MSE examination components?
A&B, SMT, PCI
Appearance & Behaviour
Speech
Affect & mood
Risk
Thought content
Perceptions
Cognition
Insight
MSE: Appearance & behaviour components
Build Dress Kempt Visible features (eg. tatoos) Agitation/retardation/ EPSE Strange behaviour Eye contact Rapport
Mood & Affect
Affect - at given time: euthymic/blunted/elated
Mood: Subjective/objective
–> Euthymic, depressed, elated
MSE: Thoughts
Thought content Formal thought disorder Preoccupations Obsessions Overvalued ideas Delusions (false belief) Thought insertion/withdrawal/broadcast
Passivity phenomena
Types of delusions
Mood congruent (grandiose, poverty, guilt, nihilistic, worthless, hypochondriacal, Cotard’s syndrome)
Persecutory (conspiracy)
Reference (TV, radio, gestures)
Erotomanic (De Clerambault’s Syndrome)
Primary Delusion = autocthonous, out of blue, may be accompanied by delusional mood
Secondary delusion = delusional explanation for hallucination
Cotard’s ?
The Cotard delusion (also Cotard’s syndrome and walking corpse syndrome) is a rare mental illness in which an afflicted person holds the delusion that they are dead, either figuratively or literally
Illusion vs hallucination vs delusion
Delusion = false belief
Illusion = misinterpretation of normal stimulus
Hallucination = false perception in absence of stimulus
AMTS?
ATLAYRDYMB
Age
Time
Location
Adress
Current Year
Recognise 2
Date of birth
Years of WWII
Monarch
Backwards from 10-1
(address)
MMSE. Scores & why someone may perform badly
Normal = 30 – 26
Mild Dementia = 25– 20
Moderate Dementia = 19 – 10
Severe Dementia = 9 – 0
Inattention Apathy Pain Hearing problems Cultural or educational reasons Dementia, delirium, psychosis, depression ro mania
General Psych management approach
Biological: Physical health care Medication, eg, Antipsychotics, Antidepressants, Mood stabilisers ECT Psychosurgery
Psychological: Cognitive behavioural therapy Psychodynamic psychotherapy Family interventions Dual diagnosis i.e. substance abuse as well as mental health issues (motivational interviewing) Relapse prevention
Social:
Occupational therapy and daily living skills
Work, education, leisure - structured, meaningful activities
Social support
Housing
Financial
Considerations
Risks
To self and others (relatives, children, strangers, professionals) – self-neglect, self-harm, violence
MHA (1983)
Setting
Inpatient vs. community
Patient’s wishes
Current and previous treatments, advance directives
Multidisciplinary team and multi-agency liaison
CMHT, Police, social services, GP
Depression Major + minor symtpoms
Major:
1) Low mood
2) Anhedonia
3) Reduced energy
Minor:
1) reduced conc
2) Guilt/worthlessness
3) Disturbed sleep/early waking
4) poor appetite
5) Pessimistic thoughts (Beck’s cognitive triad)
6) Reduced self esteem/confidence
Depression classification
Classification:
Mild depressive episode:
Depressed mood sustained for at least 2 weeks
At least 2 of A and 2 of B
Moderate depressive episode:
Depressed mood sustained for at least 2 weeks
At least 2 of A and 3 of B
Severe depressive episode
Depressed mood sustained for at least 2 weeks
All of A and at least 4 of B
Severe depression with psychosis
Depressive stupor?
Very severe depression - person stops speaking or moving (catatonia)
Depression Ddx?
1) Organic eg. hypothyroid, cushings, hypoparathyroidism, physical meds eg. antihypertensives/steroids
2) Dementia (depressive pseudodementia)
3) Substance misuse
4) personality disorder
5) Bipolar disorder
Mild depression
–> Ordinary unhappiness, bereavement/adjustment reactions, anxiety disorders
Severe depression:
- Schizophrenia/schizoaffective disorder
Depression Medication
1) TCAs: Amitriptyline, imipramine
2) MAOI: Phenelzine, moclobemide, selegiline
3) SSRIs: Fluoxetine, Sertraline, Citalopram, Paroxetine
4) SNRI: Venlafaxine
5) NaSSA: Mirtazapine
TCAs SEs
Drowsiness Anxiety Emotional blunting (Apathy/anhedonia) Restlessness Dizziness (postural hypotension) Akathisia Sexual dysfunction N+V Hypotension Tachycardia Rarely, arrythmias Antimuscarinic (Dry mouth, dry nose, blurry vision, constipation, urinary retention)
Risk of OD/drug interactions –> metabolised by cyt p450
MAOI SEs
Reserved for last line due to SE/ food/drug interactions
Drowsiness
Dizziness
Low Bp
Sexual tension
Inhibit catabolism of dietry amines –> cheese effects with foods containing tyramine (sweating, tremor, tachycardia, raised BP)
IF foods containing tryptophan are consumed –> hyperserotonemia may result.
Foods that contain Tyramine
Tryptophan?
Tyramine: Pickled meats, smoked, fermented, marinated. Chocolate, alcoholic beverages, cheese, yoghurt, tofu, avocados, bananas nuts etc
Tryptophan: Red meat, dairy products, nuts, seeds, legumes, soybeans, soy products, tune, shellfish, turkey
SSRIs SE
N+V+D
Increased risk of Peptic ulcer/bleeding - especially in older people
Drowsiness/somnolence
Headache
Bruxism
Insomnia
Weight loss/gain
Increased risk of bone fractures
Changes in sexual behaviour
Autonomic dysfunction: orthostatic hypotension, increased/reduced sweating etc
What is Ribot’s law
Law for all pathological amnesias: ‘the new dies before the old’ (opposite of normal forgetting)
Occurs with ECT
NICE guidelines depression Mx:
Initially: Psychoeducation, self-help, mood diary
Persistant subthreshold depression or mild-moderate depression with inadequate response to initial interventions: SSRI or CPT or IAPT (interpersonal psychotherapy)
Moderate/severe: SSRI + CBT or IAPT
SSRI with highest incidence of discontinuation syndrome?
Lowest?
Highest = paroxetine
Lowest = fluoxetine (longest half life)
post-SSRI suicide monitoring?
Low risk: after 2/52, then every 2-4 weeks for 1st 3/12, longer intervals after if good response
Higher risk/
Serotonin syndrome?
Increased risk with cross-tapering antidepressants + other concurrent medicines eg. tramadol
Sx: Restlessness, tremor, sweating, shivering
Myoclonus
Changes in BP
Confusion/delirium - Altered mental state
Convulsions/death
Mirtazapine SE
Often used 2nd life after SSRI
SE:
Drowsiness (can help sleep)
Weight gain
Rare cases of neutropenia
Venlafaxine - careful in which pts?
Often used 2nd/3rd line agent / treatment resistant depression
Care in pts with CVS problems -
Increased BP at higher doses + may exacerbate cardiac arrhythmias
Anti-depressant advice for risk of relapse?
Advise people with depression to continue antidepressants for atleast 2 years.
Maintain the level of medication at which acute treatment was effective (unless there is a good reason to reduce dose, eg. unacceptable adverse effects)
–> lithium should not be used as a sole agent to prevent recurrence
Anti-depressants discontinuation symptoms
Increased mood change Restlessness Difficulty sleeping Unsteadiness Sweating Abdominal symptoms Altered sensations
Appears 1-14 days after cessation, last 7-14 days
–> When stopping, gradually reduce dose, normally over atleast a 4 week period
Hyponatraemia and antidepressants/
Most antidepressants cause this
Risk factors – old age, female LBW, low baseline Na, concurrent medication, hypothyroidism, diabetes, warm weather
May need to be clinically managed
SSRIs are more likely to cause it
Lofepramine, reboxetine and moclobemide are less likely.
Bipolar disorder: Sx
Mood: Irritable, euphoria, lability
Cognition: grandiosity, flight of ideas, racing thoughts, distractibility, confusion, lack of insight
Behaviour: rapid speech, hyperactivity, lack of sleep, hypersexuality, extravagance
Psychotic symptoms: delusions, hallucinations, hypomania
Hypomania Dx
Elevated/irritable mood sustained for atleast 4 days
Atleast 3 of following, leading to some interference with personal function:
Increased activity or restlessness Increased talkativeness Distractibility Decreased need for sleep Increased sexual energy Mild reckless or irresponsible behaviour Increased sociability
Mania Dx
Predominately elevated or irritable mood sustained for atleast 1/52. Atleast 3 of the following - leading to severe interference with personal function:
- increased activity/restlessness
- Increased talkativeness
- Flight of ideas
- Loss of normal social inhibitions
- Decreased need for sleep
- Inflated self-esteem or gradiosity
- Distractibility or constant changes in activity
- Behaviour that is foolhardy or reckless
- Marked sexual energy or sexual indiscretions
What is cyclothymia
Hx or mild hypomania interspersed with periods of depression that do not meet the criteria for major depressive episodes.
low grade cycling of mood, which appears to the observer as a personality trait, and interferes with functioning
Define bipolar disorder
A major affective disorder marked by severe mood swings (manic or major depressive episodes) and a tendency to remission and recurrence.
Mania/hypomania/bipolar Tx Acute episode
Mania/hypomania Lithium Valproate Atypical antipsychotic (olanzapine, risperidone) Combinations
Bipolar depression Valproate Quetiapine Lamotrigine Olanzapine SSRIs
Bipolar - maintenance treatment
Lithium - first line (NICE Guidelines September 2014) Valproate Olanzapine Lamotrigine Risperidone Aripiprazole Quetiapine Combinations
Lithium: mechanism?
Not fully understood
Alters Na+ transport across cell membranes
Alters metabolism of neurotransmitters including catecholamines and serotonin
Reduces PKC activity, possibly affecting genomic expression associated with neurotransmission
Lithium SE
Levels 0.4-1mmol/L
Abdominal Pain Nausea Metallic taste in mouth Fine tremor Thirst Polyuria Weight gain Oedema Leukocytosis - Advice to seek medical attentino if they develop D/V or become acutely ill for any reason
Long term effects:
- hypothyroidism
- Hyperparathyridism
- hypercalcaemia
- Renal failure
- Nephrogenic diabetes insipidus
‘Fine tremor is fine, coarse tremor is not (Toxicity)’
Lithium toxicity Sx
Levels >1.5mmol
Anorexia D+V drowsiness Apathy Restlessness Dysarthria Ataxia Muscle twiches Coarse tremor Blackouts/coma
Lithium Drug monitoring
Pre-lithium work up:
ECG, TFTs, U+Es, Renal function tests
Monitoring:
- Start at 400mg once daily (200mg in elderly)
- -> Plasma level after 5-7 days
- Then every 5-7 days until required level reached (0.6-1mmol/L)
–> Toxicity occurs at > 1.5mmol/L)
- Bloods taken at 12 hours post dose (trough)
- Once stable - levels every 3 months, U+Es and TFTs every 6 months
Valproate SE
Abnormal eye movements blood/marrow problems confusion deafness EPSE agitation N+D hair loss headaches liver problems... Paraesthesiae Osteoporosis
Basically a Fuck tonne
Valproate CI/ work up/ monitoring
CI: Women of child bearing potential - teratogenic.
Work-up - TFTs, FBC, RFTs, BM, LFTs, Lipid profile, Weight + height, ECG
Monitoring: FBC, LFTs, Weight + height every 6/12
Dose monitoring - only useful to ensure adequate dosing and compliance
Olanzapine SE
Very common:
- Postural hypotension, abnormal gait, appetite gain, falls, metabolic syndrome, sedation, lethargy, weight gain, worsening of parkinson’s
Common: Constipation, decreased libido, dry mouth, erectile dysfunction, joint pain
Non-pharmacological approaches to bipolar
Psychoeducation - sleep hygiene, identifying relapsing markers, managing stress, mood monitoring
CBT - some evidence in reduction in severity of symptoms, but only early on in course of illness
- Psychopharmacology remains mainstay of treatment
Bipolar I vs II
Bipolar I - mania has occurred on atleast one occasion
Bipolar II - hypomania has occurred on atleast one occasion
Antipsychotic Tx monitoring
Pretreatment, measure and record:
- Weight/BMI
- Pulse, BP
- Fasting bloods, HbA1c
- Blood lipid profile
- offer ECG if known cardiovascular risk, FH
Monitoring
- HR + BP after each dose change
- Weight/BMI weekly for first 6 weeks, then at 12 weeks
- Blood glucose, HbA1c and lipid profile at 12 weeks
- Response to treatment including changes in symptoms and behaviour
Stopping Lithium
Reduce dose gradually over at least 4 weeks, preferably up to 3 months
during dose reduction + 3 months after, monitor closely for signs of mania/depression
Situations that may increase lithium levels
Decreased Na+ intake/increased sodium excretion (low Na+ diet, diuretics, ACEis, AR2b, excessive sweating, D+V)
Decreased water intake/increased water excretion (dehydrating, diuretics, fever, illness)
Renal disease
- Renal dysfunction
- NSAIDs
Moderate/severe bipolar depression Mx
Fluoxetine + Olanzapine
OR
Quietiapine
Lamotrigine serious SE?
Skin rash including SJS or Toxic epidermal necrolysis
Long term pharm treatment of bipolar?
Offer lithium 1st line –> Most effective long term tx
If ineffective/poorly tolerate, consider valproate or olanzapine
Attempted suicide assessment
Inner ring:
Circumstances of the attempt
What happened that day?
Were things normal to begin with?
Were there any preparations made e.g. making a will or giving things away?
Was there a last act (e.g. suicide note)?
What happened after the attempt?
Middle ring: Background to the event How have things been over the preceding months? Has the patient thought about attempting suicide in the last few months? What relationships were important over this time?
Outer ring:
Family and personal history
What was the intention behind the attempt?
What are the present feelings and intentions?
If the patient was to leave hospital today how would they cope?
Suicide attempt Mx
Agree a contract offering help by negotiation
Discuss confidentiality and then talk with family
Anti-depressants
Problem solving therapy
Follow up with preventative strategies
Anxiety Sx
anxiety, depression, fatigue, insomnia, irritability, worry, obsessions, compulsions, somatisation, agitation, feelings of impending doom, trembling, sense of collapse, insomnia, poor concentration, goose flesh, butterflies in the stomach, hyperventilation, headaches, sweating, palpitations, poor appetite, nausea, lump in the throat (globus hystericus), difficulty getting to sleep, excessive concern, repetitive thoughts and activities
Generalised anxiety disorder Dx?
Anxiety + 3 somatic symptoms; present for > 6 months
Anxiety disorder types:
GAD Panic disorder Phobia PTSD Social anxiety disorder Obsessive compulsive disorder
Anxiety disorder management
Symptom control: reassurance, listening
Regular exercise
meditation
CBT
Meds:
- Benzo eg.diazepam
- SSRI eg. paroxetine
- Antihistamines eg. hydroxyzine
- B-blockers
- others: pregabalin, venlafaxine
Progressive relaxation training
Hypnosis
Phobic disorders?
Anxiety in specific situations – leads to avoidance
Elicit the exact phobic stimulus
Mx: CBT; paroxetine
OCD?
Compulsions: senseless, repeated rituals
Obsessions: stereotyped, purposeless words, ideas or phrases that come into the mind
Perceived by the patient as nonsensical and originating from themselves
E.g. rambler who cannot do a long walk because every few paces they wonder if they have really locked the car and has to return repeatedly to ensure this has been done; repetitive cleaning, counting and dressing rituals
Pathophysiology: orbitofrontal and caudate nucleus
Mx: behavioural or cognitive therapy; clomipramine or fluoxetine
Acute stress symptoms
Fearful, horrifeid, dazed, helpless, numb, detached, decreased emotional responsiveness, intrusive thoughts, hypervigilance, depersonalisation, dissociative amnesia, reliving of events, autonomic arousal , headaches, abdo pain
PTSD
DSM-IV: symptoms have been present for more than one month:
- Re-living: flashbacks, nightmares, repetitive and distressing intrusive images
- hyperarousal (hypervigilance, exaggerated startle, sleep problems, irritability, difficulty concentrating)
- Avoidance
- Emotional numbing
from other people: - Depression - Druh or alcohol misuse Anger - Unexplained physical symptoms
PTSD Mx
- watchful waiting for mild symptoms
Anorexia nervosa definition
Compulsive need to control eating
Low self-worth
Weight loss becomes an over-valued idea - achieved by over-exercising, induced vomiting, laxative abuse, diuretics or appetite suppressants.
May also have episodes of binge following by remorse, vomiting and concealment
Anorexia Nervosa features
Reduced BMI
Bradycardia
Hypotension
Enlarged salivary glands
Anorexia Physiological abnormalities
Hypokalaemia
Low FSH, LH, oestrogens and testosterone
Impaired glucose tolerance
Low T3
Raised cortisol/growth hormone
Hypercholesterolaemia
Hypercarotinaemia
Eating disorders screening questionnaire?
SCOFF
Do you ever make yourself SICK because you feel too full?
Do you worry you’ve lost CONTROL over eating
Have you recently lost more than ONE stone in 3 months?
Do you believe you are FAT when others say you are thin?
Does FOOD dominate your life?
Anorexia Mx
Restore nutritional balance
Treat complications of starvation
Severe anorexia:
- BMI 17.5
Encourage use of self help books and a food diary
- If no response within 8 weeks, consider referral to secondary care
Therapy: cognitive, analytic, interpersonal, supportive or family therapy
Meds: Fluoextine, olanzapine
What is refeeding syndrome?
Complication of metabolic disturbances that occur when reintroducing normal calorific intake to pts who have been severe starved/malnutritioned for a prolonged period:
Signs:
rhabdo, resp/cardiac failure, decreased BP, arrhytmias, seizures, comas and sudden death
- Acute gastric dilatation if poorly nourished pt binges
- Monitor PO3-, glucose, potassium and magnesium
Bulima. What is it and Mx
Recurrent episodes of binge eating characterised by uncontrolled overeating
Preoccupation with control of body weight
Regular use of starvation, vomit-induction, laxatives or overexercise to overcome effects of binges
BMI >17.5
Mx:
Mild: support, self-help books, food diary
Moderate/severe: refer to community mental health team or eating disorder unit
Medication: antidepressants e.g. fluoxetine
Cognitive therapy
Delirium features
Acute confusional state with disorientation in time, place or person.
Memory disturbances
Difficulty concentration
Agitated/withdrawn
Mood change
Visual hallucination
Disturbed sleep cycle
Poor attention
Delirium causes
1) Infection
2) Metabolic: U+Es, glucose, decreased PaO2, Increased PaC02
3) Drugs: Benzodiazepines, opiates, anticonvulsants, digoxin, L-DOPA), Alcohol / withdrawal
4) Trauma
5) Surgery
Surgical Sieve
MEDIC HAT PINE
Metabolic Endocrine Degenerative Inflammatory Congenital Haematological Autoimmune Trauma Psychological/Neurological Iatrogenic Neoplastic Enviromental
Delirium Mx
Treat cause
Calm patient - place in quiet sideroom , music, muscle relaxation and massage. If does not work, try haloperidol/ risperidone
Dementia symptoms
Behaviour: restless, repetitive, no initiative, purposelessness activity, sexual disinhibition, social gaffes, shoplifting, rigid routines
Speech: syntax errors, dysphasia, mutism
Thinking: slow, muddled, delusions, poor memory, no insight
Perception: illusions, hallucinations
Mood: irritable, depressed, blunted affect, emotional incontinence
Dementia initial Ix
Bloods: FBC, b12, folate, ESR, U+E, LFT, yGT, Ca2+ , TSH
Serology: Syphilis, HIV
CT/MRI: excludes tumours, hydrocephalus, subdural haematoma, stroke
Alzheimer’s 3 stages
Stage I: amnesia and spatial disorientation
Stage II: personality disintegration (aggression, psychosis, agitation, depression) and focal parietal signs (dysphasia, apraxia, agnosia and acalculia); parkinsonism
Stage III: neurovegetative changes with apathy, akathisia, wasting, immobility, seizures and spasticity
Alzheimer’s meds
Anti-AchE: Donepezil, rivastigmine, galantamine
NMDA Antagonists: Memantine
Delirium tremens signs?
increased HR, decreased BP, tremor, fits, visual or tactile hallucinations
Admit and monitor vital signs
Give diazepam or chlordiazepoxide for 1st three days
Alcohol abuse Mx
Explore whether patient wants to change – abstinence or controlled intake
Treat co-existing depression Self-help/group therapy/12-step programme Disulfiram Naltrexone – reduces pleasure that alcohol brings Acamprosate – can increase abstinence rates
Personality disorder Cluster A?
Odd or eccentric behaviour:
- -> Paranoid
- –> Schizoid
- -> Schizotypal
Personality disorder Cluster B
Dramatic or emotional behaviour:
- Antisocial (Psychopathic)
- Borderline
- Histrionic
- Narcissistic
Borderline personality disorder?
Unstable affect regulation, poor impulse control, poor interpersonal relationships/self-image, repeated self-injury, suicidality and difficult life course trajectory
Tendency to form intese relationships and rapid fluctuations in mood, with impulsivity, unstable relationships
Associated with ADHD and learning difficulties
Mx: dialectical behaviour therapy, inpatient hospital programmes and medication
Personality disorder: Cluster C?
Anxious or avoidant behaviour
- -> Avoidant
- -> dependent
- -> Obsessive-compulsive
Histrionic personality?
The self-centred, sexually provocative (but frigid) person who enjoys (but does not feel) angry scenes; can maintain relationships; episodic outbursts of rage; less impulseve
Schizoid personality: Cold, aloof, introspective, misanthropic
Delusions of persecution?
Belief that someone or something is interfering with the person in a
Malicious or destructive way
Examples:
Someone (or an organisation e.g. MI5) is trying to kill or harm them
The neighbours are harassing them
People are monitoring their movements or following them
Asking about delusions of persecution:
Are there times when you worry that people are against you/ trying to harm you?
Do you have any concerns for your safety?
Grandiose delusions
Belief of being famous, having supernatural powers, having enormous wealth
Suggestions for interview: “Do you have any exceptional abilities or talents?”
Delusions of reference
Belief that actions of other people, events, media etc. are either directly referring to the person or are communicating a message
Suggestions for interview:
Have there been times when you have overheard people talking about you?
Do you ever see things on the TV or hear things on the radio which you think are about you?
Delusions of misidentification
Capgras syndrome: someone close has been replaced by an identical looking impostor
Fregoli’s syndrome: belief that strangers are actually familiar people in disguise
Delusions of control
“Passivity phenomena”: made actions, feelings or impulses
The boundaries between self and the world are broken
Thoughts, actions or feelings are subject to outside influences
Thought insertion, withdrawal, broadcasting
Often accompanied by delusional explanations
Asking about delusions of control:
Thought interference: Have you ever felt that your thoughts were being directly interfered with or controlled by another person?
Was this just because people were distracting you or being persuasive, or did it come about in a way many people would find hard to believe, for instance through telepathy?
Passivity: Have you ever felt that another person was able to control what you did directly, as if they were pulling the strings of a puppet?
Somatic delusions
Beliefs about body
Including:
Illnesses (hypochondriacal delusions)
Infestations (Ekbom’s syndrome)
Disturbances in form of thought
In flight of ideas, there are links between phrases but they are clang associations.
Clang associations are associations of words similar in sound but not in meaning.
Links may be rhymes or puns
This occurs in mania and hypomania and usually with pressure of speech.
“You come in here swinging your stethoscope…….telling me about my horoscope”
In loosening of association there is no link between phrases.
Knight’s move thinking is a type of loosening of association where there is an abrupt jump from one idea to another midway through the first thought e.g. “Inferior schools! Inferior schools! Preferably Dr Sims? Your tablets have been a miserable failure. I have had to sit with these mad surgeries. With regard to these tablets it will depend what the lord wants. With these women it is certainly destiny humph” In word salad, there is no link between words e.g. “blue does runs shaky lovely very
Circumstantiality?
Overinclusion of details and parenthetical remarks
Takes a long time to get to the desired point
Tangentiality
Inability to have goal-directed associations of thought
Never gets from desired point to desired goal
Echolalia
Repeating of words or phrases of another person
Can occur in schizophrenia, mental retardation or dementia
Perseveration
Persisting response to a prior stimulus after the new stimulus has been presented
Thought block
Abrupt interruption in train of thinking before a thought or idea is finished
After a brief pause the person indicates no recall of what was being said or what was going to be said
May be explained by the patient as thought withdrawal
Pseudohallucinations
They do not appear to the patient to be real and instead located in the mind (i.e. in subjective inner space) e.g. visual pseudohallucinations - seen by ‘inner eye’ and auditory pseudohallucinations - ‘voice in my head’
Or they seem to occur in the outside world but patient views it as unreal.
They may occur in, for example, borderline personality disorder, fatigue, bereavement
Delirium definition
Generalized impairment of cognitive functions (perception, thinking, memory, orientation), emotion, psychomotor activity and sleep-wake cycle
Psychosis : Causes
Organic:
- Infection (sepsis, encephalitis)
- Cerebral neoplasm, trauma, stroke
- Neurological disorderss: parkinson’s, epilepsy
- Psychoactive drug use
- Alcohol: withdrawl, intoxication, hallucinosis
Psychiatric:
- Schizophrenia spectrum disorders
- Mood disorders (bipolar/depression
Hallucinations: Trends?
Elementary hallucinations (noises) Visual or olfactory hallucinations = ?organic conditions (LBD) Episodic delusions and hallucinations = ?epilepsy, substance abuse Delusions / hallucinations + altered level of consciousness = delirium Bizarre delusions and hallucinations = ? Schizophrenia spectrum disorders Mood congruent delusions and hallucinations = ? Mood disorders
Schizophrenia first rank symptoms (highly suggestive if present)
- Auditory hallucinations
- Thought withdrawal, insertion & broadcast
- Somatic hallucinations
- Delusional perception
- feelings or actions experienced as made or influenced by external agents (passivity phenomena)
ICD-10 Schizophrenia Dx
Atleast 1 of:
- Thought echo, insertion, withdrawal, broadcast
- Delusions of control, influence, passivity, clearly referred to body or limb movements or thoughts, actions and sensations
- Voices giving a running commentary or discussing
- Persistent delusions
or atleast 2 of:
- Other hallucinations which occur every day for weeks on end
- Thought disorder
- Catatonic behaviour eg. excitement, posturing, wavy flexibility, negativism, mutism, echopraxia
- Negative symptoms
- Significant and consistent change in behaviour
FOR atleast 1 month, in absence of intoxication, brain disease or extensive manic/depressive symptoms.
Symptoms have to be present for 6 months for diagnosis of schizophrenia to be made
Schizophrenia positive symptoms
Hallucinations
Delusions
Ideas of reference
Schizophrenia negative symptoms
Under activity
Anhedonia
Apathy
Sexual problems
Lethargy
Social withdrawal
- Reduced speech
- Reduced motivation
- Reduced responsiveness (flat affect)
Schizophrenia sybtypes
Paranoid schizophrenia - stable delusions, usually + hallucinations
Hebephrenic schizophrenia - fleeting delusions & hallucinations Behaviour & thought disorganized
Residual schizophrenia – after a period of positive symptoms, negative symptoms predominate
Simple schizophrenia – negative symptoms, no initial positive symptoms (rare)
Catatonic schizophrenia Rare Disturbances of voluntary motor activity including Stupor Periods of over-activity Rigidity Posturing “Waxy flexibility” (maintenance of limbs and body in externally imposed positions)
Schizophrenia radiological changes
Volume of lateral ventricles is increased
Volume of brain decreased
– Especially Temporal lobe, Amygdala / hippocampal complex
Same changes found in newly diagnosed patients as chronic schizophrenics
Appear to be non-progressive
Neuropathological changes suggestive of neuronal degeneration
Males with schizophrenia?
Volume of lateral ventricles is increased
Volume of brain decreased
– Especially Temporal lobe, Amygdala / hippocampal complex
Same changes found in newly diagnosed patients as chronic schizophrenics
Appear to be non-progressive
Neuropathological changes suggestive of neuronal degeneration
Schizophrenia neurotransmitter changes
Increased dopamine
Reduced glutamate activity
Increased 5-HT activity
Schizophrenia poor cognitive factors
Male Insidious onset Long duration of untreated psychosis Drug use Family environment Non-compliance Neuro-cognitive deficits
Schizoaffective disorder?
Both affective and psychotic symptoms are prominent within illness episode, simultaneously or within a few days of each other
Therefore criteria for schizophrenia and depressive/ manic episode not met
Usually less impairment between episodes and social impairment than for schizophrenia (but more than in bipolar affective disorder)
Schizophrenia Mx
Risk assessment Care Programme approach: - Assess health & social needs - Agreed carer plan - Named Care Co-ordinator Regular monitoring and review meetings - Interagency and MDT working - Early intervention in psychosis services
These are being set up in many areas
Specialist teams who treat people experiencing their first episode of psychosis (aged 18-35)
Aim to reduce the Duration of Untreated Psychosis, because shorter time to treatment associated with better outcome
Therefore focus on early detection and treatment and maintaining contact to try to prevent relapse
Anti-psychotic medicine
CBT for psychosis
Antipsychotics for schizo?
Typical antipsychotics: chlorpromazine, haloperidol
Atypical antipsychotics: risperidone, olanzapine, quetiapine, amisulpiride, aripiprazole, clozapine
Antipsychotic medication are started at low dose and increased gradually
They take affect after 1-6 weeks
They should be continued for a minimum of a year after a person is asymptomatic. There is probably benefit in continuing for up to 5 years, but many people are reluctant to do so.
Adherence to medication is key
1st episode Schizophrenia
Start agreed antipsychotic
Titrate if necessary
1st onset of antipsychotic action – 2/52
Assess at optimum dosage over 4-6 weeks.
If successful, continue for at least 1-2 years. If withdrawal, undertake gradually.
After withdrawal monitor for at least two years
If not, change to another antipsychotic & as above.
If not successful, consider clozapine
CBT for psychosis
Recommended by NICE as a treatment in addition to medication for people with persistent positive symptoms of psychosis
Typically, around 50-65% of people who receive therapy benefit in some way
Identify a client’s main difficulties, how they arose, and what they understand about them.
The aim is not necessarily to get rid of symptoms, but to alleviate distress and disability, by helping them find:
New ways to reframe their experiences
New strategies to cope with their symptoms
Anti-psychotics informed consent
If possible, including:
Provide information and discuss the likely benefits and possible side effects of each medicine including:
Metabolic (including weight gain and diabetes)
EPSEs (including akathisia, dyskinesia and dystonia) cardiovascular (including prolonging the QT interval)
Hormonal (including increasing plasma prolactin)
Other (including unpleasant subjective experiences)
Antipsychotics monitoring
Before starting:
- weight, waist circumference
- Pulse and BP
- Fasting BM, HbA1c, blood lipid profile and proclactin
- Assessment of any movement disorders
- ECG if CVS riskMonitor and record the following throughout treatment:
- Response to treatment, including changes in symptoms and behaviour
- Side effects of treatment, taking into account overlap between certain side effects and symptoms e.g. the overlap between akathisia and agitation or anxiety, and impact on functioning
- Emergence of SEs- EPSEs, anticholinergic SEs
Weight, waist circumference, pulse and blood pressure, fasting blood glucose, HbA1c and blood lipid levels
Hyperprolactinaemia, drowsiness, postural hypotension
EPSEs?
Dystonia:
- Sustained involuntary muscle contractions, twisting of neck, limbs, trunk or face. Acute form more likely in younger
Parkinsonian:
- Rigidity, coarse tremor (no pill rolling), akinesia
Akathisia:
- Uncontrolled restlessness with feelings of inability to sit still
- -> Consider propanoll
Tardive dyskinesia:
- Involuntary hyperkinesia, increases with anxiety and relieved with sleep.
- Symptoms include tics, choreas and dystonias.
- Repetitive involuntary purposeless movements of jaw, neck and tongue.
–> Switch onto atypicals or consider procyclidine IM/IV for acute episode
Anti-muscarinic side effects
- Dry Mouth
- Blurred vision
- GI disturbance - Constip.
- Urinary retention
- Tachycardia
- Mental confusion
Neuroleptic malignant syndrome?
Rigidity, fever, confusion, fluctuating BP, tachycardia
Elevated creatine kinase
? Dopamine deficiency
Risk factors including high potency drugs, rapid dose changes, agitation, dehydration, abrupt withdrawal of anticholinergics, concurrent lithium
Treatment
- Life threatening
- Withdraw antipsychotic immediately
- Monitor TPR
- May need to be admitted to A&E
- Rehydrate, artificial ventilation
- Sedate with benzodiazepines
- Dantrolene – muscle relaxant
- Bromocriptine – dopamine agonist
- ECT for psychosis
No antipsychotics for at least 5 days.
Wait for symptoms to resolve including CPK.
Use small doses of an unrelated antipsychotic, preferably not a long acting one and one with low dopamine affinity. Monitor for symptoms of NMS –TPR, CPK
Clozapine SE?
- indicated for treatment resistance.
- Reversible neuropenia (3%)
- Agranulocytosis (0.8%)
- -> Higher risk in elder and those with lower WBC counts
- Myocarditis
- Reduce seizure threshold
Blood tests during tx
- -> weekly for 18 weeks
- -> fornightly for 52 weeks
- -> Monthly ever after
Sore throat, fever Hypersalivation – must be treated. Constipation – must be treated. Seizures – must be treated. Urinary incontinence Drowsiness Hypotension Tachycardia – investigate and treat if necessary. Weight gain – potential long term problems Raised glucose and cholesterol levels Pulmonary embolism Myocarditis Cardiomyopathy
Clozapine important interactions
- Carbamazepine and various meds which cause neutropenia are CI
- Fluovoxamine may increase clozapine levels
- Smoking
Drugs used in rapid tranquilisation?
Antipsychotic: haloperidol PO/IM, atypical antipsychotics, aripiprazole IM
Promethazine PO/IM
Benzodiazepines: lorazepam PO/IM
Combination
Some evidence that this works synergistically
Also can mean giving less of more toxic antipsychotics
Adverse effects of long term benzo use
Drugs of abuse Tolerance Hangover effect Disinhibition, Confusion Resp. depression Do not discharge with this unless longterm
Types of Behaviour therapy
Exposure/flooding/implosion therapy (phobias - pt stays with anxiety provoking stimuli until habituation/ avoidance response extinguished)
Relaxation training
Systematic desensitisation
Response Prevention –> obsessions.
Thought stopping
Aversion therapy
Social skills training
Token economy
CBT
CBT
Helps change how pt thinks and feels by consideration interaction between our thoughts, feelings in a particular situation and the action taken.
CBT lets use see how thoughts and feelings interact.
BY changing thoughts, the cycle is broken or turned into a virtuous cycle
Indication
General:
The patient prefers to use psychological interventions, either alone or in addition to medication.
The target problems for CBT (extreme, unhelpful thinking; reduced activity; avoidant or unhelpful behaviours) are present.
No improvement or only partial improvement has occurred on medication.
Side effects prevent a sufficient dose of medication from being taken over an adequate period.
Significant psychosocial problems (e.g. relationship problems, difficulties at work or unhelpful behaviours such as self-cutting or alcohol misuse) are present that will not be adequately addressed by medication alone.
Types of cognitive distortions?
Arbitrary inference—conclusions drawn with little or no evidence to support them
Selective abstraction—dwelling on insignificant (negative) detail while ignoring more important features or stimuli
Overgeneralization—drawing global conclusions about worth/ability/performance on the basis of single facts
Magnification/minimization—Gross errors of evaluation with small bad events magnified and large good events minimized.
Group Psychoterapy
Patient can be confronted by the effect his behaviour and beliefs have on others and be protected during his first attempts to change
Specific:
Personality disorders
Addictions: drug and alcohol dependence
Victims of childhood sexual abuse
People with difficulties in socialisation
Major medical illnesses e.g. breast cancer
What is psychodynamic psychotherapy?
Individual dynamic psychotherapy is based on the premise that a person’s behaviour is influenced by unconscious factors (thoughts, feelings, fantasies).
MHA 1959?
Aimed to provide a legal framework for detention of people suffering from mental disorders against their will
MHA 1983?
To ensure that people with serious mental disorders which threaten their health or safety or the safety of the public can be treated irrespective of their consent where it is necessary to prevent them from harming themselves or others
Details the circumstances in which a person with a mental disorder can be detained for treatment with or without his or her consent
Outlines the processes that must be followed
Introduces new safeguards for patients
Aims to ensure that patients are not inappropriately detained or treated without consent
Can physical illness be treated under MHA?
MHA 1983 does not provide legal framework for assessment or treatment of physical illness
Can only treat concurrent physical illness if:
Patient consents
Patient lacks capacity to consent/refuse to treatment for physical illness (under MCA)
MHA allows treatment to alleviate or prevent a worsening of a mental disorder (or one or more of its symptoms or manifestations)
This includes “treatment of physical health problems only to the extent that such treatment is part of, or ancillary to treatment for mental disorder (e.g. treating wounds self-inflicted as a result of mental disorder)”
Anorexia nervosa - which law for re-feeding?
Anorexia nervosa is classed as mental illness: re-feeding allowed under MHA
Learning difficulties and MHA?
A person with LD shall not be considered by reason of that disability to be:
Suffering from a mental disorder for purposes of the Act
Requiring treatment in hospital for mental disorder
Unless that disability is associated with abnormally aggressive or seriously irresponsible conduct by that person
MHA 2007 changes?
New definitions
“Mental disorder” refers to any disorder or disability of the mind
Omitted definitions from MHA 1983 Severe mental impairment Mental impairment Mentally impaired Psychopathic disorder
Exclusions
MHA 1983: a person cannot be deemed to be suffering from a mental disorder “by reason only of promiscuity or other immoral conduct, sexual deviancy or dependence on alcohol or drugs”
MHA 2007: alcohol/drug dependency retained; promiscuity etc. removed
Appropriate treatment test
Is appropriate treatment for this patient’s mental disorder going to be available to them when they are detained?
MHA assessment requirements?
This is used for someone over the age of 16 years who will not be admitted voluntarily. Patients who are under the influence of alcohol or drugs are specifically excluded
Can take place anywhere
Approved Mental Health Professional (AMHP)
2 x Section 12 Approved Doctors
Sometimes Psychiatrist and GP joint assessment
-------- Patient is suffering from a mental disorder that is of a NATURE and DEGREE to merit detention Risks: Patient’s health and safety Risk to self Protection of others Refuses to go to hospital No alternative to hospital admission Medical Recommendation Form completed and given to AMHP Patient is transported to hospital
Section 2?
Admission for assessment for up to 28 days, not renewable
An Approved Mental Health Professional (AMHP) or rarely the nearest relative (NR) makes the application on the recommendation of 2 doctors
One of the doctors should be ‘approved’ under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist)
Section 3?
Admission for treatment up to 6 months, can be renewed for 1 month at a time.
AMHP, along with 2 doctors, both of which must have seen the pt within the past 24hrs
- Cannot be detained under section 3 if NR objects
- Most Tx can be given, including psychotropic meds
- -> Safeguards for ECT
Community treatment order? (Section 17a)
For pts on section 3 (or 37)
–> Enforce treatment in community
Power to bring pt back to hospital if does not comply with treatment plan
- Allows them to go home under supervision of senior psych
Section 4?
72 hour assessment order
Used as an emergency, when a section 3 would involve an unacceptable delay
A GP and an AMHP or NR
Section 5(2)
A pt who is a voluntary pt in hospital can be legally detained by a doctor for 72 hours
When an informal inpt tries to leave: Any registered doctor Any ward (can't be used in A&E)
Further assessment must occur within 72 hrs: can be released from 5(2) by senior psych
- Discharge if not detainable, or detention under S2 or S3
Section 5(4)
Same as 5(2) - Allows a nurse to detain a pt voluntarily in hospital for 6 hours
Section 135?
A court order can be obtained to break into a property to remove a person to a place of safety
MAgistrate’s order - Applied for by AMHP where person refusing to allow mental health professionals into residence
Section 136
Someone found in a public place who appears to have a mental disorder can be taken by the police to a place of safety
Assessment by duty psych
- -> Discharge
- -> Admit under S2 or S3, or discharge if not detainable
Mental health review tribunal?
Appeals against detention under the Act
Members appointed by Lord Chancellor
Members include an independent doctor, a lawyer and a lay person
Detained person has right to be represented by a solicitor
2007 Act introduces one MHRT for the whole of England
Capacity assessment?
Understand information relevant to decision
Retain information
Weigh up information
Communicate decision
What is the Bournewood Gap
Arose following a case involving DOL of a man with severe autism and LD
People with who lack capacity with mental disorders/disabilities may need to be deprived of liberty for treatment or care
Not necessarily detainable under MHA
Human rights act demands people who lack capacity and are Deprived of Liberty in “best interests” have safeguards in place, as with MHA
Not detainable under MHA
No acute deterioration – do not fulfil ‘degree’ criteria
Deprivation necessary to reside in an institution to receive care, not assessment / treatment
People with dementia living in long-stay institutions
Learning disability not a detainable disorder under MHA
MCA 2005 - DOL safeguards?
Provides legal safeguards for mentally ill patients deprived of liberty when MHA not applicable
Who is covered by DoLS?
Adults (18+) in hospitals or care homes,
Mental disorder/disability not covered by MHA
Lack capacity to make decision on care/placements
Deprivation of Liberty is necessary to provide appropriate care (in their best interests)
At times during care, liberty may need to be restricted in for clinical reasons in individual’s best interests
For people who lack capacity this is done under the Mental Capacity Act.
When does restriction of liberty become deprivation of liberty? (Requiring DoL Safeguards)
What constitutes “Deprivation” of liberty?
DOLs process
DoLS process
Patient identified as needing restraint to receive care
Authority for DoL requested from Supervisory Body (usually PCT)
6 DoLS assessments (≥2 different trained assessors)
Patient representative appointed
Review process
DoL last for 12 months.
Review at 3 months to check detention still in patient’s best interests.
Elements of care that could introduce more ‘liberty’
MHA vs MCA
MHA:
- Mental health disorders only
- 3 professionals’ decision
- Formalised and standard application procedure
- Appeal to MHRT after decision made
- Not related to capacity
MCA:
- Applies to any decision
- Trumped by MHA
- Assessment procedure depends on complexity of decision
- Also depends on how restrictive the treatment is
Tx of choice in postnatal depression?
1) Reassurance.support
2) CBT
3) certain SSRIs, Paroxetine preferred due to low milk/plasma ratio, but also sertaline
Atypical risk in elderly?
Increased risk of stroke (especially olanzapine and risperidone)
Increased risk of VTE
Somatisation disorder
Multiple physical SYMPTOMS present for atleast 2 years
Pt refuses to accept reassurance or negative test results
Hypochondrial disorder
Persistent belief in the presence of an underlying serious DISEASE eg. CANCER
PT refuses to accept reassurance or -ve test results
Conversion disorder
Typically involves LOSS OF MOTOR OR SENSORY FUNCTION
Pt doesn’t consciously fign the symptoms (Factitious disorder) or seek material gain (malingering)
Pt may be indifferent to their apparent disorder - le belle indifference
Dissociative disorder
Dissociation - a process of separating off certain memories from normal consciousness
- In contrast to conversion disorder, involves psychiatric symptoms eg. amnesia, fugue, stupor
DID - new term for multiple personality disorder
Munchausen’s
Factitious disorder
- The intentional production of physical or psychological symptoms
Malingering
Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Preferred antidepressant in IHD?
Sertaline following MI as more evidence for its safe use than other antidepressants
SSRI Interactions
NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin: see above
triptans: avoid SSRIs
ECT absolute CI?
Raised ICP
Depression vs Dementia?
Factors suggesting diagnosis of depression over dementia
short history, rapid onset
biological symptoms e.g. weight loss, sleep disturbance
patient worried about poor memory
reluctant to take tests, disappointed with results
mini-mental test score: variable
global memory loss (dementia characteristically causes recent memory loss)
Next question
Mx of GAD
NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring
step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams
Drug treatment
NICE suggest sertraline should be considered the first-line SSRI
interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month
Mx of Panic disorder
Again a stepwise approach:
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services
Treatment in primary care
NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
Which TCA has the most common anti-muscarinic SE?
Imipramine
Anorexia metabolic imbalances pneumonic?
Most things low
G’s and C’s raised: Growth hormone, Glucose, salivary Glands, Cortisol, Cholesterol, Carotinaemia
St John’s wort inducer or inhibitor?
Inducer of P450 system - therefore decreased levels of drugs such as warfarin, ciclosporin and COCP.
NMS features
Neuroleptic malignant syndrome is a rare but dangerous condition seen in patients taking antipsychotic medication. It carries a mortality of up to 10% and can also occur with atypical antipsychotics. It may also occur with dopaminergic drugs (such as levodopa) for Parkinson’s disease, usually when the drug is suddenly stopped or the dose reduced.
Features more common in young male patients onset usually in first 10 days of treatment or after increasing dose pyrexia rigidity tachycardia
A raised creatine kinase is present in most cases. A leukocytosis may also be seen
Management
stop antipsychotic
IV fluids to prevent renal failure
dantrolene* may be useful in selected cases
bromocriptine, dopamiqne agonist, may also be used
LBD characteristic pathological feature?
Alpha-synuclein cytoplasmic inclusions (lewy bodies) in the substantia nigra, paralimbic and neocortical areas
What set of drugs should be avoided in LBD and why?
Neuroleptics as LBD pts are extremely sensitive and may develop irreversible parkinsonism
LBD triad?
Progressive cognitive impairment
Parkinsonism
Visual hallucinations
Autonomic dysfunction
Dx with SPECT/DAT scan
Drug induced parkinsonism differences?
1) motor symptoms generally rapid onset/ bilateral
2) Rigidity/rest tremor uncommon
Switching antidepressants
Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
the first SSRI should be withdrawn* before the alternative SSRI is started
Switching from fluoxetine to another SSRI
withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI
Switching from a SSRI to a tricyclic antidepressant (TCA)
cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- an exceptions is fluoxetine which should be withdrawn prior to TCAs being started
Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly
Switching from fluoxetine to venlafaxine
withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly
*gradually reduce dose then stop
Schizophrenia risk
Monozygotic twin
Parent
Sibling
No relatives
Risk of developing schizophrenia
monozygotic twin has schizophrenia = 50%
parent has schizophrenia = 10-15%
sibling has schizophrenia = 10%
no relatives with schizophrenia = 1%
Benzodiazepine withdrawal regime
Dose should be withdrawn in steps of about 1/8 of the daily dose every fornight. A suggested protocal is:
- switch patients to the equivalent dose of diazepam
- reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
- time needed for withdrawal can vary from 4 weeks to a year or more
Benzodiazepine withdrawal syndrome
If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug. Features include:
insomnia irritability anxiety tremor loss of appetite tinnitus perspiration perceptual disturbances seizures
Alcohol withdrawal timings:
Symptoms: 6-12 hrs
Seizures: 36 hrs
Delirium tremens: 72 hrs
Alcohol withdrawal mechanism
Mechanism
chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
Mx:
- Benzos
- Carbemazepine also effective
Most dangerous tricyclic in OD?
Dosulepin
Amitryptaline
Anti-depressants in acute psychotic episode?
NICE guidelines advice to consider stopping antidepressant (As some evidence SSRI may precipitate acute psychotic episode) before starting anti-psychotic
Clozapine drug monitoring
Don’t do normally, only do it if suspecting toxicity or sub-therapeutic levels
–> trough levels - 12 hrs after last dose
NMS vs Serotonin syndrome
Serotonin: Altered mental state. NM problems and autonomic nervous system excitiation (SEE SLIDES) . Risk factors: SSRI, MAOs, REcreational drugs, ecstacy and amphetamines
NMS: Presents similar to SS. Associated with antipsychotic use and dopaminergic drugs. Classically found in young men. A raised CK and leukocytosis (as well as Dhx) are best way to differentiate from SS
nb. Malignnant hyperthermia: Associated with anaesthetic agents
Cocaine toxicity: chest pain, convulsions, psychosis
GBH: stiffness, stiff muscles, collapse
Couvade syndrome
a man thinks he’s pregnant
De Clerambault’s syndrome
Erotomania - Delusion that a person of high-standing is in love with them.
Ekbom’s
Infestations
Fregoli
belief that strangers are actually familiar people in disguise
Othello’s syndrome
Morbid jealous obsession their partner is cheating
Associated with alcoholism
Folie a deux
A shared delusion between two family members
Capgras
someone close has been replaced by an identical looking impostor
Fregoli
Fregoli’s syndrome: belief that strangers are actually familiar people in disguise
Alcohol withdrawal management:
OP: Oral thiamine + reducing dose chlordiazepoxide
Inpatient:
IV pabrinex bags 1+2 (NOT ORAL THIAMINE), oral chlordiazepoxide
- If high risk of seizures, cover with diazepam (quicker onset of action than chlordiazepoxide)
Alcohol limits?
men: 14 units, over atleast 3 days
Binge = 8 units for a man, 6 for awomen
- Hazardous drinking = exceeding recommendations
Harmful drinking = physical or mental harm caused by exceeding recommendations
Sublimination ?
Modifying unacceptable desires to become acceptable
Projection
internal issues becomes external
Acting out
Unacceptable behaviours in response to conflict (eg. self harm following conflict)
Reaction formation
Having the opposite reaction to your true feelings
Transference
Patients attitude towards their therapist eg. pt thinks their psychiatrist is their father they don’t like
Counter-transference
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Splitting
People are either all good or all bad