What is flight of ideas a sign of?
Mania
32
Define circumstantiality thinking.
Inability to answer a question without giving excessive, unnecessary detail.
33
Define tangentiality thinking.
Wandering from a topic without returning to it.
34
Define perseveration thinking.
Repetition of ideas or words despite an attempt to change the topic.
35
Define neologism.
New word formations
- Often includes the combining of two words
36
Define clang association.
When ideas or words are related to each other only by the fact they sound similar or rhyme.
37
Define word salad.
Completely incoherent speech where real words are strung together into nonsense sentences.
- aka Broca's aphasia
38
Define echolalia.
The repetition of someone else's speech, including the question that was asked.
39
Define neurosis.
An inappropriate emotional or behavioural response to a perceived stressor (i.e. phobia, GAD, OCD)
- unlike psychotic conditions, a neurotic person never loses touch with reality and has normal mental functioning
40
Describe the Mental Capacity Act 2005.
Consent and capacity laws (for those aged 16 and 17 and adults that lack capacity)
Concerns capacity rather than mental health (i.e. use for those aged 16 to treat them)
Added advance decisions, LPAs (health & welfare, finance)
– n.b. MHA can overrule advance decisions
41
Describe the Mental Health Act 2007.
Compulsory admission and treatment of mental illness laws
Limited to treatment of mental disorder (not for physical disorders; that is covered by MCA 2005)
People can only be detained if appropriate treatment is available
42
What is Section 2 of the Mental Health Act 2007?
Sectioning someone for admission for **assessment**
- Lasts for 28 days and cannot be renewed
- Can only be applied by approved mental health professionals (recommended at least 2 doctors) or a nearest relative - Section 12 approved/with mental health disorder trained
- Discharge possible by nearest relative to mental health review tribunal with first 14 days or the responsible clinician
43
What is Section 3 of the Mental Health Act 2007?
Sectioning someone for admission for **treatment**
- Lasts for 6 months and can be renewed at 6 months and then every year if needed
- Patient can be forcibly medicated until 3 months of detention - after this if still not consenting a Second Opinion Appointed Doctor (SOAD) assessment is needed
- Can only be applied by approved mental health professionals (recommended at least 2 doctors) or a nearest relative - Section 12 approved/with mental health disorder trained
- Discharge possible by patient to mental health review tribunal, section 17, nearest relative to hospital (can be barred by clinician) or responsible clinician
44
What is Section 5(2) of the Mental Health Act 2007?
Detention of an inpatient by a doctor
- Lasts for 72hrs
- Only 1 doctors is needed according to recommendation (must be FY2 or above with or without Section 12)
45
What are Section 135 and 136 of the Mental Health Act 2007?
135 = Police order to remove a person appearing to be suffering from a mental disorder from a private place to a 'place of safety'
- Applied for my magistrate’s court if evidence from 1 doctor of a potential mental health disorder
- Lasts 24-36 hours if needed
136 = Police order to remove a person appearing to be suffering from a mental disorder from a public place to a 'place of safety'
- Only 1 police officer is needed according to recommendation
- Lasts for 24-36hrs
46
What is Section 4 of the Mental Health Act 2007?
Section for admission for **emergency treatment**
- Lasts for 72 hours and can be converted to Section 2 (28 day assessment) if another doctor agrees
- Can only be applied by a doctor (FY2 or above) or a nearest relative
47
What is Section 5(4) of the Mental Health Act 2007?
Detention of an inpatient by a nurse
- Lasts for 6 hrs
- The nurse applying it must be a registered mental health nurse
48
What is Section 17 of the Mental Health Act 2007?
Allows leave from a current section for a specified time
- Is not permanent discharge
49
What is Section 35 of the Mental Health Act 2007?
Assessment of patient accused of committing a crime
- Lasts 28 days but can be extended by 28 days per renewal up to a maximum of 12 weeks
- Applied for my magistrate’s court if evidence from a doctor of a potential mental health disorder
- Often used to check if an accused has any mental health conditions
- Cannot be appealled
50
What is Section 37 of the Mental Health Act 2007?
**Treatment** of patient convicted of committing a crime
- Lasts 6 months - can be extended by 6 months then by 1 year per renewal thereafter
- Applied for my magistrate’s court if evidence from 2 doctors of a potential mental health disorder
- Can be appealled (within 21 days to court or then after 6m to MHRT)
51
What are Section 41, 47 and 48 of the Mental Health Act 2007?
41 = Restriction order that is apllied for by the Crown Court
- Affects leave of absence, discharge and transfer between hospitals
- No appeal within the first 6 months
47 = Transfer serving **prisoner** to hospital (Section 49 adds those of 41)
48 = Transfer of **unsentenced prisoner** to hospital
52
What is defined by Section 26 and 29 of the Mental Health Act 2007?
26 – defines who the patient’s nearest relative is
29 – defines the patient’s rights to change the nearest relative
53
What is the Community Treatment Order?
Allows discharge from previous section on agreement certain conditions are met:
- May be living in a certain place, going somewhere for medical treatment, taking medications etc
- If conditions breached, can be recalled to hospital for up to 72 hours for assessment
- Requires renewal every 6 months (can be appealed at a MHRT)
54
What is an Approved Mental Health Professional?
Responsible for coordinating the assessment/admission of a patient to hospital if sectioned
- 95% are social workers
- MHPs approved by a local social services authority to carry out duties under the Mental Health Act
55
What is an Independent Mental Health Advocate?
An advocate trained to help the patient find out their rights under the MHA and provide support
56
Which patients have the right to an Independent Mental Health Advocate?
Under a section that is NOT 4, 5, 135 and 136
Under MHA guardianship, conditional discharge and CTO
Discussing treatments such as ECT
57
What is a Mental Health Advocate Guardianship?
Helps a patient live independently in the community.
58
What is Deprivation of Liberty Safeguards (DoLS)?
Depriving liberty within a care home or hospital (appropriately; not at home)
Urgent application = 7 days DoLS
Needed for restraint/restrictions used to safeguard people under the MCA which deprive liberties
- Part of the MCA 2005
59
Name 2 typical antipsychotics.
Haloperidol
Chlorpromazine
60
Name 5 atypical antipsychotics.
Quetiapine
Olanzapine
Clozapine
Risperidone
Aripiprazole
61
What is the mechanism of antipsychotics?
Block D2 receptors
- Clozapine blocks D1 and D4
62
How do the mechanism of atypical antipsychotics differ from typicals?
Atypicals are more selective
- Atypicals block D2 and 5-HT2 receptors
- This means they have less side effects
63
What conditions management can contain an antidepressant?
* Depression
* Dysthymia
* Anxiety disorders
* Eating disorders
* Personality disorders
64
What group of patients can respond 'too well' to antidepressants?
Patients in mania - undiagnosed bipolar
65
What are the consequencies of sudden discontinuation of antidepressants?
FIRM STOP
* **F**lu-like symptoms
* **I**nsomnia
* **R**estlessness
* **M**ood swings
* **S**weating
* **T**ummy problems (pain, cramps, D&V)
* **O**ff balance (ataxia)
* **P**araesthesia (shocks, tingles, etc.)
66
What is the mechanism of SSRIs?
* Block reuptake of serotonin/5-HT
* Causes more serotonin in synaptic cleft
67
What is the immediate effect of SSRIs?
* Make you feel WORSE before they make you feel better (1-2 weeks)
* Serotonin immediately increases but glutamate takes a while longer
* The difference in timing leads to slightly worse symptoms
68
What drugs interact with SSRIs?
Triptans - can cause serotonin syndrome
- NSAIDs and Aspirin must be taken with PPI
69
Name 6 SSRIs.
* “Effective For Sadness, Panic, Compulsion”
* Escitalopram
* Fluoxetine, Fluvoxamine
* Sertraline
* Paroxetine
* Citalopram
70
What are the side effects of SSRIs?
* Five S’s – S, S, S, S, S”
* Suicidal ideation (*for 1-2 weeks)*
* Stomach - weight gain, N&V\*, diarrhoea\*, headaches, dyspepsia (*\*for 5-10 days*
* Sexual dysfunction
* Sleep/Insomnia (*for 5-10 days)*
* Serotonin syndrome
* Others - hyponatraemia, blurred vision, akathisia, tremor, dizziness, headache, sweating
71
What is a specific adverse effect of citalopram?
QT prolongation
72
Which SSRI should be used for a depressed patient with cardiac pathology?
Sertaline
73
Which antidepressants should be prescribed for patients with suicidal thoughts?
SSRIs
Mirtazapine
74
How long do SSRI's tkae to have an effect?
What can happen during this initial time period?
4 to 6 weeks
- Anxiety can worsen during this initial time period
75
How long should SSRI's be taken for?
* 6 months after remission of 1st episode
* 2 years if a recurrence
76
What medication are advised not to take with SSRI's?
* **Triptans** - can be allowed for *migraines*
* **NSAIDs/Aspirin** - i*f need to be taken* *à* *combine with a PPI*
77
What is the mechanism of SNRI's?
Block reuptake of serotonin/5-HT and NA (lesser extent) leading to more 5-HT and NA in synaptic cleft
* At high doses, blocks DA re-uptake
78
Name 2 SNRI's.
Venlafaxine
Duloxetine
79
What are the side effects of SNRI's?
* Headaches
* 5 S's
* Suicidal ideation
* Stomach issues
* Sexual dysfunction
* Sleep (insomnia)
* Serotonin syndrome
* Constipation
* Hypertension
* Raised cholesterol
80
What antidepressants shouldn't be prescribed for patients at risk of suicide?
TCA's
MAOi's
Venlafaxine
81
What is the mechanism of TCAs?
Block reuptake of serotonin/5-HT and NA (lesser extent) leading to more 5-HT and NA in synaptic cleft
* High doses = blocks all receptors and is used in depression
* Low doses (25-50mg) = blocks H1 and 5-HT and is used for aiding sleep
82
What are the clinical uses of TCAs?
* Depression
* High doses blocks all receptors
* Sleeping Aid
* Low doses (25-50mg) they block H1 and 5-HT
83
What are the side/adverse effects of TCA's?
* Thrombocytopaenia
* Cardiac (arrhythmias, MI, stroke, postural hypotension)
* Anticholinergic (tachycardia, urinary retention, dry mouth, blurry vision, constipation)
* Seizures
* Hyponatraemia
84
What are the anticholinergic effects on the body?
* Tachycardia
* Blurry Vision
* Urinary Retention
* Dry Mouth
* Constipation
* “Can’t see, can’t pee – can’t spit, can’t shit”
85
Name 6 TCA's.
Amitrityline
Clomipramine
Imipramine
Lofepramine
Dosulepin
Doxepin - sleeping
86
Name a Noradrenergic and Specific Serotonin Antidepressant (NaSSA).
Mirtazapine
87
What is the inidcation for mirtazapine?
A depressed patient with insomnia and loss of appetite
88
What are the common side effects of Noradrenergic and Specific Serotonin Antidepressant (NaSSA's)?
Sedation/Sleepiness
Increased appetite/Weight gain
Oedema
89
Name 2 Noradrenaline Reuptake Inhibitors (NARI's).
Reboxetine
Atomoxetine
90
What are the side effects of Noradrenaline Reuptake Inhibitors (NARI's)?
* Anticholinergic (blurry vision, urinary retention, dry mouth, constipation, tachycardia, excess sweat)
* Insomnia
91
What is the mechanism of MAOi's?
Inhibits MAO inside of the pre-synaptic neurone
- increases MAO levels
92
Why are MAOi's falling out of use?
* Dangers of hypertensive “cheese” reaction
* NA builds up from intake of tyramine-rich food (i.e. cheese)
* Can't be combined with other antidepressants
* Especially SSRIs due to high risk of serotonin syndrome
93
Name 4 MAOi's.
* PHENomenal Ice Sled Trainer
* Phenelzine
* Isocarboxacid
* Selegiline
* Tranylcypromine
94
What are the side effects of MAOi's?
* Hypertensive crisis/Cheese reaction
* Anticholinergic (blurry vision, urinary retention, dry mouth, constipation, tachycardia, excess sweat)
* Insomnia
* Headache
95
Name a Reversible Inhibitor of MOA (RIMA).
Moclobemide
96
What are the side effects of Reversible Inhibitors of MOA?
Agitation
Sleep disturbance
Nausea
Hypertension
97
How long should benzodiaepines be prescribed for?
No longer than 2-4 weeks
98
What are the mechanisms of anxiolytics?
* Enhance GABA transmission at GABA-A receptor
* Binding sites and mechanisms:
* Barbiturates increase the **Frequency** of opening
* BZDs increase the **Duration** of opening
99
How does the selectivity of BDZs differ from barbiturates?
Barbs are less selective then BDZs, so Barbs have:
* Less excitatory transmission
* Barbs are more dangerous (i.e. *induction of surgical anaesthesia and small therapeutic window)*
100
What are the indications for anxiolytics?
Treat anxiety disorders
- Does so without impairing mantal or physical activity - should be longer-acting to aid withdrawal
101
Name 5 anxiolytics.
* Diazepam (BDZ)
* Lorazepam (BDZ)
* Chlordiazepoxide (BDZ)
* Nitrazepam (BDZ)
* Oxazepam (BDZ) - if the patient has hepatic impairment
102
How must BZD's be stopped?
103
What are the effects of depressants?
* Sedative
* Reduce mental and physical activity without producing a loss of consciousness
* Hypnotic
* Reduce mental and physical activity AND induce sleep
104
Name some depressants.
Shorter acting benzodiazepines or barbiturates:
* Examples:
* Temazepam (BDZ)
* Oxazepam (BDZ)
* Nitrazepam (BDZ) - hypnotic effect at night followed by an anxiolytic effect during the day
105
How does nitrazepam differ from other other anziolytics and depressants?
Hypnotic effect at night followed by an anxiolytic effect during the day
106
What are Z-drugs?
Drugs like benzodiazepines that are used to treat insomnia
107
Name a Z-drug.
Zopiclone
108
What are the side effects of Z-drugs?
* Agitation
* Bitter taste
* Constipation
* Hypotonia
* Dizziness
* Dry mouth
* Increased risk of falls
109
What are the side effects of BDZs?
* Sedation/Confusion
* Anterograde amnesia
* Ataxia
* Tolerance and Dependence (less intense than barbs)
* Potentiates other CNS depressants (i.e. alcohol)
* Free plasma concentration increases when co-administered with aspirin, heparin
* Cleft lip (1st trimester use) pregnancy
110
What are the advantages of BDZs compared to other drug classes for used for anxiety disorders?
* Wide therapeutic window – an overdose 'only' causes prolonged sleep
* Flumazenil is a BDZ antagonist and can reverse effect
* Only a mild effect on REM sleep
* Does not induce liver enzymes
111
What are stimulants used to treat?
ADHD
Narcolepsy
112
Name 2 stimulants.
* Methylphenidate
* Dexamphetamine
113
What are the side effects of stimulants?
* Cardiac – arrhythmias, HTN, stroke
* Drug-induced psychosis
* Appetite suppression
* Risky behaviour
* Impulsivity
* Anxiety and panic
* Insomnia
* “Crash” (dysphoria and lethargy) on stopping
114
What are mood stabiliser used to treat?
BPAD
Schizoaffective Disorder
- Even out the highs of mania and lows of depression (more effective in mania)
115
Name 4 mood stabilisers.
* Lithium
* Sodium valporate
* Carbamazepine
* Lamotrigine
116
What are the side effects of lithium?
* Fine tremor
* N&V
* Nephrogenic DI
* Arrhythmia
* Hypothyroidism
* Weight gain
* Eyebrow hair loss
117
What are the side effects of sodium valporate?
* N&V as well as diarrhoea
* Liver failure/DILI
* Thrombocytopenia
* Hair loss
* Weight gain
118
What are the side effects of carbamazepine?
* Skin rash
* Leucopenia
* Dizziness
* Ataxia
* Drowsiness/Fatigue
* N&V
* Oedema
* Weight gain
* Hyponatraemia
119
What are the side effects of lamotrigine?
* Severe skin rash
* Headache
* Fatigue
* Nausea
* Dizziness
* Insomnia
* Arthralgia, back pain
120
Which mood stabiliser can you overdose on? And what are the signs/symptoms of its overdose?
Lithium
* Therapeutic Range: 0.6-1.0 mmol/L
* Overdose: \>1.2 mmol/L
* Coarse tremor
* Hyperreflexia
* Nystagmus
* CNS (seizures, ataxia)
* GI (N&V)
121
Which mood stabiliser require monitoring? And what type of monitoring is required?
* Lithium
* 12 hours after first dose and 1 week after changing dose
* Weekly until the level is steady (about 5 weeks)
* Every 3m for lithium levels
* Every 6m for U&Es and TFTs
* Carbamazepine
122
What are the adverse effects/contraindications of lithium?
Benign leucocytosis
Pregnancy - Ebstein’s abnormality (parts of the tricuspid valve separates the right ventricle from the right atrium)
Sudden discontinue - relapse
123
What are the triggers of lithium overdose?
* Dehydration
* Drugs (NSAIDs, ACEi, diuretics, celecoxib) - interrupts with renal excretion
* Deliberate overdose
124
What are the adverse effects/contraindications of sodium valporate?
* Pregnancy - spina bifida
* Cannot be prescribed to any woman of child-bearing age unless a Pregnancy Prevention Programme in place
* Saying that it can be used if advised in pregnancy and risk is weighed up
* Folate supplements must be prescribed
125
What are the adverse effects/contraindications of carbamazepine?
* Induces enzymes - may make other medications ineffective (i.e. COCP)
* Pregnancy - spina bifida
126
What are the adverse effects/contraindications of lamotrigine?
Skin rash - Steven-Johnson syndrome
127
What is neuroleptic malignant syndrome?
Gradual onset of the triad of:
* Mental status change (catatonia)
* Muscular rigidity
* Autonomic instability
* Hyperthermia (\>40C)
* Tachycardia
* Tachypnoea
* Labile BP
* Sweating/Fever
* *“MMA” fighters are muscular, mental (crazy) and (autonomically) unstable*
128
What is the most likely drug to cause neuroleptic malignant syndrome?
Haloperidol
- 0.2% prevalence to any antipsychotic - usually in 4-11 days
129
What investigations are appropriate for suspected neuroleptic malignant syndrome?
* Leucocytosis
* Rigidity - muscle breakdown - rhabdomyolysis:
* U&Es (High CK \>1,000)
* AKI (U&E derangement)
130
What is the management of neuroleptic malignant syndrome?
* ABC
* Stop antipsychotics
* Supportive (fluids, dialysis, etc.)
* Dantrolene (for muscle cramps)
* Bromocriptine - dopamine agonist
131
What is serotonin syndrome?
* Abrupt/Sudden onset of the triad of:
* Mental status change (catatonia)
* Muscular rigidity
* Autonomic instability
* Hyperthermia (\>40C)
* Tachycardia
* Tachypnoea
* Labile BP
* Sweating/Fever
* Diarrhoea and Vomiting
132
What is the management of serotonin syndrome?
* ABC
* Stop antidepressants
* BDZ (reduced neurologic excitability)
* Supportive (fluids, dialysis, etc.)
133
Define Electroconvulsive Therapy (ECT).
Passage of a small electric current through the brain with a view of an inducing a generalised tonic-clonic seizure under ga and muscle relaxants
134
What are the short-term side effects of ECT?
* Headache and nausea
* Muscle aches
* Cardiac arrhythmia
* Memory problems
* Retrograde amnesia (far more common) = memories before the ECT
* Anterograde amnesia = problems forming new memories
135
What are the long-term side effects of ECT?
Impaired memory - poor evidence
136
What is an absolute contraindication of ECT?
Raised ICP
137
What are the indications for ECT?
Mood disorders - Major Depressive disorers, Bipolar
Schizophrenia
Non-psychiatric = Parkinson's, Neuroleptic malignant syndrome, Status epilepticus, Catatonia
138
What is CBT?
* Targets thoughts that lead to emotions and behaviours by challenging a persons own thoughts/being their own therapist
* Especially Negative Automatic Thoughts
* Challenges negative beliefs
* Knock-on effect on mood
139
What is Beck's negative cognitive triad?
* S*elf-perpetuating:*
* Negative self-view
* Negative future view
* Negative world view
140
What is the background principle of CBT?
* Identify an Event that Trigger thoughts
* Understand the emotions/behaviours behind the trigger
* Step back and take a look at your own thoughts
* Methods to challenge these thoughts…
* Longitudinal format
* Hot-cross bun methods
141
Describe the a CBT session using Longitudinal Formulation.
1. Get a detailed history including early life
* Use it to identify early experiences, critical incidents, etc.
2. Use a ‘sleep schedule’ to link the mood to activities/lack of energy
* Build in activities that generate a sense of pleasure
3. Identify Negative Automatic Thoughts:
* Identify situations that lead you to feel worse
* Where you were, what was happening
* Describe the emotion and rate from 0-10
* What was going through your mind at the time (words / images)
4. Challenging distortions:
* Tools/techniques
* Guided discovery
5. Core beliefs:
* Beck’s negative cognitive triad
* Often have to dig deep into childhood experiences
142
What is the Hot-cross Bun Method?
143
Define Psychodynamic Psychotherapy.
Therapeutic process which helps patients understand and resolve their problems by increasing awareness of their inner world and its influence over relationships both past and present
144
What are is psychodynamic psycotherapy based on?
* Alfred Adler Techniques
* Problems were shaped by childhood experiences and the family environment
* This causes conflicts between the conscious and unconscious mind
145
How does psychodynamic pyschotherapy work?
* Therapy helps reveal the unconscious mind
* Psychoanalytics = internal conflicts
* Psychodynamics = inter-personal conflicts
* The first few sessions are aimed at building the relationship between the client and the therapist
* Later sessions try to reveal the unconscious
* Therapy aims for a deep-seated change in personality and emotional development
* By changing one’s personality and emotional development, one can reduce their symptoms
146
How does CBT differ from Psychodynamic psychotherapy?
CBT = Aims to examine and undertstand thoughts and how it impacts the patient
Psychodynamic psychotherapy = Change personality and emotional development
147
What are the risk factors for suicide?
* Previous self-harm (*70x increased risk if \<1 year since self-harm*)
* Young male (*Overall suicide risk = M: F = 3: 1*)
* Occupation (*Doctor, Police, Vet*)
* Live alone
* Mental illness (*\>90% have a mental illness (i.e. depression)*)
* Substance abuse
* Lower social class
* Unmarried
* Widowed/divorced
148
What are the protective factors against suicide?
* Married
* Lithium medication
* Faith in a religion
* No substance abuses
* Rural environment
149
What are indicators of suicide intent following deliberate self-harm?
* Preplanning
* Attempts at concealment
* Stated wish to die
* Lack of help-seeking following the act
* On-going suicidal intent
* Actions in anticipation of death (a will, suicide note)
* Belief the act would be fatal (even if medically, it wouldn’t be)
* Sorrow/anger at failure
150
What agent/medication is used to reverse BDZ overdose?
Flumazenil
- A selective GABA A receptor antagonist
151
What agent/medication is used to reverse opiate overdose?
Naloxone
152
What agent/medication is used to reverse Z-drug overdose?
Flumazenil
- A selective GABA A receptor antagonist
153
What agent/medication is used to reverse paracetamol overdose?
N-acetylcysteine
154
How would a delirium diagnosis be made using the DSM-V?
**A.** Disturbance in attention and awareness
**B.** Develops over a short period of time (hours to days), represents a change from baseline attention and awareness and tends to fluctuate in severity during the course of the day
**C.** Additional disturbance in cognition
**D.** Disturbances in Criteria A and C are not better explained by another condition
**E.** Evidence from the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal
155
Name some causes of delirium.
* Infection
* Change in environment
* Medication/Drugs
* Alcohol withdrawal
* Surgery
* Pain
* Liver/renal impairment
* Hypoxia
* Hyponatraemia
* Stroke
* Encephalitis
* Constipation
* Urine retention
* Dehydration
156
How would a delirium diagnosis be made using the Confusion Assessment Method (CAM)?
* Delirium requires1, 2 and 3 or 4
* Always use CAM to evaluate delirium
157
What is the management of delirium?
* Exclusion of alternative diagnoses
* Modify risk factors if possible
* Treat the causes
* Single, well lit room with visible clock
* Familiar staff/family
* Medication:
* PO antipsychotics (short-term in dementia with infection)
* Alpha-agonists (not a lot of evidence but growing)
* Avoid anticholinergics
158
What is the prognosis of delirium?
* 37% die within 6 months
* 43% have reversible cognitive impairment
* 25% had clinically recovery in important ADLs
159
What medications are used for rapid tranquilisation?
Use lorazepam if unsure or known cardiac disease
160
How long should be left after initial administration of rapid tranquilisation? If the first dose is ineffective what should be done?
161
Describe the grid framework of the bio-psycho-social model.
162
What are the predisposing factor for an elderly widow who suffered from a fall according to the bio-psycho-social model?
- Bio = anaemia, renal, etc
- Psycho = lonely, depressed etc
- Social = on here own, cant maintain house etc
163
How intensively should a person under 30 presenting with psychosis be treated?
Very intensive iput/treatment
- evidence suggest that this provides better short and long term outcomes
164
How does an illusion differ from hallucinations?
```
Illusion = external stimulus + distorted perception
Hallucination = NO external stimulus + perception
```
165
What is the Rule of 1/3 in schizophrenia?
* 1/3 will never have another episode/respond well to treatment
* 1/3 will have chronic relapsing and remitting illness
* 1/3 will be chronically unwell and suffer badly
166
What is the peak incidence of depression in men and women? Why are these ages?
* Men = 60-70s
* Female = 40-50s
* Empty nest syndrome - traditionally men may not have released this until retiring before releasing empty nest
167
What is the suicide rates of men and women and why is the difference present?
7% in men and 1% in females
* Women more likely to take pills (harder to do/more time to think) than men who use more violence
* Only makes up part of the reason but is important
168
How common is postnatal depression?
10%
169
How common is postpartum psychosis?
1 in 500
170
What time in the day is delirium worst?
* Evening
* Sundowning delirium = ward structure disappears as well as sun drive for circadian rhythm
171
What are the key features of psychodynamic therapy?
* The unconcious
* Transference countertransference
* Free association within reliable setting
172
What is the unconcious in terms of psychodynamic therapy?
* Parts of the brain that you have NO direct access to
* Dreams, mistakes, slips of the tongue, repetitive patterns
173
What is transference in terms of psychodynamic therapy?
* New edition of earlier relationship
* Suggests that early interactions with care givers (often parents) will be replicated to care givers late on in life
* Usually infantile
174
What is countertransference in terms of psychodynamic therapy?
* Response a doctor transfers on to the patient]
* Nervous energy of a doctor transferring on to a patient
175
What is free association within reliable setting in terms of psychodynamic therapy?
* Patient can say anything and can begin where they wish
* Only structure is time, place and duration
* Setting is very well planned/organised/rationale
176
What is formulation in terms of psychodynamic therapy?
* Hypothesis to test with patient
* Core internal scenes - give meaning to patients issue
* Use symptoms as solution to current life situation
* Accounts of early life - relationships with key figures; core scenes
* Does anything in earlier life account for current situation
* Relationship with doctor
* Does anything overlap with the past - anything influencing current situation
177
How should a doctor act in a consultation to gain trust and the best outcome for patients?
* Doctor should use analytic 'neutrality'
* Blank canvas allows patient to project their true feelings with being influenced by doctor relationship
* Does anything overlap with the past - anything influencing current situation
178
What sorts of negative automatic thoughts are there?
* Mental filters – *only noticing stuff you filter to notice – i.e. filter out positive*
* Judgements – *making judgements about events*
* Prediction – *believing you know what will happen in the future*
* Emotional reasoning – *“I feel anxious – so, I must be in danger”*
* Mind-reading – *believe you know what people are thinking*
* Mountains and molehills – *exaggerating the risks/negatives of danger*
* Compare & despair – *comparing to the ‘image’ others portray on social media*
* Catastrophising – *imaging only the worst will happen*
* Black and white thinking – *i.e. things can only be good OR bad*
* “Should” and “must” – *thinking ‘I must’ puts undue pressure on oneself*
* Memories – *events trigger bad memories making us think that ‘bad’ thing is here right now*
179
What work-up must be done before ECT?
* Full physical examination
* Investigations – Bloods, ECG if over 50 (looking for arrythmia), CXR if over 55
* Medication review
* Increase seizure threshold = benzodiazepines, mood stabilisers
* Reduce seizure threshold = anti-psychotics, TCAs, lithium
180
Which anti-psychotic is licensed as a mood stabiliser/for BPAD?
Olanzapine
- For both acute mania and prophylaxis
181
What are the 4 types of EPSE?
* Parkinsonism
* Dystonia
* Dyskinesia
* Akathisia
182
What are the features of Parkinsonism?
* Tremor
* Rigidity
* Bradykinesia
183
How is Parkinsonism treated if a consequence of anti-psychotic medication?
* Anti-cholinergic (procyclidine)
* Reduce antipsychotic dose or change antipsychotic (especially typical to atypical)
184
Define Dystonia.
Sustained or repetitive muscle contractions resulting in twisting and repetitive movements and posture
185
What are the features of Dystonia?
* Often shortly after administration
* Happens in young/antipsychotic naive
* Can be life threatening if the right muscle (laryngeal)
186
How is Dystonia treated if a consequence of anti-psychotic medication?
* Anti-cholinergic (procyclidine)
* Reduce antipsychotic dose or change antipsychotic (especially typical to atypical)
187
Define Dyskinesia.
Repetitive and stereotypical jerking movements of the face
188
What are the features of Dyskinesia?
* Idiosyncratic reaction
* Choreo-athetoid movements
* Can be irreversible
* Made worse by anticholinergics
189
How is Dyskinesia treated if a consequence of anti-psychotic medication?
* Careful reduction in the dose of antipsychotic
190
Define Akathisia.
Subjective feeling of restlessness, it can be mental and/or physical
191
How is Akathisia treated if a consequence of anti-psychotic medication?
* Reduce antipsychotic dose or change antipsychotic (especially typical to atypical)
* Short-term benzodiazepine or beta-blockers (both of these are rarely used),
192
Define QTc prolongation in men and women.
* Men = \>440ms
* Women = \>470ms
193
What is the risk of a prolonged QTc?
* Torsades de Pointes
* Other arrhythmias
194
What are the risk factors for Neuroleptic malignant syndrome?
* High dose
* Rapid increase in dose
* Withdrawing anticholinergics
* Depot
* Male (2:1)
* Past Hx of NMS
* Dehydrated
195
What is the starting dose for SSRI's for Depression, Anxiety, OCD and Bulimia Nervosa?
* Depression = 20mg
* Anxiety = 40mg
* OCD, Bulimia Nervosa = 60mg or 80mg
