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Psychiatry Phase 3a Sana Ali, Alex Bucko

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Presentation on theme: "Psychiatry Phase 3a Sana Ali, Alex Bucko"— Presentation transcript:

1 Psychiatry Phase 3a Sana Ali, Alex Bucko
The Peer Teaching Society is not liable for false or misleading information…

2 Content Mood disorders Personality disorders Schizophrenia
Depression Bipolar disorder Personality disorders Schizophrenia Associated emergencies Neuroses Mental Health Act The Peer Teaching Society is not liable for false or misleading information…

3 Thinking about psych disorders
The Peer Teaching Society is not liable for false or misleading information…

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) The Peer Teaching Society is not liable for false or misleading information…

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 The Peer Teaching Society is not liable for false or misleading information…

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 The Peer Teaching Society is not liable for false or misleading information…

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 The Peer Teaching Society is not liable for false or misleading information…

8 Serotonin Syndrome Causes MAOI SSRIs ecstasy Amphetamines Rx
Supportive, Cyproheptadine – 5HT antagonist The Peer Teaching Society is not liable for false or misleading information…

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 The Peer Teaching Society is not liable for false or misleading information…

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 The Peer Teaching Society is not liable for false or misleading information…

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 The Peer Teaching Society is not liable for false or misleading information…

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 The Peer Teaching Society is not liable for false or misleading information…

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 The Peer Teaching Society is not liable for false or misleading information…

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 The Peer Teaching Society is not liable for false or misleading information…

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 The Peer Teaching Society is not liable for false or misleading information…

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 The Peer Teaching Society is not liable for false or misleading information…

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) The Peer Teaching Society is not liable for false or misleading information…

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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 The Peer Teaching Society is not liable for false or misleading information…

20 SS V NMS NLM – hyporeflexia, pale
The Peer Teaching Society is not liable for false or misleading information…

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


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