1. Psychiatry Phase 3a Sana Ali, Alex Bucko
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2. Content Mood disorders Personality disorders Schizophrenia
Depression
Bipolar disorder
Personality disorders
Schizophrenia
Associated emergencies
Neuroses
Mental Health Act
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3. Thinking about psych disorders
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4. definitions
Affect
Pattern of observable behaviours. Variable overtime – in response to changing emotional state (Weather)
Mood
Pervasive sustained emotions. Colours perception of the world. (Climate)
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5. Depression Screening questions for depression?
During the last month, have you often been bothered by feeling down, depressed or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?
DSM- IV Criteria for depression (9 symptoms)
DEAD SWAMP (need 3 core + 2 others)
Duration? 2 weeks
<5 symptoms = subthreshold depressive symptoms
>5 + minor functional impairment = mild
Moderate
Most symptoms, marked impact on ADL’s +/- psychotic symptoms (may present like dementia with memory loss with a few differences)= Severe
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6. Depression Assessment?
Hospital Anxiety and Depression (HAD) scale (out of 21). : >11= P+
Patient Health Questionnaire (PHQ-9). Measures depression severity: 0-4 none, 5-9 mild, moderate, moderately severe, severe Risk of suicide Rx
CBT
1st line drug = SSRI Fluoxetine (paroxetine, citalopram, sertraline ( best in PHx of CVD))
s/e: GI disturbance, ↑ risk of suicide <30yrs (regular reviews)
C.I: ↑ risk of convulsions in epilepsy, if used with MAO-I ↑ risk of serotonin syndrome
How long do we need to continue medical management?
Mechanism of depression=
↓5HT↓NA ↓D
6mnth- relapse
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7. Anti-depressants Class Important points
Tricyclic antidepressants (TCA)
e.g. amitriptyline, imipramine, lofepramine
s/e: arrhythmias ( avoid in heart failure) Lofepramine is most safe
MAO-I e.g. Phenelzine
Used in resistant depression. s/e: ↑ risk of hypertensive crisis, avoid tyramine containing foods (cheese, red wine, broad beans)
Noradrenergic and specific serotonergic antidepressants (NaSSA)
e.g. mirtazipine
s/e: sedative, weight
Serotonin noradrenaline reuptake inhibitors (SNRI)
e.g. duloxetin
Interact with MAO-I
Similar s/e to SSRI’s, increase BP
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8. Serotonin Syndrome Causes MAOI SSRIs ecstasy Amphetamines Rx
Supportive, Cyproheptadine – 5HT antagonist
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9. Bipolar ICD- 10 definition: Hx of 2 mood disorders
At least one= hypomania (<4 days)/ mania (>7days)
DSM-IV-TR
1 mania episode +/- depressive episode
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10. Bipolar Mental state exam Appearance/behaviour Speech Mood and affect
A: flamboyantly dressed, self neglect (unkempt/ dehydrated)
B:Overactivity, difficult to interview pt., pt. may eat and drink greedily
Speech
↑ pressure of speech, ↑ rate and amount, difficult to interrupt.
Mood and affect
Usually elated
Angry
Thoughts (form + content)
C: pt. has inflated view on own importance, grandiose
F: chance relationships, verbal associations (alliteration e.g. “crazy cool cat can catch”) clang association ( “the cat sat on a hat and that’s that”)
Perception
May have delusions of persecution or grandiose – mood congruent
Auditory hallucinations
Cognition ↓
Insight
Often absent in mania
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11. Bipolar DDx: Substance abuse (amphetamines, cocaine). Schizophrenia
Rx:
Co-ordinated care
Rapid access to support in crisis
?Hospitalisation – MHA
Psychological care – education, promoting social functioning e.t.c
Medication
Annual reviews
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12. Bipolar- medical management
Mood stabilizers
Lithium (Li)
Anticonvulsants ( S.Valporate, Carbamazepine, lamotrigine) (Li → Val → Carb)
Anti- psychotics (conventional, atypical), used in acute mania
Li reduces relapse risk by 40%
Effective against both manic/ depressive symptoms
18 mnths → get benefit
Narrow therapeutic range: mmol/L
What are the two most important tests we need carry out in patients on Lithium?
Renal function (U&E, CrCL) → Li excreted by kidney
TFT → hypothyroidism
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13. Bipolar-s/e of lithium
Lithium Toxicity (>2.5)
Blurred vision
COARSE tremor (fine tremor= early s/e)
Muscle weakness
Ataxia
N and V
Hyper-reflexia
Circulatory failure
Oliguria
Seizures
Coma
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14. Schizophrenia
WHO definition: ‘a severe mental disorder, characterized by profound disruptions in
thinking, affecting language, perception, and the sense of self.’
RF: Family history, intrauterine complications/infection, social isolation, migrants, abnormal family interactions.
Triggers include periods of stress and high emotion and drug misuse
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15. Schizophrenia Symptoms present for 1 month
At least one 1st rank symptom:
Delusional perceptions
Auditory Hallucinations (3rd person)
Somatic Passivity
External control of emotion
Thought insertion, removal
Thought broadcasting
Lack of Insight
Negative Symptoms (lack of feelings and behaviours that are normally present):
Poverty of speech
Anhedonia
Loss of motivation
Flat affect/ blunting
Residual N symp
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16. Schizophrenia Organic disorders that may cause symptoms? Ix:
Bloods – FBC, U&E, LFTs, TFTs, glucose, Calcium, cortisol. Cultures
Brain disease
Head injury
Drug and alcohol screen
CNS infection
Urine dipstick/MSU
CNS tumour/ SOL
CT/MRI head
Post-epileptic states
Metabolic
Hypernatraemia
Hypocalcaemia
Endo
Hyperthyroidism
Cushings
Drugs
Alcohol
Stimulants
Hallucinogens
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17. Antipsychotics Conventional Atypical Haloperidol Chlorpromazine
Flupentixal
Risperidone
Olanzepine (↑↑ weight, sedative)
Quetiapine
Clozapine ( used to treat patient resistant to other drugs, must have tried 2 drugs for 6wks each s/e= agranulocytosis
s/e: Decreased occupation of nigrostriatal pathway → ?
s/e: Metabolic syndrome
DM2
↑ stroke risk
( Ix; BP, BMI, HbA1C, glucose/lipid)
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19. Neuroleptic malignant syndrome (NMS)
NMS is a reaction that occurs following starting an antipsychotic/ ↑ dose Rx
Supportive ( hydration- IV, prevent AKI due to rhabdomyolysis, coolants)
S/S
FEVER
Benzodiazepines 1st line
Autonomic instability
Dantrolene – muscle relaxants
Stiffness (leadpipe)
Dop agonist- Bromocriptine
Seizures
Severe- ECT?
Coma Ix
ABG: Metabolic acidosis
↑ Creatinine Kinase
Leucocytosis
ECG: prolonged QT
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20. SS V NMS NLM – hyporeflexia, pale
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21. Anxiety Generalised anxiety Panic Disorder Obsessive-compulsive
Post-traumatic Stress Disorder
Phobias

22. GAD Feel anxious on most days
Can’t remember last time felt relaxed-can’t calm themselves down.
Worried about many things, not hung up on one thing in particular. As soon as one anxious thought is resolved, another may appear about a different issue.
Treatment: CBT +Benzo/SSRIs

23. Panic Disorder Symptoms of a panic attack: Intense fear and dread
Palpitations/tachycardia
SOB and tachypnea
Trembling
Excessive sweating
Chest pain
Choking sensation
Nausea +/- abdo pain
Feeling dizzy/lightheaded/faint
Chills/hot flashes
Tinnitus
Paraesthesia
Sense of impending doom
Feeling like they are dying
They usually last 5-20min. Can be triggered by stressors or come unexpectedly. Fear of a panic attack can trigger a panic attack. Patients can start showing avoidance behaviour and become reclusive to avoid potential triggers-dysfunctional coping mechanism. Can be very debilitating and disruptive to life.
Treatment: CBT +SSRI

24. OCD
Obsessions : uncontrollable, intrusive, recurrent thoughts of distressing nature
Compulsions: Ritualistic behaviours one has the urge to repeat over and over to relieve anxiety caused by the obsessions
Can't control his or her thoughts or behaviors, even when those thoughts or behaviors are recognized as excessive
Spends at least 1 hour a day on these thoughts or behaviors
Doesn’t get pleasure when performing the behaviors or rituals, but may feel brief relief from the anxiety the thoughts cause
Experiences significant problems in their daily life due to these thoughts or behaviors
Treatment : CBT + SSRI

25. Phobias
Strong, irrational fear of something that poses little or no real danger.
A specific thing
Avoidance of the thing they are afraid of
Usually start in childhood/adolescence
Can be learned from your parents
Treatment: CBT

26. PTSD Post-trauma – examples?
Lifetime prevalence : 10% of women, 4% of men.
Interpersonal trauma more likely to cause PTSD than e.g. natural disaster, accident. By far the most PTSD-generating trauma is sexual assault.
Risk factors : past mental health problems, past trauma (esp. childhood abuse), lack of support, victim-blaming by the environment reinforcing survivors guilt.

27. PTSD Symptoms : Hypervigilance (being overly aware of possible danger)
Intrusive thoughts recalling the traumatic event
Hypersensitivity, including at least two of the following reactions: trouble sleeping, being angry, having difficulty concentrating, startling easily, having a physical reaction (rapid heart rate or breathing, increase in blood pressure)
Nightmares
Flashbacks
Efforts to avoid feelings and thoughts that either remind you of the traumatic event or that trigger similar feelings
Feeling detached or unable to connect with loved ones
Headache
Disrupted sleep, insomnia
Depression, hopelessness
Feelings of guilt (from the false belief that you were responsible for the traumatic incident)
Irritability or angry outbursts

28. Personality disorders
SAD
MAD
BAD

29. Schizoid Personality Disorder
Detached and cold
Doesn’t feel the need to interact with others- solitary, no friends or romantic/sexual partners
No eye contact, behave like others aren’t around
Has a rich fantasy world

30. Schizotypal odd ideas and behaviours difficulties with thinking
lack of emotion, or inappropriate emotional reactions
can have hallucinations and other psychotic symptoms but not enough to diagnoze schizophrenia

31. Paranoid Personality Disorder
Suspicious, untrusting, fear of rejection
Thinking people hate you even with evidence to the contrary
Difficulty forming healthy relationships

32. Antisocial personality disorder
AKA sociopath
Incapable of empathy and doesn’t care about others
Impulsive, agressive, easily frustrated, quick temper
Incapable of guilt
Manipulative
Often cruel and agressive
Often commit violent crimes

33. Histrionic Self-centered Megalomaniac, likes to over-dramatise events
Craves attention
Very strong emotions that change quickly
Needs excitement
Concerned about appearence
Can be very charismatic

34. Narcissistic Self-centred and egoistic Volatile self-image
Doesn’t accept criticism and gets agressive when they do
Strong sense of your own self-importance, brilliance, beauty etc.
Crave success and power
Need attention
Takes advantages of people

35. Borderline/ Emotionally unstable
One most likely to come up- read it up!
Often result of insecure attachment/ domestic violence/ childhood sexual abuse etc.
Low self esteem and intense feel of rejection, abandonment, being unloved
Develops very intense feelings for people very quickly, but also one bad move can totally destroy their image of somebody
Find it hard to control emotions they feel very intensly, emotional rollercoaster
Often self-harm, overdose, engage in dangerous risky behaviour (eg. sex with randoms to feel better, desired)
Often associated with depression, alcohol abuse etc.
Finds it difficult to cope with life stresses, esp. friendship/relationship conflict
NOT a „drama queen” !

36. Avoidant Feels insecure and inferior
Worries a lot that they are not good enough/people thing they are shit etc.
Craves being liked and accepted but avoids people due to the fear of them not liking them
Extremel sensitive to criticism

37. Dependant Easily feels abandoned (see a theme here?)
Passive and expects others to make decisions for them
Find it hard to do things on their own or even make small decisions
Feels hopeless and incompetent
Can be abusive in a sneaky way (usually not intentionally though)

38. Suicide risk asessment
SAD PERSONS score
Not exhaustive but useful in e.g. A&E
Sex - Male
Age - <19, >45
Depression presnt
Previous suicide attempt
Ethanol (or other substance abuse)
Rational thinking loss (e.g. Psychosis, psychotic depression)
Single or separated
Organised (attempt wasn’t an impulse but well thought through)
No social support
Sickness (i.e. Chronic ilness)
If you think they will go home and do it again you can’t let them go home!

39. Mental Capacity Act (2005) What is capacity? Able to understand info
Able to retain info
Able to process and weight info and come to a decision
Able to communicate that decision
Creatinine phospokinase.
Gonna need help

40. Mental Health Act (1983) Section 2 Section 3 Section 4
Admission for assessment. Up to 28 days. Can’t be renewed. Signed by 2 doctors/1 doctor 1 Approved Mental Health Professional. They can treat you at the time too if needed.
Section 3
Admission for treatment. 6 months and can be renewed. Signed by 2 doctors/ 1 doctor 1 AMHP. Can give you treatment, perform investigations etc.
Section 4
Emergency treatment. Only one AMPH doctor needed.Used in emergency when youa re unsafe to go home but only 1 AMPH avaliable. Can hold you in hospital until the other one arrives and you can be sectioned under 2 or 3. Up to 72h. Can’t treat you, can literally only keep you there.
Section 5
Detention of a patient already in hospital by doctor 5(2) or nurse 5(4). Again, can only stop you from physically leaving until you can be reviewed and sectioned under 2 or 3.
2 – 28 days
3 – 6 months
4 – 72 hours
5(2) doctor 72 hours
5(4) psychiatric nurse 6 hours

41. Mental Health Act (1983) Section 135
Allows the police to take you from your private property and take you to a place of safety (station/hospital) because a doctor things you need help and are unsafe for yourself or others. Up to 72h.
Section 136
Same but from a public place.
2 – 28 days
3 – 6 months
4 – 72 hours
5(2) doctor 72 hours
5(4) psychiatric nurse 6 hours