general

Question 1

define psychosis

Answer 1

mental health problem that causes people to perceive or interpret things differently from those around them. this may include hallucinations or delusions (mental disorder so severe that pt loses contact with reality)

Question 2

what is the mental state exam?

Answer 2

a systematic evaluation of the patients mental condition at the time of interview. Aims to identify signs of mental disorder that, taken with the Hx, enable you to make, suggest or exclude a Dx.

assesses appearance, behaviour, speech, mood, thought, perception, cognition, insight

Question 3

what is the content of a psychiatric history?

Answer 3

1 presenting complaint
2 history of presenting complaint
3 past medical and psychiatric history
4 prescribed and non-prescribed medication
5 substance use: drugs, alcohol, tobacco, caffeine
6 social circumstances
7 family history 
8 personal history
9 risk history
10 forensic history
11 premorbid personality

Question 4

according to the DSM-5, what is the diagnostic criteria of schizophrenia?

Answer 4

2 or more of the following symptoms, present for a significant portion of time during 1 month (active phase) and associated with continuous problems over at least 6month period (prodromal, active and residual phases). must include at least symptom 1 or 2:

1. delusion
2. hallucinations
3. disorganised speech
4. grossly disorganised or catatonic behaviour
5. negative symptoms (reduced emotional expression)

• for Dx, the disturbance must not be attributed to the physiological effects of a substance or other medical condition
• pt may also display inappropriate affect, dysphoric mood, disturbed sleep pattern and reduced appetite or food refusal

Question 5

schizophrenic symptoms can be divided into positive and negative. what are they?

Answer 5

positive:

• delusions
• auditory hallucinations
• delusions of reference (e.g. news directly referenced at them)
• delusions of thought interference
• passivety phenomena
• thought echo (hear thoughts spoken outloud)

negative:

• apathy
• flat affect
• odd or incongruous affect
• lack of attention
• lack of spontaneity
• difficulties in abstract thinking

Question 6

bipolar affective disorder (BPAD) affects a patient mood - swing from one extreme (usually long periods of severe depression) to the other (excessively elated mood -mania). what is the criteria to diagnose mania?

Answer 6

symptoms should be present for a week and have resulted in significant impairment to social and occupational functioning.

Question 7

what are the features of mania?

Answer 7

• elevated mood
• increased energy (pressure of speech, racing thoughts, reduced sleep)
• reduced attention
• increased self-esteem
• loss of social inhibition (recklessness, out-of-character, increased spending, inappropriate sexual encounters)

Question 8

what drug reduces the risk of manic relapses by 30%

Answer 8

lithium (mood stabiliser so can also be used as AD, possible SEs on kidneys and thyroid function)

Question 9

explain what is meant by antipsychotics

Answer 9

aka neuroleptics, antischrizophrenic drugs, major tranquillisers usually recommended as the first treatment of psychosis.

• work by blocking the effect of dopamine in the brain

Question 10

what are the 2 dopamine pathways which we would be concerned about the dysregulation of in the context of schizophrenia?

Answer 10

mesolimbic and mesocortical pathways (emotion and behaviour)

[D1 associated with decrease of dopamine in mesocortical pw = -ve syptoms. D2 associated with increase of dopamine in mesolimbic system = +ve symptoms]

Question 11

what are the other 2 dopamine pathways/ systems which may be at risk of interference during targeted dopamine treatment?

Answer 11

tuberohypophyseal –> involved in regulating endocrine function

nigrostriatal pathway –> involved in fine motor and regulation of motor control (affected in Parkinson’s)

Question 12

explain the theories underlying the development of schizophrenia

Answer 12

Dopamine theory:

• developed from amphetamine studies and the development of D2 receptor agonists; upregulation of dopamine in the brain produce symptoms indistinguishable from schizophrenia
• strong correlation between clinical potency of antipsychotics and D2 blocking action

glutamate theory:

• come from drug abuse studies (e.g. ketamine); act on NMDA receptors causing a decrease in glutamate and receptor density
• animal experiments shown stereotypic schizophrenic behaviours and decrease social interactions (respond to antipsychotics)

possible ‘gate theory’:

• glutamate and dopamine exert excitatory and inhibitory effects on GABAergic striatal neurons –> thalamus (sensory ‘gate’)
• too little glutamate or too much dopamine disable the ‘gate’ allowing uninhibited sensory input to reach the cortex
• could contribute to positive (D) and negative symptoms (G)

Question 13

name 3 examples of both atypical and typical drugs used as antipsychotics

Answer 13

typical = first generation:

1. chlorpromazine
2. haloperidol
3. flupentixol

atypical = second line:

1. amisulpride (D2 and D3 selective antagonist)
2. clozapine (very unselective blocking profile)
3. risperidone (mixture of receptor types blocked)

Question 14

tend to start pt on one class of drug, ensure adherence and monitor SEs. if not tolerated swap class. if a patient is still resistant, what is the best drug to use?

Answer 14

clozapine (one of the greatest degrees of SEs risk vs benefit at this point)

Question 15

what class of drug is most likely to be chosen in pt showing both positive and negative symptoms?

Answer 15

atypical antipsychotics

*typical much more efficacious of positive symptoms

Question 16

what is MoA of antipsychotics??

Answer 16

block dopamine receptors but also have affinity, and therefore the potential to block, the following receptors:

• D1
• D2
• a1 (block sympathetic affect on blood vessels)
• H1
• mACh (block parasympathetic function)
• 5-HT2A

Question 17

list some of the major side effects of these drugs

Answer 17

• sedation (anti-H1)
• weight gain
• diabetes
• extra-pyramidal symptoms (acute, reversible Parkinson-like due to block of nigro-striatal dopamine receptors OR slowly developing and irreversible tardive dyskinesia!)
• anti-muscarinic action: blurring of vision, dry mouth and eyes, constipation
• alpha-adrenoreceptor blocking: hypotension (orthostatic)
• endocrine actions: increasing prolactin secretion by blocking D2 receptors in the pituitary (tuberohypophyseal pw)

Question 18

what are the behavioural affects of antipsychotics?

Answer 18

• apathy and reduced initiative
• display few emotions, drowsy
• aggressive tendencies inhibited
• effects are distinct from hypnotics and anxiolytics

Question 19

how many weeks due you evaluate drug for?

Answer 19

6-8

*important to titrate to minimum effective dose

Question 20

if pt is not tolerating drug or poor compliance is identified, what is the next step?

Answer 20

depot or compliance aid

Question 21

list some other used of antipsychotics

Answer 21

• acute behavioural emergencies and mania
• treatment of emesis
• Huntingdon’s disease
• depression

(dose changes)

Question 22

outline psychological factors that may predispose a patient in developing mental health problems

Answer 22

• traits e.g. neuroticism (negative thoughts) or narcissism
• low self-efficacy
• impulsivity
• individual, family and community issues
• there is overlap with social factors such as disorganised attachment (poverty, divorce, separation), exposure of violence, role of stigma etc.

Question 23

briefly describe the common pathway that links mental health with physical health according to Kurt Kroene

Answer 23

psychological symptoms can cause physical symptoms

and

physical symptoms can cause psychological symptoms as a consequence (e.g. coping with chronic illness can lead to depression)

Question 24

define PTSD

Answer 24

Disorder that may develop (either immediately or delayed) following exposure to a stressful event or situation of an exceptionally threatening or catastrophic nature

Question 25

PTSD is characterised by 4 types of symptoms that must impair function. what are the common symptoms of PTSD?

Answer 25

1. intrusions - flashbacks, intrusive images and sensory impressions, dreams/nightmares 2. avoidance - avoiding people, situations or circumstances resembling or associated with the event 3. negative alterations in cognition and mood - feeling alienated from others, diminished interest in activities, distorted negative beliefs about oneself or the world, inability to remember key features of event 4. alterations in arousal or reactivity - hypervigilance for threat, exaggerated startles response, irritability

Question 26

PTSD does not go away on its own. what are the psychological therapies for PTSD?

Answer 26

trauma-focussed psychological treatments are the most effective. 1. trauma-focused CBT 2. prolonged exposure 3. cognitive processing therapy - each directly addresses memories of the event or thoughts and feelings related

Question 27

what are the risks if a pt doesn't receive help for their PTSD?

Answer 27

- developing mental health disorder - medical problems e.g. chronic pain - suicidal thoughts and behaviours

Question 28

list 5 personal and 5 other family member causes of adverse childhood experience (ACE) = stressful events occurring in childhood that can have lifelong impacts on health and behaviour

Answer 28

personal: - physical abuse - verbal abuse - sexual - physical neglect - emotional neglect other family: - alcoholic parent - mother who is victim of domestic violence - family member in jail - family member diagnosed with mental illness - disappearance of a parent through divorce, death or abandonment

Question 29

what is the most beneficial implication that improves child outcomes of ACEs

Answer 29

parent/child relationship

Question 30

list some examples of psychosis

Answer 30

- schizophrenia - bipolar disorder - schizoaffective disorders (schizophrenia and mood disorder symptoms) - persistent delusional disorders - schizophreniform psychosis (significant symptoms present for majority of 1month but not 6months yet)

Question 31

what are the potential risk factors of schizophrenia?

Answer 31

deficits in the ability to keep thoughts and actions on track (core symptom): - genetics (associated genes involved in NTs) - physiology: overstimulation of dopamine hypothesis, dopamine-serotonin interaction hypothesis, Ach, glutamate and GABA involvement? - anatomy: reduced global brain volume, increase ventricle, microcharges; missing neurons, abnormal size, derangement - psychosocial: social class, family environment, cannabis use

Question 32

alongside drug treatment (early intervention results in better long-term outcomes) what psychological interventions are recommended in schizophrenia to help reduce likelihood of relapses?

Answer 32

- family intervention - CBT - social skills training

Question 33

what is the NICE recommendations for the short and long-term management of schizophrenia?

Answer 33

oral antipsychotic medication along with psychological intervention. has to be a long-term plan by the CMHT (e.g. CBT, adherence strategies and management/ identify SEs) with focus on physical health (e.g. manage weight gain)

Question 34

define the concept of personality and when it becomes a disorder

Answer 34

personal traits that makes someone who they are (e.g. creative and outgoing but nervous in groups); and how they think (cognitive attributes) or act (behavioural attributes). Can be harmful if they interfere with their day to day functioning, personal life, work or social settings at which stage = personality disorder.

Question 35

define personality disorder

Answer 35

an enduring pattern (inflexible) of inner experience and behaviour that manifests in 2 or more of the following: cognition, affectivity, interpersonal functioning, impulse control. pattern is usually stable and can be traced back to adolescence

Question 36

personality disorders have been categorised into 3 clusters. classify cluster A

Answer 36

SUSPICIOUS/ODD: 1. paranoid - pervasive, long-standing suspiciousness and generalized mistrust of others 2. Schizoid - lack of interest in social relationships, a tendency towards a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment, and apathy 3. schizotypical - pervasive pattern of social and interpersonal deficits with reduced capacity for close relationships as well as cognitive or perceptual distortions and eccentricities of behaviour. beliefs in magic/powers/illusions

Question 37

classify cluster B

Answer 37

DRAMATIC 1. antisocial -persistent antisocial, irresponsible, or criminal behaviour, often impulsive or aggressive, with disregard for any harm or distress caused to other people, and an inability to maintain long-term social and personal relationships 2. borderline - pattern of unstable intense relationships, distorted self-image, extreme emotions and impulsiveness 3. histrionic - pattern of excessive attention-seeking emotions, usually beginning in early adulthood, including inappropriately seductive behaviour and an excessive need for approval 4. narcissistic - long-term pattern of abnormal behaviour characterized by exaggerated feelings of self-importance, excessive need for admiration, and a lack of empathy

Question 38

classify cluster C

Answer 38

ANXIOUS 1. avoidant - characterized by feelings of extreme social inhibition, inadequacy, and sensitivity to negative criticism and rejection 2. dependent - the need to be cared for by others. This condition results in submissive and clingy behaviour, a fear of separation, and difficulty making decisions without reassurance from others 3. obsessive-compulsive - excessive concern with orderliness, perfectionism, attention to details, mental and interpersonal control, and a need for control over one's environment, which interferes with personal flexibility, openness

Question 39

how would you manage personality disorders?

Answer 39

if there is a risk of self harm/ harm to others, or unable to attend to basic self-needs --> partial hospitalisation (may be on an involuntary basis) if on-going and not life-threatening patient communication and relationship management strategies is first line - talking therapies. medication may be prescribed to treat problems associated with personality disorder; depression, anxiety or psychotic symptoms