Psychiatry Mbchb4

ANXIETY DISORDERS

1. Definition – Anxiety
a. Unpleasant feeling assoc w ideas of danger
b. It is abnormal when it occurs in –
i. an inappropriate context – eg in presence of minor threat (phobia) or when Ø danger present (PTSD)
ii. at the intense end of the spectrum
2. Epidemiology
a. Lifetime prevalence – 15-30%
b. Age of onset – 80% <35 yrs age
c. Risk factors
i. Female
ii. Ø married
iii. U/E, low SES
iv. Negative life events
3. Categories
a. Panic Disorder +/- Agoraphobia
b. Specific phobias
c. Social phobia
d. OCD
e. PTSD / Acute stress d/o
f. GAD
g. Anxiety due to GMC?
h. Subst induced
i. Anx d/o NOS (not otherwise specified)
4. Co-morbidities
a. Other anxiety d/os
b. Depression (↑ neg affect sxs in addition to ↓ pos affects sxs; cf depr ↓ pos sxs only)
c. Alcohol and subst abuse/dependence
5. Etiology
a. Genetics + Evt
b. Life events
c. Personality
6. Neurobiology
a. Not completely understood
b. GABA, Serotonin, Nor-adr are all involved
c. Role of amygdale and the fear pway

Panic Disorder

1. Defintion – Panic Disorder
a. Recurrent and unexpected attacks of intense fear and discomfort peaking in 10 mins w 4 of 13 from – “PANICS”
i. Palpitations, Paresthesias
ii. Abdominal distress
iii. Nausea
iv. Intense fear of dying or losing control, lIght headedness
v. Chest pain, Chills, Choking, disconnectedness
vi. Sweating, Shaking, Shortness of breath
b. Occur in instances where there is no real danger
c. Followed by persistent concern about having another attack or about the implications of panic attacks
d. Described in context of occurrence – eg panic d/o w agoraphobia
2. Agoraphobia common – fear of situations where escape might be difficult (ie having a panic attack in public)
3. Epidemiology
a. F>M
4. Differential Dx
a. Organic/Medical condition – pheochromocytoma, hyperthroidism
b. Social phobia – panic attacks in soc sits
c. Mood d/o – often co-exist
5. Management
a. Education – about the d/o
b. CBT – tailored for panic d/o
i. Control of panic sxs
ii. Desensitisation to fear
c. Meds –
i. antidepressants (SSRIs)
ii. Benzos (ST only due to ↑ tolerance) - ↓ dose of benzos assoc w risk of seizures and psychosis

Social Phobia

1. Def
a. Fear of being scrutinised or being evaluated negatively by other people
b. Common situations incl – eating/drinking in public, public speaking, writing in presence of others, using public toilets, being in social situations in which the individual may say or do foolish things
c. Exposure to feared situation (individual variability) causes immed anx responose
d. May be similar to pani
e. Sxs can cause further embarrassment
f. Results in avoidance of feared sit
g. Often shy when young
2. Differential Dx
a. Normal social anx or avoidance
b. Avoidant personality
c. Agoraphobia
d. Specific phobia
e. Schizophrenia
f. Delusional d/o
g. Schizoid PD – these individuals do not like social contact, social phobics still have social needs
3. Management
a. Education – about the anxiety
b. Mgt of any co-morbid subst abuse
c. CBT
i. Controlling panic sxs
ii. Graded exposure to feared sits (short expos may ↑ the fear, ensure long expos by not overloading pt too early)
iii. Relearning basic social skill and conversational skills
d. Meds
i. SSRIs (Ø inhibit therapy)
ii. Benzos – ST only (will inhibit therapy)

Specific Phobias

1. Def
a. Specific fear that is excessive or irrational and avoidance of a particular object or sit - interferes w normal routine
b. Person recognises fear is excessive (insight), yet exposure provides anx response
c. 2 general themes
i. places where falling, suffocation, drowning are possible
ii. Potential harmful objects – spiders, insects, snakes, carnivorous animals (?evolutionary advantage)
d. a
2. During exposure to feared situation
a. ↑ HR, pounding
b. Trembling
c. Faintness, light headedness
d. Difficulty breathing
e. Sweating
3. Differential Dx
a. Panic d/o
b. Social phobia
c. Agoraphobia
d. OCD
e. PTSD
4. Management
a. Education about condition
b. CBT
i. Systematic desensitisation
ii. Control of anx/panic
c. ?B-blockers

Generalised anxiety disorder (GAD)

1. Def
a. Persistent, generalised and excessive feelings of anx
b. Uncontrollable anxiety for >6 months, unrelated to anything specific
c. Sleep disturbance, fatigue and difficulty concentrating are common
d. Common themes – possibility of becoming ill or having accident, financial difficulties, work/social performance
2. Anxiety with 3 of 6 – “Mcbeth frets constantly regarding illicit sins”
a. Muscle tension (headaches)
b. Fatigue
c. Conc
d. Restlessness
e. Irritability
f. Sleep
3. Differential Dx
a. Medical/organic disease
b. Mood disorder
c. Panic d/o – acute intense attacks rather than chr b/ground anxiety
4. Management
a. Education re anxiety
b. CBT – controlling anxiety and reducing stress
c. Meds – SSRI, avoid benzos

PTSD

1. Feats
a. Long lasting anxiety response following a traumatic/catestrophic event
b. Typical events – violent assault, torture, being hostaged, severe accidents, witnessing unexpected death/accidents
c. Response involves fear, helplessness or horror
d. Leads to avoidance of stimuli assoc w the trauma and persistently incr arousal
e. Disturbance lasts >1 month and causes distress or social/occup impairment
f. Often follows acute stress d/o which can last up to 2-4 wks
2. Mnemonic – “RAAW”
a. Re-experiencing – nightmares, flashbacks, images
b. Avoidant behaviour
c. Arousal, Hypervigilance – easily started, intense arousal and anxiety on exposure to trauma cues
d. Withdrawal - Social withdrawal, emotional blunting (flat affect)
3. Differential Dx
a. Acute stress d/o (<1 month)
4. Management Plan
a. Education re PTSD
b. CBT
c. Meds

OCD

1. Defintion
a. Obsessions – thoughts, images, impulses → persistent, intrusive, unwanted
i. Examples – contamination, blasphemy, disasters, violence, sex, harm to self/others
ii. Recognised as coming from own mind
iii. Recognised as irrational
iv. Very distressing
b. Compulsions – actions or behs which are present and uncontrollable, usu assoc w the obsession
i. Washing, Cleaning
ii. Arranging, Doing things in a specific order
iii. Counting
iv. Praying
2. Differential Dx
a. Excessively repeated pleasurable behs
b. Depressive d/os
c. Delusional/Psychotic d/os
d. Obsessive-compulsive PD
3. Management Plan
a. Education about disorder
b. CBT – graded exposure + response prevention (allow obsession but not the compulsion)
c. Meds – Serotonin antidepressants (SSRIs, clomipramine, MAOIs

DSM 1V

Diagnostic and Statistics Manual of Mental Disorders

1. Definition
a. Handbook for mental health professionals
b. Lists different categories of mental d/o and the criteria for diagnosing them, according to the APA
c. Categorical classification sys
d. Categories are prototypes and a pt w a close approximation to the prototype is said to have that d/o
e. No assumption that each category of mental d/o is a completely discrete entity with absolute bountaires
2. Multi-axial system
a. Organisation of each psychiatric dx into five levels (axes) related to different aspects of disorder or disability
b. Axes
i. Axis 1 – clinical d/os, incl major mental d/o, as well as devt and learning d/os
1. Common conditions incl – depr, anx d/os, BPAD, ADHD, Schizophrenia
ii. Axis 11 – underlying pervasive or personality conditions, as well as mental retardation
1. Common conditions incl – borderline PD, schizotypal PD, antisocial PD, narcissistic PD, mild MR
iii. Axis 111 – Acute medial conditions and physical d/os
iv. Axis 1V – Psychosocial and dtal factors contributing to the d/o
v. Axis V – Global assessment of functioning or children’s global assessment scale if <18 years age (Scale from 100 to 0)
3. Other diagnostic guides
a. ICD = International Statistical Classification of Diseases and Related Health Problems

MENTAL HEALTH ACT

Section 10 – preliminary assessment
Section 11 – further assessment for 5 days

Section 13 – further assessment and tx for 14 days

Section 28 – compulsory tx order
Section 29 – community orders
Section 30 – inpateint orders

Section 44 – special pts (treated as though under a compulsory tx order)

Section 45 – application for assessment for prisoners in penal institutions

Section 16 – at any time, a pt can ask for review by a judge

MENTAL STATE EXAM (MSE)

MSE
1. A Snapshot of how the pt presents at the time you see them
2. An assessment throughout a number of domains that provide a comprehensive summary of your interview

Pitfalls
1. Be specific – qualify your subjective impressions with examples
2. Don’t use terms such as normal/abnormal
3. Don’t use terms such as bizarre, agitated, delusions etc w/o qualifying with specific examples

Mnemonic BOAT PIS

1. Behaviour and Appearance
a. Appearance
i. Age – young, middle aged, elderly
ii. Gender
iii. Hair colour
iv. Make up
v. Glasses
vi. Overweight or not
vii. Clothes they are wearing – comment if it looks dirty (specifics, don’t just say dirty)
viii. Hygiene
ix. Jewellry and make up (females) – marker of conc and energy
x. Facial hair (males)
b. Behaviour / Neurological Observations
i. Eye contact (absent in depr)
ii. Presence or absence of agitation – eg they presented as agitated, continually shaking their left leg, arising twice during interview with animated hand gestures… (agitation arises in a number of situations)
iii. Slowness
iv. Anxiety
v. Suspiciousness
vi. Threatening
c. Rapport - eg I felt we had good rapport as I felt they answered my questions openly and honestly
2. Orientation / Cognitive Assessment
a. Time person place
b. Folstein’s mini mental state examination (MMSE) – 30 point questionnaire to assess cognition and screen for dementia
i. Samples various functions such as arithmetic, memory and orientation
ii. Also useful in non-dementia assessments
iii. Describe the areas in which the pt dropped marks
iv. Disorientation suggests an organic d/o
v. Psychosis and affective d/os are assoc w ↓ attn and conc
3. Affect and Mood
a. Mood
i. Subjective
ii. Objective
b. Affect – external manifestation of a mood state
i. Congruency
ii. Range – flat → blunted → full → expansive (+/- restricted range)
iii. Changeability – Labile (usu in severe mania or psychosis)
iv. Intensity
4. Talk
a. Speech
i. Rate
ii. Rhythm
iii. Volume
iv. Reactivity – in normal speech, eg pitch goes up towards the end of the question
v. Spontaneity - do they talk when not asked a question, offer more info than asked for, depr typically no spontaneous speech
vi. Examples
1. Depr – flat, monotone, quiet, Ø spontaneous speech (ie answering more than yes/no) – unlikely to be depr as reqs energy
2. Mania – fast, loud, spontaneous, pressure of speech
b. Thought form
i. Presence or absence of a thought disorder
1. If present, describe which type and give specific examples
2. Thought disorders (pattern of disordered lang that is presumed to reflect disordered thinking; usually occurs as a sx in a psychotic illness)
a. Pressure of speech – spontaneous speech which is rapid and incessant
b. Flight of ideas – streams of unrelated words and ideas occur to pt at a rate impossible to vocalise despite pressured speech (manic phase BPAD)
c. Distractible speech – during mid speech, subject is changed in response to a stimulus
d. Tangentiality – reply to a question in oblique, tangential or irrelevant manner
e. Derailment / Loose Assoc (knights move thinking – ideas slip off tract to another which is obliquely related or unrelated
f. Incoherence (word salad) – individual words intact but speech incoherent
g. Illogicality – conclusions are reached that do not follow logically
h. Circumstantiality – speech very delayed at reach its goal, excessive long windedness
i. Loss of goal – failure to show a chain of thought to a natural conclusion
c. Thought content
i. Recurrent themes
ii. Delusions - fixed false belief, not amenable to reason, not in keeping with person’s subculture, education or religion (give ex.)
1. Caution reqd – you need a collateral hx before confirming a delusion
iii. Obsessions/Compulsions
iv. Phobias
v. Suicidal thoughts
5. Perceptions
a. Hallucinations – perception in the absence of a stimulus; visual, auditory, olfactory, gustatory or tactil
i. Auditory hallucination most impt hallucination for diagnostic purposes
ii. Describe hallucination in detail – eg 2nd or 3rd person etc
b. Illusions – misperception of a stimulus
6. Insight and Judgement
a. Insight
i. Does patient recognise that experiences are abnormal?
ii. Do they recognise they have a mental illness?
iii. Do they recognise they need treatment?
b. Judgement
7. Safety
a. Risk of self harm
b. Risk of harm to others
c. Risk of self negligence
i. Impt indicators of risk –
1. Past behaviour
2. What the pt is saying
3. Male
4. Age - <65 for suicide, <25 for violence
5. Alcohol or drug abuse
6. Living alone
7. Unemployed
8. Chr physical illness
9. Antisocial traits
10. Culture of violence
8. → Differential Dx - DSM Axis 1

Mini-Mental State Examination

Maximum Score Score
ORIENTATION
5 ( ) What is the: (year) (season) (date) (day) (month)
5 ( ) Where are we: (state) (county) (town) (facility) (floor)
REGISTRATION
3 ( ) Name three objects and have person repeat them back. Give one point for each correct answer on the first trial.
1. _ 2. _ 3. _
Then repeat them (up to 6x) until all three are learned.
[Number of trials _
_ ]
ATTENTION AND CALCULATION
5 ( ) Serial 7's. Count backwards from 100 by serial 7's. One point for each correct answer. Stop after 5 answers. [ 93 86 79 72 65 ]
Alternatively spell "world" backwards. [ D - L - R - O - W ]
RECALL
3 ( ) Ask fo rthe names of the three objects learned above. Give one point for each correct answer.
LANGUAGE
9 ( ) Name: a pen (1 point) and a watch (1 point)
Repeat the following: "No ifs, ands, or buts" (1 point)
Follow a three-stage command: "Take this paper in your [non-dominant] hand, fold it in half and put it on the floor". (3 points)
[1 point for each part correctly performed]
Read to self and then do: "Close your eyes" (1 point)
Write a sentence [subject, verb and makes sense] (1 point)
Copy design [ 5 sided geometric figure; 2 points must intersect]
(1 point)
Score: /30 Alert Overtly Anxious Concentration Difficulty Drowsy
CLOSE YOUR EYES

Sentence:

MOOD DISORDERS

Overview

1. Differentiating normal sadness from depression
a. Normal sadness triggered by event, return to baseline occurs (ie set point theory)
b. In normal sadness, functioning is retained – ie person still goes to work, eats, daily routines etc
c.
2. Classifications
a. Depressive disorders (predominant mood is depr, no elevations/mania)
i. Major depression, single episode
ii. Major depression, recurrent
iii. Dysthymic disorder
iv. Other variants – atypical depression, postpartum depr, seasonal affective disorder, depr w pschosis
b. Bipolar disorders (elevations/mania and depressions)
i. Bipolar disorder, manic
ii. Bipolar disorder, depressed
iii. Bipolar disorder, mixed
iv. Cyclothymic disorder
v. Other variants – Bipolar 1 and 11, rapid cycling, ultra rapid cycling
c. a
3. Differential dx
a. Depression
i. BPAD – mixed episode
ii. 2ndry to general medical condition
iii. 2ndry to substance abuse
iv. Bereavement – anhedonia is NOT lost, ie ask a grandparent about their grandchildren and they will smile

Depression

1. Epidemiology
a. Lifetime prevalence major depressive episode – 5-12% M / 10-25% F
2. Major Depressive Episode
a. At least 5 of the following 9 for >2 weeks including either depressed mood or anhedonia
b. SIG E CAPS
i. Depressed mood
ii. Sleep disturbance* ↑ or ↓ - key dx feature is early-morning awakenings
iii. Interest loss or anhedonia
iv. Guilt or feelings of worthlessness
v. *Energy ↓
vi. *Concentration ↓
vii. *Appetite ↑ or ↓ (or change in weight)
viii. Psychomotor disturbances – retardation or agitation
ix. Suicidal thoughts
c. *Neurovegetative sxs – sleep, energy, concentration, appetite, libido (SECAL)
d. Other sxs not in the DSM 9
i. Irritability and anger (esp men)
ii. Unexplained physical complaints (somatizers)
iii. Delusions and hallucinations (very severe depressions) – always need to rule out a mood d/o w psychosis
3. Major Depressive Disorder
a. Recurrent – requires 2 or more episodes with a sx free interval of 2 months
4. Dysthymia
a. Milder form of depression >2 years
b. Rule of 2s
i. At least 2 sxs
ii. Minimum 2 years
iii. Never w/o sxs for more than 2 months
5. Treatment
a. SSRIs or TCAs
b. ECT (electroconvulsive therapy)
i. For major depressive disorder refractory to other tx
ii. Produces painless seizure
iii. Major adv effects – disorientation, anterograde and retrograde amnesia

Bipolar Affective Disorder (BPAD)

1. Defintion
a. 6 separate criteria exist for bipolar disorders with combinations of manic (bipolar 1), hypomanic (bipolar 11) and depressed episodes
b. 1 manic or hypomanic episode defines bipolar disorder
2. Epidemiology
a. Commonly young adults 20-30s but can be later
b. Later onset is easier to tx
3. Manic Episode
a. Distinct period of abnormally and persistently elevated, expansive or irritable mood lasting >1 week
b. During disturbance, 3 or more of –
c. DIG FAST
i. Distractability
ii. Irresponsibility – seeks pleasure w/o regard to the consequences
iii. Grandiosity – inflated self esteem
iv. Flight of ideas – racing thoughts
v. Goal directed activity ↑ / Psychomotor agitation
vi. Sleep need ↓ (v effective at predicting a manic phase)
vii. Talkative or pressured speech
d. Not due to medical condition, substance abuse, mixed episode
4. Features
a. Mania myth – people are not always cheerful, enthusiastic, happy, euphoric etc
b. Irritable, hostile, cutting – common
c. Normal mood approx ½ of the time, depr 47% and manic only 3% of the time!
d. Poor response to antidepressants – think BPAD (TCAs can actually shoot depressed BPAD person into mania!)
5. Hypomanic Episode
a. Like mania episode except mmod disturbance not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalisation
b. No psychotic features
6. Cyclothymic disorder
a. Milder form of lasting >2 years
7. Tx
a. If sleep need is ↓ indicating a manic episode → you can interrupt the cycle by making the person sleep
b. Lithium (mood stabiliser)

Risk Issues that need to be addressed

1. Depression
a. Suicide
b. Poor self cares – not hygiene etc, rather tasks essential for life ie eating, water, taking meds
c. Unable to care for dependents
d. Suicide-homicide (ie postpartum)
2. Mania
a. Rarely suicidal
b. Impulsivity – anger, lashing out
c. Less inhibitions – driving, sexual, spending
d. Bec of loud in your face behaviour – risk of assault
3. Depending on family support etc, individuals may need to be contained within a hospital

Asking the hard questions

Suicide
“It sounds like things have been stressful for you, have you ever thought about giving up (that life isn’t worth living anymore)?”
If you get a positive response, never ask closed questions! Eg “Have you ever thought about how you would do it?”

Harming others
“Have you ever felt so angry, that you wanted to hurt someone or lash out at them?”

Hallucinations
“Sometimes when people feel …., their mind sometimes plays tricks on them. Has this ever happened to you?”

OLD AGE PSYCHIATRY

1. Principles of Assessment
a. Pt always have a relevant medical hx
b. Quiet rooms – hearing impairments
c. Slow pace of interview, take breaks if needed
d. Consult family early
e. Assess caregiver status
f. Consult w rest home, nursing home, inpatient nursing staff
g. Use Mr and Mrs until invited otherwise
2. Barriers to good assessment
a. Ø informed consent from pt
b. Perceived stigma of psychiatric interview
c. Sensory deficits – vision, hearing
d. Older pts → disorientation/anxious in unfamiliar evts
e. Hxs take longer
f. Clinical ageism
3. Impt Conditions – 3Ds
a. Depr → Under-recog and missed, often severe, treatable, complicates other d/os in the elderly
b. Dementia
c. Delirium

Depression and older people

1. Everyone gets down now and then – this is Ø clinical depr
2. Lifetime prev high – 25%
3. Very severe depr mood and loss of interest in usual activities
a. Anhedonia
b. Demotivation and loss of functioning
c. Poor self cares
d. Poor self worth/esteem
e. Pessimism about self and future
f. Neuroveg sxs
i. sleep disturbance – early morning wakening
ii. Appetite disturbance – weight loss
iii. Psychomotor retardation/agitation
iv. Diurnal variation of mood
v. Vegetative sxs – libido loss, constipation, general slowing of body functions
vi. Lack of attn, Conc loss
4. Why is depr under-diagnosed?
a. Sxs often confused w those of physical illness
b. Sxs considered appropriate for life stage
c. Older pts put sxs down to aging
d. Doctors think depr cant be treated or tx is dangerous
e. Older people considered less deserving of referral
5. Consequences of mixed dx
a. Poor QOL
Premature institutionalisation
b. Inappr institutionalisation
c. Suicide
d. ↑ morbidity and longer hospitalisations or concomitant physical illness
6. Suicide and elders
a. Underestimated – disguised as other deaths
b. Elders less likely to draw attn to their suicide
c. Higher rate of success in elders
d. Risk factors for suicide in late life
i. Male
ii. Living alone or recently widowed
iii. Poor social support or NW
iv. Physical illness or chr pain
v. Terminal illness
vi. Presence of psychiatric d/o – depr, early cogv impairment
vii. Financial difficulties, low SES

Dementia

1. Definition
a. Irreversible degenerative brain dis occurring usu in late life
b. Caused by loss of brain chemicals and degen of brain cells
c. Incidence 6-7% up to age 80, 20% thereafter
d. M=F
e. Several types dementia
f. Features
i. Memory loss – esp ST and immediate (LT and procedural mem preserved until quite late)
ii. Problems w activities of daily living
iii. Personality change
iv. Neurological deficits – apraxia (behal disorganisation), agnosia (recog impairment), aphasia (aphasia)
v. Disorientation
vi. Lack of insight
vii. Organic cause
viii. Irreversible
g. Mnemonic – Memory + 1 of BREW
i. Behal disorganisation (apraxia)
ii. Recog impairment (agnosia)
iii. Executive function
iv. Word problems (aphasia)
2. BPSD (Behal and Psychological Sxs of Dementia)
a. BPSD is a complication of dementia
b. Causes of BPSD
i. Disease affecting specific brain region – eg frontal lobes, amygdale
ii. Psychosis resulting from brain dis
iii. Poor adjustment to cogv impairment
iv. Failure of mastery and competency
v. Result of tx etc
c. Sxs incl –
i. Personality change
ii. Psychotic phenomena – delusions, hallucinations
iii. Psychomotor retardation or agitation
iv. Apathy
v. Depr
vi. Delirium
vii. Perceptual abnormalities – illusions, misinterpretations
viii. Falls
ix. Behal probs – verbal/physical aggr, screaming/shouting, wandering, hassling, inappropriate incontinence etc
3. Treatment strategies for problem behaviours
a. Analysis of system supporting behaviour
b. Behaviour and validation therapies
c. Compensation for physical or cogv deficits – hearing aids, glasses etc
d. Drugs – SSRIs, antipsychotics
e. Etal manip – education and support of carers

Delirium

1. Defintion
a. Reversible d/o of cogn caused by a pathophysiological factor that is extraneous to the CNS
b. It is characterised by waxing and waning in LOC
2. Criteria
a. Disturbance in LOC w fluctuations throughout the course of the day
b. ↓ ability to focus, sustain or shift attn
c. Rapid onset
d. May co-exist with dementia – “sundowning” confusion late in day
3. Epidemiology
a. Occurs mostly in v young (developing brain is myelinating) and old (brain is demyelinating)
b. Prev as high as 50% of geriatric inpatients
4. Disturbance is caused by the direct physiological conseq of a medical condition
a. Inf and fevers
b. Hypoxia
c. Toxins
d. Drugs
e. Metabolite abnormalities
f. Physiologic effect
5. Etiology
a. Systemic infections
b. Hypoxia or Hypercarbia
c. Metabolic dysfunction eg hypogly
d. E/lyte or fluid disturbance
e. LF or RF
f. Post op states
g. Thiamine deficiency and alcohol withdrawal
h. Post ictal states
i. Stroke, cerebral hem or head injuries
6. Drug and Toxin causes of Delirium
a. Benzos!!!
b. Several others – eg TCAs, Steroids, opiates, analgesics, lithium etc
7. Clinical features of acute delirium
a. S/S
i. Fluctuating LOC throughout the day
ii. Attention deficits or shifts
iii. Misperceptions and hallucinations
iv. Agitation
v. Disorientation – time, place, person
vi. Language disturbances
vii. Apraxia – visiospatial deficits
b. Medical FRAT
i. Medical cause
ii. Fluctuating course
iii. Recent onset
iv. Attention impairment
v. Thinking impairment
8. Differential Dx
a. Dementia
b. Psychosis
c. Mood d/o w psychotic feats
9. Mgt of Delirium
a. Delirium Screen
i. U/E
ii. FBC, ESR, CRP
iii. MSU
iv. Toxin screen – alcohol, drugs
v. BG
vi. Renal and LFTs
vii. Drug or toxin levels
viii. CXR
ix. ECG
x. CT Scan
b. Tx → underlying cause
i. Eliminate cause and tx medical condition
ii. Nurse in low stimulus room – heavy drapes, no pictures on walls, eliminate shadows
iii. Attn to IV lines etc
iv. Re-orientate during lucid periods
v. Familiar staff and relatives
vi. Haloperidol or Respirodone in v low doses often
10. Outcomes – Delirium and Dementia
a. ↑ risk of LT cogv impairment
b. More likely to go to LT care
c. Higher mortality

PERSONALITY DISORDERS

1. Definition
a. Mental disorder characterised by a mental state that is episodic and treatable
b. PDs are more integral personality characteristics in a person’s life
2. Classification systems
a. Categorical classification systems
i. DSM4 – more comprehensive for mental health
ii. ICD10 – hospital based, more general
b. Dimensional classification systems – ie personality is on a continum
3. DSM Classification
a. Cluster A – Odd, Eccentric
i. Paranoid – suspicious, mistrustful
ii. Schizoid – detached, socially withdrawn (indifferent to praise/criticism)
iii. Schizotypal – odd, strange (peculiar beliefs/ideas, milder spectrum of schizophrenia)
b. Cluster B – Dramatic, Emotional, Erratic
i. Antisocial – antisocial behs, criminal traits
ii. Borderline – instability (r/ships, mood, self image) – most common PD encountered in mental health setting
iii. Histronic – excitable, emotional, extroverted (attn seeking beh)
iv. Narcisstic – heightened self importance
c. Cluster C – Anxious, Fearful
i. Avoidant – anxious, sensitivity, fear of rejection, social withdrawal but still social desire, shy, eager to please, they have to be liked/accepted, low self-confidence
ii. Dependent – responsibility over one’s life given to others, will often tolerate an abusive partner
iii. Obsessive compulsive – orderly, inflexible
4. Impt features
a. Schizotypal PD, association of schizophrenia in relatives
b. BPD – assoc w affective disorders, problems of child abuse/neglect
5. Etiology
a. Congenital/Genetic
b. Temperamental – eg Cluster C PDs tend to develop in fearful children
c. Organic – eg soft (non-focal) neuro signs (eg flaccidity) assoc w ASPD/BPD
d. Developmental factors – devtal states not adequately negiotated (ie trust vs mistrust at age 1) eg harsh punitive parents are associated with obsessive compulsive PD and childhood abuse/neglect assoc w ASPD/BPD
e. Trauma / Head injury / Organic brain disease
f. Severe mental illness can permanently affect personality
6. Tx
a. Very difficult
b. BPD and ASPD can receive some txs
c. DPT (dialectal behal therapy) is becoming increasingly employed w BPD

Anti-social Personality Disorder (APD)

1. Features
a. Disregard for social rules, norms, cultural codes
b. Impulsive behaviour
c. Indifference to rights and feelings of others
d. Limited range of human emotions → lack of empathy for the suffering of others
e. Indifferent to the possibility of physical pain or punishments – no fear when so threatened
f. Risk seeking beh and subst abuse may be attempts to escape feeling empty or emotionally void
2. Epidemiology
a. M>F
b. Lifetime risks – M 6%, F 1%
c. Penitentiaries – estimated to be as high as 75%
d. Clinical settings – estimated up to 30%
3. Diagnostic criteria – DSM1V TR
a. Can only be diagnosed after 18 years of age
b. A pervasive pattern of disregard for and violation of the rights of others occurring since the age of 15 as indicated by 3 or more of –
i. Failure to conform to social norms with respect to lawful behs as indicated by repeatedly performing acts that are grounds for arrest
ii. Deceitfulness, as indicated by repeated lying, use of aliases or conning others for personal profit or pleasure
iii. Impulsivity or failure to plan ahead
iv. Irritability and aggressiveness, as indicated by repeated physical fights or assaults
v. Reckless disregard for safety of self or others
vi. Consistent irresponsibility as indicated by repeated failure to sustain steady work or honour financial obligations
vii. Lack of remorse, as indicated by being indifferent to or rationalising having hurt, mistreated or stolen from another
c. Additional necessary criteria
i. Evidence of conduct disorder w onset <15 years age
ii. Occurrence of antisocial beh is not exclusively during the course of schizophrenia or a manic episode
d. A child who shows signs of APD may be diagnosed as having either conduct disorder or oppositional defiant d/o – not all of these children will grow up to develop APD
4. Etiology
a. Unknown but biological or genetic factors may play a role
b. F.hx of d/o incr the chance of developing the condition
c. Etal factors incl lack of consistent discipline and affection, abnormal tendency to alcoholism
5. Potential markers
a. MacDonald triad – bedwetting for longer than usual, cruelty to animals, pyromania

Borderline Personality Disorder (BPD)

1. Definition
a. A PD primarily characterised by emotional dysregulation, extreme black and white thinking (or splitting) and chaotic r/ships
b. General profile of the d/o also typically includes pervasive instability in mood, interpersonal r/ships, self image, identity and beh and a disturbance in the individual’s sense of self
c. Pervasive pattern of instability of interpersonal r/ships, self-image and affects as well as marked impulsivity
d. Beginning by early a/hood and present in a variety of contexts
e. Classed on axis 11
2. DSM1V Criteria
a. 5 from the following 9 over a significant time period
i. frantic efforts to avoid real or imagined abandonment such as lying, stealing, temper tantrums etc
ii. pattern of unstable and intense interpersonal r/ships characterised by alternating betw extremes of idealization and devaluation
iii. identity disturbance; markedly and persistently unstable self image or sense of self
iv. impulsivity in at least two areas that are potentially self-damage – eg promiscuous sex, eating d/os, subst abuse, reckless drive, overspending, stealing, binge eating
v. Recurrent suicidal beh, gestures, threats or self-mutilating beh
vi. Affective instability due to a marked reactivity of mood eg intense episodic dysphoria, irritability or anx usu lasting a few hrs and only rarely more than a few days
vii. Chr feelings of emptiness, worthlessness
viii. Inappropr anger or difficulty controlling anger – eg freq displays of temper, constant anger, recurrent physical fights, getting mad over something small
ix. Transient stress-related paranoid ideation or severe dissociative sxs
b. Mnemonic – PRAISE
i. Paranoid ideas
ii. R/ship instability
iii. Angry outburns, affective instability, abandonment fears
iv. Impulse beh, identify disturbance
v. Suicidal beh
vi. Emptiness
3. Epidemiology
a. 1-2% of gen popn
b. F>M (esp young)
c. 20% in prison popns
4. Etiology
a. Traumatic childhood
b. Vulnerable temperament
c. Stressful maturational events during adolescence or a/hood
5. Differential dx
a. Affective disorders – eg mania; mood swings are rapid (does not occur in BPAD)
6. Co-morbidities
a. Affective d/os incl depr and BPAD
b. Anxiety d/os
c. Subst use
d. Eating d/os – anorexia and bulimia
e. Somatoform d/os – physical ailments (eg pain, nausea, depr, dizziness) for which there is no adequate medical explanation; implies that psychological factors are a large contributor to the onset/severity/duration of sxs; some are not the result of conscious malingering or factitious disorders

PSYCHIATRIC HISTORY

Mnemonic PP MFF PRS PMC

1. Presenting complaint
a. What are the pt’s problems
b. Why has the pt presented here and now
c. What is their understanding of why they are in hospital and their problem
d. Make a DSM Axis 1 dx and compose a mental state examination
e. 11 essential questions
i. Screening for depression– must be asked to exclude depr
1. Sleep
a. How has your sleep been recently?
b. What time do you normally go to bed?
c. How long does it take for you to get to sleep?
d. Do you ever find yourself lying there thinking about things a lot? What kind of things?
e. When do you wake up?
2. Mood
a. How would you say your mood has been recently?
b. How would you rate it on a scale of 1-10?
c. Are there many times in the day when your mood is worse?
3. Appetite
a. How has your appetite been?
b. How many meals do you eat a day?
c. Do you find yourself feeling hungry?
d. Have you lost any weight? How much over how long?
4. Concentration
a. How do you spend your day?
b. Do you watch much TV? Reading?
c. What is your favour program?
d. Are you able to watch all the way through?
e. If pt still vague – ask how their concentration has been
5. Energy
a. How have your energy levels been?
b. Have there been any days when you have not been bothered to leave the house? If so, when was the most recent occasion
6. Enjoyment
a. Do you have any hobbies? Are you still enjoying them?
b. Looking for anhedonia
ii. Screening for psychotic sxs – Schneider’s first rank sxs
1. Have there been any unusual experiences recently that you have not been able to put your finger on?
2. If no, have there been any times when you have heard noises that other people do not seem to hear, sometimes people can hear voices when they are on their own?
a. If auditory hallucinations present –
i. How many
ii. What they say
iii. Do you recognise them
iv. Do you hear them inside or outside your head
v. Are they good or bad
vi. Get example
b. a
3. Do you feel in full control of your actions? Do you ever feel as though people can make you do things you do not want to do? (passivity phenomenon)
a. If yes, find out if they know who is doing this and get example
4. Do you feel in full control of your thoughts? Do you ever feel as thought anyone or anything can mess about with your thoughts? Do you ever feel as though people can put thoughts in or take thoughts out? (thought interference)
a. If yes, find out if they know who is doing this and get example
5. Has anything happened recently of special significance? Do you ever get the feeling that there are messages for you that no one else can understand? Do you ever get the feeling that the TV, music or papers are referring to you? (delusions of reference)
a. If yes, get example
f. Suicide (never ever forget – automatic fail!)
g. Overdose patient
i. What did you take, what did you do?
ii. Did you leave a note?
iii. Did you have any alcohol?
iv. How did you end up in hospital?
v. How do you feel about it now?
2. Past psychiatric hx
a. Illustrates risk to self
i. “Have you ever tried to kill yourself before? How many times?”
ii. “Have you ever tried to hurt yourself?”
b. Idea of tx strategies employed in the past
i. “Have you ever been in contact with mental health services? First contact? What happened?”
ii. “Have you ever been admitted to a psychiatric hospital before? How many times?” Shortest and longest admissions?
iii. “Have you ever been held under the mental health act?”
iv. “Has anyone talked to you about a diagnosis? Do you agree with it?”
v. “What txs have been tried in the past?”
3. Past medical hx
a. May indicate a possible organic aetiology
b. Alerts you to cautions with medications
i. TCAs and Antipsychotics → long QT syndrome
ii. Benzos → respiratory depr
4. Family hx
a. Any hx of psychiatric illnesses in the family
5. Forensic hx
a. Potential risk to others
b. Clues to personality and ways of ocmping with stress – eg fighting, drink driving (alcohol dependence common), drugs charges
i. “Have you ever been in trouble with the law?”
ii. “Have you ever spent time inside?”
iii. “Have you ever been charged for assault?”
iv. “Have you ever been charged for drugs offences or drunk driving?”
6. Personal hx
a. Birth → c/hood → young adult → adult → old adult → pensioner
b. Birth trauma is assoc w mental illness – eg caesarean, forceps, premature babies
c. R/ships w siblings and parents (yields upbringing info and potential support networks)
d. Schooling
i. What school went to, did you enjoy it, did you have many friends?
ii. When left school, level of qualifications when leaving
e. Employment
i. How many jobs, what type of jobs?
ii. Why did they leave jobs? (consistent opposition to authority)
7. Relationships
a. Illustrates their personality and stability
b. Any children?
c. Support outside hospital
d. Length of current r/ship
e. Length of longest r/ship
f. Why did a r/ship end? (domestic violence)
8. Social hx
a. Social stressors incr the risk of relapse
b. Accommodation
i. Where do you live?
ii. Own or rent?
c. Income
i. Main source of income? Disability allowance?
ii. Do you owe anyone any money/
d. Drugs and alcohol
i. Do you smoke?
ii. Do you drink? How much? Do you ever get shaky or symptoms of withdrawal if you go without?
iii. Have you ever tried….. (ask about specific drugs)
e. Driving and have car (esp if on meds that may cause drowsiness)
9. Pre-morbid personality – best obtained through collateral hx
10. Current medications and allergies
a. What meds are they on and why?
b. How long?
c. Any side effects?
d. Do they think its working?
11. Collateral hx
a. Soures incl family, past hospital notes (psych and non-psych), GP records, probation officer, accommodation supervisor, keyworker

Tips
1. Thank you for talking to me, what is your understanding of why you’re in hospital?

PSYCHIATRIC PHARMACOLOGY

Antipsychotics

Antipsychotics (Neuroleptics)
1. Examples
a. Haloperidol
b. Chlorpromazine
2. Mechanism
a. Block D2 Receptors (excess mesolimbic dopamine assoc with schizophrenia)
3. Clinical Use
a. Schizophrenia (effective esp against positive sxs, not neg sxs or mood stabilisers)
b. Psychosis
c. Acute mania
4. Toxicity
a. Extrapyramidal system (EPS)
i. 4 hrs – acute dystonia (incr tone, rigidity)
ii. 4 days – akinesia (loss or impairment of voluntary activity of a muscle)
iii. 4 wks – akathisia (uncontrollable motor restlessness) – subjective feeling, don’t look agitated from the outside
iv. 4 months – tardive dyskinesia (invol uncontrollable mvments esp mouth, tongue, trunk and limbs - usu irreversible and assoc w LT antipsychotic use) – abnormal darting or snake-like movements
b. Endocrine – DA receptor antagonism → hyperprolactinemia → gynaecomastia
c. Dry mouth / Constipation - blockage of muscarinic receptors
d. Hypotension blockage of alpha receptors
e. Sedation – blockage of histamine receptors
5. Neuroleptic malignant syndrome
a. Rigidity
b. Autonomic instability
c. Myoglobinuria
d. Hyperpyrexia

Atypical Antipsychotics
1. Examples – “It’s not atypical for old closets to risper”
a. Olanzapine
b. Risperidone
c. Clozapine
d. Quetapine
2. Mechanism
a. Blockage of 5HT2 and D2 receptors (less dopamine blockade) – more specific blockage of mesolimbic Da blockade sparing nigrostriatal tract and thus less extrapyramidal side effects
3. Clinical Use
a. Schizophrenia – pos and neg sxs (improved efficacy vs negative sxs)
b. Olanzapine → OCD, anx d/o, depr, mania, tourettes
4. Toxicity
a. Fewer extrapyramidal and anticholinergic side effects than other antipsychotics
b. Clozapine may cause agranulocytosis (requires weekly wcc monitoring)
c. Preferred by patients

Mood stabilisers

Lithium
1. Mechanism
a. Unestablished
b. Possibly related to 2nd messenger systems
2. Clinical Use
a. Mood stabiliser for BPAD – blocks relapse and acute mania events (gold standard for BPAD)
b. Tx of choice for classical or euphoric mania
c. May need to be augmented in rapid cyclers, mixed manics, uncontrolled bipolars
3. Toxicity
a. Tremor
b. Hypothyroidism
c. Polyria (ADH antagonist causing nephrogenic diabetes insipidus)
d. Teratogenesis
e. Narrow T.index requiring close monitoring
4. Mnemonic → Lithium adverse effects (requires monitoring of serum levels, renal and thyroid function)
a. CNS toxicity - Mvment d/os – tremor
b. Renal - Nephrogenic diabetes insipidus
c. Thyroid - Hypothyrod

Sodium valproate
• Mechanism – unknown for BPAD
• Adverse effects – CNS toxicity, GI, hepatotoxicity, terratogenic, haemotologic effects
Carbamazepine
Olanzapine + Other atypical antipsychotics
• Good adjunctive antimanic effects
• Olanzapine good LT relapse prevention for mania
• Main side effects – weight gain, sedation
Lamotrigine
• Slow titration
• Beware rash 10% - you wont know if benign or SJS/TEN

Anti-depressants

SSRIs
1. Examples
a. Fluoxetine (prozac)
b. Paroxetine (aropax)
c. Citalopram (cipramil)
2. Mechanism
a. Serotonin specific re-uptake inhibitors
3. Clinical Use – usu takes 2-3 wks to have effect
a. Endogenous depression
b. OCD
4. Toxicity
a. < than TCAs
b. GI distress
c. headache
d. Sexual dysfunction
e. Serotonin syndrome with MAO inhibitors (and tramadol)
i. Hyperthermia
ii. Muscle rigidity
iii. CV collapse
f. Serotonin syndrome with MAO inhibitors (and tramadol) Serotonin syndrome with MAO inhibitors (and tramadol)
5. Contraindications
a. Serotonin syndrome – ataxic, myoclonic, confused (range of sxs from anxiety through to coma)
i. Occurs when adding a serotonergic drug
ii. Egs – tramadol + SSRI or changing anti-depressants meds w ineffective washout of first drug
b. Hyponatremia
i. Elderly pts generally hyponatremic (declining renal function with age) – they are generally ok at 120-125 but adding an SSRI may drop their Na levels even further)

TCAs
1. Examples
a. Imipramine
b. Amitriptyline
c. Nortriptyline
2. Mechanism
a. Blocks NE and Serotonin reuptake
b. Affects 5 NT systems – nor-adr reuptake, 5HT reuptake + anticholineric, alpha adrenergic antagonist + antihistamine
3. Clinical Use
a. Major depression
b. OCD - clomipramine
4. Side Effects
a. Sedation
b. Alpha blocking effects
c. Atropine-like (anticholinergic) effects – tachycardia, urinary retention
5. Toxicity
a. Tri-Cs – convulsions, coma, cardiotoxicity (arrhythmias)
b. Anti-cholinergic signs – dry mouth, blurred vision, urinary retention, constipation, hallucinations (esp in elderly)
c. Anti-histamine signs – sedation, weight gain
d. Alpha-adrenergic signs – dizziness, hypotension
e. Respiratory depr
f. Hyperpyrexia
g. Confusion

MAO Inhibitors (Monoamine Oxidase Inhibitors)
1. Eg - Tranylcypromine
2. Mechanism
a. Non-selective MAO inhibition → ↑ levels of amine NTs (MAO breaks down nor-adr and 5HT in presynaptic neuron – inhibition results in more nor-adr and 5HT available for release into synapse)
3. Clinical Use (underutilised despite high efficacy)
a. Atypical depression – ie psychotic or phobic features
b. Anxiety
c. Hypochondriasis
4. Toxicity
a. Hypertensive crisis w tyramine ingestion (in many foods) – adherence to MAO diet required
b. Contraindication w SSRIs or B-agonists (to prevent serotonin syndrome)

Dosing
1. Each medication trail should be of proper dose and duration – at least 4-8 weeks before on to the next medication trial considered)
2. Duration of tx
a. Standard practice 6-12 months to avoid relapse
b. For 3 or more episodes, chr course of tx is suggested

Anti-anxiety Medications

1. Antidepressants (main medication tx for most anxiety d/os)
2. Benzodiazepines (adjunct)
a. Examples – Diazepam, Clonazepam, Alprazolam, Triazolam
b. Indications – anxiolytic, sedative-hypnotic, alcohol withdrawal, anticonvulsant, muscle relaxant
c. Adverse effects – sedation, cognitive blunting, risk of falls, abuse/dependence, withdrawal syndrome
3. Avoid using whenever possible, esp in the elderly (difficult for pt to reduce)
4. Avoid SA benzos in particular (triazolam, alprazolam, oxazepam) as they release a hit and are more addictive

Summary of Indications

BPAD
• Mood stabilisers → lithium, valproic acid, carbamazepine, olanzapine, benzodiazepines
• Olanzapine – useful if psychotic component in BPAD eg grandiose delusions, less intense monitoring reqd, quicker onset action, good for first episode and wish to avoid LT Tx
• Lithium – prevents mania, Ø depressive sxs, can cause tremor/agitation, use recurrent BPAD, pt will need to commit to LT tx as stopping early may exarcerbate mania, esp useful in pts w f.hx of mania and f.hx of lithium response
• Benzos – sedating tool in a pt w an acute mania
• Valproate / Carbimazepine – more effective for non-lithium classic mania, eg rapid cyclers or mixed (concurrent depr and manic sxs)
Depression
• Anti-depressants → SSRI (fluoxetine, paroxetine, citalopram), TCA
• Generally interchangeable – citalopram ↓ drug interactions and shorter ½ life so can be quickly stopped
• Adolescent depression → fluoxetine
• Atypical Depression → MAO inhibitors
OCD → SSRI (fluoxetine)
Alcohol withdrawal → Benzodiazepines
Anxiety → Barbiturates, Benzodiazepines, Buspirone, MAO inhibitors
Schizophrenia → Antipsychotics
• Don’t give too much – esp of the neuroleptics

Pregnancy

1. Avoid all mood stabilisers except lithium
2. Don’t use newer antipsychotics – use haloperidol
3. TCAs and Fluoxetine generally OK

ECT (Electroconvulsive Therapy)

1. Mechanism of Action
a. Seizure is necessary
b. Stabilises dysregulated intracellular signalling linked to multiple transmitter systems
2. Indications
a. Severe depressive d/o
b. Immediate suicide risk
c. Major depressive d/o w psychosis
d. Severe mania
e. Tx resistant schizophrenia
f. Catatonic stupor
3. Efficacy
a. 30-50% chance of response in medication resistant depression
4. Adverse effects
a. Mortality rate low
b. Dysrhythmias
c. Confusion
d. Cogv dsyfunction

PSYCHOTHERAPY

1. Definition
a. Tx of emo, behal, personality and psychiatric d/os based primarily on verbal or nonverbal communication and interventions with the pt (in contrast to txs utilising chemical and physical measures)
2. Types
a. Psychodynamic
b. Behal therapy
c. Cogv therapy and CBT
d. Interpersonal therapy
e. Family therapy
f. Group therapy
3. Psychodynamic
a. Drive theory – id, ego, superego (3 distinct agencies)
b. Object relations – self/other and good/bad representations
i. Eg - a child must learn that a bad parent is the same as the nuturing parent
ii. BPD → splitting (alternating idealisation and devalueing) – have not been able to internalise these representations
c. Dyanamic point of view – stress the interplay of forces in the mind when the instinctual drive meets the necessities of ext reality
d. Early freud – conscious, preconscious, unconscious (iceberg metaphor)
e. Defence mechanisms (importance of early r/ships) –
i. Transference – earlier conflicts re-emerge in therapeutic r/ship
ii. Ego’s protective mechanisms
1. Regression – retreat to infantile state
2. Reaction formation – ego makes unacceptable thoughts look acceptable
3. Projection - disguise threatening impulses by attributing them to others
iii. Displacement – shift sexual or aggressive impulses toward more acceptable or less threatening object/person
iv. Rationalisation – self-justifying explanation in place or real more threatening unconscious reason of intent
v. Repression – id wants it now, ego threatening, unacceptable wishes/ideas become charged with unpleasurable feelings, thus barred from consciousness
4. Behaviour therapy
a. Classical and operant conditioning
b. Examples
i. Behaviour analysis – ABC charts (antecedents, behaviour, consequences)
ii. Graded exposure – anx d/os
iii. Activity scheduling – to prevent vicious cycles in mood d/os
iv. Aversion therapy addictive and other damaging behs
v. Problem solving
vi. Relaxation
vii. Distraction
5. CBT
a. Working with thoughts and behs to create mood change
b. ST, structured and goal orientated therapy
c. Helping pt to become their own therapist
d. 5 part model – mood, physical, thoughts, behaviour (all interconnected)
e. Onion model – core beliefs at inside → intermediate beliefs (rules or assumptions) → negative automatic thoughts
f. Cognitive tools – understanding thinking pattenrs, thought record, eliciting assumption/rules/cogv distortions
i. Eg - automatic thought record
6. Interpersonal therapy
a. Link betw depr and interpersonal relations (social context of depr)
b. Unresolved grief, interpersonal disputes, role transitions, interpersonal deficiencies
c. Used mainly in depr, but modified for dysthymia, bulimia, misuse and somatisation
d. Techniques include – CTB, supportive listening, role playing, communication analysis, encouragement of affect
7. Dialectical Behal Therapy (DBT)
a. Combines behal, cogv, analytic and eastern ideas
b. Individual therapy and skills groups
c. Esp useful for BPD
d. Principles – dialectics means balancing tensions good and bad, creating a non-blaming context and replacing unhelpful behs
e. Skills –
i. midnfulness (incr awareness of present state)
ii. distress tolerance (distraction, self soothing)
iii. emotional regulation (identify triggers, label emotions, chain analysis)
iv. interpersonal effectiveness (self assertiveness)
8. Efficacious psychotherapies
a. Schizophrenia – cogv therapy, supportive therapy, structural family interventions, social skills training, vocational
b. BPAD – psychoeducation, CBT, family tx
c. Depr – BT, CBT, IPT all effective, equivalent to anti-depressants
d. Panic d/o – CBT incl resp control, cogv techniques, exposure, relaxation
e. GAD – relaxation, CBT
f. Specific phobias – exposure, CBT
g. OCD – exposure and response prevention, CBT
h. PTSD – exposure therapy, CBT, anx modification techniques, EMDR
i. Personality d/os – difficult to tx
j. Eating d/os – CBT + nutritional advice

SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

1. Psychosis
a. Definition
i. Severe mental disturbance indicating gross impairment in reality testing
ii. The term psychosis is not a dx, but is a useful term to employ while the underlying dx is being formulated
b. Key features - hallucinations, delusions, thought d/o
c. Other features - looseness of associations, grossly disorganised and bizarre speech or behaviour
d. Stages
i. Prodrome – at risk mental state (cant attribute until after psychosis has developed)
1. Sleep disturbance
2. Depr mood
3. Social withdrawal
4. Drop off in function – eg work, study
5. Irritable / oversensitive
6. Odd beliefs/behaviour
7. Suicidial
ii. Acute or active psychotic state
iii. Recovery
iv. Prolonged recovery
2. Schizophrenia
a. A common type of psychosis
b. Characterised by abnormalities in perception, thought content and thought processes (hallucinations, delusions) and by extensive withdrawal of interest from other people and the outside world; with excessive focus on one’s own mental life; now considered a grp or spectrum of disorders rather than a single entity
3. Symptoms of Schizophrenia
a. Positive Sxs
i. Delusions
1. Fixed false belief, not amenable to reason, not in keeping with that person’s subculture
ii. Hallucinations
1. Perception experienced in external space in the absence of normal stimuli
2. Auditory, Visual, gustatory, tactile sensations
3. Pseudohallucination – pt knows the voice is in their mind and not in external space
iii. Formal thought disorder
1. Bizarre or incongruent transition from one idea to another
iv. Bizarre behaviour
v. Other psychotic Sxs
1. Ideas of reference – ?misinterpretation of others/things are them believing it relates to them
a. Other people are taking notice of the very thing they are ashamed of
b. Thoughts come from within themselves and are excessive
2. Delusions of reference
3. Illusions – false perception (misinterpretation of sensory info)
4. Overvalued ideas
5. Derealisation – things around you are not real
6. Depersonalisation – out of body experience
b. Negative Sxs
i. Attention – difficulty focusing and paying attention
ii. Alogia – inability to speak
iii. Avolition / Apathy – lack of motivation
iv. Anhedonia – Ø enjoyment
v. Asociality – social isolation
vi. Affective disturbance – flat in affect
c. Cognitive Sxs
i. Verbal memory and learning
ii. Executive function (higher level, eg abstract reasoning)
iii. Attention
iv. Spatial memory
4. Etiology
a. Stress-vulnerability model
i. Vulnerability
1. Biological – genetics (twin studies, both parent studies suggest 50% risk), organic brain injury, ↑ dopamine
2. Psyc – cogv style (more likely to blame oneself)
3. Social – minority ethnic grp
ii. Stress
1. Biological – substances (esp amphetamines/P, less so for cannibis)
2. Psychological – loss and grief
3. Social – r/ship breakup
5. Schizophrenia
a. Syndrome based on a process of psychological disintegration manifesting itself ultimately as a fragmentation of the personality
b. Periods of psychosis and disturbed beh w a decline in functioning lasting >6 months
c. Onset typically gradual, w/o obvious precipitating cause
d. Early sxs – shortened attn span, memory deficits, diminished ability to make decisions
e. Cogv malfunctions usu accompanied by ↓ energy level, flat or depressed affect and anhedonia
f. Impoverished thought content, social withdrawal, impairment of occupational functioning
g. 10% suicide risk
h. Neuroleptic drugs shorten the episodes of acute psychosis, limit the need for institutional care, reduce the risk of relapse, but their LT use is assoc w serious side effects, esp tardive dyskinesia
i. Newer agents such as clozapine, olanzipine, quetiapine and risperidone are more effective in improving cogv func and less likely to induce extrapyramidal side effects
6. Epidemiology of Schizophrenia
a. 1% (M=F)
b. Common age of onset 15-25 years but can present earlier or later (this age grp esp vulnerable due to major life events and subst use)
c. Similar incidence worldwide
d. Men have earlier onset
e. Genetic factors outweigh etal factors in etiology
f. Illness characterised by a prodromal, active and residual phase
g. Pathological neurodevelopment in schizophrenia
i. Incr incidence of minor physical anomalies – eg clumsiness
ii. Prenatal viral exposure
iii. Incr freq of obstetric complications
iv. Premorbid cogv and neuromotor abnormalities
v. Dyskinesias
7. Diagnosis of Schizophrenia
a. DSM1V
i. A – 2 or more of -
1. Delusions
2. Hallucinations (often auditory)
3. Disorganised thought (loose associations)
4. Disorganised or catatonic beh
5. Negative sxs
a. Flat affect
b. Social withdrawal
c. Lack of motivation
d. Lack of speech or thought
6. OR only 1 sx reqd if bizarre delusions or commentary hallucinations (constant commentary on what you are doing)
a. Non-bizarre delusion – eg s/thing which could happen but rationale illogical ie wife cheating on you
ii. B – Social Occupational dysfunction
iii. C – Duration 6 months
b. Subtypes
i. Paranoid
ii. Disorganised
iii. Catatonic
iv. Undifferentiated
v. Residual
c. Other psychotic disorders
i. Schizoaffective d/o – Schizophrenia + Mood disorder
1. Manic or depressive (voices can say bad or good things about you)
ii. Schizophreniform d/o – schizophrenia but <6 months
iii. Brief psychotic d/o - <1 month to resolve
iv. Delusional d/o – non-bizarre delusion >1 month, criteria for schizophrenia not met
1. Grandiose
2. Jealous
3. Somatic
4. Persecutory
5. Erotomanic
6. Mixed
v. Etiology
1. Paranoia is non-specific
2. Less prevalent than schizophrenia or mood d/os
3. Later onset than schizophrenia
4. Paranoid or avoidant personality d/o more common in relatives
5. Premorbidly different to schizophrenia
8. Diagnosis from Psychosis
a. If delusions, hallucinations or thought disorder are present – dx must be schizophrenia, affective d/o (depr or BPAD), an organic d/o or a paranoid state
b. Most auditory hallucinations (not assoc w falling asleep or waking up) are caused by schizophrenia
c. Most non-auditory hallucinations are caused by substance abuse, drug withdrawal or physical dis
d. Middle age is not a typical time for schizophrenia to present, alcohol abuse or a primary CNS condition are more likely
9. Differential Dx
a. Depression – esp if negative sxs
b. Substance abuse (note – high co-morbidities ie pshyosis co-exists w subst abuse or depr)
10. Management
a. Safety – 10% commit suicide (50% within 5 years of dx)
b. Clarify the dx
c. Biological mgt
i. Atypical antipsychotics
ii. First episode – risperidone, quetiapine, olanzapine
iii. Clozapine only effective for tx of resistant schizophrenia
iv. Depot (injection) antipsyhotics as last resort – 3 months to steady state
d. Psychological mgt
i. Therapeutic alliance and recovery focus
ii. Psychoeducation
iii. Early warning signs
iv. Triggers and stress
v. Subst abuse
vi. CBT for persistent sxs of schizophrenia
e. Social and family
f. Rehab
i. Assessment involves understanding of impairment (sxs), disability (functional life domains), handicap (social roles), skill retrieval, skill devt, community integration
11. Prognosis
a. 25% complete recovery
b. 40% recurrent psyhosis
c. Good prognostic factors
i. Abrupt onset
ii. Later onset (women have better prognosis bec later onset)
iii. Absence of premorbid disturbances
iv. Acute stress
v. Large social N/W
vi. Family hx of affective illness (more likely to have sig depr component)
vii. Less delay in tx

SCIENCE OF HAPPINESS

Happiness = Set range + Current circumstances + voluntary variables (H = S+C+V)
1. H – enduring happiness, not transient, not ST, not a summation of momentary periods of happiness, general feelings of contentment
2. S – happiness thermostat, genetic – up to ~50% of happiness
a. Habituation – progressive diminution of behal response probability w repetition of stimulus
i. Positive examples – body pleasures, winning the lotto, food
ii. Negative examples – amputees (back to baseline happiness over time)
iii. Exceptions – delayed habituation possible with death of child/spouse or caregivers of alzheimers relatives
b. Hedonic treadmill – material possessions, accomplishments, status, incr pay
3. C – 8-15% of happiness
a. $, marriage/partnership, social life, health
b. In wealthier nations, where basic needs are met, incr in wealth have negligible effects on personal happiness
c. Older people are generally happier
d. Those married – depends on quality of p/ship
e. Religion – variable; can be beneficial or detrimental
f. Gender – men and women similar baseline levels, women more fluctuation
4. V – Positive emotions regarding past present and future
a. Focusing on the past affects current happiness – learning to forgive is impt
b. Gratitude journal v beneficial – those who benefited the most had a wider span of things grateful for and elaborated more
c. Present variables – pleasures, gratification, mindfulness, altruism and kindness, strong personal r/ships, skill in life situations and stressors, physical health
i. Mindfulness – focus on now, not what is going to happen; retraining of brain to focus on the now (thoughts, feelings, emotions)
ii. Western beliefs – always looking to the future and anticipating
d. Future – temporary vs permanent thinking

SLEEP DISORDERS

1. DSM 1V Sleep disorders
a. Primary sleep disorders
b. Sleep d/o related to another mental disorder
c. Sleep d/o due to a gen med condition
d. Substance induced sleep d/o
2. Presentation
a. Insomnia
b. Hypersomnia
i. Primary
ii. 2ndry – OSA, Narcolepsy, Circadian rhythm
c. Parasomnia – funny things happen when asleep
i. Sleep terror
ii. Sleep walking
iii. Nightmare disorder

Insomnia

1. Definition
a. Prolonged and usually abnormal inability to obtain adequate sleep
b. It is sx not a dx!
c. It is a complaint of – poor, unsatisfactory, unrefreshing sleep and resulting in daytime dysfunction
d. Acute vs Chronic - < or > than 4 weeks
2. Common causes of insomnia
a. Emotional stress (emotional arousal)
b. Acute medical illness accompanied by pain/anxiety
c. Time zone changes or changes in sleep wake cycle
d. Learned behaviours
3. Causes of chronic insomnia
a. Psychiatric
i. mood disorders - major depr, BPAD, dysthymia
ii. anx d/os – GAD, OCD, PTSD, panic, hypochondriasis
b. Substances
i. Prescribed – sedative-hypnotics, antidepressants, stimulants, bronchodilators, anti-HTNs, steroids
ii. Recreational – nicotine, amphetamines, alcohol
c. Circadian rhythm d/os – jet lag, delayed or advanced sleep phase syndrome, shfit work
d. Medical / Neurological d/os – eg pain sxs, periodic limb mvment d/o, restless leg syndrome, sleep disordered breathing
e. Gen med causes of insomnia - COPD, Bronchial asthma, CHF, IHD, PUD (peptic ulcers), reflux, rheumatic d/os
4. Primary Insomnia
a. Dx of exclusion
iv. Rule out depression an anxiety – 50%
5. Management
a. CBT (standard tx for primary insomnia but often limited by resources)
i. Effective ST and LT
ii. Addressing cogv distortions and false beliefs re sleep
iii. Daily sleep diary during tx – 4-8 wks
iv. Behal tx - stimulus control, sleep restriction*
v. Cognitive therapy
1. reforming pts misconceptions re sleep
2. realistic view of what is happening → decr anx and anger related to not sleeping
3. 3 step process
a. Identify dysfunctional cognitions
i. Catestrophising transient sleep difficulties
ii. Blaming sleep for daytime impairments
iii. Unrealistic expectations regarding sleep requirements
iv. Misunderstanding catch up sleep – missing one night does not double the amount needed for the next night
v. Above cognitions → performance anx (hyper-arousal before sleep, oversleeping and napping to compensate → disrupted circadian rhythm → difficulty falling asleep)
b. Confront and challenging their validity
c. Replacement with more adaptive and rational alternatives
vi. Stimulus control
1. Train the insomniac to reassociate the bed/bedroom with sleep and relaxation
a. Go to bed only when sleepy
b. Bedroom only used for sleep and sex
c. Get out of bed, to another room when unable to fall asleep / return to sleep within 15-20 mins + return only when sleepy
d. Maintain regular waking time regardless of sleep quality/duration the previous night
e. No daytime napping
vii. Sleep restriction
1. curtail amount of time spent in bed to match amount of total sleep needed
2. time allowed to spend in bed adjusted regularly so that sleep efficiency is about 80-90%
3. Goal is to create a state of mild sleep deprivation → more rapid onset of sleep, more efficient sleep, less internight variability
4. Example
a. Typical pres – goes to bed at 10, falls asleep at 12, wakes at 6, snoozes till 7
b. Tx – delay bedtime till 11-12, absol get out of bed at 6 no matter what
b. Relaxation techniques - progressive muscle relaxation, biofeedback, meditation
c. Medications or herbal preparations
i. Benzos or benzo analogues (eg zopiclone) – only ST for stress related, intermittent dosing (2-4x per week), used for <4 wks, gradual discontinuation and watching for rebound insomnia
1. Risks – dependence, tolerance, excessive sedation, motor effects, worsening OSA
2. Benzos incr stage 1/2 sleep but decr slow wave (restorative) sleep
ii. Sedating antidepressants and antihistamines, atypical antipsychotics
iii. Melatonin – insufficient evidence for chr insomnia, helpful in jet lag
iv. ?valerain root (some GABA like effects), kava
d. Sleep hygiene - education re health and etal practices (effective in combination with CBT, less effective as monotherapy)
i. No caffeine or nicotine 4-6 hrs prior to sleeping
ii. Alcohol avoidance in evening
iii. Exercising 5-6 hrs before bedtime but not closer than 3 hrs
iv. Minimising noise, light, excessive temp

SUBSTANCE USE DISORDERS

1. Main classes
a. Depressants – eg ETOH, opiates, benzos
b. Stimulants – eg amphetamines, speed
c. Hallucinogens
2. DSM Criteria for substance dependence
a. 3 or more at same time within a 12 month period
i. Tolerance - ↑ amounts required to achieve same effect
ii. Withdrawal sxs – eg autonomic hyperactivity (sweating, PR >100), ↑ hand tremor, insomnia, n/v, hallucinations/illusions, psychomotor agitation, anx, grand mal seizures
iii. Often taken in larger amounts or longer period than intended
iv. Persistent desire or unsuccessful efforts to cut down or control use
v. Sig time spent obtaining, using or recovering from subst
vi. Impt social, occupational, recreational activities given up on or reduced
vii. Continued use despite knowledge of physical/psychological problems
3. DSM Criteria for substance abuse
a. 1 or more of the following within a 12 month period –
i. Role impairment – impact on major role obligations at work, school or home eg repeated absences
ii. Hazardous use - use in situations in which it is physically hazardous – eg driving a car under the influence
iii. Legal problems
iv. Social or interpersonal problems
4. Epidemiology
a. Highest rates – 18-25 yr age group
b. 1 year prevalence of any subst abuse/dependence ~8% (M:F 2:1)
5. Comorbidity
a. ~40% w serious mental illness have a subst use problem
b. ~60% w subst use problem will have mental ill health
6. Biology of Addiction
a. Almost all drugs → final common pathway
b. Release of Da in nucleus acumbens leads to feeling of well being or a high (directly or indirectly)
7. Assessment → u/stand subst use within context of a person’s life
a. What – alcohol, cannibis, party drugs etc
b. How much – amount, potency, freq, binging
c. When
d. How taken – smoke, eat, drink, snort, inject
e. Effects – high, calming, out of it, alertness
f. Why taking – peers, mood, buzz, boredom, hooked
g. Where – school, home, parties, friends place
h. With whom – alone, peers, siblings
8. Patient Approach
a. Screening
i. AUDIT = Alcohol Use Disorders Identification Test
ii. 12 multi-choice questions
iii. Fianl score indcates safe, hazardous, harmful or dependent use
iv. Can be used to begin a brief intervention
b. Engagement – stressing confidentiality is impt
c. Open and non-judgemental
i. First q – what are the good things about using ….?
ii. Decisional balance – good and bad things about using
iii. Typical session/day
iv. Explore concerns – does this stuff ever make you worried?
d. Check for harmful and risky behaviour – intoxication, safe sex, driving accidents etc
e. Sxs of dependence and withdrawal
f. Past subst use
g. Identify comorbidites
h. Collateral hx if possible
i. Establish motivation – “stages of change model – prochaska and diclemente”
i. Stages of change → goals of the health professional
1. Precontemplation → raise doubt
2. Contemplation → tip the balance
3. Detemination → determine course of action
4. Action → assist client with change
5. Maintenance → assist client with maintenance of change
6. Relapse
j. Motivation approach (Miller and Rollnicks five principles of motivational interviewing)
i. Express empathy – acceptance, don’t judge, reflective listening
ii. Develop discrepancy – awareness of consequences, amplify discrepancy
iii. Avoid argument – confrontation leads to defensiveness and resistance
iv. Roll with resistance – emphasise personal choice and control, shift focus
v. Support self efficacy – self-responsibility, optimism, belief in an individuals capacity to change
k. Motivational approach (micro-skills and strategies)
i. Open ended questions
ii. Reflective listening
iii. Affirming – statements of appreciation and understanding
iv. Summarising
v. Eliciting self-motivation statements
l. Brief intervention (most cost-effective strategy)
i. Efficacy equivalent to long term interventions
ii. 5-30 mins of education about subst use targeting harmful effects and impact on individual
1. Screen for problem use
2. Advise reduction to safe levels
3. Advise on harm minimisation strategies
4. Involves personally linking info to current sxs/problems
5. Provision of material, resource etc
iii. FRAMES
1. Feedback about risk
2. Responsbility is with the individual
3. Advise and educate
4. Merits of strategies and options
5. Empathic approach essential
6. Self efficacy and optimism emphasised
9. Management
a. Two types of tx – biological or psychosocial
b. Two management philosophies
i. Abstinence
1. USA
2. Drug problems viewed as a disease
3. Eg – AA, 12 steps
a. 12 Steps – strong spiritual/moral approach, pway to recovery
ii. Harm reduction
1. Euro-Australasian
2. Wider conception of AOD (alcohol and other drugs) problems → more flexible goals
3. Wider range of approaches – eg substitute prescribing, brief interventions, needle exchange
c. AOD Interventions
i. Individual
1. Motivational interviewing
2. CBT
a. Certain beliefs and behaviours increase the chances of relapse
b. Focus on teaching methods of coping with high risk situations
c. Monitoring, keeping a diary
d. Education
e. Drink and drug refusal
f. Social skills, communication skills, assertiveness, problem solving
g. CBT interventions – eg thought stopping etc
3. Relapse prevention
4. Meds
ii. Medications
1. Substitution – methadone, LAAM, Buprenorphine,
2. Adverse conditioning – disulfiram, naltrexone
3. Anti-craving meds – naltrexone, acomprosate (not particularly effective)
4. tx of co-morbid conditions – SSRIs for anx/depr, mood stabilisers for BPAD
iii. Detox
1. Inpatient – alcohol, opiates, poor physical health
2. Home – less severe additions, good support networks, motivation to change
iv. Family
1. Family involvement
2. Couple or family therapy
v. Social
1. Social behavioural network therapy (SBNT)
2. Community programmes
a. CADS = Community Alcohol and Drug Services
i. Counselling, community and inpt detox, methadone service, youth service
vi. Group
1. 12 steps, AA
2. Day programmes
3. OP community groups

SUICIDE AND SELF HARM

1. Suicide
a. 90% have a psychiatric d/o
b. 70% of this is depressive d/o
c. Rest – schizophrenia, subst abuse or a combination of the three
2. Statistics
a. Men predominate
b. Relatively stable
c. No data prior to 2004 as 2005 cases still before the coroner
d. Male death rate on the decline but not for females
e. Maori suicide death rates higher than non-Maori for both M and F
f. ↑ deprivation assoc w ↑ suicide rate (applicable to all mental health with the exception of eating d/os)
g. >50% of suicides occur at home
h. Method of death – hanging and CO poisoning predominate (esp men), women more likely to overdose
i. 10-15% of individuals presenting to the ED have suicidal thoughts
3. Risk factors for Suicide Completion
a. Mnemonic → SAD PERSONS
i. Sex – male
ii. Age – teenager or elderly
iii. Depression
iv. Previous attempt
v. Ethanol or drug use
vi. Loss of Rational thinking
vii. Sickness – medical illness, 3 or more prescription meds)
viii. Organised plan
ix. No spouse – divorced, widowed, single, esp if childless)
x. Social support lacking
b. Women make more attempts, men more successful
4. Strategies
a. Primary care education
b. ↓ access to means
i. Cars → fishtail exhausts, catalytic converters
ii. Paracetamol → blister packs, limit numbers in each package, limit packages that can be bought at any one time
c. Manage high risk people – those engaging in self harm or recent d/c from psych hospital
5. Four level intervention model
a. Promotion of well being (entire popn)
b. Prevention of problems (at risk grps)
c. Early intervention
d. Specialist services
6. Self Harm
a. Important
i. Common
ii. R/ship to suicide – Suicide rate 1% per year for the next 5 yrs (see below)
iii. ↑ mortality from all causes – 10-15% 5 yr mortality (mostly from smoking, alcohol etc)
iv. Significant co-morbidity
b. Epidemiology
i. Younger age group → females
ii. Older age group → Ø sex differences
c. ***Self harm and r/ship to suicide are separate but overlapping problems
i. different epidemiology and r/ship to mental illness
1. those that self harm are less likely to have a mental d/o
ii. overlapping bec –
1. 25% of those that suicide have hx of self-harm in preceding year
2. 1% of those who intentionally self injure suicide per year (for the following 5 years)
d. Assessment after self harm (applies to suicide also)
i. Engagement – individuals often in crisis, can be difficult, Ø infantilise people like happens in hospital (ie give them a chair, own clothes)
ii. Assess future risk
iii. Identify risk factors for harm (esp those modifiable)
iv. Create mgt plan
v. Understand pts wish to die – ie why now?
vi. Dx psychiatric d/o if present

PSYCHIATRY – SUMMARY NOTES

Psychiatric History

1. Screening for depression
a. Mood
b. Interest, Enjoyment
c. Sleep
d. Appetite
e. Concentration
f. Energy
2. Neurovegetive sxs - SECAL
a. Sleep
b. Energy
c. Concentration
d. Appetite
e. Libido
3. Screening for psychosis
a. Unusual experiences
b. Noises others don’t hear
c. In control of actions
d. In control of thoughts
e. Messages that no-one else understands
4. Screening for suicidal thoughts

Mental State Exam

BOAT PIS
1. Behaviour and Appearance
a. Appearance
b. Behaviour, Neurology
c. Rapport
2. Orientation, Cognitive assessment
a. Time, person, place
b. Mini MSE, Folstein (30 point questionnaire to assess cognition and screen for dementia)
3. Affect and Mood
a. Subjective mood
b. Objective mood
c. Affect (external manifestation of a mood state)
i. Congruency
ii. Range (flat → blunted → full → expansive) +/- restricted range
iii. Changeability
iv. Intensity
4. Talk
a. Speech
i. Rate
ii. Rhythm
iii. Volume
iv. Reactivity (pitch at end of sentence)
v. Spontaneity (talking w/o being asked a question, offer more info than asked for)
vi. Pressured
b. Thought form, Thought disorders
i. Pressure of speech
ii. Flight of ideas
iii. Distractible speech – subject changed during mid speech
iv. Tangentality – reply to a question in oblique, tangential or irrelevant manner
v. Derailment / Loose association / Knights move thinking – ideas slip off to another obliquely related or unrelated idea
vi. Incoherence (word saled)
vii. Illogicality – conclusions reached do not follow logically
viii. Circumstantiality – speech delayed at reaching goal, excessive long windedness
c. Thought content
i. Recurrent themes
ii. Delusions – fixed false belief, not amenable to reason, not in keeping with person’s subculture, education or religion
iii. Obsessions, Compulsions
iv. Phobias
v. Suicidal thoughts
5. Perceptions
a. Hallucinations – perception in absence of a stimulus
b. Illusions – misperception of a stimulus
6. Insight and Judgement
a. Abnormal experiences?
b. Mental disorder?
c. Require tx?
7. Safety
a. Harm to self
b. Harm to others
c. Self cares, Neglect

DSM 1VR – Diagnostic and Statistics Manual of Mental Disorders

1. Categorical classification system
2. Multi-axial
a. Axis 1 – clinical disorder, major mental disorders, major devtal and learning disorders – eg depr, BPAD, ADHD, schizophrenia
b. Axis 2 – personality disorders, intellectual disability
c. Axis 3 – acute medical conditions, physical disorders
d. Axis 4 – psychosocial and devtal factors contributing to the disorder
e. Axis 5 – global assessment of functioning

Depression

1. Epidem - Lifetime prevalence → 5-12% male / 10-25% female
2. Presentation of a major depressive episode – L’SIG E CAPS
a. Requires 5/9 for >2 weeks incl either depressed mood or anhedonia
i. Low mood
ii. Sleep disturbance ↑ or ↓
iii. Lack of interest / Anhedonia
iv. Feelings of guilt / worthlessness
v. Energy ↓
vi. Concentration ↓
vii. Appetite ↑ or ↓ (or change in weight)
viii. Psychomotor retardation or agitation
ix. Suicidal thoughts
b. Other sxs not in DSM1V
i. Irritability and anger (esp men)
ii. Unexplained physical complaints
iii. Delusions and hallucinations (mood disorder with psychosis)
3. Major depressive disorder
a. Requires 2 or more episodes with a sx free interval of 2 at least 2 months
4. Dysthymia
a. Milder form of depression
b. ACHEWS – 2/6 for >2 years
i. Appetite
ii. Concentration
iii. Hopelessness
iv. Energy
v. Worthlessness
vi. Sleep
c. Rule of 2s
i. >2/6 sxs
ii. >2 years
iii. Never w/o sxs for >2 months
5. Other classifications – atypical depression, postpartum depression, seasonal affective d/o, depr w psychosis
6. Management
a. SSRIs
b. TCAs
c. ECT
i. Depression refractory to other txs
ii. Produces painless seizure
iii. Major adv effects – disorientation, anterograde and retrograde amnesia

BPAD

1. Definition
a. Bipolar 1 (manic)
b. Bipolar 11 (hypomanic) – mood disturbance not severe enough to cause marked impairment in social or occupational functioning or requiring hospitalisation, Ø psychotic feats
c. 1 manic or hypomanic episode defines BPAD
2. Epidemiology – commonly young adults 20-30s
3. Manic Episode
a. Distinct period of abnormality and persistently elevated, expansive or irritable mood lasting >1 week
b. 3+ of – DIGFAST
i. Distractibility
ii. Irresponsibility – pleasure seeking w/o regard to consequences
iii. Grandiosity – inflated self esteem
iv. Flight of ideas – racing thoughts
v. Goal directed activity / psychomotor agitation
vi. Sleep requirements ↓
vii. Talkative or pressure speech
c. Not due to a medical condition or substance abuse
4. Cyclothymic disorder
a. Milder form BPAD >2 years
5. Tx
a. Interrupt cycle by making pt sleep
b. Mood stabiliser – eg lithium

Suicide and Self harm

1. Suicide completion risk factors – SAD PERSONS
a. Sex male
b. Age – teenager, elderly
c. Depression
d. Previous attempt
e. Ethanol or drug use
f. Rational thinking loss
g. Sickness – medical illness
h. Organised plan
i. No spouse
j. Social support lacking
2. Epidem
a. 90% who commit suicide have a psychiatric illness – 70% depr, remainder mostly schizophrenia or subst abuse
3. Prevention strategies
a. Primary care education
b. ↓ access to means – eg cars and fishtail exhausts, paracetamol limitations
c. Mange high risk individuals – those who self harm or recent d/c from psych hospital
4. Self harm
a. Self harm and suicide are separate but overlapping problems
i. Separate → eifferent epidemiology – those that self harm are less likely to have a mental d/o
ii. Overlapping
1. 25% of those that suicide have hx of self harm in preceding year
2. 1% per year suicide risk in those that intentionally self injure over subsequent 5 years
iii.
b. ↑ mortality from all causes – 10-15% 5 year mortality (eg alchol, smoking etc)

Schizophrenia and other psychotic disorders

Psychosis
1. Severe mental disturbance indicating gross impairment in reality testing
2. NOT a dx, rather a useful term to employ while the underlying dx is being formulated
3. Key features – delusions, hallucinations, thought disorders

Schizophrenia
1. Definition
a. A common type of psychosis characterised by abnormalities in perception, thought content and thought processes (delusions, hallucinations) and by extensive withdrawal of interest from other people and the outside world
b. A syndrome based on a process of psychological disintegration manifesting itself ultimately as a fragmentation of the personality
c. Characterised by prodromal, active (psychotic) and residual phases
i. Prodromal sxs – sleep disturbance, depr mood, social withdrawal, decr function, irritable, odd beliefs/behaviour, suicidal (cannot attribute until after psychosis has developed)
2. Epidemiology – 1% lifetime, M=F (men earlier onset), common age onset 15-25 yrs
3. DSM Criteria
a. A – 2+ of: “Delusions Herald Schizophrenics Bad News”
i. Delusions
ii. Hallucinations (typically auditory)
iii. Disorganised thought (loose associations) – speech disorganisation
iv. Disorganised or catatonic behaviour
v. Negative sxs – flat affect, social withdrawal, lack of motivation, lack of speech or thought
b. Note – only 1 sx reqd if bizarre delusion or commentary hallucinations
c. B – Social or Occupational dysfunction
d. C – Duration >6 months
4. Sxs
a. Positive sxs
i. Delusions
ii. Hallucinations
iii. Formal thought disorder – bizarre or incongruent transition from one idea to another
iv. Bizarre behaviour
v. Other psychotic sxs
1. Ideas of reference – misinterpretation of others/things and believing it relates to them
2. Delusions of reference – if severe
3. Illusions – false perception
4. Overvalued ideas
5. Derealisation – things around you are not real
6. Depersonalisation – out of body experience
b. Negative sxs
i. Attention
ii. Alogia (inability to speak)
iii. Avolution / Apathy
iv. Anhedonia
v. Asociality
vi. Affective disturbance
c. Cognitive sxs
i. Verbal memory and learning
ii. Executive function – eg abstract reasoning
5. Subtypes
a. Paranoid
b. Disorganised
c. Catatonic
d. Undifferentiated
e. Residual
6. Etiology → Stress vulnerability model
a. Vulnerability
i. Biological – genetics, ↑ dopamine, organic brain injury
ii. Psychological – cognitive style (blaming oneself)
iii. Social - minority ethnic group
b. Stress
i. Biological – substances (esp amphetamines)
ii. Psychological – loss and grief
iii. Social – r/ship break up
7. Management
a. Safety - duicide risk 10%
b. Clarify the dx
c. Medications
i. Atypical antipsychotics
ii. First episode – resperidone, quetiapine, olanzapine (clozapine if resistant schizophrenia)
iii. Depot (injection) resperidone only as last resort (3 months to reach steady state)
d. Psychological
i. Therapeutic alliance + recovery focus
ii. Psychoeducation
iii. Early warning signs
iv. Triggers and stress
v. Substance abuse
vi. CBT
e. Social and Family
f. Rehabilitation – skill retrieval, skill devt, community integration
8. Prognosis
a. 25% complete recovery
b. 40% recurrent psyhosis
c. Favourable prognostic factors – abrupt onset, later onset, absence of premorbid disturbance, acute stress, large social network, family hx of affective disorder (more likely to be mood disorder), early tx

Other Psychotic disorders
1. Schizophreniform disorder – meets schizophrenia criteria but duration <6 months
2. Delusional disorder – non-bizarre delusions >1 month (schizophrenia criteria not met)
a. Non-bizarre delusion means something could be true, but rationale illogical eg cheating wife
3. Brief psychotic disorder – resolves <1 month
4. Schizoaffective disorder – schizophrenia + mood disorder

Anxiety Disorders

1. Definition – Anxiety
a. Unpleasant feeling associated with ideas of danger
b. It is abnormal when it occurs in either –
i. Abnormal context – eg no real threat
ii. Intense end of spectrum
2. Anxiety disorders are all treated using a 3-pronged approach
a. Education
b. CBT
c. Meds

Panic Disorder
1. Definition – Recurrent and unexpected attacks of intense fear and discomfort in instances of no real danger, peaking in 10 mins and often followed by concern about having another attack and the implications
2. Diagnosis – PANICS (4/13 reqd)
a. Palpitations, Parasthesias
b. Abdo distress
c. Nausea
d. Intense fear of dying / losing control, light headedness
e. CP, choking, disconnected
f. Sweating, shaking, SOB
3. Management
a. Education
b. CBT – control of panic sxs, desensitisation to fear
c. Meds – SSRIs, Benzos

Social Phobia
1. Definition – fear of being scrutinised or being evaluated negatively by others
a. Common situations – eating/drinking in public, public speaking, social situations where the person may do foolish things
2. Management
a. Education
b. Management of any co-morbid substance abuse
c. CBT
i. Controlling panic sxs
ii. Graded exposure to fear situations
iii. Relearning basic social and conversational skills
d. Meds – SSRIs, Benzos

Specific Phobias
1. Definition
a. Specific fear that is excessive or irrational +
b. Avoidance of a particular object or situation +
c. Interferes with normal routine
2. Common themes
a. Places involving falling, drowning or suffocation
b. Potential harmful objects – eg spiders, insects, snakes
3. During exposure → ↑ HR, pounding heart, trembling, faintness, light headedness, difficulty breathing, sweating
4. Management
a. Education
b. CBT
i. Systematic desensitisation
ii. Control of anxiety/panic
c. Meds - ?b-blockers

GAD (generalised anxiety disorder)
1. Definition – persistent, generalised and excessive feelings of uncontrollable anxiety >6 months and not related to anything specific
2. Common themes – becoming ill, having accident, financial difficulties, work or social performance
3. Diagnosis – McBeth frets constantly regarding illicit sins (3/6)
a. Muscle tension
b. Fatigue
c. Concentration difficulties
d. Restlessness
e. Irritability
f. Sleep disturbance
4. Management
a. Education
b. CBT
i. Controlling anxiety eg relaxation techniques
ii. Reducing stress
c. Meds – SSRIs, avoid Benzos

PTSD
1. Definition – long lasting anxiety response following a traumatic/catastrophic event and leading to avoidance of stimuli associated with the trauma and persistently increased arousal
2. Eg – violent assault
3. Diagnosis – RAAW >1 month + distress or social/occupational impairment
a. Re-experiencing – nightmares, flashbacks, images
b. Avoidant behaviour
c. Arousal / Hypervigilance – easily startled, intense arousal/anxiety on exposure
d. Withdrawal – social withdrawal, emotional blunting
4. Acute stress disorder if <1 month
5. Management - Education, CBT, Meds

OCD
1. Definition
a. Obsessions – thoughts, images, impulses that are persistent, intrusive and unwanted – eg contamination
b. Compulsions – uncontrollable actions or behaviours which are usu assoc w the obsessions – eg washing, cleaning hands
2. Management
a. Education
b. CBT – graded exposure + response prevention (allow obsession but not compulsion)
c. Meds – SSRIs

Substance Use Disorders

1. Main classes
a. Depressants – ETOH, opiates, benzos
b. Stimulants - amphetamines
c. Hallucinogens
2. Epidemiology
a. Highest rates 18-25 yr age grp
b. 1 year prevalence any substance abuse/dependence ~8% (M:F 2:1)
3. Co-morbidity – 40% with a serious mental illness have subst use problem, 60% w substance use problem have a mental disorder
4. DSM Criteria – Substance abuse (3/12 within a 12 month period)
a. Tolerance - ↑ amounts reqd
b. Withdrawal sxs – autonomic hyperactivity (eg sweating, tachycardia, hand tremor, insomnia, n/v, hallucinations, psychomotor agitation, anx)
c. Larger amounts or longer periods than intended
d. Persistent desire or unsuccessful efforts to cut back
e. Sig time spent – obtaining, using, recovering
f. Impt social, occupational, recreational activities impacted on
g. Continued use despite knowledge of physical/psychological probs
5. DSM Criteria – Substance use (1/4 within a 12 month period)
a. Role impairment – impact on major role obligations at work, school or home
b. Hazardous use – eg DUI
c. Legal problems
d. Social or interpersonal problems
6. Biology of addiction
a. Almost all drugs final common pway involv dopamine release in nucleus acumbens leading to a feeling of well being or a high
7. Screening
a. AUDIT (alcohol use disorders id test) – 12x multichoice qs w final score indicating safe, hazardous, harmful or dependent use
8. Approaches
a. Establish motivation – wheel of change (prochaska and diclemente)
i. Precontemplation, contemplation, determination, action, maintenance, relapse
b. Motivational approach (Miller and Rollnicks 5 principles)
i. Express empathy
ii. Develop discrepancy
iii. Avoid argument
iv. Roll with resistance
v. Support self-efficacy
c. Brief intervention (most cost effective strategy, equiv to LT interventions)
i. 5-30 mins education → re substance use, harmful effects, impact on individual
1. screen for problem use (eg AUDIT)
2. advise reduction to safe levels
3. advise on harm minimisation strategies
4. involves personally linking info to current sxs/problems
5. provision of material, resources etc
9. Management
a. Philosophies
i. Abstinence – eg 12 steps
ii. Harm reduction – wider conception of problems, more flexible goals, wider range of approaches (eg substitute prescribing, brief interventions, needle exchange)
b. AOD Interventions
i. Individual
1. Motivational interviewing
2. CBT
a. Teaching of coping methods to deal with high risk situations
b. Diary keeping
c. Education
d. Drink and drug refusal
e. Social skills – communication skills, assertiveness, problem solving
f. Interventions – ie thought stopping
ii. Medications
1. Substitution – eg methadone
2. Adverse conditioning
3. Anti-craving medications – eg naltrexone
4. Tx of co-morbidities – eg SSRIs, mood stabilisers
iii. Detox
1. Inpatient – alcohol, opiates, poor physical health
2. Home – less severe, good support networks, motivation to change
iv. Family – involvement, family therapy
v. Social – eg community programmes (community alcohol and drug services – CADS) → counselling, community and inpatient detox, methadone service, youth service
vi. Group – eg day programmes, community groups

Psychopharmacology

1. Antipsychotics (neuroleptics)
a. Mechanism – block D2 receptors
b. Examples – haloperidol, chlorpromazine
c. Indications – schizophrenia, psychosis
d. Toxicity
i. Extrapyramidal system (EPS)
1. 4 hrs – acute dystonia
2. 4 days – akinesia (impairment of voluntary muscle)
3. 4 wks – akathisia (uncontrollable motor restlessness)
4. 4 months – tardive dyskinesia (involuntary uncontrollable darting or snake like mvments – usu irreversbible)
ii. Gynaecomastia
iii. Dry mouth / Constipation → blockage of antimuscarinic receptors
2. Atypical antipsychotics
a. Mechanism – block dopamine (D2) and 5HT-2 receptors
i. More specific blockage of mesolimbic dopamine receptors sparing the nigrostriatal tract → ↓ EPS side effects
b. Examples
i. Olanzapine – KATIE study showed slightly more efficacy but more weight gain
ii. Risperidone - ↓ weight gain but ↑ risk of EPS side effects
iii. Quetapine – better side effect profile, but less efficacious
iv. Clozapine
c. Indications – schizophrenia, mania
d. Toxicity
i. Clozapine and agranulocytosis (weekly monitoring reqd)
ii. Olanzapine and weight gain, sedation
3. Mood Stabilisers
a. Lithium
i. Mechanism – unclear
ii. Clinical use – gold standard for classical/euphorical mania (tx and prevention of manic episodes)
1. May require augmentation in rapid cyclers, mixed manics or uncontrolled bipolars
iii. Toxicity (narrow therapeutic index)
1. Tremor (CNX tox)
2. Hypothyroidism → measure TFTs
3. Polyuria (ADH antagonist causing nephrogenic diabetes insipidus) → measure renal function
4. Teratogenesis
b. Sodium valproate - better response against atypical mania
c. Carbamazepine
d. Olanzapine – faster onset than lithium, sedating effects
e. Lamotrigine
4. Anti-depressants
a. SSRIs
i. Mechanism – block 5HT reuptake, 3+ weeks to achieve effect
ii. Examples – citalopram (cipramil), fluoxetine (prozac), paroxetine (aropax)
iii. Indications – depression, OCD
iv. Toxicity (less than TCAs)
1. GI distress
2. Headache
3. Sexual dysfunction
v. Contraindications
1. Serotonin syndrome
a. Clinical features (triad)
i. Cognitive effects – confusion, agitation, headache, coma
ii. Autonomic effects – shivering, sweating, HTN, tachycardia, nausea, diarrhea
iii. Somatic effects – clonus, tremor
b. Etiology – adding serotonergic drugs (eg insufficient washout after change over, SSRI + tramadol)
2. Hyponatremia – ↓ Na levels, esp problematic in elderly who are already hyponatremic
b. TCAs
i. Mechanism – blocks nor-adr and 5HT reuptake
1. Affect on 5x NT systems – add anticoholnergic, alpha adrenergic antagonist and antihistamine to above
ii. Examples – amitriptyline, nortriptyline
iii. Toxicity
1. Tri-Cs – convulsions, coma, cardiotoxicity (arrhythmias)
2. Anti-cholinergic – dry mouth, blurred vision, urinary retention, constipation
3. Anti-histamines – sedation
4. Alpha-adrenergic – hypotension, dizziness
c. MAO inhibitors
i. Mechanism – non-selective MAO inhibition → ↑ nor-adr and 5HT
ii. Indications – atypical depr (psychotic or phobic feats), anxiety
iii. Toxicity – Hypertensive crisis (adherence to MAO diet reqd)
5. Benzodiazepines
a. Indications – added to antidepressants for many anxiety disorders (ie adjunct)
b. Examples – diazepam, clonazepman, alprazolam, triazolam
c. Adverse effects – sedation, cogv blunting, risk of falls (esp in eolderly)

Psychotherapy

1. Definition – Psychotherapy
a. Tx of emo, behal, personality and psychiatric d/os based primarily on verbal and nonverbal communication and interventions involving the pt (in contrast to chemical or physical measures)
2. Types
a. Psychodynamic
b. Behavioural therapy
c. Cognitive therapy and CBT
d. Interpersonal therapy
e. Family therapy
f. Group therapy
3. Behavioural therapy
a. Principles - classical and operant conditioning
b. Strategies
i. Behaviour analysis – ABC charts (antecedent, behaviour, consequences)
ii. Graded exposure
iii. Activity scheduling
iv. Relaxation
v. Distraction
4. CBT
a. Defintion - a psychotherapy based on modifying cognition, assumptions, beliefs and behaviours with the aim of influencing disturbed emotions
b. Premise
i. Thoughts influence feelings and behaviour
ii. Feelings influence behaviour
iii. Behaviours influence emotions and thoughts (problem cycle)
iv. 5 part model – thoughts, behaviour, emotions and the physical are interconnected
v. Onion model – core beliefs, intermediate beliefs, superficial thoughts (ie negative automatic thoughts)
c. Strategies
i. Diary keeping – sig events, feelings, thoughts, behaviours
ii. Questioning and testing cognitions, assumptions and beliefs that may be unhelpful and unrealistic
iii. Gradually facing activities which may have been avoided
iv. Trying new ways of behaving and reacting
v. Relaxation and distraction techniques
5. Interpersonal therapy – link betw depression and interpersonal relations (social context of depr)
6. DBT (dialectical behavioural therapy)
a. Combines behal, cogv, analytic and eastern ideas
b. Dialectics means balancing tensions good and bad, creating a non-blaming content and replacing unhelpful behaviours
c. Skills
i. Mindfulness – awareness of present state
ii. Distress tolerance – distraction, self soothing
iii. Emotional regulation – identify triggers, label emotions
iv. Interpersonal effectiveness – self assertiveness
d. Effective esp for BPD
7. Efficacious psychotherapies
a. Schizophrenia → cogv therapy, family interventions, social skills training, vocational
b. BPAD → psychoeducation, CBT, family tx
c. Depression → BT, CBT, IPT
d. Panic d/o → CBT, relaxation
e. GAD → CBT, relaxation
f. Specific phobias → exposure, CBT
g. OCD → exposure and response prevention, CBT
h. PTSD → exposure therapy, CBT
i. Personality disorders
j. Eating disorders → CBT

ECT (electroconvulsive shock therapy)

1. Mechanism
a. Seizure is necessary
b. Stabilises dysregulated intracellular signalling linked to multiple transmitter systems
2. Indications
a. Severe depressive disorder (esp if tx resistant)
b. Immediate suicide risk
c. Major depressive d/o with pyschosis
d. Severe mania
e. Catatonic stupor
f. Tx resistant schizophrenia
3. Efficacy
a. 30-50% chance of response in medication resistant depression
4. Contraindications
a. No absolute contraindications
b. Relative contraindications –
i. Unstable or severe CV disease
ii. Space occupying intracranial lesion w ↑ ICP
iii. Recent cerebral hem or stroke
iv. Unstable vascular aneurysm
v. Severe pulm condition
vi. Anaesthetic las 4 or 5
c. Low mortality rate
d. Confusion and cognitive side effects
e. Dysrhythmias

Personality Disorders

1. Definition – general term for a group of behavioural disorders characterised by lifelong ingrained maladaptive patterns of subjective internal experience and deviant behaviour, lifestyle and social adjustment
2. DSM 1V Classification
a. Cluster A – odd, eccentric
i. Paranoid – suspicious, mistrustful
ii. Schizoid – detached, socially withdrawn, indifferent to praise/criticism
iii. Schizotypal – odd, strange, peculiar beliefs/ideas, associated + milder spectrum of schizophrenia
b. Cluster B – dramatic, emotional, erratic
i. Antisocial – antisocial behaviours, criminal traits
ii. Borderline – instability (r/ships, mood, self image) – most common in a mental health setting
iii. Histronic – excitable, emotional, extroverted, attention seeking beh
iv. Narcisstic – heightened self importance
c. Cluster C – anxious, fearful
i. Avoidant – anxious, sensitivity
ii. Dependent – responsibility of one’s life given over to others, often tolerate abusive partner
iii. Obsessive compulsive – orderly, inflexible
3. Borderline personality disorder
a. Diagnosis → PRAISE
i. Paranoid ideas
ii. Relationship instability
iii. Angry outbursts, affective instability, abandonment fears
iv. Impulsive beh, identity disturbance
v. Suicidal beh
vi. Emptiness
b. Management - DBT

Old Age Psychiatry

1. Barriers to good assessment
a. Ø informed consent
b. Perceived stigmata of psyc interview
c. Sensory deficits – hearing, vision
d. Disoriented or anxious in unfamiliar evt
e. Hxs take longer
f. Clinical ageism
2. Impt conditions – 3Ds
a. Depression
b. Dementia
c. Delirium

Dementia
1. Definition - Irreversible degenerative brain dis usu occurring late in life
2. Epidemiology – 6-7% up to age 80, 20% thereafter, M=F
3. Presentation
a. Memory + 1 of BREW
i. Memory loss (esp ST and immediate mem; LT and procedural mem preserved till late)
ii. Behavioural disorganisation (apraxia) – use of an object not carried out although it can be named and use described
iii. Regognition impairment (agnosia)
iv. Executive function
v. Word problems (aphasia)
vi.
b. Features
i. Irreversible
ii. Organic cause
iii. Personality change
iv. Problems with ADLs
v. Disorientation
vi. Lack of insight
4. BPSD (behavioural and psychological sxs of dementia)
a. Definition – BPSD is a complication of dementia
b. Sxs
i. Personality change
ii. Psychotic phenomena – delusions, hallucinations
iii. Perceptional abnormalities – illusions
iv. Psychomotor agitation or retardation
v. Apathy
vi. Depression
vii. Delirium
viii. Falls
ix. Behaviour problems – verbal/physical aggressiveness, shouting/screaming, wandering, hassling, inappropr incontinence etc
c. Tx strategies for problem behaviours
i. Analysis of system supporting beh
ii. Behaviour and validation therapies
iii. Compensation for physical or cogv deficits – eg hearing aid, glasses
iv. Drugs – SSRIs, antipsychotics
v. Environmental manipulation – education and support of carers

Delirium
1. Definition
a. Reversible d/o of cognition caused by a pathophys factor extraneous to CNS and characterised by a waxing and waning in LOC
2. Clinical features of acute delirium
a. Disturbance in LOC with fluctuations throughout the day
b. Attention deficits
c. Disorientation – TPP
d. Agitation
e. Misperceptions and hallucinations
f. Language disturbance
g. Rapid onset
h. May co-exist with dementia (eg sundowning = confusion late in the day)
3. Epidemiology – prevalence may be high as 50% of geriatric pts
4. Etiology
a. Systemic infection / fevers
b. Drugs – benzos!!!, TCAs, steroids, opiates, analgesics, lithium etc
c. Hypoxia or Hypercapnia
d. Metabolic – eg hypogly
e. Electrolyte or fluid disturbance
f. LF or RF
g. Post operative states
h. Thiamine deficiency, Alcohol withdrawal
i. Post ictal states
j. Stroke, CVA, head injury
5. Management
a. Delirium Screen
i. Bloods – U&E, FBC, ESR, CRP, LFTs, renal function
ii. BG
iii. MSU
iv. Toxic screen – alcohol, drugs
v. CXR
vi. ECG
vii. CT Scan
b. Tx the underlying cause
i. Eliminate cause and tx any medical condition
ii. Low stimulus room
iii. Attn to IV lines etc
iv. Reorientation during lucid periods
v. Familiar staff and relatives
vi. Haloperidol or Resperidone in low doses frequently

Mental Health Act

1. Definition of a mental disorder → 2 limb test
a. Abnormal state of mind (delusions, mood disorders, volition, cognition, perception)
b. To such a degree that it –
i. Poses a serious danger to the health or safety of the person or others OR
ii. Seriously diminishes the capacity of the person to take care of themselves
2. Section 10 – Preliminary assessment
3. Section 11 – Further assessment for 5 days
4. Section 13 – Further assessment and tx for 14 days
5. Section 28 – compulsory tx order
6. Section 29 – community order
7. Section 30 – inpatient order
8. Section 16 – at any time, a pt can ask for a review by a judge

Science of Happiness

1. H = S + C + V (happiness = set range + current circumstances + voluntary variables)
2. H = happiness, enduring not transient, general feelings of contentment not ST feelings
3. Set range = genetics, ~50%
a. Habituation – progressive diminution of behaval response w repetition of stimulus
b. Eg – body pleasures, food, amputees return to baseline (exceptions – delayed habituation with death of child/spouse)
c. Hedonic treadmill – material possessions, accomplishments, status, incr pay etc
4. Current circumstances = ~8-15%
a. Eg - $, marriage, social life, health
b. In wealthier nations where basic needs are met, increases in wealth have negligible effects on personal happiness
5. Voluntary variables = positive emotions re past, present and future
a. Don’t dwell in the past, learn to forgive
b. Gratitude
c. Mindfulness – focus on the now, not what is going to happen, retraining the focus of the brain on current thoughts, feelings and emotions

Mindfulness

1. Definition - mindfulness
a. A technique in which a person becomes intentionally aware of their thoughts and actions in the present moment, non-judgementally
b. It plays a central role in buddism
2. Three components
a. Paying attention to moment by moment experiences in a non-judgemental way
b. Being present and actively engaged in the moment without making automatic judgements
c. Intentionally aware of one’s thoughts, feels and actions, non-judgementally

Neurobiology

1. Depression
a. Genetics - monozygotic twins – 50% concordance rate
b. Neurotransmitters – hypoactive monoamine NT systems (esp serotonin and nor-adrenaline) → clinical efficacy of SSRIs/MAOs
2. BPAD
a. Genetics – 5-10% lifetime risk if first degree relative (otherwise, risk = 1%)
3. Schizophrenia
a. Dopamine
i. Overactivity of dopamine neurons betw midbrain and anterior cortex
ii. Antipsychotic drugs – dopamine antagonism
iii. Amphetamines (dopaminergic) can induce psychotic sxs
b. Genetics
i. Monozygotic twins → 50% concordance
ii. First degree relatives – 10% concordance
4. Dementia (alzheimers type)
a. Structural
i. Extracellular amyloid deposition
ii. Intracellular neurofibrillary tangles
iii. Loss of neurons
b. Genetics
i. APP (amyloid precursor protein) mutations → ↑levels of amyloid (early onset AD)
ii. The gene apolipoprotein E has 3x forms (apo E2-4) predicting risk of late onset AD
1. Apo E4 is assoc w higher risk of AD
2. 4x ↑ risk if one copy of apo E4
3. 10↑ risk if two copies of apo E4
5. OCD - genetics → high concordance rate among twins and first degree relatives

Differential Diagnosis

1. Schizophrenia
a. Brief psychotic disorder <1 month
b. Delusional disorder
c. Schizophreniform disorder <6 months
d. Substance induced psychosis
e. BPAD
f. Psychotic depression
g. Schizoaffective disorder
h. Schizoid personality disorder
i. PTSD
j. Organic medical illness eg delirium
2. Major Depression
a. Dysthymia
b. BPAD
c. Psychotic depression
d. Schizoaffective disorder
e. Schizophrenia, esp catatonic type
f. Organic medical disorder – eg hypothyroid, diabetic coma, hypoglycaemia, Parkinsons
3. BPAD
a. Bipolar 1 or 11
b. Major depressive disorder
c. Dysthymic disorder
d. Cyclothymic disorder
e. Schizoaffective disorder
f. Schizophrenia
g. Organic illness
h. Substance induced
i. Narcisstic PD
4. Dementia
a. Delirium
b. Major depressive episode
c. Drugs
d. Schizophrenia
e. Mild cognitive impairment
f. Normal process of ageing

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