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Flashcards in Psychiatry Deck (21):
1

Postnatal Depression

DDx

Hx

Risk

Dx

Rx

RFs

Inpatient Indications 

Baby blues <7 days, PND 2-3 weeks, PPP 3-4 weeks 

 

Hx - Birth, Pregnancy, Breastfeeding, Interaction with baby, Support, Low age, Unwanted baby, Lack of support, Single mother, Difficult childhood. Normal affective questions. Past history of PND

Risk - Suicide, Infanticide, Neglect, substant abuse, do you feel safe. 

Dx-  Edinburgh postnatal depression (<13/30), TFTs, B12/Folate, FBC 

Rx - Bio (Sertraline, Paroxetine) Psycho (Breastfeeding classes, CBT, Mentalising)  Social (Groups, Health Visitor, Social worker, Review weekly, Scheduling, involve key people in patient's life) 

RFs - Low maternal age, Unwanted baby, Traumatic, Not supported, History of sexual abuse, FH, PPH, 

Inpatient indications - Psychosis, Suicidal, Infanticidal, Risk of neglect of baby/ mother 

 

2

Delirium

Hx

Dx

Mx

Rx

Hx - Acute confused state. Fluctuates in mood or cognition. Presence of perceptive disturbance. 

Dx - Confusion Assessment Method - Questionnare for delirium.

Look for evidence of recent infection, change in drugs, change in drug levels, addition of drugs, hip fracture. 

Delirium can be both hyperactive or hypoactive so watch for both

Try to ascertain baseline level of function and get collateral

Investigate - ABCDE, Examination general, Temperature, Urine dip, FBC, Us and Es, CRP, ESR, Toxicology for drugs. Imaging - CT/MRI if considering stroke or underlying brain pathology.

Mx - ABCDE. Treat underlying cause.

To manage the delirium: Keep orientated (near a clock, calendar), near the nursing bed, keep pictures around the bed, will need OT and PT input, neuropsychological input as follow up to assess deterioration in baseline function. 

Short term for agitated patients: IM Haloperidol - But if they have parkinsons/LBD then IM Lorazepam. 

 

3

Alcohol Counselling

Screening- CAGE (>2), AUDIT-C (>15 for men/ >13 for women), FAST, TWEAK

Dependence CANT STOP - 

Compulsion,

Aware of physical harms,

Neglects other activities,

Tolerance to alcohol,

Stopping drinking leads to withdrawal symptoms,

Time spent with alcohol increases,

Out of control use,

Persistent futile efforts to cut down   

 

Extra history - Past psychiatry history, Forensic History, Impact on social history, other substances, Drive? (inform DVLA if they don't agree to stop driving) 

Managemental

Biological

For withdrawal - Chlordiazepoxide, For cravings - Acamprosate (NMDA/GABA) Naltrexone - antagonist of endogenous endorphins., Deterrent  Disulfiram - Acetaldehyde dehydrogenase inhibitor

Deficiencies - Thiamine, B12, Folate, Iron Deficienceis

Tests - FBC, Us and Es, LFTs, Vitamins, Glucose, Clotting Screen, Albumin,  

Detoxifications - inpatient generally

Psychological 

Motivational Interviewing

CBT

Social 

Alcoholics anonymous

Involve family

Intensive support

Psychological Consequences

Withdrawal - 6-12 hours (sweating, tachycardia, anxeity, autonomic hyperactivity, coarse tremors worse at night, hallucinations, nausea) 

Seizure - 36 hours 

Delirium Tremens - 72 hours (Sweating, tachycardai, lilipuchens, formication)

Affective - anxiety and depression

Alcohol induced psychosis

Dementia 

Delusional Disorders i.e. morbid jealously 

Increased risk of suicide 

4

Manic Episode 

Core Sx: Elation, impulsivity, increased energy, irritation, risky behaviour (drugs, sexual activity). Differentiation between hypomania and mania is mania has psychotic elements. Lasts longer than a week

Hallucinations: When did they start - before or after mood features? How many voices? Nature of voices? Command hallucinations? 

DDx: Acute mania, Bipolar affective disorder, Drug induced mania. 

Dx: Reversible causes: Drug screen, TFTs, organic pathology, 

Mx: Bio - Atypical antipsychotic +/- lithium augmentation(Aripirazole if younger than 18)  Psycho (CBT, Family therapy, rapid access services) - Social - (support groups, OT, back to work programme) 

Rx - Atypical (Olanzapine, Quetiapine, Risperidone) / Typical - Haloperidol. Drug monitoring. Checks before you start (ECG, BMI, FBC, Us and Es, Lipids, Glucose, Waist circumference). Take note of smoking and other CVS risk factors 

 

5

Lithium Monitoring

0.4-1.0 Therapeutic Range / 0.8-1.0 Therapuetic range for mania

Weekly until stable and then three monthly Lithium Levels: when starting treatment or adjusting dose 

Baseline and 6 monthly - renal functioning, TFTs and ECG 

6

PTSD

Dx categories:

Mx: 

Rx: 

4 Categories: 

i) Reliving the event  

ii) Avoid situations 

iii) Emotional Numbness / Hyperarousal 

iv) Inability to recall part or all of the experience of the stressor 

non - core: not leaving house, irritation, alcohol/drug abuse, violence/aggression, suicidality, assess for risk to others

Ask about movement and sensation - somatisation disorder/ conversion disorder

Dx: Symptoms for more than 4 weeks, starting in between 1 month to 6 months of the incident. Graded into mild, moderate and severe based on severity of social activity impairment

Mx: 

Bio: Mirtazipine/ Paroxetine

Psycho: Don't initially Debrief - can make it worse after the event. DO - Trauma based CBT (Challenges negative thoughts and beliefs abotu the event and helps to develop better coping strategies) , Eye Movement Desensitisation therapy (asked to move eyes while thinking about the event) 

Social - Family involvement, Involve workplace/ school, encourage outdoors activities. 

7

OCD

Dx

Rx

Dx: Characterised by Obsessions (Unwanted thoughts that enter their heads. Are unwanted and intrusive) Compulsions (Acts that must be performed and if they're not lead to distress until they are performed) 

Forms of OCD: Manifest as i) Checking , ii) Clearning and iii) Excessively orderly behaviour and iv) Ritualistic behaviours

Important distinctions:

Recognise they are occuring from within their own mind (not psychotic)

are egodystonic (not pleasurable)

Key Questions: 

Do you wash or clean a lot?

Do you check things a lot?

Do you find that you take a long time with your daily activities?

Are you concerend about order/ upset by mess?

Assess for risk (suicide can be prevalent)

Assess for risk to others 

Screen for substance abuse and other co-morbid psych conditions (overlap with affective disorders)

 

Rx:

Talk about methods of though redirection - Rubber Band etc. 

Bio - SSRIs (In Moderate/ Sever or if in mild where adult is unwilling to commence psychological treatment). Children --> SSRIs are reserved for more severe cases. fluoxetine, paroxetine, sertralline, citalopram 

NB for BDD the treatment of choice is fluoxetine.

Psycho - Low/More intensive CBT - Including exposure response prevention 

Social - OCD support groups, Work and study support 

8

Overdoses 

History

Dx

Mx

Rx

 

 

Abstinence regimens 

History: (PPH, PMH, PSH, DH, FH, SH, Education, employment, premorbid personality) 

What drug? With anything else (alcohol usually)?

When? How many/much? Over what time period? Have they been treated yet? Any symptoms 

Antecedents: 

Planned or impulsive? 

Was there a trigger?

Final acts? avoiding discovery? Past history of OD/DSH? Did you tell anyone? 

During:

Seek help? What did you wnat to happen?

Consequences:

Did you want to die? How were you found?

Feelings about it - regret? disappointment at not dying?

Hope?

Protective factors

Plans for the future? - Will you do it again? Have you got plans to do it again?

Screen for substance abuse 

Mx: ABCDE, stabilise, obs, IV fluids 

Medical - Treat overdose. <1 hour activated charcoal (1-2 hours for TCAs) 

Consult Toxbase - 

i) paracetomal: Check levels between 4-15 hours and assess need for N-Acetylcysteine/ Liver transplant 

ii) Benzodiazepines : Give flumanezil in small doses - only done by trained staff

iii) Salicylates: have mixed respiratory alkalosis (tachypnoea and tachycardia) + metabolic acidosis. Bicarbonate infusison

iv) Opiod: worry is respiratory depression. treatment is with lowest dose nalaxone to start with. Lofexidine for withdrawal symptoms. 

v) TCA - Cardiotoxic effects (QRS widening and right axis deviation), sedation, seizures. Bicarbonate infusion

vi) SSRIs - seizures, arrhythmias, rhabdomyolysis, high temperature. seratonin antagonists- cyproheptatidine 

Long term management

Bio-psycho-social

Biological - After treatment of the overdose, biological mangement should be based upon clinical findings of mental illness. Consider discussions regarding anti-depressants with patients but patients should be warned of transient worsening of mood up to  6 weeks after treatment initiation. (they should be reviewed within a week of commencement). Lithium augmentation can be considered as this has been shown to be effective in treatment of suicidality. 

Consider antipsychotics etc. where appropriate.

treatment of concurrent substance abuse 

Psychological - treatment options should be discussed with patient and discussions should be noted in the discharge letter to the GP. CBT, DBT/Mentalising - BPD, Family Therapy. 

Screen for substance abuse 

Social - Discussion of social precipitants should occur. These should be elicited and may include - employment and relationship discord. Recent bereavement etc. 

Should be given information regarding help services i.e. samaritans etc. give leaflets phone numbers etc.

 

 

Treatment of abuse

Alcohol: Chlordiazepoxied (reducing dose) , Acamprosate, Disulfiram

Opiate: withdrawal - Lofexidine, abstinence - buprenoprhine (partial), methadone (full) 

 screen for mental health 

 

9

Mental Health Service Teams

Psychological therapy Services

Community Mental Health Teams 

Early Intervention Team

Home Treatment Team

Eating Disorder Services

Forensic mental Health Services

Liasion psychiatry Team 

Memory Assessment services

Perinatal mental Health Services 

Learning Disability Services

Older Adult's Services

Substant Misuse Services

CAMHS

Mental Health Rehabilitation 

Psychological therapy Services - Low intensity- high intesity psychological interventions

Community Mental Health Teams - MDT, walk 

Early Intervention Team

Home Treatment Team

Eating Disorder Services

Forensic mental Health Services

Liasion psychiatry Team 

Memory Assessment services

Perinatal mental Health Services 

Learning Disability Services

Older Adult's Services

Substant Misuse Services

CAMHS

Mental Health Rehabilitation 

10

MSE

 

 

ASEPTIC

Appearance and behaviour - eye contact, dress, hygiene, abnormal motor activity (akathisia, dystonia, tardive dyskinesia, bradykinesia) 

Speech - Tone rate and volume (pressure, loosness of association, knight's move, word salad, circumstantial, tangiential), Spontaneous, Logical and Coherent. 

emotion - Mood and affect. Subjective and objective 

Perception - hallucinations and illusions

Thought - Content ( negative, ruminations, obsessions, depersionalisation/derealisation, abnormal belifs, delusions) and process (flight of ideas, looseness of associations, thought block)

Insight - and judgement

cognition - time, person and place 

11

Dementia 

History: Memory, Mood, ADLs, Cognitive functioning, Dangers - driving, oven, swimming, stairs ,

What timescale?

Worsening? When it's worse?

Movement problems?

Falls?

Hallucinations/ Delusions? 

Social withdrawal? 

Carer - Are you coping, Do you have health problems in yourself? 

substance abuse, depression, incontinence, balance problems. 

PPH 

Dx:

AMTS (<8/10), MOCA, 

Mx:

First - I would like to rule out organic causes

Bio - Acetylcholinesterase Inhibitors (Rivastigmine), Memantine, Avoid antipyschotics (if he's admitted tell them antipsychotics) 

Psycho - CBT, Behavioural therapy, Memory Clinic, 

Social - Carers, Support Groups, Carer Support, Carer Respite, ADvanced directives, lasting power attorneys  

12

AMTS 

A image thumb
13

Where to seek advice about toxicity

Toxbase

Lactmed

and BUMPS ( for mums ) 

14

Schizophrenia 

Hx

Dx

Mx

 

Imbalance in dopamine in the brain too much dopamine in mesolimbic (positive) and too little in mesocortical pathway (negative) 

Hx: 

Social withdrawal, delusional perceptions, overvalued ideas, negative symptoms (Blunted affect etc.), hallucinations (auditory usually), 

First Rank Symptoms:

Third person Auditory Hallucinations

Delusional Perceptions

Passivity Phenomena 

Thought DIsorder - TI, TW, TB 

Need to present for more than a month 

may be related to drug/alcohol abuse 

Dx

Clinical diagnose, Say you would exclude organic causes and screen for alcohol/ drug abuse. 

Consider other causes - structural, drug use,

If <1month = Acute and transient episode 

Schizophreniform Disorder = Acute traumatic experience 

Schizoaffective = 50% mood 50% psychotic component

Depression with psychosis = more than mood than psychotic features

 

Mx

Bio - Atypical Antipsychotic (unless elderly due to stroke or VTE risk) - Aripiprazole has least metabolic/weight gain side effects, Risperidone, Olanzapine, Quietiapine

Try two antipsychotics for 4-6 weeks (one being atypical)  then start clozapine ( clozapine monitoring. Once a week for 18 weeks, Two times a week for upto a year and then monthly)

Consider depot in poor compliance

Newly diagnosed patients are advised to be treated for 2 years 

Screen for concurrent mental health 

Psycho - CBT, Family therapy, Counselling for alcohol/drug use. 

Social - Support groups, Back to work schemes, Educational Schemes 

 

15

Anorexia Nervosa

 

Bullimia Nervosa

AN

Hx: Obsession with being fat, obsession with food, Obsession with purging/exercise/laxative use, Avoidance of food, Avoidance of social activities involving food

ICD-10 : BMI >17.5, self induced wieght loss, distorted body image and endocrine disturbance

Derm - Hiar changes (lenugo), dry skin, brittle hair, Thickening on dorsum of hand 

Oral - teeth chains (erosions), parotid gland enlargement,

Endocrine  - amenorrhoea, signs of hyperglycaemia, hypothyroidism (low T3/T4), delayed puberty, electrolytes(Hypokalaemia, hyponatraemia, hypothermia, amenorrhoea), peripheral neuropathy, lack of concentration 

Screen for concurrent psych conditions

Dx:

Weight, Height, BMI. FUll examination 

Investiagte - urine dip ketones, glucose, toxins

FBC, CRP, ESR, BMs, Endo screen

ECG

Mx: 

Biological: dietician, slow re-feeding (in hospital 1kg a week or outpation 0.5 kg a week), Monitor electrolytes, Consider SSRI (Fluoxetine

Psycho: CBT, Psychodynamic, CAMHS

Social: Family therapy, SUpport groups, 

Refeeding Syndrome:

Sx- Cardiac arrhythmias, convulsions and coma

Caused by fatal shifts in fluids and electrolytes after reinstutition of feeding.

 

 

Bullemia Nervosa

i) BMI >17.5 ii) Purging activities iii) Bing eating/ cravings for food iv) morbid fear of being fat 

 

Managemenet similar to AN. But moreso use of high dose fluoxetine (60mg). Generally not treated in hospital. 

 

SCOFF questions

Make your self sick

Loss of control of how much you eat 

One stone loss in a 3 month period

Think you're fat when others say you are thin

Would you say food dominates your life 

 

16

MSE For Dementia 

 

A - dishevelled, reduced eye contact, unkempt +/- abnormal motor activity (LBD)

S - was reduced in rate, tone and volume.

E - May be normal. 

P- Visual hallucinations in LBD 

T- Poverty of thought

I - Lack of inisght ( if insight present consider depression)

C - Impaired cognition

17

MSE FOR DEPRESSION

 

A - dishevelled with reduced eye contact

S was reduced in rate, tone and volume.

E - subjectively low mood and objectively hypothymic. Affected - blunted/irritable

P- No hallucinations or illusions present

T- Negative and ruminant thoughts. With poverty of thought

I - Usually have insight

C - Orientated to TPP.

18

FOR SCHIZOPHRENIA

 

A - dishevelled, unkempt, agitated, suspicious, poor eye contact 

S - ?. May be negative symptoms

E - may be normal. Affected - blunted (negative symptoms)/ hyperactive 

P- Hallucinations may be present

T- Delusions, Thought block, FLight of ideas/loosenes of  association

I - Lack of insight

C - Orientated to TPP ? 

19

MSE FOR MANIA

 

A - dishevelled, unkempt, agitated, elated

S - Increased tone, rate and volume 

E - Mood- hyperthymic. Affect - Exaggerated or heightened

P-  Hallucinations?

T- Delusions of grandeur, FLight of ideas/loosenes of  association, Knights move, 

I - Lack of insight

C - Orientated to TPP ? 

20

FOR SUBSTANCE ABUSE 

 

A - dishevelled, unkempt, agitated, suspicious, poor eye contact

S - Increased rate, tone and volume 

E - may be normal/hypothymic. Affected - Agitated, hyperactive 

P - Intact. ?Psychosis induced by drugs 

T- Ruminant thoughts regarding substance. 

I - Lack of insight

C - Orientated. 

21

Somatisation 

PC : Pain somewhere. SOCRATES. 

Associated:

URTI (Mesenteric adenitis) 

Vomiting,

diarrhoea,

blood rash,

weight loss,

constipation,

urinary symptoms,

wake up at night with the pain 

---> IF NO then more likely somatisation

HPC: ICE. Has this happened before? Does it happen in more than one location/time? Do you get pain anywhere else?

Review: How are thing at home? How are things at school? Are you happy? Screen for abuse. Any unexplained injuries/ bruises? Ask about school performance? Ask about change in circumstance? Ask about parental relationship/employment? Substance Misuse?

 

Dx: 

>3 months cannot be medically explained and be effecting functioning. 

Exclusion. Need to thnk about normal causes of stomach pain and offer these investigatons to the examiner to show you're not being negligent.  (FBC, CRP, ESR, LFTs, Diary of the pains, Urine Dip, BM) 

Don't want to over-investigate as somatisation is the top differential

Examinations - General, abdominal, if concerned abuse (look for scars or bruising and consider genitalia exam)

Try to find underlying emotional disturbance. 

 

Manage:

Make a plan with the school/ or whatever is causing it and enforce that they should continue despite pain. 

Bio - Agree that the pain is real. Mild analgesics (paracetomal) 

Psycho - Safety Net - Come back if doesn't get better in Family Therapy, CBT if severe prolonged, School involvement. Refer to CAMHS (if prolonged). Safety Net - if they continue to have this 

Social - Social Services referral