Psychiatry

Psychiatry

Psychiatry

πŸ‘¨πŸΌβ€βš•οΈ Assessment

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πŸ—’ History
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Name the additional general fields that are important in a psychiatry history.
  1. ROS (psych): Depression (mood, anhedonia), schizophrenia (TAPD)
  2. RISK - Self / others
  3. Past psychiatic history
  4. Forensic history
  5. Personal history
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What questions are important to ask for the following presenting complaints:
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Depression
  • Core: ↓ mood, anhedonia, anergia
  • Additional:
    • Biological: ↓ sleep, ↓ appetite, ↓ libido
    • Psychological: ↓ concentration, social isolation, self-worth
    • Harm: Self/others
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Anxiety
  • Triggers: Social situations,
  • OCD: Obsessions or compulsions?
  • PTSD: Re-experiencing, avoidance, hyperarousal, emotional numbing

Symptoms:

  • Constant or in short attacks: GAD vs panic
  • Physiological: Tachycardia (palpitations/chest pain), excessive sweating, headaches
  • Psychological: Social isolation, depressive symptoms
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Mania/hypomania
  • Mania vs hypomania: Psychosis? (Delusions, hallucinations, thought disorders)
  • Symptoms:
    • Increased energy
    • Little sleep
    • Disinhibition: Sexual or financial
    • Thought: Flight of ideas
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Psychosis

Any odd or unusual happenings recently? Do you hear anything in an empty room? See things that aren't there?

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Hallucinations
  • Auditory: Key voices are third person commenting / talking behind back
  • Visual
  • Somatic
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Thought disorders
  1. Formation (formal):
    • Knight's move: Random jumps between topics that aren't related
    • Neologisms
    • Flight of ideas: Jumping between related topics: 'You're a doctor, doctor who? Great programme, etc.'
    • Tangential
    • Confabulation: Made-up stories fill gaps in memory
  2. Content: Delusions - Fixed, false belief not fitting with their social, cultural or educational background. Needs to be affecting their daily life.
    • Persecutory
    • Grandiose
    • Jealousy (Othello syndrome)
    • Love with somebody of importance/higher social class (De ClΓ©rambault syndrome). Erotomania - Similar but more sexualised
  3. Possession:
    • Thought broadcasting, insertion, withdrawal
    • Being controlled by someone else
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πŸ§‘πŸΌβ€πŸŽ€ MSE

For the following sections, what is the description of normal and what factors do you need to consider in each?

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Appearance
  • Describe clothing: Dishevelled, appropriately dressed
  • Body language
  • Hygiene
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Behaviour
  • Normal: Behaviour was appropriate for the consultation and we developed a good rapport and maintained good eye contact
  • Abnormal:
    • Distracted/fidgeting
    • Psychomotor retardation (slow)
    • Poor eye contact
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Speech
  • Normal: Speech was congruent with their emotions and of a normal speed.
  • Abnormal:
    • Speed: Slow/normal/fast
    • Tone: monotonous/congruent]
    • Volume
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Emotion
  • Normal: Both objectively and subjectively euthymic
  • Objective (my impression):
    • Mood: Low/euthymic/high
    • Affect: Flat/normal
  • Subjective (patient’s impression):
    • Low/euthymic/high
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Perception
  • Normal: Patient did not respond to any stimuli that weren't present
  • Hallucinations: Auditory/visual/somatic
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Thoughts
  • Normal: Patient did not have any disorders of thought formation, content or possession

Comment on:

  • Content: Delusions (thought formation, content or posession)
  • Form: Neologisms, flight of ideas, tangential
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Insight
  • Present or not at this given time
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Cognition
  • Normal: Cognition grossly intact but not formally assessed (memory, orientation)
  • Assess using Addenbrooke’s Cognitive Examination (ACE-III) - attention, memory, fluency, language, visuospacial
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πŸ“œ Mental Health Act (MHA)

What are the requirements for the following sections & what do they permit?

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2
  • Requirements: 1 AMHP & 2 doctors (that know the patient, one section 12(2) approved)
  • Permit: 28 days for assessment (non-renewable)
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3
  • Requirements: 1 AMHP (approved mental health practitioner) & 2 doctors (that know the patient)
  • Permit: 6 months for treatment (renewable)
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5(2)
  • Requirements: Doctor
  • Permit: 72 hours detainment in hospital for assessment
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5(4)
  • Requirements: Nurse
  • Permit: 6 hours detainment in hospital
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17a
  • Requirements: Consultant psychiatrist
  • Permit: CTO (community treatment order) - Release from hospital to treat in community
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135
  • Requirements: Police
  • Permit: Court order to enter a property to bring a patient to a place of safety
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136
  • Requirements: Police
  • Permit: Detain a patient in a public place to bring them to a place of safety

πŸ‘Ή Disease

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🀬 Schizophrenia
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What are the first rank symptoms of schizophrenia?
  1. Auditory (commonly third person & can be commenting) & somatic hallucinations
  2. Thought:
    • Formal thought disorder - Loosening of associations
    • Content - Delusions
    • Possessional thought disorder - Thought insertion, withdrawal, broadcasting
  3. Negative symptoms - Emotional blunting, social withdrawal
  4. Behaviour - Distracted by the high volume of stimuli, threatened fom voices
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Name 3 types of schizophrenia.
  1. Paranoid - Well organised persecutory delusions & hallucinations
  2. Hebephrenic - Behaviour, mood and thought disturbance are predominant
  3. Catatonic - Motor symptoms, lack of eating, drinking and speaking
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Name 5 differentials.
  1. Schizoaffective disorder - Combination of schizophrenia and mood disorder (manic auditory hallucinations are usually second person and make more sense than the schizophrenic hallucinations)
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    How is this managed?
    • Mood stabiliser: Lithium
    • Antipsychotic: Olanzapine
  2. Bipolar disorder
  3. Organic cause β†’ Delirium
  4. Depression - Negative symptoms can mimic depression
  5. Charles Bonnet syndrome - Visual hallucinations (insight preserved)
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What factors are associated with a poor prognosis?
  1. Low IQ
  2. Strong FH
  3. Gradual onset
  4. Lack of clear precipitant
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How is it broadly managed?
  • Antipsychotics (discussed below)
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πŸ₯Ί Affective disorders
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Anxiety
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What are the psychiatric differentials? (Follow-on Qs)
  1. GAD
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    Name the 4 lines of management for GAD & panic disorder.
    1. Lifestyle: Education & reassurance. Exercise & meditation.
    2. Psychoeducational groups, individual-guided self-help.
    3. CBT / Sertraline
  2. Panic disorder
  3. PTSD
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    How long do symptoms need to have been present for?
    • > 1 month
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    Name the 4 key features.
    1. Re-experiencing
    2. Avoidance
    3. Emotional blunting
    4. Hyperarousal - Hypervigilance for threat
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    What are the management options? (2)
    • EMDR
    • CBT
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    A patient was mugged 2 weeks ago, they have not slept since and have been extremely anxious. He has avoided the park where it happened, and says it feels like it was a dream. Diagnosis?
    • Acute stress reaction
      1. < 1 month β†’ Acute stress rather than PTSD
      2. Dissociative symptoms
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Name 3 medical differentials to explain these symptoms.
  1. Hyperthyroidism
  2. Cardiac chest pain
  3. Medication-induced: Salbutamol, theophylline, steroids, caffeine
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Depression
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How is depression classified & what is needed for each?
  • Mild: 2 core, β‰₯ 2 additional
  • Moderate: 2 core, β‰₯ 3 additional
  • Severe: 3 core, β‰₯ 4 additional
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How do you manage mild depression?
  1. Psychological therapy
  2. SSRI - Fluoxetine / sertraline
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How long do the symptoms need to have been present for?
  • β‰₯ 2 weeks
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75 year old patient presents with a short history of poor memory, sleep disturbance and reluctant to take tests. Their mini-mental test score varies and they have global memory loss. Differentials & diagnosis?
  • Differentials: Dementia & depression
  • Diagnosis: Depression because short history and global memory loss is key
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Bipolar
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How do you differentiate between mania & hypomania?
  • Mania β†’ Psychosis & symptoms β‰₯ 7 days
  • Hypomania β†’ No psychosis & symptoms < 7 days
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What are the common symptoms of both mania & hypomania?
  • Mood: ↑ mood & energy
  • Speech & thought: Pressured, flight of ideas, poor attention
  • Behaviour: Insomnia, loss of inhibitions (sexual, financial)
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How does referral from primary care differ between hypomania and mania?
  • Mania: Urgent referral to the CMHT
  • Hypomania: Routine referral to the CMHT
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How would you manage the following patients in A&E:
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Acute mania with agitation
  • IM lorazepam/aripiprazole
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Acute mania without agitation
  • Stop antidepressant (exacerbates manic symptoms)
  • Start PO antipsychotic: Risperidone
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How are they managed long-term?
  1. Lithium
  2. Sodium valproate
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πŸ‘΄πŸΌ Delirium vs dementia
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How do you differentiate between the two?
  1. Onset: Delirium (hours-days). Dementia (months-years)
  2. Cause: Delirium (infective/metabolic). Dementia (degenerative)
  3. Features: Delirium (confused, disordientated, hallucinating). Dementia (in early disease can be alert & orientated)
  4. Long-term: Delirium (after management the patient improves to baseline). Dementia (often won't return to baseline)
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Name 5 causes of delirium.
  1. Infection
  2. Metabolic - Electrolyte imbalance
  3. CNS - Space occupying lesion
  4. Vascular - Stroke/TIA
  5. Toxic - Substance misuse
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Name 4 types of dementia.
  1. Alzheimer's
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    Name the key features of this. (Follow-on Q)
    • Ξ²-amyloid plaques - Build up of Ξ²-amyloid around neurons
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      Why do individuals with Down's syndrome have ↑ risk & what age may they present?
      • APP gene is linked to Alzheimer's and it's found on chromosome 21
      • May present around 40 years
    • Neurofibrillary tangles - Phosphate added to TAU proteins β†’ Dysfunctional microtubules β†’ Apoptosis
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    How is this managed? (Mild/moderate vs severe)
    • Mild/moderate: Acetylcholinesterase inhibitors
      • Rivastigmine, donepezil
    • Severe: Memantine
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    What are the side effects of the drugs used?
    • AchEi: Insomnia (most common), diarrhoea, N&V, bradycardia, increased salivary production
    • Memantine: Constipation
  2. Lewy body
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    What causes this?
    • Ι‘-synuclein build up β†’ Lewy body formation β†’ Neuronal dysfunction
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    What features is it associated with?
    • Parkinsonism (Motor): Differentiate whether dementia started first or parkinsonism as could be parkinson's dementia
    • Visual hallucinations
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    How is it managed?
    • Acetylcholinesterase inhibitors
    • Levodopa (for Parkinsonism)
  3. Vascular
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    What is the cause?
    • Small microvascular infarcts β†’ Brain necrosis β†’ ↓ Memory
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    What are the key features?
    • Step-wise decline in cognitive function that doesn't return to baseline
    • Abnormal neurological signs
    • Vascular RFs: Metabolic syndrome, hypertension
    • Previous stroke/TIA
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    How is it managed?
    • Lifestyle: Improve vascular RFs
    • Acetylcholinesterase inhibitors
  4. Frontotemporal (Pick's disease)
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    What are the key features?
    • Behavioural/personality changes
    • Early onset: 45-65 years
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    Why is it important to rule this out?
    • AchEI make this worse and it's commonly used to manage all of the rest.
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What metabolic abnormality can cause dementia?
  • ↓ Folate
  • ↓ B12 may also give neuropathy symptoms (vision & peripheral)
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Name 3 other differentials for these.
  1. Substance misuse
  2. Sensory impairment
  3. Hypothyroidism
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A patient presents with urinary incontinence, dementia & being unsteady on his feet (gait abnormality). Diagnosis? Management?
  • Normal pressure hydrocephalus: Classic triad
  • Management: VP shunt
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πŸ™„ Personality disorders
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What age does an individual have to be to be diagnosed with a personality disorder?
  • 18 years - Personality needs to have fully developed

Based on the following descriptions, what is the personality disorder?

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21 year old man with a past forensic history and is deceptive, impulsive and aggressive. He is consistently irresponsible and when questioned on this has a lack of remorse.
  • Antisocial
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28 year old woman has an unwillingness to be involved in activities due to fear of criticism and will only do so if certain of being liked. She has a reluctance to take personal risks and as a result is socially isolated.
  • Avoidant
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23 year old man with unstable interpersonal relationships which vary from idealisation to devaluation. Fear of abandonment and as a result is sexually impulsive.
  • Borderline
  • Often childhood trauma
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35 year old woman with difficulty making everyday decisions without excessive reassurance. Need for others to be responsible for major areas of their life and difficulty disagreeing with others.
  • Dependent
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31 year old woman with inappropriate sexual seductiveness and the need to be centre of attention. Self-dramatisation and attention seeking physical appearance.
  • Histrionic
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52 year old male with a grandiose sense of self-importance with fantasies of success, power and beauty. Sense of entitlement and lack of empathy for others.
  • Narcissistic
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40 year old male with perfectionism that hampers with completing tasks. Occupied with details, rules, lists and order.
  • Obsessive complusive personality disorder
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19 year old male with oversensitivity and an unforgiving attitude when insulted. Tendency to perceive attacks on their character.
  • Paranoid
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30 year old female with an indifference to praise and criticism and a preference for solitry activities. Does not desire companionship and has few friends other than family.
  • Schizoid
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23 year old presents with ideas of reference (some insight retained), odd beliefs and magical thinking. They have odd, eccentric behaviour and an inappropriate affect.
  • Schizotypal
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🀨 Unexplained symptoms

What disorder do the following patients have:

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Despite negative tests, a patient is adament that they have breast cancer.
  • Hypochondrial disorder - Cancer
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A patient has had many tests finding no pathology but still has multiple symptoms that have been present for 2 years.
  • Somatisation - Symptoms
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A runner has a loss of sensation below his knee in a non-dermatomal distribution and all tests are normal.
  • Conversion disorder
    • Can be factitious (AKA Muchhausen's - not seeking material gain) or malingering (for material gain)
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A patient has been into hospital multiple times purposely taking too much insulin to cause a hypo.
  • Munchhausen's syndrome (factitious disorder)
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🍻 Substance misuse
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Alcohol
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What is the mechanism of alcohol withdrawal and what are the resulting symptoms?
  • Alcohol β†’ ↑ GABA inhibition in the brain β†’ Tolerance to GABA
  • Withdrawal β†’ ↓ GABA inhibition β†’ Sympathetic effects
  • Symptoms: Tremor, tachycardia, sweating, dry mouth
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What is delirium tremens? And what other severe symptom can occur during withdrawal?
  • DT: 48 hours after stopping alcohol β†’ Delusions, hallucinations, fever, tremor, tachycardia
  • Seizures can occur around 36 hours after withdrawal
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How do you manage alcohol withdrawal?
  • Lifestyle: Advice, support from community team and referral to alcohol services
  • Chlordiazepoxide reducing regime
    • Acamprosate is another option
  • Pabrinex (B1)
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How does disulfram work?
  • Produces an acute sensitivity to ethanol: Used in management of chronic alcohol misuse

Acute thiamine deficiency:

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What disease occurs due to this?
  • Wernicke's encephalopathy
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What symptoms does it give?

Triad:

  1. Confusion
  2. Ataxia
  3. Ophthalmoplegia
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If this is left untreated, what complication can occur? Symptoms of this?
  • Korsakoff's psychosis
  • Irreversible anterograde amnesia
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Heroin
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How does methadone work? Why is it better than heroin?
  • Β΅-opioid receptor agonist
  • Better because it has a longer onset of action and half life (less addictive) and less crosses the BBB causing less of a high
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If at a low dose of methadone, what drug can it be switched to?
  • Buprenorphine - Partial opioid antagonist
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When is naltrexone indicated?
  • Attempting to stop relapse of addiction
  • Full opioid antagonist causing the individual to get less of a high from heroin
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🌭 Eating

A girl presents with a BMI of 15.5.

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What values do you expect to be low?
  • HR
  • BP
  • FSH & LH (infertility)
  • T3 (hypothyroid)
  • K⁺
  • WCC
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What values do you expect to be high?

G's & C's

  • Growth hormone
  • Glucose
  • Salivary glands (hypersalivation)
  • Cholesterol
  • Cortisol
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Her sister has a BMI of 18 and is found to have epidsodes of binge eating followed by intentional vomiting and exercise. What is her diagnosis? Name 2 other purgative behaviours.
  • Bulimia
  • Purgative: Laxatives, diuretics
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What are the biochemical changes in refeeding syndrome?

Rapid insulin production β†’ Intracellular shift of ions

  • ↓ PO₄³⁻
  • ↓ Mg²⁺
  • ↓ K⁺
  • ↑ Glucose

πŸ’Š Management

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πŸ₯Ί Antidepressants
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SSRIs
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Name the 2 SSRIs often given first-line. (Follow-on Q)
  1. Fluoxetine
  2. Citalopram
    3. β€£
    What do you need to monitor if they're on citalopram?
    • ECG because can cause prolonged QT β†’ Risk of Torsades
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What advice needs to be given to the patient when starting an SSRI?
  • Normal for mood to fall first before starting to feel better, takes 4-6 weeks to feel full effects
  • ↑ suicidal risk early as motivation is increased but mood is still the same
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How are they monitored?
  • Review 2 weeks after initiation
  • Continue monthly until they are stable
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Name the SSRI indicated post-MI.
  • Sertraline
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What medications do they interact with?
  • NSAIDs: ↑ risk of peptic ulcers & GI bleed β†’ Prescribe PPI
  • Warfarin: Avoid completely
  • Triptans: Risk of serotonin syndrome. Avoid completely
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If they have had a good response after 2 months should they be stopped?
  • No - Minimum course is 6 months. If stopped earlier: ↑ risk of relapse
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Can they be stopped immediately?
  • No, they need to be reduced over 4 weeks. If not they may get discontinuation symptoms
    • Fluoxetine can be stopped immediately due to long half-life
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How does SSRI discontinuation syndrome present?
  • D&V
  • Abdominal pain
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If used in pregnancy, what is the risk?
  • Congenital heart defects
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Others
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Name 2 SNRIs.
  • Venlafaxine
  • Duloxetine
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How does mirtazapine work?
  • Ι‘-2-adrenoceptor blocker β†’ ↑ serotonin & noradrenaline
  • Causes sedation & ↑ appetite at low doses and these effects are less prominent in high doses
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How do you manage an amitryptyline overdose?
  • IV sodium bicarbonate
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What are the common SEs of tricyclics?

Antimuscarinic:

  1. Blurred vision
  2. Dry mouth
  3. Overflow incontinence
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How do monoamine oxidase inhibitors work? When are they indicated? What must patients on this avoid & why?
  • Monoamine oxidase is the enzyme that metabolises serotonin & noradrenaline in the presynaptic neuron β†’ MOAs stop this action
  • Avoid cheese as it causes a hypertensive reaction
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Switching medications
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A patient wants to change from citalopram to sertraline. How do you do this?
  • Withdraw citalopram, when completely off introduce the sertraline
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A patient wants to swap from fluoxetine to paroxetine. How do you do this?
  • Withdraw fluoxetine, wait 7 days, introduce paroxetine
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A patient wants to swap from citalopram to amitryptyline. How do you do this?
  • As you withdraw the citalopram, increase the amitryptyline
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What SSRI is the anomaly?
  • Fluoxetine - Long half life therefore needs more time to get out of the system
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🀬 Antipsychotics
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Name 5 atypicals and 2 typicals.

Atypicals:

  1. Olanzapine
  2. Quetiapine
  3. Risperidone
  4. Aripiprazole
  5. Clozapine

Typicals:

  1. Haloperidol
  2. Chlorpromazine
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What is their mechanism of action?
  • D2 receptor antagonists
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Clozapine
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What do you need to monitor carefully when patients are on this & why?
  • FBC - Risk of agranulocytosis
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How does smoking affect it?
  • Smoking cessation β†’ Significant ↑ clozapine levels
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Why do you need to do a baseline ECG?
  • Risk of myocarditis
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What neurological side effect can it induce?
  • ↓ seizure threshold
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Side effects
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Name the 4 main extrapyramidal SEs that may occur. (Follow-on Qs)
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Diagram:
image
  1. Parkinsonism
  2. Acute dystonia
    3. β€£
    Give 2 examples of this
    1. Torticollis (wry neck) - Unilateral pain & deviation of the neck
    2. Oculogyric crisis - Upward deviation of the eyes
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    How is this managed?
    • Procyclidine
  3. Tardive dyskinesia
    4. β€£
    What is this?
    • Late-onset choreoathetoid movements (kinesia = movements)
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    Give 3 examples.
    1. Lip smacking
    2. Excessive blinking
    3. Pouting of jaw
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    How is this managed?
    • Tetrabenazine
  4. Akathisia
    5. β€£
    What is this?
    • Restless leg - Severe reselessness and inability to stay still
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Why would a woman present with breast changes when started on risperidone?
  • Dopamine β†’ Prolactin inhibition
  • ↓ Dopamine β†’ ↑ Prolactin secretion β†’ Galactorrhoea
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Which antipsychotic is most likely to cause metabolic syndrome?
  • Olanzapine
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Which atypical antipsychotic has the best SE profile?
  • Aripiprazole

Cases:

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A patient is diagnosed with schizophrenia. Which antipsychotic would you like to start and what would be the treatment regime if the medications were not effective?
  1. Trial olanzapine/risperidone for 4-6W
  2. Try a different antipsychotic (one not tried above) for 4-6W
  3. Consider clozapine
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A patient presents with pyrexia, muscle stiffness and seizures. What side effect is this?
  • Neuroleptic malignant syndrome
    • β€£
    Management?
    1. IV fluids
    2. Dantrolene/bromocriptine
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A patient presents in VT after an overdose of quetiapine, how do you manage this?
  • IV magnesium sulphate (Torsades)
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😴 Benzodiazepines
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How do they work?
  • ↑ GABA inhibition within the brain
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How does their MOA differ from barbituates?

'I bend frequently during barbeque'

  • Benzodiazepines - ↑ chloride channel frequency
  • Barbituates - ↑ chloride channel duration of opening
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Name 3 examples.
  1. Diazepam
  2. Lorazepam
  3. Midazolam
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What is the process when withdrawing a benzodiazepine?
  • Convert the current dose to the equivalent of diazepam
  • Slowly decrease the diazepam by approx. 1/8 every fortnight (can take between 1M-1Y)
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What drug is used to manage overdose?
  • Flumazenil
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😢 Lithium
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Name 2 indications.
  • Bipolar affective disorder
  • Refractory depression
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What is the therapeutic range?
  • 0.4-1
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Where is it primarily excreted?
  • Kidneys
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What are the signs of lithium toxicity?
  1. Coarse tremor
  2. CNS disturbance: Seizures, impaired co-ordination, dysarthria
  3. Arrhythmias
  4. Visual disturbance
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What do you need to monitor in a patient on lithium? Why? How often?
  • Every 3 months
    • Lithium levels (Dose start/change check levels weekly until stable)
  • Every 6 months
    • U&E: Nephrotoxic
    • TFTs: Risk of hypothyroidism
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⚑️ Electroconvulsive Therapy
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When is ECT indicated?
  1. Refractory depression
  2. Treatment-resistant schizophrenia
  3. Catatonia due to either of the above
    4. β€£
    What is catatonia?
    • Waxy flexibility - Move the pillow from behind the patients head and the head stays in the same place
    • Posturing - Patient holds odd positions for prolonged periods
    • Often will not eat, drink or speak
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What are the contraindications?
  • ↑ ICP
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Name 4 side effects of ECT treatment.
  1. Headache
  2. Nausea
  3. Amnesia - Mainly retrograde but can be anterograde
  4. Cardiac arrhythmia

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