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Psychiatry
π¨πΌββοΈ Assessment
- ROS (psych): Depression (mood, anhedonia), schizophrenia (TAPD)
- RISK - Self / others
- Past psychiatic history
- Forensic history
- Personal history
- Core: β mood, anhedonia, anergia
- Additional:
- Biological: β sleep, β appetite, β libido
- Psychological: β concentration, social isolation, self-worth
- Harm: Self/others
- 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
- Mania vs hypomania: Psychosis? (Delusions, hallucinations, thought disorders)
- Symptoms:
- Increased energy
- Little sleep
- Disinhibition: Sexual or financial
- Thought: Flight of ideas
Any odd or unusual happenings recently? Do you hear anything in an empty room? See things that aren't there?
- Auditory: Key voices are third person commenting / talking behind back
- Visual
- Somatic
- 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
- 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
- Possession:
- Thought broadcasting, insertion, withdrawal
- Being controlled by someone else
For the following sections, what is the description of normal and what factors do you need to consider in each?
- Describe clothing: Dishevelled, appropriately dressed
- Body language
- Hygiene
- 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
- Normal: Speech was congruent with their emotions and of a normal speed.
- Abnormal:
- Speed: Slow/normal/fast
- Tone: monotonous/congruent]
- Volume
- Normal: Both objectively and subjectively euthymic
- Objective (my impression):
- Mood: Low/euthymic/high
- Affect: Flat/normal
- Subjective (patientβs impression):
- Low/euthymic/high
- Normal: Patient did not respond to any stimuli that weren't present
- Hallucinations: Auditory/visual/somatic
- 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
- Present or not at this given time
- Normal: Cognition grossly intact but not formally assessed (memory, orientation)
- Assess using Addenbrookeβs Cognitive Examination (ACE-III) - attention, memory, fluency, language, visuospacial
What are the requirements for the following sections & what do they permit?
- Requirements: 1 AMHP & 2 doctors (that know the patient, one section 12(2) approved)
- Permit: 28 days for assessment (non-renewable)
- Requirements: 1 AMHP (approved mental health practitioner) & 2 doctors (that know the patient)
- Permit: 6 months for treatment (renewable)
- Requirements: Doctor
- Permit: 72 hours detainment in hospital for assessment
- Requirements: Nurse
- Permit: 6 hours detainment in hospital
- Requirements: Consultant psychiatrist
- Permit: CTO (community treatment order) - Release from hospital to treat in community
- Requirements: Police
- Permit: Court order to enter a property to bring a patient to a place of safety
- Requirements: Police
- Permit: Detain a patient in a public place to bring them to a place of safety
πΉ Disease
- Auditory (commonly third person & can be commenting) & somatic hallucinations
- Thought:
- Formal thought disorder - Loosening of associations
- Content - Delusions
- Possessional thought disorder - Thought insertion, withdrawal, broadcasting
- Negative symptoms - Emotional blunting, social withdrawal
- Behaviour - Distracted by the high volume of stimuli, threatened fom voices
- Paranoid - Well organised persecutory delusions & hallucinations
- Hebephrenic - Behaviour, mood and thought disturbance are predominant
- Catatonic - Motor symptoms, lack of eating, drinking and speaking
- Schizoaffective disorder - Combination of schizophrenia and mood disorder (manic auditory hallucinations are usually second person and make more sense than the schizophrenic hallucinations)
- Mood stabiliser: Lithium
- Antipsychotic: Olanzapine
- Bipolar disorder
- Organic cause β Delirium
- Depression - Negative symptoms can mimic depression
- Charles Bonnet syndrome - Visual hallucinations (insight preserved)
- Low IQ
- Strong FH
- Gradual onset
- Lack of clear precipitant
- Antipsychotics (discussed below)
- GAD
- Lifestyle: Education & reassurance. Exercise & meditation.
- Psychoeducational groups, individual-guided self-help.
- CBT / Sertraline
- Panic disorder
- PTSD
- > 1 month
- Re-experiencing
- Avoidance
- Emotional blunting
- Hyperarousal - Hypervigilance for threat
- EMDR
- CBT
- Acute stress reaction
- < 1 month β Acute stress rather than PTSD
- Dissociative symptoms
- Hyperthyroidism
- Cardiac chest pain
- Medication-induced: Salbutamol, theophylline, steroids, caffeine
- Mild: 2 core, β₯ 2 additional
- Moderate: 2 core, β₯ 3 additional
- Severe: 3 core, β₯ 4 additional
- Psychological therapy
- SSRI - Fluoxetine / sertraline
- β₯ 2 weeks
- Differentials: Dementia & depression
- Diagnosis: Depression because short history and global memory loss is key
- Mania β Psychosis & symptoms β₯ 7 days
- Hypomania β No psychosis & symptoms < 7 days
- Mood: β mood & energy
- Speech & thought: Pressured, flight of ideas, poor attention
- Behaviour: Insomnia, loss of inhibitions (sexual, financial)
- Mania: Urgent referral to the CMHT
- Hypomania: Routine referral to the CMHT
- IM lorazepam/aripiprazole
- Stop antidepressant (exacerbates manic symptoms)
- Start PO antipsychotic: Risperidone
- Lithium
- Sodium valproate
- Onset: Delirium (hours-days). Dementia (months-years)
- Cause: Delirium (infective/metabolic). Dementia (degenerative)
- Features: Delirium (confused, disordientated, hallucinating). Dementia (in early disease can be alert & orientated)
- Long-term: Delirium (after management the patient improves to baseline). Dementia (often won't return to baseline)
- Infection
- Metabolic - Electrolyte imbalance
- CNS - Space occupying lesion
- Vascular - Stroke/TIA
- Toxic - Substance misuse
- Alzheimer's
- Ξ²-amyloid plaques - Build up of Ξ²-amyloid around neurons
- 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
- Mild/moderate: Acetylcholinesterase inhibitors
- Rivastigmine, donepezil
- Severe: Memantine
- AchEi: Insomnia (most common), diarrhoea, N&V, bradycardia, increased salivary production
- Memantine: Constipation
- Lewy body
- Ι-synuclein build up β Lewy body formation β Neuronal dysfunction
- Parkinsonism (Motor): Differentiate whether dementia started first or parkinsonism as could be parkinson's dementia
- Visual hallucinations
- Acetylcholinesterase inhibitors
- Levodopa (for Parkinsonism)
- Vascular
- Small microvascular infarcts β Brain necrosis β β Memory
- Step-wise decline in cognitive function that doesn't return to baseline
- Abnormal neurological signs
- Vascular RFs: Metabolic syndrome, hypertension
- Previous stroke/TIA
- Lifestyle: Improve vascular RFs
- Acetylcholinesterase inhibitors
- Frontotemporal (Pick's disease)
- Behavioural/personality changes
- Early onset: 45-65 years
- AchEI make this worse and it's commonly used to manage all of the rest.
- β Folate
- β B12 may also give neuropathy symptoms (vision & peripheral)
- Substance misuse
- Sensory impairment
- Hypothyroidism
- Normal pressure hydrocephalus: Classic triad
- Management: VP shunt
- 18 years - Personality needs to have fully developed
Based on the following descriptions, what is the personality disorder?
- Antisocial
- Avoidant
- Borderline
- Often childhood trauma
- Dependent
- Histrionic
- Narcissistic
- Obsessive complusive personality disorder
- Paranoid
- Schizoid
- Schizotypal
What disorder do the following patients have:
- Hypochondrial disorder - Cancer
- Somatisation - Symptoms
- Conversion disorder
- Can be factitious (AKA Muchhausen's - not seeking material gain) or malingering (for material gain)
- Munchhausen's syndrome (factitious disorder)
- Alcohol β β GABA inhibition in the brain β Tolerance to GABA
- Withdrawal β β GABA inhibition β Sympathetic effects
- Symptoms: Tremor, tachycardia, sweating, dry mouth
- DT: 48 hours after stopping alcohol β Delusions, hallucinations, fever, tremor, tachycardia
- Seizures can occur around 36 hours after withdrawal
- Lifestyle: Advice, support from community team and referral to alcohol services
- Chlordiazepoxide reducing regime
- Acamprosate is another option
- Pabrinex (B1)
- Produces an acute sensitivity to ethanol: Used in management of chronic alcohol misuse
Acute thiamine deficiency:
- Wernicke's encephalopathy
Triad:
- Confusion
- Ataxia
- Ophthalmoplegia
- Korsakoff's psychosis
- Irreversible anterograde amnesia
- 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
- Buprenorphine - Partial opioid antagonist
- Attempting to stop relapse of addiction
- Full opioid antagonist causing the individual to get less of a high from heroin
A girl presents with a BMI of 15.5.
- HR
- BP
- FSH & LH (infertility)
- T3 (hypothyroid)
- KβΊ
- WCC
G's & C's
- Growth hormone
- Glucose
- Salivary glands (hypersalivation)
- Cholesterol
- Cortisol
- Bulimia
- Purgative: Laxatives, diuretics
Rapid insulin production β Intracellular shift of ions
- β POβΒ³β»
- β MgΒ²βΊ
- β KβΊ
- β Glucose
π Management
- Fluoxetine
- Citalopram
- ECG because can cause prolonged QT β Risk of Torsades
- Normal for mood to fall first before starting to feel better, takes 4-6 weeks to feel full effects
- β suicidal risk early as motivation is increased but mood is still the same
- Review 2 weeks after initiation
- Continue monthly until they are stable
- Sertraline
- NSAIDs: β risk of peptic ulcers & GI bleed β Prescribe PPI
- Warfarin: Avoid completely
- Triptans: Risk of serotonin syndrome. Avoid completely
- No - Minimum course is 6 months. If stopped earlier: β risk of relapse
- 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
- D&V
- Abdominal pain
- Congenital heart defects
- Venlafaxine
- Duloxetine
- Ι-2-adrenoceptor blocker β β serotonin & noradrenaline
- Causes sedation & β appetite at low doses and these effects are less prominent in high doses
- IV sodium bicarbonate
Antimuscarinic:
- Blurred vision
- Dry mouth
- Overflow incontinence
- 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
- Withdraw citalopram, when completely off introduce the sertraline
- Withdraw fluoxetine, wait 7 days, introduce paroxetine
- As you withdraw the citalopram, increase the amitryptyline
- Fluoxetine - Long half life therefore needs more time to get out of the system
Atypicals:
- Olanzapine
- Quetiapine
- Risperidone
- Aripiprazole
- Clozapine
Typicals:
- Haloperidol
- Chlorpromazine
- D2 receptor antagonists
- FBC - Risk of agranulocytosis
- Smoking cessation β Significant β clozapine levels
- Risk of myocarditis
- β seizure threshold
- Parkinsonism
- Acute dystonia
- Torticollis (wry neck) - Unilateral pain & deviation of the neck
- Oculogyric crisis - Upward deviation of the eyes
- Procyclidine
- Tardive dyskinesia
- Late-onset choreoathetoid movements (kinesia = movements)
- Lip smacking
- Excessive blinking
- Pouting of jaw
- Tetrabenazine
- Akathisia
- Restless leg - Severe reselessness and inability to stay still
- Dopamine β Prolactin inhibition
- β Dopamine β β Prolactin secretion β Galactorrhoea
- Olanzapine
- Aripiprazole
Cases:
- Trial olanzapine/risperidone for 4-6W
- Try a different antipsychotic (one not tried above) for 4-6W
- Consider clozapine
- Neuroleptic malignant syndrome
- IV fluids
- Dantrolene/bromocriptine
- IV magnesium sulphate (Torsades)
- β GABA inhibition within the brain
'I bend frequently during barbeque'
- Benzodiazepines - β chloride channel frequency
- Barbituates - β chloride channel duration of opening
- Diazepam
- Lorazepam
- Midazolam
- Convert the current dose to the equivalent of diazepam
- Slowly decrease the diazepam by approx. 1/8 every fortnight (can take between 1M-1Y)
- Flumazenil
- Bipolar affective disorder
- Refractory depression
- 0.4-1
- Kidneys
- Coarse tremor
- CNS disturbance: Seizures, impaired co-ordination, dysarthria
- Arrhythmias
- Visual disturbance
- Every 3 months
- Lithium levels (Dose start/change check levels weekly until stable)
- Every 6 months
- U&E: Nephrotoxic
- TFTs: Risk of hypothyroidism
- Refractory depression
- Treatment-resistant schizophrenia
- Catatonia due to either of the above
- 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
- β ICP
- Headache
- Nausea
- Amnesia - Mainly retrograde but can be anterograde
- Cardiac arrhythmia
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