Clinical Handbook - Main Conditions 1

Question 1

What psychiatric support is available in the community?

Answer 1

CMHT- MDT

Crisis resolution team - psych emergencies, 24/7, short term interventions to prevent admission

Outreach team - for chroncially unwell patients, community nurses can visit multiple times a week

Care programme approach (CPA) - help after inpatient admission once discharged

Early intervention in psychosis team - for under 35s in first episode

Question 2

List the key members of the psych MDT

Answer 2

Psychiatrist
Community psychiatric nurse (CPN)
Occupational therapist
Social worker
Clinical psychologist
Secretary/Administrator

Question 3

Define a delusion. How would you ask a patient about it?

Answer 3

Fixed false beliefs, which are firmly held despite evidence to the contrary and go against the individual’s normal social and cultural belief system.

‘Do you have any personal beliefs that others find strange?’

Question 4

What is a grandiose delusion?

Answer 4

a false fixed belief that one has special powers, is talented, wealthy or important. Grandiose delusions may be religious in nature, e.g. one is chosen by God.

Question 5

What is a persecutory delusion?

Answer 5

a false fixed belief that other people are conspiring against them in order to inflict harm or destroy their reputation.

Question 6

what are delusions of reference?

Answer 6

a false fixed belief that random events, objects or the behaviour of others, have a special significance to oneself.

Question 7

What are nihilistic delusions?

Answer 7

a false fixed belief that they are worthless or dying. In severe cases they claim that everything is non-existent including themselves (Cotard’s syndrome)

Question 8

What are obsessive thoughts? How would you ask a patient about them?

Answer 8

Distressing thoughts that enter the mind despite the patient’s effort to resist them. This is a feature of obsessive–compulsive disorder.

‘Do certain ideas or images keep entering your mind, even when you try to keep them out?’

Question 9

What are preoccupations / overvalued ideas?

Answer 9

Strongly held beliefs which are particularly important in four disorders: depressive, anxiety, eating and sexual. Preoccupations differ from obsessions in that they can be put out of the mind with effort, whereas obsessions repeatedly enter the patient’s mind despite their attempted resistance.

Question 10

What is loosening of association?

Answer 10

loss of the normal structure of thinking, occurs mainly in schizophrenia.

There are three types:
(1) Derailment of thought (Knight’s move thinking): unrelated or only remotely related ideas.
(2) Tangential thinking: The person diverts from the original train of thought but never returns to it.
(3) Word salad: speech that is reduced to a senseless repetition of sounds and phrases

Question 11

Give 3 abnormalities of thought flow

Answer 11

Acceleration: can manifest as: (1) Pressured thought and (2) Flight of ideas, often occurs in manic illness.

Retardation: Slow speed of thinking which occurs in depressive illnesses.

Thought blocking: Refers to the sudden cessation of flow of thoughts. The previous idea may then be taken up again or replaced by another thought, mainly occurs in schizophrenia.

Question 12

How would you ask a patient about passivity phenomena?

Answer 12

‘Do you ever feel that your mood or actions are being controlled by someone or something else?’

Question 13

What are the different types of auditory hallucinations?

Answer 13

Second person – voice(s) directly addressing the patient
Third person – voices talking amongst themselves, or about the patient
Running commentary – voice(s) giving account of what the patient is doing

Question 14

What are the different types of hallucinations that you should ask about in a psychotic patient ?

Answer 14

visual
auditory
olfactory (unpleasant smell)
gustatory
somatic (unusual sensation e..g insects crawling on skin)

Question 15

Hallucinations may be confused with the following:

Answer 15

1. Pseudohallucination: Would include the experience of hearing voices inside your head, not true external hallucinations.
2. Illusion: A false mental image produced by misinterpretation of an external stimulus. Often occurs in normal people.
3. Depersonalization (feature of neurosis): Feeling of detachment from the normal sense of self. ‘Do you ever feel unreal or that a part of your body is unreal?’
4. Derealization (feature of neurosis): Feeling of unreality in which the environment and people are experienced as unreal.

Question 16

Causes of visual hallucinations?

Answer 16

more characteristic of an organic brain disease or substance misuse (they are rarer in schizophrenia)

Question 17

Causes of secondary person auditory hallucinations?

Answer 17

schizophrenia, severe depression with psychosis and mania with psychosis

Question 18

Define mood

Answer 18

Refers to a patient’s sustained, experienced emotional state over a period of time. It may be reported subjectively (in the patient’s own words) or objectively as dysthymic (low), euthymic (normal) or elated (elevated).

Question 19

Define affect

Answer 19

Refers to the transient flow of emotion in response to a particular stimulus

Question 20

What are the different mood disorders identified in the ICD-10 classification?

Answer 20

1. Manic episode: including hypomania, mania without psychotic symptoms and mania with psychotic symptoms
2. Bipolar affective disorder
3. Depressive episode: including mild, moderate, severe and severe with psychotic symptoms
4. Recurrent depressive disorder
5. Persistent mood disorders: cyclothymia, dysthymia.
6. Other mood disorders
7. Unspecified mood disorder

Question 21

How can mood disorders be classfied?

Answer 21

1. Primary mood disorder: a mood disorder that does not result from another medical or psychiatric condition, either unipolar (depressive disorder, dysthymia) or bipolar (bipolar affective disorder, cyclothymia)
2. Secondary mood disorder: a mood disorder that results from another medical or psychiatric condition.

Question 22

Define depressive disorder

Answer 22

an affective mood disorder characterized by a persistent low mood, loss of pleasure and/or lack of energy accompanied by emotional, cognitive and biological symptoms

Question 23

Risk factors for depression?

Answer 23

Risk factor mnemonic ‘FF, AA, PP, SS’:

Female/Family history
Alcohol/Adverse events
Past depression/Physical co-morbidities
↓ Social support/↓ Socioeconomic status

Question 24

What are the core symptoms of depression?

Answer 24

low mood (at least 2 weeks)
anhedonia
anergia (low energy)

Question 25

Give some biological sxs of depression

Answer 25

Diurnal Variation in Mood (DVM) : The patient’s low mood is more pronounced during certain times of the day, usually in the morning. Early Morning Wakening (EMW) : waking up 2 hours earlier than they would premorbidly Loss of libido Psychomotor retardation Changes in weight and appetite

Question 26

What is Beck's cognitive triad (depression)?

Answer 26

three types of negative though The triad involves negative thoughts about: the self (i.e. the patient feels worthless), the world/environment (i.e. the world is unfair), and the future (i.e. the future is hopeless).

Question 27

Outline the ICD-10 classification of depression

Answer 27

Mild depression = 2 core symptoms + 2 other symptoms Moderate depression = 2 core symptoms + 3–4 other symptoms Severe depression = 3 core symptoms + ≥4 other symptoms

Question 28

How would you investigate for depression?

Answer 28

Diagnostic questionnaires: e.g. PHQ-9, HADS and Beck’s depression inventory Blood tests: FBC (e.g. to check for anaemia), TFTs (hypothyroidism), U&Es, LFTs, calcium levels (biochemical abnormalities may cause physical symptoms which can mimic some depressive symptoms), glucose (diabetes can cause anergia). Imaging: MRI or CT scan may be required where presentation or examination is atypical or where there are features suspicious of an intracranial lesion e.g. unexplained headache or personality change.

Question 29

DDx for depression?

Answer 29

Other mood disorders: Bipolar affective disorder, recurrent depressive disorder, SAD, PMDD, dysthymia , postnatal depression Secondary to physical condition e.g. hypothyroidism Secondary to psychoactive substance abuse Secondary to other psychiatric disorders: Psychotic disorders, anxiety disorders, adjustment disorder, personality disorder, eating disorders, dementia. Normal bereavement

Question 30

Outline the mx of mild-moderate depression

Answer 30

Watchful waiting: reassess the patient again in 2 weeks Antidepressants: Not recommended as a first-line therapy unless: (1) depression has lasted a long time; (2) past history of moderate–severe depression; (3) failure of other interventions; (4) or the depression complicates the care of other physical health problems Self-help programmes Computerized cognitive behavioural therapy (CBT): educating them about depression and challenging negative thoughts Physical activity programme

Question 31

Outline the mx of moderate- severe depression

Answer 31

Psychiatry referral: Indicated if: (1) suicide risk is high; (2) depression is severe; (3) recurrent depression; (4) or unresponsive to initial treatment Mental Health Act may become necessary in some cases Antidepressants: First-line antidepressants are SSRIs e.g. citalopram. Other antidepressants include TCAs, SNRIs and MAOIs Adjuvants: Antidepressants may be augmented with lithium, or antipsychotics Psychotherapy: Refer for CBT and interpersonal therapy (IPT) Social support ECT

Question 32

How long should antidepressants be continued for after remission?

Answer 32

Should be continued for 6 months after resolution of symptoms for first depressive episode, 2 years after resolution of second episode, and long term in individuals who have had multiple severe episodes

Question 33

Indications for ECT tx in depression?

Answer 33

(1) acute treatment of severe depression which is life-threatening; (2) rapid response required; (3) depression with psychotic features; (4) severe psychomotor retardation or stupor; (5) or failure of other treatments.

Question 34

Define bipolar affective disorder

Answer 34

a chronic episodic mood disorder, characterised by at least one episode of mania (or hypomania) and a further episode of mania or depression

Question 35

What are the risk factors for bipolar affective disorder?

Answer 35

(Aggressive Spenders) Age in early-20’s Anxiety disorders After depression Stressful life events Substance misuse Strong family hx

Question 36

Give some sxs of mania

Answer 36

I DIG FASTER Irritability Distractibility / Disinhibited Insight impaired / increased libido Grandiose Delusions Flight of Ideas Activity / Appetite Increased Sleep decreased Talkative - pressure of speech Elevated mood / energy increased Reduced concentration / reckless behaviour

Question 37

Describe hypomania

Answer 37

Mildly elevated or irritable mood present for > 4 days symptoms of mania are to a lesser extent than true mania considerable interference with work and social life but not severe disruption partial insight may be preserved

Question 38

Describe mania without psychosis

Answer 38

symptoms present for > 1 week with complete disruption of work and social activities may have grandiose ideas, excessive spending, sexual disinhibition, exhaustion due to lack of sleep

Question 39

Describe mania with psychosis

Answer 39

severely elevated or suspicious mood with psychotic features e.g. grandiose or persecutory delusions and auditory hallucinations that are mood congruent

Question 40

How can bipolar affective disorder be classified?

Answer 40

Bipolar 1 - Involves periods of severe mood episodes from mania to depression Bipolar 2 - Milder form of mood elevation, involving milder episodes of hypomania that alternate with periods of severe depression Rapid cycling - More than four mood swings in a 12-month period with no intervening asymptomatic periods. Poor prognosis.

Question 41

What is the ICD-10 criteria for mania?

Answer 41

Mania requires 3/9 symptoms to be present: (1) Grandiosity/inflated self-esteem (2) Decreased sleep (3) Pressure of speech (4) Flight of ideas (5) Distractibility (6) Psychomotor agitation (restlessness) (7) Reckless behaviour, e.g. spending sprees, reckless driving (8) Loss of social inhibitions (leading to inappropriate behaviour) (9) Marked sexual energy

Question 42

ICD-10 diagnostic criteria for bipolar affective disorder?

Answer 42

at least two episodes in which a person’s mood and activity levels are significantly disturbed – one of which MUST be mania or hypomania

Question 43

ICD-10 divides bipolar disorder into five states:

Answer 43

(1) Currently hypomanic; (2) Currently manic; (3) Currently depressed; (4) Mixed Disorder; (5) In remission

Question 44

Describe typical MMSE appearance of a patient with bipolar

Answer 44

Flamboyant/unusual combination of clothing, heavy makeup and jewellery. Personal neglect when condition is severe.

Question 45

Describe typical MMSE behaviour of a patient with bipolar

Answer 45

Overfamiliar, disinhibited (flirtatious, aggressive), increased psychomotor activity, distractible, restless.

Question 46

Describe typical MMSE speech of a patient with bipolar

Answer 46

Loud, ↑ rate and quantity, pressure of speech, uninterruptible, puns and rhymes, neologisms.

Question 47

Describe typical MMSE mood of a patient with bipolar

Answer 47

Elated, euphoric, and/or irritable.

Question 48

Describe typical MMSE thought of a patient with bipolar

Answer 48

Optimistic, pressured thought, flight of ideas, loosening of association, circumstantiality, tangentiality, overvalued ideas, grandiose/persecutory delusions.

Question 49

How may you investigate bipolar affective disorder?

Answer 49

Self-rating scales: e.g. Mood Disorder Questionnaire. Blood tests: FBC (routine), TFTs (both hyper/hypothyroidism are differentials), U&Es (baseline renal function with view to starting lithium), LFTs (baseline hepatic function with view to starting mood stabilizers), glucose, calcium (biochemical disturbances can cause mood symptoms) Urine drug test: Illicit drugs can cause manic symptoms CT head: to rule out space-occupying lesions (can cause symptoms such as disinhibition).

Question 50

DDx for bipolar affective disorder?

Answer 50

Mood disorders: hypomania, mania, mixed episode, cyclothymia Psychotic disorders: schizophrenia, schizoaffective disorder Secondary to medical condition: hyper/hypothyroidism, Cushing’s disease, cerebral tumour (e.g. frontal lobe lesion with disinhibition), stroke Drug related: illicit drug ingestion (e.g. amphetamines, cocaine), acute drug withdrawal, side effect of corticosteroid use Personality disorders: histrionic, EUPD

Question 51

When would hospitalisation be required for a manic patient?

Answer 51

(1) reckless behaviour causing risk to patient or others; (2) significant psychotic symptoms; (3) impaired judgement; (4) or psychomotor agitation.

Question 52

Mx of bipolar affective disorder?

Answer 52

CALMER Consider hospitalization/CBT Antipsychotics (Atypical) Lorazepam Mood stabilizers (e.g. lithium) Electroconvulsive therapy Risk assessment

Question 53

Lithium is the standard long-term therapy in bipolar affective disorder. It minimizes the risk of relapse and improves quality of life. What are the key side effects?

Answer 53

polydipsia, polyuria, fine tremor, weight gain, oedema, hypothyroidism, impaired renal function, memory problems and teratogenicity (in 1st trimester)

Question 54

Signs of lithium toxicity (1.5–2.0 mmol/L):

Answer 54

N+V, coarse tremor, ataxia, muscle weakness, apathy

Question 55

Signs of severe lithium toxicity (>2.0 mmol/L) :

Answer 55

nystagmus, dysarthria, hyperreflexia, oliguria, hypotension, convulsions and coma

Question 56

How should lithium tx be monitored?

Answer 56

Lithium levels – 12 hours following first dose, then weekly until therapeutic level (0.5–1.0mmol/L) has been stable for 4 weeks. Once stable check every 3 months. U&Es – every 6 months; TFTs – every 12 months.

Question 57

What mood stabilisers may be used in an acute manic episode?

Answer 57

lithium or sodium valproate

Question 58

Define psychosis

Answer 58

Psychosis is defined as a mental state in which reality is greatly distorted. It typically presents with: 1. Delusions: A fixed false belief, which is firmly held despite evidence to the contrary and goes against the individual’s normal social and cultural belief system. 2. Hallucinations: A perception in the absence of an external stimulus 3. Thought disorder: An impairment in the ability to form thoughts from logically connected ideas.

Question 59

List some non-organic causes of psychosis

Answer 59

Schizophrenia Schizotypal disorder Schizoaffective disorder Acute psychotic episode Mood disorders with psychosis Drug-induced psychosis Delusional disorder Induced delusional disorder Puerperal psychosis

Question 60

List some organic causes of psychosis

Answer 60

Drug-induced psychosis Complex partial epilepsy Delirium, Dementia Huntington's disease Systemic lupus erythematosus Syphilis Endocrine disturbance, e.g. Cushing's syndrome Metabolic disorders including vitamin B, deficiency and porphyria

Question 61

What mnemonic can you use to remember key causes of psychosis?

Answer 61

‘Schizophrenia And Schizoaffective Persist For >1 Month, Paraphrenia Presents Late’ Schizotypal disorder Acute and transient psychotic disorders (< 1 month) Schizoaffective Disorder (schizophrenia + mood disorder) Persistent delusional disorder (delusion is only/most prominent symptom) Folie a deux Mood disorders with psychosis Puerperal psychosis Late paraphrenia - late onset schizophrenia

Question 62

Define schizophrenia

Answer 62

Schizophrenia is the most common psychotic condition, characterized by hallucinations, delusions and thought disorders which lead to functional impairment. It occurs in the absence of organic disease, alcohol or drug-related disorders and is not secondary to elevation or depression of mood.

Question 63

Give some predisposing factors for schizophrenia

Answer 63

family hx childhood abuse substance misuse low socioeconomic status migrants African-Carribean background urban living

Question 64

Give some precipitating factors for schizophrenia

Answer 64

Smoking cannabis or using psychostimulants Adverse life events Poor coping style

Question 65

Peak age of onset of schizophrenia?

Answer 65

15–35 years

Question 66

What are the positive sxs of schizophrenia?

Answer 66

mnemonic: Delusions Held Firmly = Think Psychosis Delusions Hallucinations Formal thought disorder Thought interference Passivity Phenomena

Question 67

Schneider’s first-rank symptoms of schizophrenia are symptoms which, if one or more are present, are strongly suggestive of schizophrenia. What are they?

Answer 67

Delusional perception: A new delusion that forms in response to a real perception without any logical sense, e.g. ‘the traffic light turned red so I am the chosen one.’ Third person auditory hallucinations: usually a running commentary Thought interference: thought insertion, withdrawal or broadcast Passivity phenomenon

Question 68

What are the negative sxs of schizophrenia?

Answer 68

(the A factor) Avolition (↓ motivation) Asocial behaviour: Loss of drive for any social engagements Anhedonia: Lack of pleasure in activities that were previously enjoyable to the patient Alogia (poverty of speech): A quantitative and qualitative decrease in speech Affect blunted: Diminished or absent capacity to express feelings. Attention deficits: May experience problems with attention, language, memory, and executive function.

Question 69

What are the different types of schizophrenia according to ICD-10?

Answer 69

[Mnemonic]: Paranoid Psychotic Humans Can’t Supply Understandable Reasoning paranoid postschizophrenic depression heberphrenic catatonic simple undifferentiated residual

Question 70

Describe paranoid schizophrenia

Answer 70

most common type, dominated by positive sxs such as hallucinations and delusions

Question 71

Describe hebephrenic schizophrenia

Answer 71

onset of illness is earlier (15-25) and has poorer prognosis, thought disorganisation predominates

Question 72

Describe simple schizophrenia

Answer 72

rare form where negative sxs develop without psychotic sxs

Question 73

describe residual schizophrenia

Answer 73

1 year of chronic negative sxs preceded by a clear cut psychotic episode

Question 74

Describe appearance and behaviour of a typical schizophrenia patient in MMSE

Answer 74

Appearance can be normal (positive), or inappropriate with poor self-care (negative) Behaviour: Preoccupied, restless, noisy or suspicious (positive). A few show sudden, unexpected changes in behaviour. Withdrawn, poor eye contact and apathy (negative)

Question 75

Describe speech of a typical schizophrenia patient in MMSE

Answer 75

May reflect underlying thought disorder (loosening of associations, pressured and distractible speech), interruptions to flow of thought (thought blocking), and poverty of speech (negative)

Question 76

Describe mood of a typical schizophrenia patient in MMSE

Answer 76

Incongruity of affect or mood changes such as depression, anxiety or irritability. Flattened affect (negative)

Question 77

Describe thought of a typical schizophrenia patient in MMSE

Answer 77

Delusions (e.g. persecutory, delusions of control, delusions of reference) thought insertion/withdrawal/broadcast formal thought disorder (loosening of associations, word salad, concrete thinking, circumstantiality/tangentiality)

Question 78

Describe cognition of a typical schizophrenia patient during MMSE

Answer 78

Normal orientation. Attention and concentration often impaired (positive). Specific cognitive deficits (negative)

Question 79

What investigations could you do for a patient with suspected schizophrenia?

Answer 79

Blood tests: FBC: anaemia, infection TFTs: thyroid dysfunction can present with psychosis serum calcium: hypercalcaemia can present with psychosis U&Es and LFTs : assess renal and liver function before giving antipsychotics glucose or HbA1c, cholesterol: as atypical antipsychotics cause metabolic syndrome vitamin B12 and folate : deficiencies can cause psychosis Urine drug test ECG: Antipsychotics cause prolonged QT interval CT scan: To rule out organic causes such as space-occupying lesions EEG: To rule out temporal lobe epilepsy as possible cause of psychosis

Question 80

What are the options for biological mx of schizophrenia?

Answer 80

Atypical antipsychotics are first-line, e.g. risperidone and olanzapine Depot formulations should be considered if there is a problem with non-compliance Clozapine is used for treatment-resistant schizophrenia (failure to respond to two other antipsychotics) Adjuvants: Benzodiazepines can provide short-term relief of behavioural disturbance, insomnia, aggression and agitation. (Lorazepam doesn’t work as quickly as diazepam but has less risk of respiratory depression) Antidepressants and lithium can be used to augment antipsychotics ECT if tx resistant or catatonic

Question 81

What are the options for psychological mx of schizophrenia?

Answer 81

CBT Family intervention Art therapy : good for negative sxs in young people Social skills training

Question 82

What are the options for social mx of schizophrenia?

Answer 82

Support groups - Rethink and SANE Peer support Supported employment programs

Question 83

What are the factors associated with a poor prognosis in schizophrenia?

Answer 83

Strong family history Gradual onset ↓ IQ Premorbid history of social withdrawal No obvious precipitant

Question 84

Give the potential side effects of atypical antipsychotics

Answer 84

extrapyramidal side effects (e.g. parkinsonism) blurred vision urinary retention, dry mouth, constipation sedation weight gain postural hypotension, tachycardia ejaculatory failure or sexual dysfunction reduced bone mineral density menstrual disturbances breast enlargement, galactorrhoea impaired glucose tolerance, hypercholesterolaemia neuroleptic malignant syndrome prolonged QT interval