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Similar to Psychiatry Presentation
Psychiatry Presentation
- 1.
- 2. Background Info onMental Health 1 in 4 people experience some kind of MH problem in 1 year Mixed anxiety & depression is the most common MH disorder in Britain Women are more likely to have been treated for a MH problem than men 10% children have a mental health problem Depression affects 1 in 5 older people The UK has one of the highest self-harm rates in Europe (400/100000 population) 9/10 prisoners have a mental disorder
- 3. Mental Health &The Law
- 4. Human Rights Act ‘Everyonehas the right to liberty and security of the person.’ ‘No-one shall be subjected to torture or to inhuman or degrading treatment or punishment.’ ‘Everyone has the right to respect for his private and family life, his home, and his correspondence.’
- 5. Mental Capacity Act Assumecapacity unless established that he/she doesn’t Do not treat as unable to make a decision unless all practicable steps to do help have been taken without success Do not treat as unable to make a decision just because it is unwise Any act or decision made under the MCA for or on behalf of someone who lacks capacity must be done in his/her best interests Before anything is done, you must consider whether the purpose can be achieved in a way that is less restrictive of a persons right’s and freedom’s
- 6. Assessing Capacity MUST havea diagnosis that may impair functioning Need to assessed as to whether they can make a decision on a SPECIFIC matter ◦ Understand the information ◦ Retain the information ◦ Use and weigh the information to make a choice ◦ Communicate the decision
- 7. Mental Health Act 1983Act of UK Parliament, revised in 2007 Covers reception, care and treatment of mentally disordered persons Also covers detention of people (AKA sectioning)
- 8. People Defined inthe Act Approved Mental Health Professional Section 12 Approved Doctors Approved Clinicians Responsible Clinicians
- 9. Civil Sections Section 2 Section3 Section 4 Section 5(2) Section 5(4) Section 135 Section 136
- 10.
- 11. Mental State Exam Appearance Attitude Behaviour Mood& Affect Speech Thought Process Thought Content Perception Cognition Insight
- 12.
- 13. Assessing Suicide Risk MaleGender Age Unemployed Concurrent mental disorder Treatment and care received after a previous suicide attempt Alcohol and drug abuse Physically disabling or painful illness Low socio-economic status Previous psychiatric treatment Professions Low social support/living alone Significant Life events Institutionalisation Bullying
- 14. PATHOS scoring Have youhad PROBLEMS for longer than 1 month? Were you ALONE in the house when you attempted suicide? Did you plan the suicide for more than THREE hours? Are you feeling HOPELESS about the future and that things will not get much better? Were you feeling SAD for most of the time before the attempt?
- 15.
- 16. SSRIs INDICATION: Moderate-severe depression.MAY be effective in bulimia nervosa. EXAMPLES: Citalopram, Fluoxetine, Sertraline MECHANISM: Increase 5-HT neurotransmission by blocking 5-HT reuptake SIDE-EFFECTS: GI, side effects, agitation, sexual dysfunction SPECIAL INSTRUCTIONS: Dyscontinuation syndrome if sertraline/citalopram stopped suddenly. Fluoxetine has longer half-life therefore safer.
- 17. SNRIs INDICATION: Major depression EXAMPLES:Venlafaxine MECHANISM: Increase noradrenaline & serotonin availability by blocking re-uptake SIDE-EFFECTS: loss of appetite, weight and sleep. Sexual dysfunction. SPECIAL INSTRUCTIONS: More dangerous in overdose than SSRIs
- 18. TCAs INDICATION: Depression withanxiety and/or agitation EXAMPLES: Amitriptyline, clomipramine, dothiepi MECHANISM: Increase 5-HT, NA and DA availability by non-elective blockade of mono-amine reuptake SIDE-EFFECTS: dry mouth, constipation, sedation. Cardiotoxic in overdose SPECIAL INSTRUCTIONS: Treat overdose with activated charcoal
- 19. MAOIs INDICATION: Depression resistantto SSRIs/TCAs EXAMPLES: Moclobemide, Isocarboxazid, Phenelzine MECHANISM: block the monoamine oxidase enzymes responsible for intracellular metabolism of monoamine neurotransmitters SIDE-EFFECTS: serotonin syndrome!! Hypertensive crisis due to interaction with sympathomimetic amines. SPECIAL INSTRUCTIONS: when starting MAOIs ensure SSRIs/TCAs have been stopped for 2 weeks
- 20. Anxiolytics INDICATION: Short-term treatmentof severe, disabling anxiety/ EXAMPLES: Benzodiazapines, beta blockers, buspirone, SSRIs MECHANISM: Increase the effect of GABA. Benzodiazapines increase GABAergic activity. Beta blockers act on sympathetic nervous system and busprione is a 5-HT agonist. SIDE-EFFECTS: Dependence, withdrawal, daytime sedation SPECIAL INSTRUCTIONS: Decrease slowly and make sure only on them short term. Don’t drink on them (increased sedative effect)
- 21. Hypnotics INDICATION: Short-term treatmentof insomnia causing significant distress/disability EXAMPLES: Benzodiazapines, zopiclone, barbituates (but not really), antihistamines MECHANISM: Increase effect of GABA SIDE-EFFECTS: Dependence & tolerance. Withdrawal, daytime sedation, SPECIAL INSTRUCTIONS: Same as anxiolytics
- 22. Lithium INDICATION: Bipolar disorder MECHANISM:Unclear. SIDE-EFFECTS: Nausea, thirst, polyuria, hypothyroidism, tremor, ataxia and teratogenicity. Toxicity – dysrhythmias, renal impairment, convulsions. SPECIAL INSTRUCTIONS: Titrate dose to achieve plasma conc of 06-1.0mmol/L. Narrow therapeutic range. Treat toxicity with fluid resuscitation, haemodialysis. Do not withdraw abruptly.
- 23. Typical Antipsychotics INDICATION: Acutetreatment of psychotic states, schizophrenia & chronic psychoses EXAMPLES: Chlorpromazine, promazine, prochlorperazine, haloperidol MECHANISM: Dopamine receptor antagonists. Primarily affect D2 receptors. SIDE-EFFECTS: Sedation, extra-pyramidal side effects of parkinsonism, dry mouth, drowsiness, postural hypotension, weight gain, photosensitivity. NEUROLEPTIC MALIGNANT SYNDROME = hyperthermia, loss of consciousness and autonomic dysfunction. Chlorpromazine associated with raised prolactin & galactorrhoea SPECIAL INSTRUCTIONS: Do NOT give haloperidol in parkinsons. Contraindicated in cardiovascular disease, epilepsy, coma patients, bone marrow disorders.
- 24. Atypical Antipsychotics INDICATION: Psychosesas in typical. Behavioural challenges in Alzheimer’s, controlling tics in tourettes. EXAMPLES: Clozapine, olanzapine, quetiapine, risperidone MECHANISM: Affect D3 and D4 receptors. SIDE-EFFECTS: Increased appetite and weight gain. Metabolic syndrome. Clozapine causes agranulocytosis. SPECIAL INSTRUCTIONS: Clozapine = last resort, monitor FBC on all atypical antipsychotics.
- 25. Cognitive Enhancers INDICATION: Treatmentof cognitive symptoms in Alzheimer’s disease. EXAMPLES: Donepizil, galantamine, rivastigmine, memantine MECHANISM: Acetylcholinesterase inhibitors. SIDE-EFFECTS: Nausea, vomiting, diarrhoea, headache, insomnia, dizziness. SPECIAL INSTRUCTIONS: Do NOT prescribe in asthmatics or COPD. Nor in patients with a history of gastric/duodenal ulcers.
- 26. CNS stimulants INDICATION: Narcolepsyand ADHD. EXAMPLES: Methylphenidate (Ritalin), atomoxetine, dexamfetamine MECHANISM: Increase availability of monoamines by stimulating release into synapse and/or blocking reuptake SIDE-EFFECTS: Insomnia, restlessness, tremors, anxiety, anorexia, dependence, psychosis. Growth retardation in children. SPECIAL INSTRUCTIONS: Do not prescribe in patients with cardiovascular disease or in pregnancy/breastfeeding women.
- 27.
- 28. Dementia Describes the symptomsthat occur when the brain is affected ◦ Memory loss ◦ Confusion & mood changes ◦ Problems with speech & understanding NOT a natural part of growing old. Various types. ALL are progressive.
- 29. Alzheimer’s A woman attendssurgery with her 72-year old mother. She reports that her mother has recently been misplacing everyday things such as keys and has missed a few bill payments and she demands you test her memory. Her mother feels there isn’t a problem at that her daughter is exaggerating everything that has happened, she then begins to tell you about the builder who knocked on her door two weeks ago saying she needed her kitchen renovated under new council laws.
- 30. Vascular An 81-year oldmale presents with his wife to the GP. He had a stroke 8 months ago and, despite recovering reasonably well, he has found his memory just isn’t the same as it used to be and he sometimes struggles to understand what people are saying. Four months later he has another stroke. This time his wife brings him in post- recovery saying she has noticed he drastically worsened. He is now unable to remember what he has said, constantly repeating himself, and is often very agitated due to struggling to communicate and understand what is being said.
- 31. Dementia with LewyBodies A 65-year old male presents to the surgery informing you he thinks he has a memory problem. It started about 6 months, he has noticed he has been increasingly forgetful misplacing objects, and the other day he couldn’t recognise his wife. This is very distressing for him and he is scared about what will happen. Observing him you notice a resting tremor in his right hand and that the movements are quite slow. He informs you the tremor has been going on for about 2 months. Two years later he is being assessed by a psychiatrist and reports that he often see’s people that aren’t there and hears dogs barking that his wife can’t hear.
- 32. Investigating Potential Dementia Routinehaematology U&Es, Serum Calcium, Glucose, LFTs TFTs Vitamin B12 and folate levels Refer to a MEMORY ASSESSMENT SERVICE
- 33. At the memoryclinic… History & Examination Medication Review Clinical Cognitive Assessment
- 34.
- 35.
- 36. Other considerations In-patient care ◦Psychiatric inpatient admission if severely disturbed ◦ If in for medical reasons ALWAYS liaise and assess impact on dementia Palliation
- 37. Mental and Behavioural Disorders DUETO PSYCHOACTIVE SUBSTANCE USE
- 38. Substance Abuse Histories Howlong? How much? How strong? What time in the day/week? Has it interfered with daily life? Do you need more to create the same effect? Do you get withdrawal symptoms? If so, are these relieved by having more of the substance?
- 39. Alcohol Use A 32-yearold woman comes to you feeling depressed and complaining of work, housing and financial stresses. She admits she is struggling to cope and her children are being very difficult to handle at the moment. When you question about how she is coping she reluctantly tells you she has started drinking a bit more than usual, but it’s just because of the stress and it isn’t causing her any problems. Her boss has caught her drunk after lunch once though.
- 40. Quick Scores forAlcohol Use CAGE Have you ever felt you needed to CUT down on your drinking? Have people ANNOYED you by criticising your drinking? Have you ever felt GUILTY about drinking? Have you ever felt you needed a drink first thing in the morning (EYE-OPENER) to steady your nerves or get rid of a hangover? FAST Test 1:- MEN: How often do you have EIGHT or more drinks on one occasion? WOMEN: How often do you have SIX or more drinks on one occasion? NEVER LESS THAN MONTHLY MONTHLY WEEKLY DAILY 2:- How often during the last year have you been unable to remember what happened the night before because you had been drinking? NEVER LESS THAN MONTHLY MONTHLY WEEKLY DAILY 3:- How often during the last year have you failed to do what was normally expected of you because of drinking? NEVER LESS THAN MONTHLY MONTHLY WEEKLY DAILY 4:- In the last year has a relative, or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? No YES, ON ONE OCCASION YES, ON MORE THAN ONE OCCASION
- 41. AUDIT 10 point questionnaire Scoredout of 40 8 or more is considered an indicator of hazardous and harmful use
- 42. Assessment Bombard the patientswith questionnaires ◦ Severity of Alcohol Dependence Questionnaire ◦ Alcohol Problems Questionnaire Motivational intervention ◦ Identify drinking problem ◦ Resolve ambivalence and encourage positive change ◦ Be persuasive rather than confrontational Refer Children and Young People Triage Adults Assess co-morbidities, patterns of use and other problems INTERVENE
- 43. Assessment Advice to Adultsre safe alcohol consumption ◦ Potential harm ◦ Barriers to change ◦ Practical strategies to reduce alcohol consumption ◦ Create a set of goals Brief interventions for young adults and adults ◦ Motivational interviewing Refer to specialist services ONLY IF NEEDED ◦ Show signs of moderate or severe alcohol dependence ◦ Failed to benefit from structured brief interventions ◦ Show signs of alcohol-related impairment
- 44.
- 45. If Withdrawal isUnsuccessful… Consider offering alternatives ◦ Acamprosate ◦ Oral Naltrexone ◦ +- CBT ◦ Disulfiram
- 46. Physical Complications Acute alcoholwithdrawal Wernicke’s encephalopathy Wernicke-Korsakoff syndrome Alcohol-related liver disease Alcohol-related pancreatitis
- 47. Prevention IS Better… Schoolprogrammes to educate children Increasing the cost of alcohol Limiting the licences on places selling alcohol Encouraging companies to place warnings on the alcohol containers
- 48. Opioids Use How torecognise… ◦ Physical signs :- miosis, needle marks, respiratory depression, increased sphincter tone, hypovolaemia ◦ Request specific opioids ◦ Unresponsive to the medication, always insisting they need a higher dose ◦ Malingering ◦ Failure to do what is expected of them
- 49. Treating Intoxication A –clear if needed B – provide ventilation if needed C – IV fluids OBSERVATIONS IV Naloxone
- 50. Mechanism of Tolerance& Withdrawal Internalisation of Mu and Delta opioid receptors Down regulation of secondary messengers such as cAMP Therefore need larger amount of opioid to create same effect Withdrawal occurs when endogenous opioid cannot activate the remaining receptors
- 51. Recognising Withdrawal Autonomic symptoms CNSArousal Pain Cravings
- 52. Treating Withdrawal INFORMATION CREATE APLAN WITH GOALS OFFER SUPPORT TO FAMILIES AND CARERS METHADONE OR BUPRENORPHINE = FIRST LINE LOFEXIDINE = OPTION FOR SHORT-TERM DETOXIFICATION DETOXIFICATION LASTS 4 WEEKS IF INPATIENT ◦ 12 WEEKS IF IN COMMUNITY
- 53. CAN ALSO OFFER‘ULTRA- RAPID’ OR ‘RAPID’ DETOX
- 54. Cannabinoids Recognised using CAGEfor dependence May have: - ◦ Miosis ◦ Loss of balance ◦ Impaired cognitive functioning ◦ Loss of sensory perceptions
- 55.
- 56. Aetiology Genetics Development Brain abnormalities Neurotransmitter abnormalities Lifeevents High expressed emotion environment
- 57. Epidemiology Onset ◦ Between 17& 30 in men ◦ 20 and 40 in women Lifetime risk between 0.7 and 0.9% Increased prevalence in urban areas and lower social classes
- 58. Schneider’s First RankSymptoms Auditory hallucinations Thought withdrawal, insertion and interruption Thought broadcasting Somatic hallucinations Delusional perceptions Feelings/actions experienced as if made or influenced by external agents
- 59. General Clinical Features SchizophrenicThought Disorder Disorders of Stream of Thought Delusions Abnormalities of Mood Hallucinations
- 60. Paranoid Schizophrenia An 24-yearold male comes into GP. He has been feeling especially stressed since a van parked outside his house has started watching him. He claims it is because they know about his mission. Half-way through the consultation he becomes incredibly aggressive towards you claiming you’re colluding with them and storms out.
- 61. Hebephrenic Schizophrenia A 39-yearold female is bought to the GP by her concerned husband. Both of them lost their jobs a year ago and had to move into council housing. He says recently she’s changed drastically, sometimes talking about one thing then going off on a tangent and he struggles to keep up. She’s also started rhyming her words a lot and on other occasions it’s very hard to get anything out of her. They were also at a funeral the other day and she just began laughing uncontrollably and wouldn’t stop.
- 62. Catatonic Schizophrenia A psychiatristattends a home visit to see a patient that has been referred to him. Upon arrival at the property he is met by a mother who shows him her son. He is standing at the window on one leg, with the other slightly flexed and one finger pointing upwards. She tells you he will wake up at 8.30 in the morning and maintain this position for the entire day. If ever he does talk it’s intelligible words that make no sense.
- 63.
- 64. Treating Schizophrenia BUT WHICHDRUG? POSITIVE NEGATIVE ATYPICALTYPICAL
- 65. Treating Schizophrenia Psychological Interventions ◦CBT ◦ Family Based Therapies ◦ Arts therapy Social Interventions ◦ Education ◦ Housing ◦ Finance
- 66. Delusional Disorder Patient expressesidea with unusual persistence/force Idea is exerting influence on patients life Quality of secretiveness/suspicion Humorless and sensitive about the belief No matter how unlikely patient believes it fully and completely Any contradiction to the idea is met with force Belief is out of keeping with patients cultural and social background Others who observe the behaviour believe it to be abnormal
- 67. Delusional Disorder Stable disordercharacterised by delusions that are clung to Chronic illness Delusions are logical and have internal consistency Delusions do not interfere with logic unless related to the delusion
- 68.
- 69. Schizoaffective disorder Mixture ofSchizophrenia & Mood Disorders Bipolar Type or Depressive Type Treat symptoms of mood disorders and of schizophrenia
- 70.
- 71. Manic Episodes “An episodewhere mood is higher than the person’s situation warrants and may vary from relaxed high spirits to barely controllable exuberance, accompanied by hyperactivity, a compulsion to speak, a reduced sleep requirement, difficulty sustaining attention and, often, increased distractability” PSYCHOLOGICAL • Pressured speech • Flight of ideas • Grandiose delusions • Expanded self-esteem • Preoccupying thoughts • Over-indulgence in behaviours with high risk PHYSICAL • Sweating • Pacing • Weight loss
- 72. Bipolar Affective Disorder A23-year old man walks into your practice. He stands out wearing brightly coloured clothing and wearing shorts and flip-flops despite the snow. He talks incredibly quickly and you struggle to keep up with him, but understand a few words about ‘living on mars’ and ‘communicating with the Gods for his mission.’ When you try to get him to slow down he gets irritable telling you there’s no time and that he is of vital importance to all their plans.
- 73. Bipolar Affective Disorder Occurrenceof at least one manic episode ◦ If hypomanic episode (without full manic episode) occurs then bipolar II disorder Major social complications ◦ Marital ◦ Financial ◦ Social Medical complications ◦ Increased mortality ◦ Substance abuse tends to occur concomitantly
- 74. Investigations CT/MRI of brain ◦Brain tumour ◦ Head injury FBC, LFTs, U&Es, Haematinics ◦ Anaemia ◦ Hepatic/renal failure ◦ Pernicious anaemia Endocrinology assessments ◦ Thyroid dysfunction ◦ Addison’s/Cushing’s ◦ Hypoglycaemia
- 75. Treatment ACUTE MANIA DISCUSSEDLATER Mood stabilisers ◦ Lithium ◦ Semisodium valproate Second-line ◦ Add carbamazepine or lamotrigine
- 76. Lithium Treatment Before startingtreatment ◦ TFTs ◦ Renal function ◦ ECG ◦ Avoid if in first trimester/advocate reliable contraception in women of child-bearing age Check levels 12 hours after latest dose ◦ Therapeutic range = 0.7-1.0 mmol/L if dose is taken once daily ◦ Twice daily dose = 0.4-0.8 mmol/L at 12 hours When starting check 1 week after commencing and 1 week after every dose change Monitor monthly in first 6 months then every 3 months if lithium levels are stable and adherence is good Check TFTs & U&Es every 6 months
- 77. Lithium Toxicity Occurs atlevels above 1.4mmol/L Symptoms ◦ Diarrhoea ◦ Vomiting ◦ Ataxia ◦ Nystagmus ◦ Dysarthria Management ◦ Isotonic saline fluids ◦ Haemodialysis if renal failure o Confusion o Epileptic Seizures o Hypereflexia o Hypertonia o AV Heart Block
- 78. Depression A 33-year oldwoman comes to see her GP. It takes her a while to start talking, but she reports symptoms of insomnia and early morning waking. She denies feeling of low mood, but on further probing she has lost interest in her gardening and does feel tired a lot of the time. She has been losing weight steadily over the past few months, and has struggled to get the energy for her job.
- 79. Persistent sadness orlow mood Loss of interests or pleasure Fatigue or low energy +/- ◦ Disturbed sleep ◦ Poor concentration or indecisiveness ◦ Low self-confidence ◦ Poor or increased appetite ◦ Suicidal thoughts or acts ◦ Agitation or slowing of movements ◦ Guilt or self blame
- 80. Management Refer if thereis psychosis, a risk of suicide or a history of bipolar Mild – moderate depression ◦ Watchful waiting ◦ Exercise ◦ Self Help ◦ Psychological therapies Moderate depression ◦ SSRIs ◦ CBT Consider need for ECT in severe depression
- 81. Neurotic, stress & somatoformdisorders
- 82. Specific Phobias Irrational fear Provokesphysical response Usually purely behavioural conditioned response Treat with:- ◦ Counselling ◦ Psychotherapy ◦ CBT ◦ Desensitisation ◦ Medication
- 83. Panic Disorder Characterised bypanic attacks ◦ Sudden, overwhelming, discrete episodes of anxiety ◦ Patients think they might die, collapse or lose control ◦ Psychosomatic symptoms ◦ Palpitations Sweating Trembling Shortness of breath Choking Chest pain Nausea Dizziness Derealisation/Depersonalisation Fear of losing control Fear of dying Paraesthesias Chills Hot Flushes Initial attacks sudden, later associated with environments
- 84. Generalised Anxiety Disorder Anxietytowards everything Constant worrying Interferes with daily life
- 85. Management of AnxietyDisorders SSRIs = first line along with CBT Increase dose Tricyclics second-line Hypnotics third-line If still no response reconsider diagnosis
- 86. Post-Traumatic Stress Disorder Directresponse to extreme stress or life-threatening event Characteristics ◦ Recurrent reliving of the traumatic experience ◦ Nightmares/flashbacks ◦ Phobic avoidance of stimuli associated with trauma ◦ Persistent arousal ◦ Hypervigilance & abnormal startle response Offer trauma focussed CBT Eye movement desensitisation & reprocessing Drugs are NOT first-line
- 87. Obsessive Compulsive Disorder Recurrentobsessions &/OR compulsions Unpleasant, intrusive repetitive thought Recognised to be the patients own Cause a degree of anxiety to patient Treat same as other anxieties
- 88. Conversion Disorders Typically involvesloss of motor or sensory function Symptoms aren’t consciously feigned or for material gain Patients may be indifferent to symptoms (La Belle Indifference)
- 89. Somatisation Disorders Multiple physicalSYMPTOMS present for at least 2 years Multiple investigations but patient refuses to accept reassurances or test results
- 90. Hypochondriacal Disorder Persistent beliefin the presence of an underlying DISEASE
- 91. Body Dysmorphic Disorder DEPRESSIONDELUSIONS ANXIETY LOW SELF-ESTEEM INABILITY TO WORK BEHAVIOURAL PROBLEMS
- 92.
- 93. Anorexia Nervosa Behavioural disturbanceleading to marked weight loss or lack of weight gain BMI <17.5 A morbid fear of fatness An endocrine disorder ◦ Amenorrhoea ◦ Loss of sexual interest May employ drastic means for weight control ◦ Laxative abuse ◦ Excessive exercise ◦ Self-induced vomiting
- 94. PHYSICAL ◦ Poor PeripheralCirculation ◦ Hypotension ◦ Bradycardia ◦ Electrolyte Disturbances ◦ Dehydration ◦ Lanugo hair PSYCHOLOGICAL ◦ Depression ◦ Anxiety ◦ Irritability ◦ Social Withdrawal ◦ Low self-esteem ◦ Obsessional Thoughts
- 95. Bulimia Nervosa Recurrent episodesof binge eating with loss of control Extreme compensation (purging) ◦ Self-induced vomiting ◦ Laxative abuse Morbid fear of fatness
- 96. Managing Eating Disorders Anorexia ◦Motivational interviewing ◦ CBT ◦ Family therapies ◦ DO NOT USE MEDICATION Bulimia ◦ CBT ◦ Interpersonal therapy ◦ SSRIs
- 97. Postnatal Mental Health 'Baby-blues'Postnatal depression Puerperal psychosis Seen in around 60-70% of women Typically seen 3-7 days following birth and is more common in primips Mothers are characteristically anxious, tearful and irritable Affects around 10% of women Most cases start within a month and typically peaks at 3 months Features are similar to depression seen in other circumstances Affects approximately 0.2% of women Onset usually within the first 2-3 weeks following birth Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations) Reassurance and support, the health visitor has a key role As with the baby blues reassurance and support are important Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe - whilst they are secreted in breast milk it is not thought to be harmful to the infant Admission to hospital is usually required There is around a 20% risk of recurrence following future pregnancies
- 98. Disorders of adult personalityand behaviour
- 99. Paranoid Personality Disorder Paranoia Long-standingsuspiciousness Mistrust of others
- 100. Schizoid Personality Disorder Lackof interest in social relationships Tendency towards secretiveness, emotional coldness and apathy
- 101. Antisocial Personality Disorder Disregardfor the rights of others Begins in childhood/adolescence and continues into adulthood History of legal problems Poor moral sense/conscience
- 102. Emotinally Unstable PersonalityDisorder Variability and depth of moods Affects interpersonal relationships Impulsive behaviour Unstable self-image and relationships Feelings of abandonment
- 103.
- 104. Acute Psychosis Characterised bythe presence of delusions, hallucinations, thought disorder and affective disorder May occur secondary to organic brain disorders, substance abuse, as an acute psychotic episode or part of a chronic mental health issue Assessment ◦ Evidence of Organic Brain Disorder ◦ Presence of Substance Abuse ◦ Risk of Self-Harm/Harm to Others ◦ Physical complications such as self-neglect May need Rapid Tranquilisation Consider oral antipsychotics or IM depo injection
- 105. Severe Depression 1. Organiccause? 2. Mini mental state exam 3. Psychosis? 4. Psychomotor retardation 5. History of bipolar? 6. Medical complications of neglect/self-harm? 7. Physical complications 8. SUICIDE RISK/RISK OF HARM TO OTHERS ADMIT UNDER MHA IF NECESSARY CONSIDER NURSING REQUIREMENT TREAT PHARMACOLOGICALLY ECT FIRST-LINE
- 106. Management of SuicidalBehaviour 1. Is there evidence of a psychiatric disorder? 2. Is there evidence of medical consequences? 3. Has there been a previous suicide attempt? 4. Is there evidence of a social crisis? 5. What social and financial support is available? 6. Is there on-going suicidal intent? 7. Does the patient intend to harm others? 1. To what extent was the act planned? 2. Were there final acts (e.g. note/will)? 3. How dangerous was the act of self harm? 4. How dangerous was it perceived by the patient? 5. Were any precautions to avoid discovery taken? 6. Did the patient seek help? SYMPATHY TREAT PHYSICAL CONSEQUENCES TREAT PSYCHIATRIC CONDITIONS IDENTIFY PRECIPITATING FACTORS CONSTANT REVIEW & REASSESSMENT
- 107. Acute Mania ORGANIC SUBSTANCE ABUSE RISKTO SELF AND OTHERS PHYSICAL COMPLICATIONS
- 108. Acute Mania Pure ManiaRapid CyclingMixed Lithium OR atypical OR semisodium valproate Semisodium Valproate Olanzapine OR semisodium valproate Add Benzodiazapine Add Benzodiazapine Add Lithium/ Carbamazapine Add Atypical Add Atypical Add Atypical ASSESS RESPONSE
- 109. Severe Anorexia Nervosa Severedefined as:- ◦ Bradycardic/hypotensive ◦ Glucose <4mmol/L ◦ Electrolyte imbalance – HYPOKALAEMIA ◦ WCC <2 ◦ Hypothermia ◦ Dehydration ◦ Muscle weakness ◦ Hepatic, renal or CVS impairment ◦ BMI <13
- 110. Severe Anorexia Nervosa MultidisciplinaryApproach Required ◦ Refer to local psychiatric services ◦ Refer to eating disorder service ◦ Refer to local endocrinologist/gastroenterologist for medical evaluation ◦ Refer to a dietician Motivational interviewing Physical monitoring Nutritional therapy with psychological support MONITOR FOR RE-FEEDING SYNDROME Treat any depression
- 111. Rapid Tranquilisation RISKS vsBENEFITS CAUTIONS CONSULTATIONS & PATIENT CHOICE MEDICATION Over-sedation & airway problems CVS & Respiratory Collapse Interaction with prescribed/illicit medications Damage to therapeutic relationship Underlying physical/psychological disorders Congenital prolonged QT syndrome Hypo/hyperthermia Stress Physical exertion Advanced Directive if possible ORAL IM IV Lorazepam/antipsychotics Lorazepam+-Haloperidol Benzodiazapines/Haloperidol
- 112. Acute Violence MAINTAIN YOURSAFETY DO NOT BE ALONE WITH THE PATIENT USE PERSONAL ALARMS SUMMON THE POLICE IF NECESSARY CONSIDER ESCAPE ROUTES IDENTIFY POTENTIAL WEAPONS IDENTIFY PARTICULARLY AT RISK INDIVIDUALS ATTEMPT TO TALK TO PATIENT & CALM THEM MAINTAIN DISTANCE GIVE SIMPLE SHORT POSITIVE INSTRUCTIONS ASK THE PATIENT WHAT THEY WANT AND MEET NEEDS IF POSSIBLE DEPERSONALISE THE SITUATION GAIN CONSENT FOR TREATMENT AIM TO TRANSFER PATIENT TO A SAFE PLACE TREAT APPROPRIATELY CONSIDER RAPID TRANQUILISATION SUGGESTED USE IM OLANZAPINE OR LORAZEPAM MONITOR VITAL SIGNS CONSIDER DIAGNOSIS POST-EVENT CONTINUE TO MONITOR PATIENT CONSTANT RISK ASSESSMENTS REVIEW THE INCIDENT AND PROCEDURES TAKEN ENSURE ADEQUATE COUNSELLING AND SUPERVISION OF INDIVIDUALS INVOLVED
- 113. Delirium Disordered thinking Euphoric, fearful,depressed or angry Language impaired Illusions/delusions/hallucinations Reversal of sleep-awake cycle Inattention Unaware/disorientated Memory deficits
- 114. Delirium Systemic Infection Intracranial Infection Drugs AlcoholWithdrawal Metabolic Hypoxia Vascular Head Injury Epilepsy Nutritional
- 115. Tests in Delirium FBC– INFECTION, ANAEMIA U&Es – ELECTROLYTE IMBALANCES LFTs – LIVER FAILURE, ALCOHOL WITHDRAWAL Blood Glucose - HYPOGLYCAEMIA ABG - HYPOXIA Sepsis Screen - INFECTION ECG – CARDIAC CHANGES Lumbar Puncture – CNS INFECTION, CSF PRESSURE CT/MRI – BLEEDING, MASSES Malaria Films – IF SUSPICIOUS OF MALARIA AS SOURCE OF INFECTION EEG – POST-ICTAL
- 116. Management of Delirium TREATUNDERLYING CAUSE AS APPROPRIATE Reduce distress, prevent accidents, encourage family to stay with patient Nurse in a moderately lit, quiet room Same staff in attendance Do not use physical restraints, try not to cathetrise Augment self-care, discourage passive dependency & napping 3M’s of delirium. Music, Massage, Muscle relaxation Minimise medication
Editor's Notes
- #5 Article 5 & 3 & 8 need to be considered with mental health Article 5 = right to liberty. Strict rules on detention. MUST be done in authorised institution, assessment done by objective independent expert, disorder must be severe. Article 3 = compulsory medical treatment can be degrading. Treatment MUST be therapeutic and in best interest Article 8 = includes physical and psychological integrity. Again must be justified to be broken.
- #10 Section 2 = assessment order (28 days). Cannot be renewed. Instituted by 2 doctors and an AMHP, one must be section 12 approved. Section 3 = treatment order (6 months) and can be renewed. Must be clear about diagnosis and proposed treatment plan. Section 4 = emergency order (72 hours). Implemented by one doctor and an AMHP. Can be converted into section 2 once another doctor reviews. Section 5 = holding powers (2) = doctors (72 hours), (4) = nurses (6 hours) Section 135 = magistrate order. Allows police detention in private property Section 136 = police detention in public
- #12 Appearance = very specific!! Height weight, manner of dressing, grooming. Do they look their age, belong to a subculture, personal hygiene. Signs of depression & neglect/mania Attitude = rapport. Approach to the interview process and interactions. Behaviour = level of activity and arousal. Observations of eye contact and gait. Tremor/choreiform/athetoid movements. Akathisia, psychomotor agitation/hyperactivity. Mood = subjective state described by patient Affect = objective apparent emotion portrayed by individual. Speech = Pressured/poverty of speech. Rhythm, intonation, pitch, phonation, articulation Thought process = quantity, tempo and logic of thought. Flight of ideas, perseveration, formal though disorder. Thought content = delusions, overvalued ideas, obsessions, phobias & preoccupations. Perception = SENSORY EXPERIENCE. hallucinations, (sensory perception in the absence of external stimuli). Pseudohallucination (sensory perception in the presence of external stimuli) or illusion Cognition = alertness, orientation, attention, memory, visuospatial functioning, language Insight = ideas, concerns, expectations
- #15 More features = greater significance of suicidal intent
- #20 Serotonin syndrome = drug reaction, often happens within minutes AKA serotonin toxicity. Cognitive effects = headache, hypomania, hallucinations. Autonomic affects = tachycardia, HYPERTHERMIA, shivering, sweating, hypertension. Somatic effects = hyperreflexia, myoclonus, tremor
- #30 Pathology:- accumulation of neurofibrillary tangles (due to pairing of tau proteins) and beta-amyloid plaques. Develop in hippocampus and cerebral cortex. Risk factors include:- advancing age, family history, APOE 4 enotype, obesity, insulin resistance, dyslipidaemia, hypertension, inflammatory markers, down syndrome, traumatic brain injury 4 stages. Preclinical:- may begin in 5th decade of life. NFTs and BA plaques begin to accumulate. Mild Alzheimer’s disease = memory loss, confusion about familiar places, taking longer to accomplish normal, daily tasts, trouble handling money and paying bills, compromised judgement, loss of spontaneity, increased anxiety. Moderate = increased of the above. AND short attention span, problems recognising friends and family, difficulty organising thoughts and thinking logically, inability to learn new things, restlessness & agitation, repetitive statements, hallucinations, loss of impulse control. Severe = no recognition of family or loved ones and can’t communicate. Weiht loss, seizures, skin infections, groaning, moning or grunting, increased sleeping, lack of bladder/bowel control
- #31 Stepwise
- #32 If symptom onset within 1 year DwLB. If outside of 1 year then Parkinsons with Dementia.
- #33 Only perform mid-stream urine test, CXR, ECG if indicated by clinical presentation. Do NOT examine CSF. Do not test for syphilis or HIV unless there are risk factors.
- #34 Cognitive assessment = MMSE <28/30 = Dementia 6-Item Cognitive Impairment Test = score greater than 7 = memory problems GP Assessment of Cognition = <5 = cognitively impaired. 5-8 = equivocal and >8 = intact cognition 7-minute screen Addenbrooke’s Cognitive Examination revised
- #36 Educate the patient on the disease course and management options. Advise them to inform family, and advise them of sources of support and options. Promote independence – try and give them as much support as needed to stay in familiar locations Cognition - Alzheimer drugs = anti-cholinesterase inhibitors (donepezil, galantamine, rivastigmine) in moderate disease, memantine in severe disease. Group cognition stimulation. Depression – treat as depression Behaviour – non-pharmacological = aromatherapy, animal-assisted therapy, massage, music/dance therapy. Pharmacological = antipsychotics/anti-cholinesterase inhibitors
- #41 FAST – if answer to Q1 is never, not misusing alcohol. If answer to Q1 is weekly, misusing alcohol. If Q1 is monthly or less than monthly ask Qs 2, 3 and 4. Score for hazardous drinking = 3 or more.
- #42 Alcohol Use Disorders Identification Test
- #43 SADQ for severity of dependence APQ for the nature and extent of problems arising from alcohol misuse Assess BIOPSYCHOSOCIAL – mental and physical health problems, relatonships and functioning, cognitive needs, education, abuse history, risk to self and others, readiness to change
- #45 Assess alcohol consumption (need to score 20 or more on AUDIT OR drink 15 units of alcohol per day). Assess likelihood of drinking as an outpatient and not complying. Community-based programme 2-4 meetings per week + drug regimen, and psychosocial support. CONSIDER IF:- drink between 15-30 units per day, score less than 30 on the SADQ, are NOT on benzodiazapines Inpatient & resident withdrawal:- consider if above the thresholds above OR have a history of epilepsy or have previousl experienced delirium tremens OR have significant psychiatric/physical co-morbidities If 10-17 year olds base withdrawal plan on adult recommendations. Promote abstinence and prevent relapse offering CBT, family therapies (functional or brief strategic family therapy). DRUGS:- use a benzodiazepine as the preferred medication,
- #46 Acamprosate = GABA receptor agonist, reduces glutamate surge in withdrawal and neuroprotective. Naltrexone antagonises opioid receptors. Helps in withdrawal because endogenous opioids have augmented effects in the presence of alcohol. Disulfiram inhibits acetaldehyde dehydrogenase, creating unpleasant reactions when alcohol is consumed.
- #47 Acute alcohol withdrawal = give thiamine to protect from Wernicke’s. Decide whether to admit or not based on:- suicide risk and risk of DT. Assess appropriately. THIAMINE FOR WERNICKE’S ENCEPHALOPATHY Korsakoff = supported independent living if mildly impaired. 24 hour care if severe cognitive impairment Alcoholic hepatitis = corticosteroids/liver transplant Alcoholic pancreatitis = offer analgesia, pancreatic enzymes, refer to specialist, surgery
- #50 Naloxone = opiate antagonist without euphoric effects.
- #52 Autonomic symptoms = diarrhoea, rhinorrhoea, lacrimation, shivering, nausea CNS arousal = sleeplessness, restlessness, tremors Pain = abdominal cramping
- #53 Gain informed consent, talking about physical and psychological aspects of withdrawal. Non-pharmacological interventions, continued support. Risk of overdose due to decreased tolerance. ADVICE on a balanced diet, adequate hydration, sleeping well, physical exercise Lofexidine is an alpha-2 receptor agonist. Alleviates symptoms but does not provide replacement.
- #54 - Ultra rapid and rapid detox start with naloxone treatment and sedation.
- #57 Genetics – MZ concordance = 50% Development – influenza in 2nd trimester may increase risk Brain abnormalities – Ventricular enlargement & reduced brain size Overactivity of dopamine in the mesolimbic pathway Life events – stress occurs more frequently in the month before the first psychotic episode and may precede illness Expressed emotion – family/carers becoming over-involved, critical or hostile
- #61 Delusions of persecution, reference, exalted birth, special mission or jealousy. Hallucinatory voices that threaten or give commands. Or Auditory hallucinations without verbal form (whistling, humming/laughing) Olfactory/gustatory hallucinations. Negative symptoms may be present but the above features dominate the clinical picture.
- #62 Also known as disorganised schizophrenia. Formal thought disorder is most common presentation, alongside flattening or inappropriate emotions/effects. Delusions and hallucinations not prominent.
- #65 No difference in typical or atypical for antipsychotics
- #66 Offer CBT to ALL schizophrenics Offer family intervention Arts therapy for negative symptoms
- #80 Need at least one of top 3 persistent for two weeks. If <4 symptoms, not depressed. 4 symptoms = mild. 5-6 = moderate, >6 = severe
- #83 Antidepressants/beta blockers
- #87 If psychological intervention not working, consider mirtazapine/paroxetine and amitriptyline/phenelzine Hypnotics for sleep disturbance
- #97 Little evidence for medication in AN. Also people with AN often have prolonged QT and many psychiatric medications prolong QT further putting them at risk of Torsades des Pointes and Sudden Death
- #98 Paroxetine recommended because of low milk:plasma ratio Fluoxetine is best avoided due to long half life
- #105 Risperidone if glucose intolerance, weight gain or sedation are an issue. Olanzapine if extra-pyramidal side effects are an issue IM depot injection if non-compliant
- #106 Consider Venlafaxine due to quick onset of action Beware Antidepressants in bipolar, may precipitate mania And treatment of psychomotor retardation may enhance suicide risk (allows patient to carry out plans)
- #107 6 – discussing suicide does NOT increase risk. Factors indicating suicidal intent in 2nd box Only prescribe drugs that are safe in overdose & limit access to tablets
- #111 Re-feeding syndrome:- individual who has had negligible nutrition for 2 days is at risk. Occurs within 4 days. Develop fluid & electroly disorders. Fluid retention/CCF. Cardiac arrhythmias, delirium, seizures, hypophosphataemia or acute bowel obstruction can occur.
- #112 Consider psychotic context (use antipsychotics/haloperidol in psychosis otherwise do not use) IM olanzapine is another alternative DO NOT USE HALOPERIDOL IN PARKINSONS DISEASE
- #115 Sepsis – UTI, pneumonia Drugs – opiates, anticonvulsants, l-dopa, sedatives, recreational drugs Metabolic – hypoglycaemia, uraemia, liver failure, hyper/hyponatremia, anaemia, malnutrition Nutritional – thiamine, B12