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Psychiatry Depression Personality Disorder Antipsychotic Medication Anxiety Bipolar Disorder Mental Health Act Alcohol Withdrawal Schizophrenia Eating Disorders Obsessive Compulsive DisorderMaria, a 55 year old female presents to her GP with a one-month she feels sad and no longer gets any enjoyment from life. She has lost 3kg in the past month as her appetite has been low. During the consultation,she becomes tearful as she explains that she has recently gone through a divorce from her husband of 20 years. Which scale would be most useful in diagnosing Maria’s condition? A. Epworth B. PHQ-9 C. HAD D. Beck Depression Inventory E. GAD-7Maria, a 55 year old female presents to her GP with a one-month she feels sad and no longer gets any enjoyment from life. She has lost 3kg in the past month as her appetite has been low. During the consultation,she becomes tearful as she explains that she has recently gone through a divorce from her husband of 20 years. Which scale would be most useful in diagnosing Maria’s condition? A. Epworth B. PHQ-9 C. HAD D. Beck Depression Inventory E. GAD-7 Major Depressive Disorder Screening Tools - Patient Health Questionaire-9 (PHQ) - Hospital Anxiety Depression Scale (HAD) - Edinburgh Postnatal Depression Scale Screening Questions(NICE CKS) • During the last month have you often been bothered by feeling down, depressed, or hopeless? • Do you have little interest or pleasure in doing things? Depression DSM-5 1. Major DepressiveDisorder 2. Persistentdepressivedisorder (previously known as dysthymic disorder) 3. Premenstrualdysphoric disorder 4. Other depressive disorders (not meeting major depressive disorder criteria due to substance abuse, medication side effects, medical conditions, or other reasons). Major Depressive Disorder 5 or more symptoms (including 1 Psychological core symptom) - Psychomotor agitation - Low mood - Feelings of worthlessness/ - Anhedonia guilt/ hopelessness - concentrateo think/ Biological/ Somatic (S.E.A) - Sleep disturbed - Anergia Severe - Appetite up or down/ weight - Psychosis change - Suicidal ideation/ self harm Categorisation • Subthreshold Depression • Less than 5 symptoms Other Categorisations • Persistent Subthreshold Depressive Symptoms • Mild - Subthreshold symptoms > 2 years on • Just 5 symptoms – causing minor most days functional impairment • Seasonal Affective Disorder • Moderate - Episodes of depression which recur • >5 symptoms,greater functional annually at the same time each year impairment with remission in between • Severe • +++ symptoms,significant functional impairment,presence of psychotic features/ suicidal ideation/ paranoia Investigations Clinical Diagnosis • PHQ-9 / HAD / EdinburghScale Investigations to rule out organic cause: • FBC, U+Es • TFTs Consider: • 24 hour cortisol • Vitamin B12 • Folic acid Management Bio-psycho-social Model • Biological • 1 line: SSRI e.g. citalopram, sertraline, fluoxetine (Consider if mild) • 2 line: SNRI • Important to follow patient up (increased risk of suicide <30 yrs old) • Psychological • Psycho-education:self help books, online resources • Cognitive behavioural therapy • Social • Social services input/ signpostingto relevant authoritiese.g. for housing Severe Depression • Psychiatric referral (Community Mental Health Team) • Hospitalisation • Consider RISK to self and others • Other management options • ECT (Catatonicdepression – only initiated by psychiatrist) • Benzodiazepines • AntipsychoticsAli, a 22 year old male, presents to the GP with a 7 day history of elevated mood. He states that he has been feeling very energetic over the past week and not felt the need to sleep or eat. He tells the GP he is elated as he has just used his savings to buy a Tesla and is planning to drive around the world. The GP notices he is rapidly moving from one topic of discussion to the next, and that his speech is pressured. Which one of the following features indicate this is an episode of mania rather than hypomania? A. Decreased appetite B. Insomnia C. Duration of symptoms D. Pressured speech E. Flight of ideasAli, a 22 year old male, presents to the GP with a 7 day history of elevated mood. He states that he has been feeling very energetic over the past week and not felt the need to sleep or eat. He tells the GP he is elated as he has just used his savings to buy a Tesla and is planning to drive around the world. The GP notices he is rapidly moving from one topic of discussion to the next, and that his speech is pressured. Which one of the following features indicate this is an episode of mania rather than hypomania? A. Decreased appetite B. Insomnia C. Duration of symptoms D. Pressured speech E. Flight of ideas Bipolar Disorder Mania Hypomania >7 days <7 days, typically 3-4 days Severe functional impairment No significant functional impairment, lesser form Elevated energy/ activity: grandiosity, of mania extravagance, rapid speech, increased libido, No psychotic features reduced sleep Less likely to require hospitalisation Thought disorder: flight of ideas, poor concentration, confusion Psychotic symptoms - Delusions of grandeur - Auditory hallucinations Bipolar Disorder • Periods of mania/ hypomania alongside episodes of depression • Onset usually in late teens and 20s • Risk Factors: family history, stressful life events • Bipolar Type 1: ≥1 episode of mania +/- depressive episode • Bipolar Type 2: episode of hypomania + depressive episode Management of Bipolar Disorder • Patient referred to community crisis team if in manic episode • If the patient is on an antidepressant, it should be tapered and discontinued • Admission: if the patient is a risk to themselves or others admission may be required Acute management: trial an oral antipsychotic • First line: NICE suggests one of haloperidol, olanzapine, quetiapine, or risperidone • Second line: trial an alternative antipsychotic medication • Third line: Lithium or valproate may be considered Long term management: commenced four weeks after resolution with the following options available • Continue current therapy for mania or • Lithium • Add valproate if lithium is ineffective Typical Antipsychotics Atypical Antipsychotics - Haloperidol, chlorpromazine - Olanzapine, risperidone, clozapine, quietapine, amisulpride, aripiprazole Mechanism of action Dopmaine D2 Receptor Antagonists Act on a variety of receptors (D2, D3, Block transmission in mesolimbic pathways D4, 5HT) Adverse effects Extrapyramidal side-effects Weight gain • Acute dystonia – tx procyclidine Dyslipidaemia (esp. Olanzapine) • Akathisia Hyperprolactinaemia (Risperidone) • Parkinsonism (bradykinesia, rigidity, Aripiprazole – good side effect profile tremor) • Tardive dyskinesia Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation, sedation, weight gain Raised prolactin Impaired glucose tolerance Neuroleptic Malignant Syndrome Prolonged QT – HaloperidolTardive DyskinesiaAli is admitted with an acute episode of mania. He is initially treated with haloperidol which seems to improve his mental state. Later that day he develops a high fever, tachycardia, tachypnoea and muscle rigidity. Which drug may be beneficial in the treatment of this patient? A. Quetiapine B. Metoclopramide C. Granulocyte colony stimulating factor (G-CSF) D. Raclopride E. BromocriptineAli is admitted with an acute episode of mania. He is initially treated with haloperidol which seems to improve his mental state. Later that day he develops a high fever, tachycardia, tachypnoea and muscle rigidity. Which drug may be beneficial in the treatment of this patient? A. Quetiapine B. Metoclopramide C. Granulocyte colony stimulating factor (G-CSF) D. Raclopride E. Bromocriptine Neuroleptic Malignant Syndrome • Rare but dangerous condition – 10% mortality • May occur in hours to days after starting an antipsychotic • Also with stopping dopaminergic drugs e.g. levodopa Clinical Features • Pyrexia • Muscle rigidity • Autonomic lability (Hypertension, tachycardia, tachypnoea) • Altered mentals status (delirium/ confusion) Management • Stop antipsychotic,liaison psychiatry input • IV fluids, benzodiazepines • Dantrolene/ bromocriptinein severe cases Serotonin Syndrome • Caused by SSRIs, Monoamine oxidase inhibitors, ecstasy • Onset within hours Clinical Features ▪ Neuromuscular excitation: hyperreflexia, clonus, muscle rigidity ▪ Autonomicexcitation: hyperthermia, sweating ▪ Altered mental state: confusion Management • IV fluids, benzodiazepines • Liaison psychiatry input • Severe cases: serotonin antagonists ➢Cyproheptadine,chlorpromazineGeorgia is a 27 year old female being seen in the GP following discharge for a psychotic illness which was diagnosed as schizophrenia. Her symptoms included hallucinations and persecutory delusions. She tells the GP that whilst in hospital, she believed the government was implanting thoughts into her mind and that others could hear what she was thinking. She recalls being unable to speak at one point during her hospital admission, although she feels much better now. Which of the following is not a first rank symptom of schizophrenia? A. Thought insertion B. Thought broadcasting C. Visual hallucinations D. Auditory hallucinations E. Delusional perceptionsGeorgia is a 27 year old female being seen in the GP following discharge for a psychotic illness which was diagnosed as schizophrenia. Her symptoms included hallucinations and persecutory delusions. She tells the GP that whilst in hospital, she believed the government was implanting thoughts into her mind and that others could hear what she was thinking. She recalls being unable to speak at one point during her hospital admission, although she feels much better now. Which of the following is not a first rank symptom of schizophrenia? A. Thought insertion B. Thought broadcasting C. Visual hallucinations D. Auditory hallucinations E. Delusional perceptions Schizophrenia • Mental health condition in which a person’s perception, thoughts, mood and behaviour are significantly altered. • Positive symptoms: auditory hallucinations, other delusions, disrupted speech • Negative symptoms: blunted affect, social withdrawal, self-neglect Risk Factors • Family History • Urban • Obstetric complications • Cannabis use Risk of Developing Schizophrenia •Monozygotic twin has schizophrenia = 50% •Parent has schizophrenia = 10-15% •Sibling has schizophrenia = 10% •No relatives with schizophrenia = 1% Schizophrenia Over a period of ≥ 1 month, patients must have one first rank symptom OR at least two other symptoms Schneider’s First Rank Symptoms 1. Auditory Hallucinations (e.g. third person persecutory) 2. Delusional Perception 3. Thought Disorder ▪ Insertion, broadcast,withdrawal 4. Passivity phenomena ▪ Belief that body is under the control of an external influence catatonia, avolition (poor motivation)ted affect, anhedonia, alogia, neologisms, Schizophrenia Investigations: rule out an organic Management cause • First Onset Psychosis / Crisis • Urine drug screen: ?substance Resolution/ Home Treatment induced psychosis Team • Oral antipsychotic e.g. • Infectious cause: syphilis or HIV olanzapine, quetiapine testing • Psychological interventions: CBT, • CT or MRI brain: rule out art therapy, family interventions intracranial pathology, such as space-occupying lesion • Endocrinescreen: e.g. high • antipsychotictrial an alternative cortisolA 29-year-old man with a history of treatment resistant schizophrenia comes into the emergency department complaining of a general malaise over the last few days with accompanying chest pain. He looks uncomfortable and sweaty on the bed. Which of the following medications is most likely to have caused these symptoms? A. Clozapine B. Olanzapine C. Citalopram D. Mirtazapine E. AmitriptylineA 29-year-old man with a history of treatment resistant schizophrenia comes into the emergency department complaining of a general malaise over the last few days with accompanying chest pain. He looks uncomfortable and sweaty on the bed. Which of the following medications is most likely to have caused these symptoms? A. Clozapine B. Olanzapine C. Citalopram D. Mirtazapine E. Amitriptyline Schizophrenia Management • First Onset Psychosis / Crisis Resolution/ Home Treatment Team • Oral antipsychotic e.g. olanzapine, quietapine • Psychological interventions: CBT, art therapy, family interventions • Second line: trial an alternative antipsychotic • Treatment resistant schizophrenia → Clozapine Clozapine • Very effective – used in treatment resistant schizophrenia • Extensive side effect profile • Constipation – most common • Myocarditis, ↓seizure threshold, intestinal obstruction, hypersalivation • Life threatening – Agranulocytosis • Dose adjustment if smoking is stopped/ started during treatment • FBC monitoringA 41-year-old man with a history of severe depression is admittedinformally to the mental health ward following an attemptto jump off a bridge. He had to be restrained by members of the public. deemed to be a high risk to himself.d. On assessment, he is still actively suicidal and A decision is made to section the patient under the Mental Health Act. Which section of the mental health act should be used in the first instance? A. Section 2 B. Section 3 C. Section 4 D. Section 5(2) E. Common LawA 41-year-old man with a history of severe depression is admittedinformally to the mental health ward following an attemptto jump off a bridge. He had to be restrained by members of the public. deemed to be a high risk to himself.d. On assessment, he is still actively suicidal and A decision is made to section the patient under the Mental Health Act. Which section of the mental health act should be used in the first instance? A. Section 2 B. Section 3 C. Section 4 D. Section 5(2) E. Common Law Mental Health Act • Allows you to detain a patient a mental disorder who is at risk of harm to themselvesor others (nothing to do with capacity) • Only allows you to treat mental illness without consent • Exception: physical harm caused by mental illness e.g. self harm lacerations or overdose Types of Section Section 2: 28 days for assessment (by 2 doctors – one MHA approved) Section 3: 6 months for treatment (by 2 doctors – one MHA approved)– can be renewed Section 4: 72 hours for emergency assessment (by 1 doctor and an approvedmental health practitioneror closest relative) – used if Section 2 would cause unacceptabledelay Section 5(2): 72 hours for assessment of patient already in hospital (doctor in charge of patient’s care) Section 5(4): 6 hours for assessment of patient already in hospital (by nurse) Common law: used in the emergency department to keep patients from leaving and treating them Generalised Anxiety Disorder DSM-V • >6 monthsof excessive worry about everyday issues that is disproportionateto any inherent risk → distress, or impairment • The worry is not confined to features of another mental disorder, or as a result of substance abuse, or a general medical condition Clinical Features (at least 3 of the followingmost of the time) • Restlessness, nervousness • Being easily fatigued • Poor Concentration • Irritability • Muscle Tension • Sleep disturbance Generalised Anxiety Disorder • May only present with physical symptoms • Palpitations,chest pain • Dizziness • Epigastric discomfort, nausea/ vomiting • Examination and investigation is needed to rule out an organic cause • Key Differentials • Hyperthyroidism: weight loss, warm, moist skin, heat intolerance • Cardiac disease: e.g. atrial fibrillation;palpitations,dizziness, chest pain • Pulmonary disease: e.g. COPD • Medication-inducedanxiety: e.g. salbutamol,theophylline, beta-blockers, St John’s wort • Recreational drugs and alcohol Generalised Anxiety Disorder Risk Factors • Family history of anxiety • Physical or emotional stress • History of physical, sexual or emotional trauma • Other anxiety disorder oPanic disorder (25% of people with GAD) oSocial phobia oOther specific phobia Generalised Anxiety Disorder Management • Cognitive BehaviouralTherapy • Alternative: psychodynamicpsychotherapy • Mindfulness training/ sleep hygiene education/ exercise/ self help • SSRI/ SNRI • Sertaline, citalopram • Duloxetine • Benzodiazepines are not routinely used • Reserved for acute anxietyA 36 year old homeless woman is brought into the ED after being found slumped by a bus stop with an acutely swollen and erythematous left arm. She is treated for cellulitis with IV fluids and flucloxacillin.During the night, you are called to see her. You notice she is restless, sweaty and she tells you she is trying to “shake off the spiders on her arm”. She is very distracted and hard to take a history from. Physical examinationreveals tachycardiaand a red, swollen left arm. You look at her laboratory findings from earlier on and notice an abnormalityon her LFTs. Which of the following would best treat this lady’s symptoms? A. Escalation of antibiotics to tazocin (piperacillin with tazobactam) B. IM Haloperidol C. IV Naloxone ALT 45 IU/L (10 - 50) D. Oral chlordiazepoxide AST 52 IU/L (10-40) E. One to one nursing ALP 100 IU/L (25 - 115) Bilirubin 22 μmol/L (<17) Gamma glutamyl 110 U/L (9 - 40) transferase (γGT)A 36 year old homeless woman is brought into the ED after being found slumped by a bus stop with an acutely swollen and erythematous left arm. She is treated for cellulitis with IV fluids and flucloxacillin.During the night, you are called to see her. You notice she is restless, sweaty and she tells you she is trying to “shake off the spiders on her arm”. She is very distracted and hard to take a history from. Physical examinationreveals tachycardiaand a red, swollen left arm. You look at her laboratory findings from earlier on and notice an abnormalityon her LFTs. Which of the following would best treat this lady’s symptoms? A. Escalation of antibiotics to tazocin (piperacillin with tazobactam) B. IM Haloperidol C. IV Naloxone ALT 45 IU/L (10 - 50) D. Oral chlordiazepoxide AST 52 IU/L (10-40) E. One to one nursing ALP 100 IU/L (25 - 115) Bilirubin 22 μmol/L (<17) Gamma glutamyl 110 U/L (9 - 40) transferase (γGT) Alcohol Withdrawal Clinical Features • 6-12 hours: tremor, sweating, tachycardia, anxiety • 36 hours: peak incidence of seizures • 48-72 hours – Delirium tremens • Coarse tremor, confusion, delusions, hallucinations Management • CIWA-Ar Scoring – IV Chlordiazepoxide (long acting benzodiazepine) • Nutritionalsupport: IV Pabrinex (thiamine) • Prevents/ treats Wernicke’s encephalopathy • General measures: IV fluids, electrolyte replacement,monitoringblood glucose,A 22 year old man presents to the GP with his mother, who is concerned for him. She tells the GP that he lives alone, has never had any friends or relationships, and doesn’t have any hobbies interests. He tells you he prefers to be alone. He is presenting after losing a job due to trouble getting along with colleagues at work. This is the third job he has lost in the past year. Based on the history given, what is the most likely diagnosis? A. Depressive Personality Disorder B. Avoidant Personality Disorder C. Antisocial Personality D. Schizoid Personality Disorder E. Major Depressive DisorderA 22 year old man presents to the GP with his mother, who is concerned for him. She tells the GP that he lives alone, has never had any friends or relationships, and doesn’t have any hobbies interests. He tells you he prefers to be alone. He is presenting after losing a job due to trouble getting along with colleagues at work. This is the third job he has lost in the past year. Based on the history given, what is the most likely diagnosis? A. Depressive Personality Disorder B. Avoidant Personality Disorder C. Antisocial Personality D. Schizoid Personality Disorder E. Major Depressive Disorder Personality Disorder • Disorderedpersonality traits that interfere with normal functioning. • Affects around 1 in 20. Cluster A: Odd or Eccentric ▪ Paranoid;Schizoid; Schizotypal Cluster B: Dramatic, Emotional or Erratic ▪ Antisocial;Borderline (Emotionallyunstable); Histrionic Cluster C: Anxious and Fearful ▪ Obsessive-Compulsive;Avoidant; Dependent Management - Dialecticalbehaviour therapy Cluster A Paranoid Schizoid Schizotypal •Hypersensitivity and an unforgiving •Indifference to praise and criticism •Hypersensitivity and an unforgiving attitude when insulted •Preference for solitary activities attitude when insulted •Unwarranted tendency to questions •Lack of interest in sexual •Unwarranted tendency to questions the loyalty of friends interactions the loyalty of friends •Reluctance to confide in others •Lack of desire for companionship •Reluctance to confide in others •Preoccupation with conspirational •Emotional coldness •Preoccupation with conspirational beliefs and hidden meaning •Few interests beliefs and hidden meaning •Unwarranted tendency to perceive •Few friends or confidants other than •Unwarranted tendency to perceive attacks on their character family attacks on their character Cluster B Antisocial Borderline (Emotionally Histrionic Narcisstic Unstable) •Failure to conform to •Efforts to avoid real or •Histrionic Grandiose sense of self social norms with respect imagined abandonment Inappropriate sexual importance to lawful behaviours as •Unstable interpersonal seductiveness •Preoccupation with indicated relationships which •Need to be the centre of fantasies of unlimited •More common in men alternate between attention success, power, or beauty •Deception, repeatedly idealization and devaluation •Rapidly shifting and •Sense of entitlement lying, use of aliases, or •Unstable self image shallow expression of •Taking advantage of others conning others for personal •Impulsivity (e.g. Spending, emotions to achieve own needs profit or pleasure sex, substance abuse) •Suggestibility •Lack of empathy •Impulsiveness or failure to •Recurrent suicidal •Physical appearance used •Excessive need for plan ahead behaviour for attention seeking admiration •Irritability and •Chronic feelings of purposes •Chronic envy aggressiveness emptiness •Self dramatization •Arrogant and haughty •Reckless disregard for the •Difficulty controlling •Relationships considered attitude safety of self or others; temper to be more intimate than •Consistent irresponsibility •Quasi psychotic thoughts they are •Lack of remorse Cluster C Obsessive Compulsive Avoidant Dependent •Is occupied with details, rules, lists, •Avoidance of occupational activities •Difficulty making everyday decisions order, organization, or agenda to the which involve significant without excessive reassurance from point that the key part of the activity interpersonal contact due to fears of others is gone criticism, or rejection. •Need for others to assume •Perfectionist •Unwillingness to be involved unless responsibility for major areas of their •Is extremely dedicated to work and certain of being liked life efficiency to the elimination of spare •Preoccupied with ideas that they are •Difficulty in expressing disagreement time activities being criticised or rejected in social with others due to fears of losing •Is meticulous, scrupulous, and rigid situations support about etiquettes of morality, ethics, •Restraint in intimate relationships •Lack of initiative or values due to the fear of being ridiculed •Unrealistic fears of being left to care •Is not capable of disposing worn out •Reluctance to take personal risks due for themselves or insignificant things even when they to fears of embarrassment •Urgent search for another have no sentimental meaning •Views self as inept and inferior to relationship as a source of care and others support when a close relationship •Social isolation accompanied by a ends craving for social contactA 18-year-old sprinter who is currently preparing for a national athletics meeting asks to see the team doctor due to an unusual sensation in his legs. He describes a numb sensation below his knee. On examination the patient there is apparent sensory loss below the right knee in a non-dermatomal distribution. The team doctor suspects a non-organic cause of his symptoms. This is an example of a: A. Conversion Disorder B. Hypochondrial Disorder C. Malingering D. Munchausen’s syndrome E. Somatisation DisorderA 18-year-old sprinter who is currently preparing for a national athletics meeting asks to see the team doctor due to an unusual sensation in his legs. He describes a numb sensation below his knee. On examination the patient there is apparent sensory loss below the right knee in a non-dermatomal distribution. The team doctor suspects a non-organic cause of his symptoms. This is an example of a: A. Conversion Disorder B. Hypochondrial Disorder C. Malingering D. Munchausen’s syndrome E. Somatisation Disorder Unexplained Symptoms Somatisation Disorder • Multiple physical symptoms for at least 2 years • Refusal to accept reassurance or negative test results Illness Anxiety (Hypochondrial Disorder) • Persistent belief in the presence of an underlying serious DISEASE, e.g. cancer • Refusal to accept reassurance or negative test results Conversion Disorder • Typically involves loss of motor or sensory function • Patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering) Important Points Obsessive Compulsive Disorder • Obsessions/ compulsions interfering with normal functioning, taking more than 1 hour per day →Exposure Response Prevention Therapy Eating Disorders (Anorexia/ Bulimia) • Low body weight/ food avoidance/ body image issues • Bulimia – binge eating followed by episodes of purging (self induced vomiting, excessive exercise, fasting) → Eating Disorder Focussed CBTFeedback Form