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Psychiatry Flashcards

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1
Q

When can involuntary admission be implemented?

A
  1. Patient has mental disorder
  2. Needs detention for assessment/treatment of it
  3. Admission is to protect themselves or others
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2
Q

What is section 2 of the mental health act

A
  • Admission for assessment for up to 28 days
  • 2 doctors and AMHP present
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3
Q

What is section 3 of mental health act

A
  • Admission for treatment for up to 6 months
  • Can be renewed indefinitely
  • Exact mental disorder stated and appropriate treatment available
  • Two doctors sign and find reason that community treatment is contraindicated
  • Treatment must be likely to benefit patient, prevent deterioration, necessary for health or safety of patient or protection of others
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4
Q

What is section 4 of the mental health act

A
  • Admission for emergency treatment for up to 72 hours
  • Admission must be urgent necessity
  • AMHP makes application after recommendation from one doctor
  • Patient must be seen within 72 hrs by doctor to decide whether to put section 2/3, voluntary admission or discharge
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5
Q

What is section 5(2) of mental health act

A
  • Detention of patient already in hospital for up to 72 hours
  • Doctors holding powers
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6
Q

Section 5(4) of mental health act

A
  • Nurse’s holding powers for up to 6 hours
  • Detain patient who is taking discharge against advice
  • During 6 hours nurse must find personnel to sign section 5(2) or allow discharge
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7
Q

Section 135 of mental health act

A
  • Allows police to force entry into someone’s premises to allow assessment under MHA to be made or bring them to place of safety
  • Warrant from Magistrates court required and accompanied by AMHP and/or doctor
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8
Q

Section 136 of mental health act

A
  • Allows police to arrest person ‘in a place to which public have access’ who they believe to be suffering from a mental disorder in order to convey them directly to a place of safety
  • Held under section 136 for up to 72 hrs during which they should be seen by doctor and AMHP to choose to complete MHA assessment, admit them informally or discharge them
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9
Q

Mental capacity act (2005)

A
  • Presumption of capacity
  • Individuals supported to make their own decisions
  • Unwise decisions
  • Best interests
  • Less restrictive option
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10
Q

What is a hallucination

A
  • Occur in any sensory modality without an external stimulus
  • Felt to occur in the external world along other objects, have the same qualities as everything else and cannot be consciously manipulated or stopped
  • To the person experiencing them, these experiences are real
  • Auditory = thoughts spoken aloud, second-person hallucinations, third-person hallucinations
  • Visual = More common in eye pathology and epilepsy than psychosis
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11
Q

What is a delusion

A

beliefs held unshakably, irrespective of counter-argument, that are unexpected and out of keeping with patient’s cultural background

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12
Q

Loosening of association

A

thought disturbance demonstrated by speech that is disconnected and fragmented with individual jumping from one idea to another unrelated or indirectly related idea

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13
Q

Circumstantiality

A

including a lot of unnecessary and insignificant details in your conversation or writing

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14
Q

Confabulation

A

production or creation of false or erroneous memories without intent to deceive. Or, falsification of memory by person who believes they are genuinely communicating truthful memories

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15
Q

Somatic passivity

A

experience of bodily sensations (including actions, thoughts or emotions) imposed by external agency
* E.g. voices commentating on one’s action
* E.g. voices describe patient’s activities as they occur

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16
Q

Anhedonia

A

inability to feel pleasure

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17
Q

Thought alienation

A

subjective experience of one’s own thoughts being under control of an outside agency
* Thought Insertion = foreign thoughts places into one’s mind
* Thought Withdrawal = thoughts suddenly disappearing (having been taken by external thought)
* Thought Broadcast = thoughts being transmitted to everyone around as though being played on a radio

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18
Q

Thought echo

A

form of auditory hallucination in which a patient hears their thoughts spoken aloud
* Associated with schizophrenia

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19
Q

Thought block

A

someone loses a train of thought for no apparent reason, which may cause them to suddenly stop speaking
* Can occur at any time due to tiredness or stress

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20
Q

Akathisia

A

inability to remain still
* Neuropsychiatric syndrome associated with psychomotor restlessness
* Experience intense sensation of unease or inner restlessness

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21
Q

Catatonia

A

group of symptoms that usually involve movement and communication
* Agitation, confusion, restlessness

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22
Q

Flight of ideas

A

Subjective quickening of thoughts so most are not carried to completion before being overtaken
* Meaningful connections between ideas are kept although often linked by distracting environmental cues or form words themselves spoken aloud
o E.g. puns, rhymes, clang associations
* Retardation of thinking is slowing of train of thought although is remains goal directed
* Opposite is pressure of speech

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23
Q

Dissociation

A

hysteria
* Amnesia
* Depersonalisation = feeling being detached from one’s body or ideas
* Dissociative identity disorder = patient has multiple personalities which interact in complex ways
* Fugue = inability to recall one’s past, loss of identity or formation of new identity

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24
Q

What is generalised anxiety disorder

A

Excessive state of anxiety across different situations that last >6m and interferes with daily life

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25
Causes of GAD
Genetic predisposition Stress = work, noise, hostile home Events = losing/gaining spouse/job, moving house Faulty learning or secondary gain
26
Clinical features of GAD
Psychological symptoms * Unpleasant feeling of suspense * Recurrent automatic thoughts about negative outcomes * Reduced concentration * Hypervigilance Behavioural symptoms * Avoidance of anxiogenic stimuli * Restlessness/agitation * Irritability Physiological symptoms * Palpitations * Dyspnoea * Muscle tension * Disturbed sleep (initial insomnia) * Fatigue * Nausea Children’s symptoms * Thumb-sucking * Nail biting * Bed wetting
27
Signs of GAD
Tachycardia Tachypnoea Tremor Sweating Pallor Pupil dilation
28
Severity scoring of GAD
GAD2 or GAD7
29
Management of GAD
Self-help based on CBT principles Meditation and Progressive relaxation training SSRI
30
What is panic disorder
Anxiety disorder associated with panic attacks
31
Presentation of panic disorder
Physical * Palpitations * Chest pain * Choking * Tachypnoea * Dry mouth * Urgency of micturition * Dizziness * Blurred visions * Parasthesiae Psychological * Feeling of impending doom * Fear of dying * Fear of losing control * Depersonalisation * Derealisation
32
Management of panic disorder
Acute treatment = propranolol 1st line = CBT + SSRI (sertraline) 2nd line (no response after 12wks or CI) = imipramine or clomipramine 3rd line = pregabalin or clonazepam
33
What is obsessive-compulsive disorder
Compulsions = senseless, repeated rituals Obsessions = stereotyped, purposeless words, ideas or phrases that come into mind
34
Presentation of OCD
Compulsions (ACTS) * Usually a way to reduce stress from obsessions * Often resisted by patient but if chronic patient may have given up resisting * Repetitive behaviours * Checking, washing, counting, symmetry, repeating certain words or phrases Obsessive thoughts * Unpleasant = death, sexual, blasphemous * Intrusive * Irrational * Recognised as patient’s own thoughts Presents with * Derm, genital or anal, HIV/illness worries
35
Severity of OCD
Yale-Brown OC scale
36
Management of OCD
CBT = Exposure and response prevention SSRIs = sertraline, fluoxetine Clomipramine
37
What are phobic disorders
Group of disorders in which anxiety is experienced only or predominantly in certain well-defined situations that are not dangerous
38
Types of phobic disorders
Agoraphobia = fear of crowds, travel, events away from home Social phobias = situations where closely observed Simple phobia = e.g. dentists, spiders, clowns Fear of fear
39
Presentation of phobic disorders
Situations are avoided or endured with dread Become disorder when they cause marked distress and/or significantly impair ability to function Can lead to panic attacks
40
Management of phobic disorders
Panic attacks * CBT * SSRI, TCA, pregabalin, clonazepam
41
What is PTSD
Develops after an exceptionally stressful, life-threatening or catastrophic event or situation and lasts for over 4 weeks
42
Presentation of PTSD
Re-experiencing event in vivid nightmares or flashbacks * Any sensory modality: visual, smell, sound, touch Precipitating anxiety or panic attacks Avoidance of things that associated with event (place, person, thoughts) Hypervigilance Sleep disturbance Poor concentration Inability to recall key features of trauma Overly negative thoughts and assumptions about oneself or the world Exaggerated blame of self or other for causing trauma Negative affect Decreased interest in activities Feeling isolated Irritability or aggression Risky or destructive behaviour Heightened startle reaction In children * Re-enacting experience * Repetitive play * Frightening dreams without recognisable content
43
Associations of PTSD
Depression Emotional numbing Drug and alcohol misuse Anger
44
Management of PTSD
Watchful waiting if <4wks = acute stress disorder Trauma-focused treatments * CBT * Eye movement desensitisation and reprocessing (EMDR) * Hypnotherapy Stress management Medication (2nd line to therapy) * SSRIs or venlafaxine * SGA Treat comorbidity (depression) No debrief or counselling
45
What is anorexia nervosa
Compulsive need to control eating and body shape
46
Epidemiology of anorexia nervosa
F>M Men likely to be underdiagnosed Typical age of onset mid-adolescence (16-17)
46
Risk factors for anorexia nervosa
Biological * Genetics * Serotonin dysregulation Psychological * Depression * Anxiety * Obsessive compulsive features * Perfectionism * Low self-esteem * Absent sense of identity Developmental * Adverse life events and difficulties * Dietary/feeding problems in early life * Parents preoccupied with food * Psychosexual immaturity Sociocultural * Substance abuse * Negative body images due to media exposure * Image-aware activities * Past teasing or criticism for fatness * Asexuality
47
Presentation of anorexia nervosa
Weight loss becomes over-valued idea Marked distortion of body image Males with anorexia tend to want high muscle mass rather than thinness Ideal body shaped achieved by food refusal combined with over-exercising, induced vomiting, laxative abuse Many have episodes of binge eating, followed by remorse, vomiting and concealment Low self-worth Comorbid depression/insomnia
48
Signs of anorexia nervosa
Most due to starvation and vomiting Fatigue Decreased cognition Altered sleep cycle Sensitivity to cold Dizziness Constipation Fullness after eating Psychosexual problems Subfertility, Amenorrhoea Decreased visuo-spatial ability Decreased visual memory Increased speed of information processing Peripheral neuropathy Caries Dry skin Brittle hair Lanugo hair
49
Diagnostic criteria for anorexia nervosa
Weight <85% of predicted or BMI <17.5 Intense fear of gaining weight, becoming fat with persistent behaviour that interferes with weight gain Feeling fat when thin Endocrine change (Amenorrhoea, decreased libido)
50
Screening for anorexia nervosa
SCOFF questionnaire * Sick (make yourself) * Control (lost over eating) * One stone lost in 3m * Feel fat * Food (dominates life)
51
Red flags for anorexia nervosa
BMI <13 or <2nd centile Weight loss >1kg/wk Temp <34.5 Hypotensive (BP <80/50) Pulse <40 O2 sats <92% Limbs blue and cold Weakness in muscles = Unable to get up without using arms for leverage Purpura K+ <2.5 Na+ < 130 Phosphate <0.5 Long QT, flat T waves on ECG
52
Management of anorexia nervosa
Aim to restore nutritional balance * Weight gain 0.5-1kg/wk * 3500-7000 extra calories/wk * Final BMI 20-25 Treat complications of starvation Explore comorbidity Involve family/carers (Family therapy = 1st line in children) Address factors maintaining illness Eating disorder CBT Maudsley anorexia nervosa treatment for adults (MANTRA) Specialist supportive clinical management (SSCM)
53
Complications of anorexia nervosa
Re-feeding syndrome Cardiac Amenorrhoea Osteopenia
54
What is bulimia nervosa
Recurrent episodes of binge eating characterised by controlled overeating
55
Epidemiology of bulimia nervosa
F>M Increased prevalence in developed countries Young, Asian women increased risk
56
Risk factors for bulimia nervosa
Homosexuality/bisexuality in males Urbanisation Premorbid obesity Female relatives of anorexics Genetic contribution 54-83%
57
Presentation of bulimia nervosa
Preoccupation with control of body weight Regular use of mechanisms to overcome fattening effects of binges (starvation, vomit-induction, laxatives, overexercise) Fatigue Lethargy Feeling bloated Constipation Abdominal pain Oesophagitis Gastric dilation with risk of gastric rupture Heart conduction abnormalities Cardiomyopathy (if laxative use) Tetany Occasional swelling of hands and feet Irregular menstruation Erosion of dental enamel Enlarged parotid glands Calluses on back of hands (Russell’s sign) = from tooth marks during induction of vomiting Oedema = use of laxatives and diuretics Metabolic acidosis (if laxative use)
58
Diagnostic criteria for bulimia nervosa
Recurrent episodes of binge eating and feeling loss of control Recurrent compensatory behaviour to prevent weight gain Episodes occur at least once a week for 3m Self-evaluation is influenced by body weight or shape Disturbance does not occur exclusively during episodes of anorexia nervosa
59
Management of bulimia nervosa
Mild symptoms * Support * Self-help books * Food diary Referral to EDU if * No response * Moderate/severe symptoms Refer to medical unit if medical complications Antidepressants * Decrease binges and purging * First line = SSRIs (Fluoxetine) CBT Children = family therapy
60
What is refeeding syndrome
Metabolic abnormalities due to rapid initiation of food after >10 days of undernutrition
61
Presentation of refeeding syndrome
Rhabdomyolysis Resp/cardiac failure Low BP Arrhythmias Seizures
62
High risk of refeeding syndrome if
BMI <16 Unintentional weight loss >15% over 3-6m Little nutritional intake >10 days Hypokalaemia, hypophosphatemia or hypomagnesaemia prior to feeding Hx of alcohol abuse, drug therapy including insulin, chemotherapy, diuretics, antacids
63
Management of refeeding syndrome
Slow refeeding Thiamine and multivitamins Monitor phosphate, potassium, glucose and magnesium levels
64
Complications of refeeding syndrome
Hypomagnesaemia = torsades de pointes Abnormal fluid balance Death
65
What is depression
Chronic feelings of low mood, low energy and loss of interest
66
Causes of depression
Biological * Genetic susceptibility * Decreased monoamine * Structural brain change ventricular enlargement and raised sucal prominence Psychological * Personality traits neuroticism * Low self-esteem * Childhood experiences Social * Disruption due to life events * Stress associated with poor social environment, social isolation * Social drift to lower social class
67
Diagnosis of depression
Symptoms present every or nearly every day without significant changes throughout day for over 2 weeks and represent change from normal personality without alcohol/drugs, medical disorders or bereavement 2 Core symptoms * Low mood * Loss of interest or pleasure (Anhedonia) * Loss of energy 2 or more typical symptoms * Change in appetite (marked with weight loss without dieting) * Change in sleep = initial insomnia or early waking * Psychomotor retardation or agitation * Change in libido * Reduced ability to concentrate * Loss of confidence * Feelings of worthlessness, inappropriate guilt, self-reproach, hopelessness * Recurrent thoughts of death, suicide ideation or suicide attempts * Diurnal mood variation
68
Severity of depession
ICD-10 Mild = 4 symptoms Moderate = 5-6 symptoms + functioning affected Severe = 7+ symptoms + suicidal + loss of functioning Severe with psychotic Sx = Nihilistic, guilty delusions, derogatory voices
69
Investigations for depression
PHQ9 0-27
70
Management of mild depression
* Low-intensity psychological interventions * Sleep hygiene * Anxiety management (mindfulness) * Problem-solving techniques * Computerised CBT * Structured group-based physical activity
71
Management of moderate depression
* SSRI * CBT or interpersonal therapy
72
Management of severe depression
* Rapid specialist mental health assessment * Inpatient admission * ECT
73
Antidepressants for depression
1st line = fluoxetine, citalopram, sertraline 2nd line = different of first line 3rd line = mirtazapine, venlafaxine 4th line = try any other = lithium, tricyclics, monoamine oxidase inhibitors, serotonin agonist and reuptake inhibitor
74
Epidemiology of suicide
Most common cause of death in men <35 M > F Elderly Widow > divorced > single > married Unemployed and retired Seasonal variation = higher in spring, summer
75
Risk factors for suicide
Bipolar disorder Depression Borderline personality disorder Anorexia Substance abuse Past self-harm Past suicide attempts
76
Assessment of suicide risk
Circumstances of act * What happened that day? * How they feel about it? * Feeling and events leading up Background of act * How things over last few months? * Previous attempts * Plans in place Relevant family and personal history Intention lying behind act * Present feelings and intentions * Try again? * Wish it had been successful?
77
SAD persons score
Sex: male Age: <19, >45 Depression Previous suicide attempt Ethanol (or other substance abuse) Rational thinking loss (psychosis, psychotic depression) Single/separated Organised No social support Sickness (chronic illness)
78
Prevention of suicide
* Promote access to help * Limit access to lethal means * Shift position from unstable to stable * Social support
79
What is self harm
Self-poisoning or injury, irrespective of apparent purpose of act Expression of personal distress not an illness
80
Methods of self harm
Overdose Laceration
81
Reasons for self harm
Communicating a message Gaining power by escalating conflict often after argument with partner Emotional immaturity Inability to cope with stress Weak religious ties Availability of drugs Offers release from psychological pain
82
Risk factors for self harm
Witness deliberate self-harm * FHx of DSH * Learned behaviour from friends/ celebrities * Exacerbated by social media Biological * Reduced endorphin response to emotional arousal (traumatic brain damage) * Abnormalities in serotonin release Developmental * Poor early care * Physical, Emotional, Sexual abuse * Parental separation Peer relations * Conflicts * Bullying * Poor interpersonal skills Psychological * Identity problems * Low self-esteem Antisocial behaviour * Conduct disorder * Impulsivity * Substance misuse
83
Management of self harm
Prioritise treating physical effects of DSH Psychiatric assessment * Initial risk management (suicide risk, admission) * On-going risks with subsequent DSH * Relevant psychiatric, medical, social issues
84
Types of bipolar disorder
Bipolar I = mania and depression (sometimes only mania) Bipolar II = more episodes of depression, only mild hypomania Rapid cycling = episodes only last few hours or days Cyclothymia = highs and lows milder and don’t meet criteria for bipolar
85
Causes of bipolar disorder
Medication * Steroids * Illicit substances (cocaine, amphetamines) * Antidepressants Physical * Infection * Stroke * Neoplasm * Epilepsy * MS * Metabolic disturbances (hyperthyroidism)
86
Presentation of a manic episode
(>1wk) * Mood = irritability, euphoria, lability * Grandiosity * Distractibility/poor concentration * Fight of ideas/racing thoughts * Confusion * Lack of insight * Rapid speech * Hyperactivity * Decreased need for sleep * Change in appetite * Hypersexuality (increased libido/sexual disinhibition) * Inflated self-esteem * Reckless/ extreme risk-taking behaviour * Extravagance (manic overspending) * Social disinhibition * Delusions * Hallucinations * Impairment severe enough to limit function
87
Presentation of hypomania
* No psychotic symptoms * No impairment of daily functioning or need for inpatient treatment * Sociability/overfamiliarity * Lasts less than a week (4 days)
88
Management of bipolar disorder
Treatment of manic episode  Stop antidepressant and start antipsychotic (olanzapine) Risk assessment Mood stabiliser for longer term control = lithium or valproate
89
Psychosocial interventions for bipolar disorder
Emotional consequences of cycling disorder with periods of acute illness, stigma, fear of recurrence Psychoeducation CBT Support groups
90
Complications of bipolar disorder
Mood swings increase risk of suicide * Previous suicide attempt * FHx of suicide * Early onset of bipolar disorder * Extent of depressive symptoms * Increasing bad affective signs * Mixed affective states * Rapid cycling * Abuse of alcohol or drugs
91
Risk factors for substance misuse
Individual factors  Age, Gender, Family External factors  Culture, Price, Availability, Advertising Being a novelty seeker Impulsive Inherited vulnerability
92
Presentation of substance misuse
Acute intoxication  Administration of psychoactive substances resulting in disturbances of level of consciousness, cognition, perception, affect, behaviour Harmful use  Pattern of psychoactive substance use causing damage to mental/physical health or social functioning Dependence syndrome * Strong desire or send of compulsion to take substance (craving) * Difficulty in controlling substance use * Physiological withdrawal state when reducing or ceasing substance use * Tolerance = increased doses required to produce original effect * Progressive neglect of alternative pleasures or interests * Persisting use despite clear evidence of harmful consequences
93
Associations of substance misuse
Arrests for theft (to buy drugs) Odd transient behaviour (visual hallucinations, elation, mania) Unexplained nasal discharge (cocaine sniffing/ opiate withdrawal) Withdrawal symptoms (red eyes, shaking) Injection stigmata (marked veins, abscesses, hepatitis, HIV) Repeated requests for analgesics, only opiates acceptable, sedatives
94
Management of substance misuse
Opiate detoxification Methadone maintenance (transition to abstinence) * Free (no crime) * Safer (no injecting) * Still an addiction * Daily observed dosing Naltrexone = opioid antagonist Psychological support * Counselling * Motivational therapy * Cognitive therapy * Counsel on HIV and Hep C risk, needle exchange, safe sex
95
Relapse prevention of substance misuse
Barbiturate withdrawal may cause seizures (+-death) so admit as inpatient Anti-craving drugs (unvalidated approach)
96
Opioid withdrawal presentation
Intoxication * Drowsy * Mood change * Bradycardia * HTN * Pupil constriction * Resp depression * Decreased body temp Withdrawal * Muscle cramps * Low mood * Insomnia * Agitation * Diarrhoea * Shivering * Flu like Sx
97
Management of opioid withdrawal
IV naloxone = rapid onset and short Opioid detoxification Methadone Buprenorphine Needle exchange Testing for HIV, Hep B and C
98
Complications of opioid misuse
Infection (sharing needles) = IE, septic arthritis, septicaemia, necrotising fascitis VTE Overdose = resp distress Crime/prostitution
99
Risk factors for alcohol dependence
Male Unemployment and stress Peer pressure Younger age of usage/mental illness History of substance abuse Genetics
100
Presentation of alcohol dependence
Increased tolerance to alcohol Narrowing of drinking repertoire Difficulty or failure of abstinence Withdrawal = sweats, nausea, tremor Priority to maintain alcohol intake Often aware of compulsion to drink Gradual deterioration in function Alcohol dependence overtakes work, relationships, financial stability, health Patient’s drinking habits excessive within their own social context
101
Screening for alcohol dependence
CAGE questionnaire * Have you ever felt you should CUT down on your drinking? * Have you ever become ANNOYED by criticisms of your drinking? * Have you ever felt GUILTY about your drinking? * Have you ever had a morning EYE opener to get rid of a hangover? TWEAK questionnaire * Tolerance (2) * Worried (2) * Eye opener (1) * Amnesia (1) * Cut down (1) * >3 points indicates problem with alcohol
102
Management of alcohol dependence
Immediate management * Water * Vitamins (B1, B6, B12) * Food (calories and protein) * Benzo (Diazepam, chlordiazepoxide) Treat co-existing depression Refer to specialists Self-help/group therapy Disulfiram (drugs that produce nasty reaction if alcohol taken) Naltrexone (reduce pleasure alcohol brings and cravings on withdrawal) Acamprosate (improve abstinence rates by reducing cravings)
103
Complications of alcohol dependence
Liver = fatty liver, cirrhosis CNS = Poor memory/cognition, Cortical/cerebellar atrophy, Retrobulbar neuropathy, Fits, Falls, Neuropathy Gut = Vomiting and diarrhoea, Peptic ulcer, Erosions, Varices, Pancreatitis Heart = Arrhythmias, Increased BP, Cardiomyopathy Increased osteoporosis risk Sperm = Decreased fertility, Decreased sperm motility GI and breast cancer Marrow = Decreased Hb, Increased MVC Violent crime Suicide
104
Stages of alcohol withdrawal
6-12 hrs – symptoms 12-24 hrs = hallucinations 24-48 hours = seizures 48-72 hours = delirium tremens
105
Presentation of alcohol withdrawal
Tachycardia Hypotensive Tremor Fits/seizures (generalised tonic clonic) = seen at 36 hrs Visual or tactile hallucinations Diarrhoea and vomiting, nausea Shaking Sweaty Anxiety Insomnia/sleep disturbance Mood disturbance
106
Management of alcohol withdrawal
Water Vitamins = thiamine, IV pabrinex Food Chlordiazepoxide 5-7 days Complex withdrawals may need admission to hospital
107
Presentation of delerium tremens
* Confusion state * Hallucinations (tactile or visual) * Vomiting * Extreme paranoia * Coarse tremor * Delusions * Fever * Tachycardia
108
What is wernicke's encephalopathy
Thiamine (B1) deficiency related to alcohol abuse
109
Causes of wenicke;s encephalopathy
Chronic alcohol consumption Brain tumour Malabsorption Prolonged vomiting Hyperemesis gravidarum Chemotherapy
110
Presentation of wernicke's encephalopathy
Triad = confusion, wide-based gait ataxia, ophthalmoplegia (nystagmus, conjugate gaze, bilateral lateral rectus palsies) peripheral neuropathy Clouding of consciousness memory disturbance hypotension hypothermia ptosis
111
Management of wernicke's encephalopathy
MEDICAL EMERGENCY High dose IV/IM thiamine over 1 wk Oral supplementation until no longer at risk Give before glucose if hypoglycaemic
112
What is Korsakoff's syndrome
Hypothalamic damage and cerebral atrophy due to thiamine deficiency
113
Presentation of korsakoff's syndrome
Anterograde amnesia = inability to acquire new memories Confabulation Retrograde amnesia Lack of insight Apathy
114
Management of Korsakoff's syndrome
IV pabrinex + chlordiazepoxide
115
Classification of personality disorders
* Cluster A = odd or eccentric * Cluster B = dramatic, emotional, erratic * Cluster C = anxious and fearful
116
Paranoid personality disorder
* Suspicious, preoccupied with conspiratorial explanations, distrusts others, holds grudges * Hypersensitivity and unforgiving attitude when insulted * Unwarranted tendency to question loyalty of friends * Reluctance to confide in others * Preoccupation with conspirational beliefs and hidden meaning * Unwarranted tendency to perceive attacks on character
117
Schizoid personality disorder
* Emotionally ‘cold’, lacks interests in others, rich fantasy world, excessive introspection * Indifference to praise and criticism * Preference for solitary activities * Lack of interest in sexual interactions * Lack of desire for companionship * Few interests or friends other than family
118
Schizotypal personality disorder
* Ideas of reference * Odd beliefs and magical thinking * Unusual perceptual disturbances * Paranoid ideation and suspiciousness * Odd, eccentric behaviour * Lack of close friends * Inappropriate affect * Odd speech without being incoherent
119
Antisocial personality disorder
* Aggressive, easily frustrated, callous lack of concern for others, irresponsible, impulsive, unable to maintain relationships, criminal activity, lack of guilt, conduct disorder * Failure to conform to social norms * Deception, repeatedly lying, conning others for personal profit or pleasure * Impulsiveness or failure to plan ahead * Irritability and aggressiveness * Reckless disregard for safety of self or others * Consistent irresponsibility * Lack of remorse
120
Emotionnally unstable personality disorder
* Feeling of emptiness, unclear identity, intense and unstable relationships, unpredictable affect, threats or acts of self-harm, impulsivity, pseudohallucinations * Inability to control anger or plan, unpredictable affect and behaviour * Quasi psychotic thoughts * Efforts to avoid real or imagined abandonment
121
Histrionic personality disorder
* Over-dramatise, self-centred, shallow affect, labile mood, seeks attention and excitement, manipulative behaviour, * Inappropriate sexual seductiveness * Need to be centre of attention * Rapidly shifting and shallow expression of emotions * Suggestibility * Physical appearance used to attention seeking purposes * Impressionistic speech lacking detail * Relationships considered more intimate than they are
122
Narcissistic personality disorder
* High self-importance, lacks empathy, grandiose, needs admiration * Preoccupation with fantasies of unlimited success, power, beauty * Sense of entitlement * takes advantage of others to achieve own needs * Chronic envy * Arrogant and haughty attitude
123
Obsessive-compulsive personality disorder
* Worries and doubts, orderliness and control, perfectionism, sensitive to criticism, rigidity, indecisiveness, pedantry, judgemental * Stingy spending style towards self and others * Meticulous, scrupulous, rigid about etiquettes of morality, ethics or values
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Anxious avoidant personality disorder
* Extremely anxious and tense, self-conscious, insecure, fearful of negative evaluation by others, timid, desires to be liked * Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism or rejection * Unwillingness to be involved unless certain of being liked * Preoccupied with ideas of being criticised or rejected in social situations
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Dependent personality disorder
* Passive, clingy, submissive, excess need for care, feels helpless when not in relationship, feels hopeless and incompetent * Difficulty making everyday decisions without excessive reassurance from others * Need for others to assume responsibility for major areas of life * Difficulty in expressing disagreement with others due to fears of losing support * Lack of initiative * Unrealistic fears of being left to care for themselves * Urgent search for another relationship as source of care and support when close relationship ends
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Management of EUPD
No evidence for medication Psychological therapies * Dialectical behaviour therapy = self-soothing, distraction techniques, radical acceptance, wise mind vs emotional mind * Therapeutic communities * Cognitive analytic therapy * Mentalisation based therapy
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Risk factors for post-partum depression
History of postpartum depression Unipolar/bipolar depression Unplanned pregnancy Lack of support Marital problems Social circumstances Sleep deprivation Hormonal changes
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Screening for post-partum depression
Edinburgh postnatal depression scale - Low threashold for referring to MDT in mother and baby units
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Management of post-partum depression
Involve partners/ other parent of child Short-term antidepressants  Stop breastfeeding as antidepressants can end up in breast milk CBT ECT (if severe, stop eating/drinking, suicidal)
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Complications of post-partum depression
Impairs infants cognitive and social skills Suicide is leading cause of maternal death postpartum
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Risk factors for post-partum psychosis
Previous postpartum psychosis Single parenthood Reduced social support Previous mental illness
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Presentation of post-partum psychosis
Psychotic episode usually peaks 2w post-partum Prominent affective symptoms (depression or mania) Rapidly fluctuating symptoms Mood lability Insomnia Disorientation
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Prevention of post-partum psychosis
High-risk patients need individualised care plan with antenatal specialist perinatal mental health input Early detection essential
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Management of post-partum psychosis
Medication to target affective symptoms * Mood stabiliser * Antidepressant * ECT Medication to target psychotic symptoms * SGA * Long-acting benzodiazepine Therapy Reassurance Emotional support Refer to local mental health services and health visitors at discharge
135
Causes of lithium toxicity
Dehydration Renal failure Drugs * Diuretics (thiazides) * ACE inhibitors/angiotensin II receptor blockers * NSAIDs * Metronidazole
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Presentation of lithium toxicity
Coarse tremor Hyperreflexia Acute confusion Polyuria Seizure Coma
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Management of lithium toxicity
Mild-moderate  Volume resuscitation with normal saline Severe  Haemodialysis
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What is neuroleptic malignant syndrome
Neurotoxicity and muscle damage from antipsychotics
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Presentation of neuroleptic malignant syndrome
Occurs within hrs to days of starting antipsychotic Fever Muscle rigidity Autonomic dysfunction * Hypertension * Tachycardia * Tachypnoea Agitated delirium with confusion Decreased reflexes
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Investigations in NMS
Raised creatine kinase AKI (secondary to rhabdomyolysis) Leucocytosis
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Management of NMS
Stop antipsychotic Transfer to medical ward IV fluids (prevent renal failure) Dantrolene (benzos) Bromocriptine, dopamine agonist
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Causes of serotonin syndrome
SSRIs and SNRIs MAO-I Ecstasy Amphetamines Drug interactions with * St Johns Wort * Triptans * TCAs * Linezolid
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Presentation of serotonin syndrome
Neuromuscular abnormalities = myoclonus, tremor, hyperreflexia, ataxia, incoordination, seizures Altered mental state = agitation, confusion, euphoria, hallucinations, LOC Autonomic dysfunction = tachycardia, HTN, fever, diaphoresis, arrhythmias, tachypnoea, sweating, shivering, diarrhoea Rapidly onsets after increased dose of serotonin boosting drug
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Management of serotonin syndrome
Benzos S blocking drug = cyproheptadine (5-HT2 antagonst) Stop SSRI/SNRI Monitor
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types of psychoses
* Schizophrenia * Delusional disorder * Schizotypal disorder * Depressive psychosis * Manic psychosis * Organic psychosis = head injury, drug induced
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Positive psychotic symptoms
* Thought insertion, thought broadcasting, thought withdrawal, repeating thoughts, thought alienation * Persistent delusions (culturally inappropriate and completely impossible) * Persistent hallucinations * Passivity phenomena * Disturbance in mood = Sudden excitement, posturing, waxy flexibility, negativism, echopraxia
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Negative psychotic symptoms
* Reduced speech * Loss of motivation * Self-neglect * Social withdrawal * Apathy, blunting or incongruity of affect * Poverty of thought * Poor non-verbal communication * Clear deterioration in functioning * Lack of insight
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Psychotic terms
Knights move = no links Flight of ideas = flight from one place to another Circumstantiality = comes back round Perseverance = same point Tangentiality = off on tangent, never returns Echolalia = repeat same word/phrase Clanging/clang associations Word salad Othello = delusional jealousy Fregoli = stranger is family in disguise Capgras = family member has evil twin Cotard = nihilistic, dead body Charles bonnet = hallucinations due to sight loss
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Management of psychoses
Oral antipsychotic Psychological interventions = CBT, family therapy
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What is schizophrenia
Common chronic relapsing condition with psychotic symptoms, disorganisation symptoms, negative symptoms and sometimes cognitive impairment
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Risk factors for schizophrenia
Early use of cannabis Genetic susceptibility (Family history) Brought up in cities Migrant groups (Asians, African-Caribbeans)
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Presentation of schizoprenia
First rank symptoms (>1) * Thought alienation * Passivity phenomena * 3rd person auditory hallucinations * Delusional perception Second rank symptoms (2+) * Delusions * 2nd person auditory hallucinations * Hallucinations in any other modality * Thought disorder * Catatonic behaviour * Negative symptoms
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Prodromal symptoms in schizoprenia
* Precedes most first episodes of psychosis by up to 18m * Gradual deterioration in functioning * Transient and/or attenuated psychotic symptoms * Odd thoughts, beliefs and behaviours * Concentration problems * Altered affect * Social withdrawal * Reduced interest in daily activities
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Management of schizoprenia
Anti-psychotics (started ASAP) Psychosocial interventions * CBT * Treating substance misuse * Addressing housing, benefits, social skills training * Supported employment Support for family * Family therapy * Support groups Referral to Early Intervention Service
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Schizoprenia prognosis better if
* Sudden onset * No negative symptoms * Supportive home * Female (better social integration) * Later onset of illness * No CNS ventricular enlargement * No family history
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Schizoprenia prognosis worse if
* Strong family history * Gradual onset * Low IQ * Prodromal phase of social withdrawal * Lack of obvious precipitant
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Somatisation disorder
* Multiple physical symptoms present for at least 2 years * Patient refuses to accept reassurance or negative test results
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Illness anxiety disorder
* Persistent belief in presence of underlying serious disease * Patient refuses to accept reassurance or negative test results
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Conversion disorder
* Loss of motor or sensory function * Patient doesn’t consciously feign symptoms or seek material gain * individual experiences neurological or physical symptoms that cannot be explained by neurological or medical causes
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Dissociative disorder
* Separating off certain memories from normal consciousness * Psychiatric symptoms = amnesia, fugue, stupor
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indications for ECT
o Prolonged or severe manic episode o Severe depression o Catatonia
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Cautions for ECT
o Recent subdural/subarachnoid haemorrhage bleed o Stroke o MI o Arrhythmia o CNS vascular anomalies
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Side effects of ECT
o Memory loss o Short term retrograde amnesia o Confusion o Headaches o Clumsiness o Common anaesthetic S/E
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Withdrawal symptoms of benzos
o Insomnia o Irritability o Anxiety o Tremor o Loss of appetite o Tinnitus o Perspiration o Perceptual disturbances o Seizures
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Side effects of SSRIs
o headache, nausea, insomnia o Indigestion, stomach aches, diarrhoea, constipation o Loss of appetite o Dizziness o Loss of libido o Erectile dysfunction o increased risk of GI bleeding = PPI if taking NSAID o Hyponatraemia o Increased anxiety and agitation o Fluoxetine and paroxetine higher risk of drug interactions o Citalopram  QT interval prolongation
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Contraindications to SSRIs
o Do not use with warfarin/heparin = switch to mirtazapine o Avoid triptans o In first trimester = congenital heart defects (particularly paroxetine) o In third trimester = persistant pulmonary hypertension of newborn
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Side effects of TCA
o tachycardia, o dry mouth o blurred vision o Constipation o Problems passing urine o anticholinergic/muscarinic effects, o postural hypotension o sedation o weight gain o Excessive sweating (especially at night) o Arrhythmias, palpitations, tachycardia
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side effects of first generation antipsychotics
o Extrapyramidal: parkinsonism, acute dystonia (sustained muscle contraction), akathisia (severe restlessness), tardive dyskinesia (movements) o Hyperprolactinaemia o Increased risk of stroke and VTE in elderly o Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation o Sedation and weight gain o Neuroleptic malignant syndrome o Reduced seizure threshold o Prolonged QT (haloperidol) o Olucogyric crisis
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Side effects of second generation antipsychotics
o Metabolic effects o Weight gain o Hyperprolactinaemia o Hypercholesterolaemia
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Side effects of clozapine
agranylocytosis, constipation, hypersalivation, reduced seizure threshold, sedating, postural hypotension, toxic megacolon, cardiomyopathy
Finals
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