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Flashcards in Mental Health Deck (97):

Assessment of capacity

1. Understand information
2. Retain information long enough to make a relevant decision
3. Weigh information as part of the process of making a decision
4. Communicate the decision (talking/sign language or other means)


Key Principles of Mental Capacity Act

A person must be assumed to have capacity unless it is established that he lacks capacity
A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success
A person is not to be treated as unable to make a decision merely because he makes an unwise decision
An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests
Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action


Features of Mental Health Act

• Presence of a mental disorder as defined by law (any disorder or disability of the mind)
• Disorder is of a certain nature or degree
• Significant risk to persons health and safety, safety of others or a risk of self neglect
• No alternative to hospital admission as a means of safeguarding that risk


Impairments in autistic spectrum disorder

 Social interaction
- Difficulty with interpretation of sensory information
- Can affect any sense -->Over/under sensitive
- Sensory seeking/avoidance
 Communication
- Problems in expressive and receptive language
- Non-verbal communication problems
- Literal understanding/humour
- Visual learning
- Problems with social communication; Worse when anxious
 Rigidity of thinking
- Rituals and routines
- Obsessions (not as in OCD)
- Problems with imaginary play
- Impaired theory of mind
- Reduced empathy
- Difficulty generalising


Management of autistic spectrum disorder

• Mainly educational
• Speech and language therapy
• Occupational therapy
• Behavioural management
• Medication (rarely used)
• Visual strategies – TEACHH, PECS
• Dietary – GF/CF, fish oils, additives


Problems associated with the autistic spectrum disorder

• Learning Difficulties
• Dyspraxia/ dyslexia
• Hyperactivity
• Special abilities
• Behavioural difficulties
• Anxiety
• Sleep and eating problems


Core features of ADHD

 Poor attention and concentration
- Poorer than expect for age. Often seen when doing school work or ‘flitting’ from toy to toy. Cant watch whole tv programme. Poor academic achievement- reading often affected
 Hyperactivity
- Significantly more active than expected for the age, therefore difficult to assess in very young children
- Running off, Fidgeting, appearing full of energy constantly, Difficulty in sleeping
 Impulsivity
- Acting without considering the consequences.
- Interrupting conversations. Crossing the road without looking. Risk taking behaviour. - Aggression can be a consequence


Complications of ADHD

- difficulties in education
- risk of accidents
- low self-esteem
- rejection by peers


ICD - 10 classification of ADHD

Both are necessary for diagnosis:
- Impaired attention – manifested by a lack of persistent task involvement and tendency to move from one activity to another without completion
- Overactivity – characterised by restlessness, talkativeness, noisiness and fidgeting, particularly in situations requiring calm
Early onset – behavioural symptoms present prior to 6 years of age, and of long duration
Impairment must be present in two or more settings (e.g. home, classroom, clinic)
Diagnosis of anxiety disorders, mood affective disorders, pervasive developmental disorders and schizophrenia must be excluded.


Management of ADHD

Bio --> If severe
- Methylphenidate/ Atomoxetine/ Dexamfetamine
Psycho -->Parent education programmes/ interventions
Social --> Social skills training


Actions and SE of drugs used for ADHD

 Methylphenidate/Ritalin (short or long acting)
- Stimulant. Acts only in daytime
-About 2.3 of patients show significant improvement in their symptoms
-↑ Da and NAdr in synapse, as frontal lobe deficit – could cause personality changes.
- S.E – HTN, insomnia, headaches, weight loss/anorexia- ↓ appetite; tics; anxiety and dysphoria
-Abuse potential
- Acts on NAdr system-->Maintains NAdr levels and enhances frontal lobe
- 2 months to become effective.
- S.E - upset stomach, ↓ appetite, n&v, dizziness, tiredness and mood swings
 Dexamphetamine
- sympathomimetic amine with central stimulant and anorectic activity (also used in narcolepsy)
SE - restlessness, headache, reduced appetite


Complications ADHD can cause in adulthood

- Increased criminality
- Decreased academic performance
- Increased substance abuse
- Increased aggression
- Poor relationships
- Poor employment record
- Girls have increased pregnancy and STD rates


Core symptoms of Depression

- Continuous low mood for at least 2 weeks
- Anhedonia
- lack of energy


Other and somatic symptoms of Depression

- reduced self-esteem/confidence
- guilt and self-blame
- hopelessness
- hypochondrical thoughts
- poor concentration/ attendence
- suicidal thoughts/ self-harm
- irritably

- loss of libudo
- psychomotor agitation
- Early morning wakening
- weight loss/ anorexia


ICD 10 classification of depression

Mild - 2 core symptoms and 2 others
Moderate 2/3 core and 3/4 others
Severe 3 core and 4+ others (or some very severe)
Severe with psychotic symptoms
- hallucinations (2nd person auditory)
- delusions (hypocondrical guilt, nilhilistic, persecutary)


Treatment of depression

Mild - reassess in 2 weeks --> exercise/ lifestyle and self-help/ CBT
Moderate - CBT/ Antidepressants
Severe - CBT and Antidepressants +- ECT
- Fluoxetine is antidepressant of choice

Psych--> psycho-education (about illness, relapse signatures meds), CBT (stop patterns of negative thinking), IPT, peer support and supportive counselling

Social --> family, housing, education, finance, employment, general coping strategies, assess physical needs


ICD-10 classification of Bipolar

at least 2 episodes in which a patients mood and activity are significantly disturbed

1) 1+ manic/mixed +/- 1+ depression
2) 1+ depression + 1 Hypomania


Criteria and Symptoms of mania

Elevated/expansive/irritable mood (1 week) and 3+ or more other symptoms
• ↑ energy/activity (including agitation)
• Grandiosity/ ↑ self-esteem
• Flight of ideas/racing thoughts; Pressure of speech; Distractible (poor concentration)
• Reduced need for sleep; ↑ libido
• Social inhibitions lost- sexual indiscretion (and reckless behaviour e.g overspending)
• Psychotic symptoms (of mood congruent nature) - hallucinations, grandiose delusions
• Psychomotor agitation - risk of self-injury, dehydration
• Thoughts of self-harming self or others


Criteria and symptoms of hypomania

3 or more characteristic symptoms for at least 4 days, not severe enough to interfere with social or occupational functioning
• Mildly elevated, expansible or irritable mood; ↑ energy/activity (can still function)
• ↑ self-esteem; Difficulty focussing on one task alone
• Sociability; talkativeness; over familiarity
• ↑ sex drive (out of character); Reduced need for sleep


Management for bipolar

 Biological:
• Mood Stabilisers: Lithium
• Atypical anti-psychotics e.g. risperidone, olanzapine, quetiapine
 Psychological- CBT, psychoeducation (about illness, relapse, medication, supportive psychotherapy)
 Social- targeted interventions (family, housing, finance, employment, general coping strategies)


Environmental risk factors for ADHD

- Premature birth
- prenatal tobacco exposure
- single-parent household
- maternal depression
- lower social class


Pre-disposing factors for depression

- genetics
- abuse in childhood
- personality traits
- family support


Precipitating factors for depression

- brain illness
- physical illness
- iatrogenic
- family relationships
- increased workload
- life events
- substance use
- change in routine


Perpetuating factors for depression

- substance use
- difficult relationship
- financial difficulty
- work
- housing


Indications for ECT

- severe depressive illness, where other treatments haven't been effective
- life-threatening illness
- prolonged/severe manic episode
- catatonia- high suicide risk
- stupor
- severe psychomotor retardation


Components of MSE

Emotion (mood and affect)
Perception - hallucinations
Thought - content, form


Features of a cognitive assessment

General - alert/ conscious
Attention and Concentration
R hemisphere function


Sections in the MHA

136 - police can move to a place of safety from public place - 72h

5 (4) - nurse can detain inpatient for up to 6h for medical assessment

5(2) - consultant can detain inpatient for up to 72h

2 - 2 doctors and MH practiioner - section for assessment (+/- treatment IM) for 28d
- can appeal within 14d

3- 2 doctors and 1MHP can section up to 6m for treatment

17 - leave when on section 2/3


ICD-10 classification of OCD

Obsessions and compulsions present for at least 2 weeks on most days and are a source of distress
- Obsessions - involuntary and unwanted thoughts, images or compulsions - often intrusive, distressing and repeptitive
- compulsions - repetitive mental operations/physical acts - feel compelled to perform to help reduce anxiety - not pleasurable

Acknowledges as coming from patients own mind - patient knows irrational


Management of OCD

- CBT - exposure and response prevention

- SSRI - fluoxetine. 2nd line - clomipramine

- help with work, peer support group


ICD-10 definition of PTSD

Presents for at least 1m, <6m from stressor

A) exposure to a stressful event or situation of exceptionally threatening or catastrophic nature
B) Persistent remembering or 'reliving' the stressor by intrusive flashbacks, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or associated with the stressor
C) Avoidance of circumstances resembling/ associated with the stressor
D) 1- inability to recall some important aspects of the period of exposure to the stressor
2- persistent symptoms of increased physiological sensivity and arousal - 2 of:
> difficulty in falling/ staying asleep
> irritability
> difficulty concentrating
> hypervigilence
> exaggerated startle response


Predisposing factors for developing PTSD

- personality traits
- previous hx of neurotic illness
- childhood trauma
- poor social support


Management of PTSD

- trauma focused CBT or EMDR
- psychoeducation
- short term hypnotics
- mirtazepine, paroxetine, amitriptylline


ICD 10 classification of schizophrenia

1) At least 1 of the following:
a - thought echo, insertion, withdrawal or broadcasting
b - delusions of control, influence or passivity
c - hallucinatory voices
d - persistent delusions

2) At least 2 of the following
a - persistent hallucinations
b- breaks in train of thought
c - catatonic behaviour
d- -ve symptoms (apathy)
e - significant and consistent change in overall quality of personal beaviour


Classifications of schizophrenia

Paranoid - delusions and hallucinations
Disorganised - disorganised speech, behaviour and flat/inappropriate affect
Catatonic - psychomotor disturbance
Simple - no delusions or hallucinations


Management of schizophrenia

- CBT - reality testing
- Olanzapine/ Haloperidol
- Psychoeducation
- Family interventions


Differentials of mania

- normal fluctuation in mood
- drug intoxication
- PD
- Thyrotoxicosis
- Dementia


ICD-10 definition of dependence

3+ at the same time in the preceeding year
- strong desire to take the chemical
- ↑ tolerance
- difficulties controlling use
- continue to use despite clear evidence of harm


Presentation of alcohol intoxication

- slurred speech
- ataxoc
- dishevelled
- tremulous
- sweating


Management of alcohol dependence

- In patient detox (if delirium tremens, seizers, cognitive impairment etc)
- disulfarim
- Acamprosate
-Chlordiazepoxide (prevent seizures)
- thiamine
- Motivational interviewing


Symptoms of alcohol withdrawal

- restlessness
- tachycardia
- sweating
- tremor
- anxiety
- n&v
- loss of appetite
- insomnia
- Delirium tremens
- Seizures


Features of delirium tremens

- hallucinations
- confusion
- disorientation
- seizures
- paranoid ideation
- ↑ HR and RR
- fever
- ataxia


Features of Wernicke's encephalopathy

- nystagmus
- ataxia
- opthamoplegia
+/- altered consciousness, com, fever, consusion, ptosis


Features of Korsakoff's

- irreversible
- impaired recent and remote memory
- disordered time sense
- cant learn new things +/- confabulation


What causes Wernicke's and Korsakoffs

Thiamine (B1) deficiency
- glucose oxidation requires it so deficiency inhibits cell metabolism

- always give glucose after Pabrinex injection

- early features are poor memory, irritability and sleep disturbance


Define and give features of psychosis

A state of impaired reality
1) perception - illusions and hallucinations
2) thought - delusions/flight of ideas
3) -ve symptoms - apathy, poverty of thought & speech, blunting of afect
4) psychomotor function - catatonia


Define illusions and hallucinations

illusion - misperception of a real stimuli
hallucinations - perception in absence of external stimuli


Define delusion and give different types

a belief that is incorrect, incorrigible and incompatible with social/cultural norms

- persecutory (being harmed/threatened)
- grandiose
- of refernce
- religious
- erotomonia
- infedility
- misidentigiation
- nilhilistic
- somatic
- infestation
- though control - insertion/withdrawal/ broadcasting


Differentials of psychosis

- substance misuse
- depression with psychotic symptoms
- dementia/ delirium
- brief psychotic episode (<1m)


Examples of disorganised thinking in psychosis

- circumstantial speech
- tangential thinking
- flight of ideas
- loosening of association
- neologisms
- thought blocking
- palialia /echalalia
- irrelevant answers


Features, types, Ix and Rx of frontotemporal dementia

- insidious onset and gradual profression
- early decline in social interpersonal conduct
- early emotional blunting and loss of insight

3 types
1) behavioural - changes in personality/behaviour/emotions and judgement
2) non-fluent aphasia - early changes in language
3) semantic - lose understanding of what objects are

IX - bilateral atropy of frontal and anterio temporal lobes on CT
Rx - SSRI and language therapy


Define dementia and give ICD-10 definition

global impairment of cognitive function and personality without impairment of consciousness

ICD-10 - 6m+ of:
- a decline in memory
- a decline in other cognitive abilities
- preserved awareness of the environment
- a decline in emotional control/ motivation/ changes in social behaviour


Reversible causes of dementia

- chronic alcohol abuse
- vit b12/thiamine/t2 def
- normal pressure hydrocephalus
- infection
- frontal lobe tumour


Risk factors for dementia

- ApoE4 allele
- smoking
- alcohol
- obesity
- raised total cholesterol and diet high in sat fat
- BP
- CVD and cerebrovasc disease
- lower education
- poor social network
- depression


Factors protective for dementia

- diet, vit e&C, Mediterranean diet
- increased exercise
- mental activity e.g. musci/reading
- complex mental activity


Features of AD

- gradual onset with progressive cognitive decline - beta=amyloid plaques and tau tangles

- amnesia and disorientation
- spatial dysfunction
- changes in behaviour (wandering, irritable)

- significant memory loss (orientaion and global aphasia)
- personality deterioration
- apraxia, agnosia, amnomia

- physical deterioration - incontinence, falls, seizures
- extra-pyramidal signs
- dysphasia
- paranoid delusions, auditory and visual hallucinations
- depression
- personality changes
- behavioural disturbances - aggression/ sexual disinhibition. restlessness


Ix and Rx of AD

Ix - SPECT - generalised atrophy
prevention - modify risk factors, identify mild cognitive impairment

meds - donepezil, rivastigmine, galantamine
- memantine (mod-severe)

cognition training


SE of AD drugs

Donepezil, Rivastigmine, Galantamine
- do baseline ECG
- n,v,d, anorexia, bradycardia, syncope, insomnia, muscle cramps

- constipation, dyspnoea, headache, dizzy, drowsy


Features of vascular dementia

- Acute onset
- stepwise deterioration in cognitive function
- emotional and personality changes - fluctuating


Pathogenesis of vascular dementia

- reduced cerebral blood flow - oxidative stress - damaged endothelial cells - chronic hypoperfusion


Features of LBD

A) fluctuating cognition
B) visual hallucinations
C) parkinsonism
+/- falls, sycope, LOC

A-synuclein and ubiquitin --> substania nigra and cortex seen on DAT scan


Features of delirium

- acute confusional state
- impaired consciousness and attention
- global impairment of cognition (impaired short term memory, diorientated, language abnormalities, perception disturbance)
- psychomotor disturbance (hypo/hyper)
- sleep-wake cycle disturbance
- emotional disturbance


Predisposing factors for delirium

- old
- male
- visual/hearing impairment
- previous stroke
- PD
- funcitonal impairment


Precipitating factors for delirium

- medication
- infection
- hypoxia
- ↑/ ↓ - glucose, calcium, sodium
- shock
- hepatic/renal failure
- hypoperfusion
- thyrotoxicosis/myxoedema coma
- anaemia
- sleep depreivation
- pain
- surgery/anaesthesia
- neurological (tumour locally compresses)


Management of delirium

- treat underlying cause
- environmental and supportive measure
> educate those who interact with patient
>remove catheter
>avoid transfer
>consistent nursing staff
> calm environment, large clocks, easily readable notes, induce healthy sleep-wake cycle
> correct sensory deficit
> reality orientation
- review meds
- refer to geriatrician +/- psych
- avoid sedation


SE of haloperidol

Acute Dystonia
Tardive dyskinesia



ICD-10 classification of generalised anxiety disorder

- present for most days for at least 6m -
- symptoms of autonomic arousal
+ 3 of:
- physical symptoms - SOB, chest, pain, nausea
- mental state symptoms - dizzy, derealisation, fear of losing control
- general symptoms - hot flushes/cold chills, numbness/ tingling
- symptoms of tension - muscle/mental, lump in throat
- other - exaggerated startle response, concentration difficulties, persistent irritability, difficulty getting to sleep


Management of GAD

- Applied relaxation


Social anxiety disorder features and Mx

symptoms of incapacitating anxiety, not secondary to delusional/obsessive thoughts and are restricted to a particular social situation
- leading to a desire to escape/avoidance

fear of negative evaulation by others and low self-esteem
- more likely to have substance/addiction problems

Mx - psychodynamic psychotherapy


Agoraphorba features and Mx

Anxiety in 2 situations
- leads to avoidance

- CBT - systematic desensitisation


Panic disorder features

- recurrent attacks of severe anxiety - spontaneous/ situational
- symptoms develop rapidly, reach a peak of intensity in about 10 min and generally font last longer than 20-30 mins
- usually persistant worry about having another attack/ consequences of attack


Mx of panic disorder

- CBT - non-phobic focus
- family therapy
- SSRI/ TCA - citaoplam (takes up to 12wk to work) +/- diazepam short term
- beta blocker for autonomic arousal


Symptoms of anxiety

- dry mouth
- shaking
- sweating
- light- headedness
- nausea
- SOB/ increased RR
- fatigue
- muscular tension
- diarrhoea
-urinary urgency

- fear of dying
- fear of losing control
- catastrophising
- anticipatory anxiety
- presence of obsessional thoughts
- increased alertness
- irritability


Differentials of anxiety

- Phobia
- psychosis
- depression
-Pheo/ hypoglycaemia/ cushings/ anaemia/ AF
- drugs - anti-hypertensives/arrthmics, anti-cholinergics, withdrawal from benzos


Features of personality disorder

- presence since adolescence
- stable over time despite fluctuations in mood
- manifest in different environments
- recognised by friends and acquaintances

- deeply ingrained maladaptive traits


Clusters of personality disorder

- paranoid -suspicious, jealous, self-important
- schizoid - emotionally cold, lack of enjoyment, +/- hallucinations

- dissocial - neglect, abuse, violence
- emotionally unstable - anger, emotional dysregualtion- hx abuse
- histrionic - attention seeking

- anakastic - obessional
- anxious avoidant - overcome with feelings of worry
- dependent - look for other people to make decisions


Management of personality disorders

- Group therpay
- EUPD --> quetiapine, and dialectical behaviour therapy +/- therapeutic community
- dissocial - stop and think group


Complications of personality disorder

- distress
- adverse effects on society
- substance abuse
- suicide
- violent behaviour


Borderling personality disorder features

- frantic effort to avoid abandonment
- unstable/intense relationships
- disturbed sense of self
- impulsive/ suicide threats
- inappropriate intense anger
- can hallucinate


ICD-10 classification of anorexia nervosa

All of the following
- low body weight (BMI<17.5)
- self-induced weight loss
- overvalued idea (dread gaining weight)
- endocrine disturbance (amennorhoea >3m)

+/- body shape disturbance and undue influence of weight and shape on self-evaluation


ICD-10 classification of Bulimia Nervosa

All of the following
- binge eating (at least 2 x week over 3m)
- compensatory behaviours (purging - lax/vom or non-purging- exercise)
- cravings and preoccupation with eating
- self-perception of being too fat


Predisposition to anorexia

- low self-esteem
- perfectionism -
- geentics
- NT/ predisposition to stress


complications of anorexia

- amenorrhoea
- infertility
- constipation and abdo pain
- cold intolerance
- bradycardia, low BP, arrhythmia's
- peripheral oedema
- osteoporosis
- seizures
- depression

due to vom
- erosion of dental enameal
- enlargement of salivary glands
- calluses
- oesophageal tears
- ↓- K+ and Na+
- raised amylase
- hypochloraemic alkalosis

- GI perf/ upper GI bleed
- reflux oesophagitis
- acute pancreatitis
- bowel obstruction
- delayed gastric emptying (AN)
- loss of gag reflex (BN)

Reduced grey and white matter

Thiamine deficiency


Pathophysiology of refeeding syndrome

- starvation reduces insulin - drives phosphate and potassium out of the cell and depletes stores

- when introduce CHO insulin rapidly increases - this drives K/P into cells and rapidly drops the serum levels

- this can cause oxidative phosphorylation to uncouple - arrythmias, HF, cardaic arrest


Management of anorexia

Fluoxetine (to reduce binging and purging)
Guided self-help
Education on risks/treatment


Reasons for hospitalisation in anorexia

- BMI <13.5
- Rapid weight loss
- Electrolyte disturbance
- Suicide risk


Ix for anorexia

Bloods - ↑ urea, abnormal LFT, ↓ T3, ↓ glucose, ↑ amylase, ↓ zinc, ↑ cholesterol , ↓ vitb12, ↓ mg, ↓ folate, ↓ CK, ↓ thiamin
- ↑GH, ↓FSH &LH, Leucopenia
- dexamethosone suppression test - ↑ cortisol
- DEXA bone scan


SSRI - names and SE

Fluoxetine, citalopram

-n,v,d, agitation, erectile dysfunction, reduced libido, anorexia ↓ NA, temor


symptoms of 5HT toxicity

- altered mental state
- autonomic hypersensitivity (↑ BP, HT, RR, fever)


NaSSa - name,SE and CI


- ↑ appetite, weight gain, dry mouth, sedation, confusion, postural hypotension
CI - renal/hepatic impairment, jaundice, pregnancy


Classification of anti-psychotics and SE

Typical - Holoperidol and chlorpromazine
Acute - Dystonia Akanthesia Parkinsonism (rigidity, trmor, fenestrating gait) Tardive Dyskinesia
- Neuroleptic malignancy syndrome - rigidity, hyperthermia, ↑CK, flucuating consciuness, autonomic disturbance
- weight gain

Atypical - Olanzapine, risperodone, clozapine
- Fewer EPSE
- excessive weight gain (o)
- amenorrhoea, glactorrhoea (r)
- agranulocytosis and myocarditis (c)
- ↑QTc


SNRI - name and SE

Duloxetine and venlafaxine
SE - n,v,d, agitation, erectile dysfunction, reduced libido, anorexia ↓ NA, temor
- sleep disturbance, dry mouth, hyponatraiea, fluctuating BP, sexual dysfunction


TCA - name, SE and CI

Amitriptyline, lofepramine, clomipramine

SE _ sedation, dry mouth, eye accomodation block, tachycaria, post hypotension, arrthymias, constipation, weight gain
- in overdose - VF, hypotension, resp dep, twitching, hallucinations, pyrexia
CI - agranulocytosis, liver damage, glaucoma, BPH


SE of Sodium Valproate

Appetite increase
Liver failure
Reversible hair loss


Action and SE carbamazepine

I v-g sodium ch
SE - dizzy, visual disturbance, n,v, rash, hyponatramemia, ataxia


SE of lithium and therapeutic dose
- toxicity symptoms and Rx

SE - polyuria, dipsia, n, weight gain, fine tremore, AKI, ECG changes, drowsy, memory problems, hypothyroid
TOXICITY - coarse tremor, ataxia, reduced consciousness, v&d, slurred speech, coma, death
Rx - IV fluids +/- haemodialysis


Name and SE of anxiolytics

Benzodiazepines - diazepain - GABAa R
SE - dependence, tolerance, drowsy, ataxia, resp depression (flumazenil)
SE - dizzy, drowsy, blurred vision, confusion
Zopicone - insomnia