Psychiatry Notes

Psychiatry Notes

Psychiatry History

• Introduction
• Name, age, DOB and employment status
• Remember MSE and safety

Presenting complaint

• What has brought you here?
• Why are you here?

(Keep this open and obscure in case of delusions)

HPC

• When did the problem start (timeline)
• When did you last feel well?
• Did anything precede the problem? (Bereavement, relationship problems)
• How did it develop? (Symptoms)
• Associated Sx
• Psych-(Anhedonia, poor concentration, guilt)
• Physical- (sleep, appetite etc)
• Impact on daily living?
• Any help or Rx, were they useful?

Screen for any other problems

Depression screen, delusional or obsessional thoughts, unusual perceptions or experiences, suicidal

thoughts, changes in social contact, sleep probs and anxiety?

Past Psychiatric History

• Have you seen a psychiatrist in the past? Admissions?
• What were your reasons (for Rx, Sucide, Self-harm, stopping meds etc)
• How have you been between episiodes? (Work, socially)

PMH

• Keep this brief and probe Psych related conditions (e.gThyrotoxicosis, Medications etc)

FH

• Can I ask about your family?
• Relationships, employment and social circumstances
• FH of psych conditions
• Alcohol or drug misuse at home

Personal Hx

• Can I ask you questions about your past?
• Childhood
• School
• Occupations
• Relationships and Sexual history
• Habits and Dependencies

Forensic Hx

• Any trouble with the police?

Social Hx

• Housing- type, state, who do you live with?
• Support- friends, relatives, neighbours, CAMS
• Daily activities- describe a typical day, social activities
• Finances- do they manage them, debts or worries, benefits, recent spending spree?

Personality

• How would people describe you?
• Attitude to self
• Religious and moral beliefs
• Activities and interests

Anything else you would like to tell me?

Mental StateExamination

• Appearance
• Behaviour
• Mood (Objective and Subjective)
• Speech (Rate, Rhythm and Volume)
• Affect (Correct for consultation)
• Thoughts (Insertion, broadcast,)
• Perception (Delusions, Illusions, Hallucinations)
• Cognition (cognitive abilities)
• Insight (do they know they have a problem)

Mental Health Act

Section / Ground / Application / Med Recommendation / Max. Duration
2 / Assessment / ASW or Relative / 2 Dr’s (1 is section 12 approved) / 28 days
3 / Treatment / ASW or Relative / 2 Dr’s (1 is section 12 approved) / 6 months
4 / Emergency / ASW or Relative / Any Dr / 72 hrs
5(2) / Detention of inpatient / ASW or relative / Dr in charge of pt care / 72 hrs
5(4) / Detention of in patient / MH Nurse / None / 6 hrs
135 / Magistrate - police to enter home / Magistrate / None / 72 hrs
136 / Admission by police / Police / None / 72 hrs

Schizophrenia

Schneider’s First Rank Symptoms

• Auditory Hallucinations
• Thought echo
• Running commentary
• 3rd person reference
• Thought alienation
• Thought insertion
• Thought withdrawal
• Thought broadcasting
• Somatic passivity
• Somatic Phenomena
• Made feelings
• Made impulses
• Made actions
• Delusional Perception
• Religious, Grandiose, Nihilistic etc

Negative Sx

• Low mood
• Flattened affect
• Low IQ
• Lack of energy
• Sleep disturbances
• Loss of motivation/drive

Management

• Antipsychotics
• Olanzapine, Risperidone – 2nd generation antipsychotics
• Psychosocial
• Family therapy
• CBT
• Social skills rehabilitation

Schizoaffective Disorder

Schizophrenic Sx + Sxof mood (affective) disorders in same episode

Schizoaffective disorder, manic type

Schizoaffective disorder, depressive type

Management: Treat acute symptoms with antipsychotics and antidepressants

Paranoid Disorders

More common in females, Onset 40-55 years

Othello Syndrome

• Delusional belief that one’s partner is cheating
• High risk of violence

De Clerambault’s Syndrome

• Delusional belief that someone of higher status is in love with the patient

Persecutory Delusions

• Delusional belief that others are constantly plotting against the patient

Cotard’s Syndrome

• Nihilistic delusional belief

Capgras’ Syndrome

• Delusional belief that a familiar person has been replaced by an identical double

Fregoli’s Syndrome

• Delusional belief that a familiar persona has taken on the appearance of another person

Folie a duex

• A delusional belief adopted by someone close to a patient suffering from a psychotic disorder

Depression

• Core Symptoms:
• Pervasive lowering of mood
• Anhedonia
• Reduced energy

• Further Symptoms:
• Reduced self-esteem/confidence
• Reduced concentration & attention
• Ideas of guilt & worthlessness
• Feelings of hopelessness
• Thoughts of self-harm
• Biological symptoms

Mild:2 core + 2 further

Moderate:2 core + 4 further

Severe:3 core + 5 further (or pyshchosis)

Management

Address underlying co-morbidities

• Biological:
• SSRIs e.g. Fluoxetine
• TCAs e.g. Amitriptyline
• MAOIs e.g. Phenelzine
• ECT-psychosis, catatonic state, refractory

• Pschological:
• CBT
• Interpersonal Psychotherapy
• Social: Financial, Housing problems etc
• Admit to hospital

Postnatal Depressive Disorder’s

Baby blues: occurs in 50-70% of deliveries, peaks at 3-5 days. Educate & Reassure

Postpartum depression: 10-15%, Family Hx of depression, CBT & antidepressants

Postpartum psychosis: 0.1%. Onset 2-4 weekspostnpartum. Depression>Mania + 1st rank symptoms.

Bipolar affective disorder

History of at least 2 episodes of mood disturbance, at least one of which should have been mania (or hypomania)

Types:

Bipolar I disorder:

• One or more manic or mixed episodes and one or more major depressive episodes

Bipolar II disorder:

• Recurrent major depressive and hypomanic but not manic episodes

Cyclothymia:

• Hx of at least 2 years’ of instability of mood involving mild depression and hypomania of lesser degree than BPAD

Management of Mania

• Treatment
• Antipsychotic’s
• Benzodiazepine
• Lithium

• Prophylaxis
• Lithium
• Carbamazepine & Sodium Valproate(if Lithium fails)

• Psychological
• Family therapy
• Social worker involvemnt
• Support groups

Management of Depression

• As for unipolar

Somatoform Disorders

• Physical symptoms truly experienced by the patient
• Extensive investigation by many physicians from different specialities

Subtypes:

• Somatisation disorder
• Hypochondriasis
• Somatoform autonomic dysfunction disorder

Management

• Build up a good relationship and trust with one doctor e.g. GP
• Regular appointments to keep their behaviour and presentation under control

Dissociative disorders

• Patients present with a true dysfunction
• Often triggered by a psychological trauma
• Signs may follow the patient’s understanding of the body rather than true clinical signs

Subtypes:

• Disscociative amnesia/fugue
• Dissociative stupor
• Dissociative convulsions
• Dissociative motor disorder
• Dissociative anaesthesia and sensory loss

Management

• Psychotherapy
• Address underlying issues

Factitious disorders

Munchausen’s syndrome

The patient invents his or her symptoms in order to gain admission and care in hospital – need to fulfil the ‘sick role’

Malingering

Symptoms are made up in order to fulfil another primary gain e.g. avoid going to court

Dysmorphophobia

Persistent concern about the appearance of body or conviction that part of the body is not part of the self

Personality Disorders

Classification / Features / Treatment

Paranoid PD

/

• Suspicious
• Jealous
• Bears grudges
• Self-important

/

• Supportive to prevent accumulation of problems caused by suspiciousness or angry responses to others

Schizoid PD /

• Emotionally cold
• Detached
• Lacking enjoyment
• Prone to fantasy
• Don’t make intimate relationships

/

• Often drop out after few sessions
• Therapy to help them to be more aware of their problems and respond to them

Schizotypal PD / Classified with Schizophrenia in ICD-10
Dissocial (anti-social) PD /

• Callous
• Transient shallow relationships
• Grossly irresponsible
• Lack guilt
• Fail to accept responsibility
• Low frustration and aggression threshold

/

• Fluoxetine can reduce measures of aggression
• Individual psychotherapy can be useful
• Group therapy
• Therapeutic community

Emotionally unstable PD / Borderline

• Uncertain self-image,
• Intense, unstable relationships
• Recurrent threat of self-harm

Impulsive

• Impulsiv,
• Liability to anger and violence
• Quarrelsome
• Difficulty maintaining course of action

/

• Problem-solving counselling: focus on dealing with everyday probs.
• SSRIs may ↓ impulsive behaviour in some and small dose of anti-psychotics may ↓ aggression short-term.
• MAOIs may be helpful
• Group psychotherapy

Histrionic PD /

• Self-dramatization
• Suggestibility
• Labile affect
• Seek attention and excitement
• Over-concern with physical attractiveness

/

• May attempt to impose impractical conditions on treatment
• Set clear limits
• Treatment focuses on responding to stressful situations.
• Medication of little value

Anakastic PD

/

• Preoccupied with details and rules
• Inhibited by perfectionism
• Rigid and stubborn
• Excessively doubting and cautious

/

• Do not respond well to psychotherapy
• Treatment directed to avoiding situations that increase the pts difficulties and to coping with stressful situations.

Avoidant (anxious) PD /

• Tension
• Feel socially inferior/inadequate
• Preoccupation with rejection or criticism
• Avoidance of risk
• Avoidance of social activity

/

• Providing a therapeutic relationship in which they feel valued
• Be alert to co-morbid depressive disorder.

Dependent PD

/

• Let others take responsibility for important decisions
• Unduly compliant with wishes of others
• Feel unable to care for self and fear having to do so
• Needs excessive advice to make decisions

/

• Problem-solving
• Should not be seen too frequently to avoid dependence.
• Avoid meds unless associated depression.

GeneralizedAnxiety Disorder

Often present as somatic symptoms:

• Gastrointestinal (dry mouth, dysphagia, abdo discomfort, wind, diarrhoea)
• Respiratory (chest tightness, hyperventilation)
• Cardiovascular (palpitations, chest pain)
• Genitourinary (frequent/urgent micturation, erectile dysfunction)
• Neuromuscular (tremor, parathesiae, dizziness, headache)
• Sleep disturbance (insomnia, night terrors)
• Psychological (fearfulness, irritability, restlessness, poor concentration)

Management

• Supportive measures using reassurance
• Benzodiazepines (severe episodes)
• Relaxation training

• Futhersx control:
• TCAs
• SSRIs
• MAOIs
• Beta-Blocker (for palpitations)

Phobic Disorders

Symptoms are almost identical to generalized anxiety except:

• Only in specific circumstances
• Avoidance of these circumstances
• Anticipatory anxiety of circumstances

Simple Phobia

• Due to particular situations or circumstances
• Treatment is usually by exposure to the stimulus ( behaviour therapy)

Social Phobia

• Inappropriate anxiety due to being observed or criticised by others
• Symptoms include blushing, trembling and alcohol use
• Treatment may be anxiolytic medication, MAOIs, SSRIs, CBT and psychodynamic therapy

Agoraphobia

• Inappropriate anxiety caused by being away from home or in crowds
• Anxiety may be reduced when accompanied by trusted companions or objects
• Treatment is graded exposure and anxiety management (medication and relaxation)

Panic Disorder

• Features include the physical symptoms of generalized anxiety and can occur with other anxiety disorders
• Treatment is supportive therapy followed by medication (benzodiazepines and antidepressants)
• Cognitive therapy can also be used

Obsessive-Compulsive Disorder

• These disorders are characterised by obsessional thinking and/or compulsivebehaviour.
• There may be slowness due to the necessity to perform obsessional rituals and symptoms of depression and depersonalisation.
• May be precipitated by stressful life-events
• Treatment is reassurance, SSRIs, anxiolytics and tricyclics.
• Behaviour therapy may also be considered.

Dementia

Disease / Symptoms / Other Features
Alzheimer’s Disease /

• Memory loss (short term)
• Dysphasia and Dyspraxia
• Persecutory beliefs

/

• Relentless progression
• 5-10 year survival

Vascular Dementia /

• Personality change
• Labile mood
• Preserved insight

/

• Stepwise progression
• CVA risk factors
• Neurosx

Lewy Body Dementia /

• Flucuating Cognition
• Visual Hallucinations
• Parkinsonism

/

• Worsened by anti-psychotics

Pick’s Disease /

• Frontal lobe/executive function impairment
• Preserved memory
• Personality change

/

• FH
• Slow progression

Huntington’s Disease /

• SZ-like psychosis
• Depression
• Abnormal movements
• Dementia occurs later

/

• 20-40 yrs
• Strong FH

CJD /

• Seizures
• Cerebellar ataxia
• Myoclonic jerks

/

• Often presenile
• Rapid onset and progression

Child & Adolescent Psychiatry

Early Childhood(0-5yrs)

Disorder / Features
Behaviour Disorders /

• Active, attention-seeking, disobedient children
• Often found with negative parent attitudes and incongruous discipline
• Management is usually with support and behavioural advice or therapy

Sleep Disorders /

• Night-waking and severe sleep problems are relatively common
• Illness, stress and maternal depression contribute
• Management by behavioural techniques
• Medication is seldom used

Temper Tantrums /

• Outbursts are common and peak in year 2 of life
• Causes include frustration over speech delay, difficulties in parent-child relationship and anxiety in new situations
• Behavioural therapy can be used

Enuresis / Encopresis /

• Involuntary urinary or faecal incontinence may be linked to events during toilet training or current stress
• Behavioural programmes, including bell and pad, may help
• Drug treatments may be used in bedwetting

Autism /

• Affects 2-4 per 10,000 M>F and usually seen by age 3
• There are severe problems with understanding speech and grammar as well as social interaction and relationships
• Ritualistic routines are common
• Treatment is supportive

Hyperkinetic Disorder /

• Also known as ADD, characterised by overactivity
• Problems with attention and can cause learning difficulty, low self-esteem and relationship problems.
• High incidence of familial disharmony.
• Treatment is by structured daily routine, behavioural therapy and possibly medication (eg amphetamines)

Middle Childhood(5-12yrs)

Disorder / Features / Treatment
Emotional /

• Most common symptom is anxiety in anticipation of an unpleasant event
• Associated with tension, physical complaints, bed-wetting and soiling
• Association with introvert personality
• Linked to over-protective parenting

/

• Stress reduction
• Improving understanding of anxiety a
• Enhancing coping mechanisms

Conduct /

• More common in boys
• Antisocial behaviour usually with aggression
• Lying and disobedience
• Linked to social deprivation and broken homes

/

• Counselling or psychotherapy
• Behaviour modification through feedback
• Rarely tranquillisers

Psychosomatic /

• Recurrent abdominal pain and headaches are the most common
• May be due to other physical illness, concern over academic issues and is linked to high-achievers.

/

• Joint psychiatric and paediatric management

School Refusal /

• More common in single and youngest children who are passive and introvert
• Usually due to separation anxiety and may be influenced by overprotection

/

• Mainly dealt with by parents and teachers.
• Firmness and encouragement

Adolescence(12-16yrs)

The common psychiatric problems are:

• Depressive disorder
• Suicide and deliberate self-harm

Substance Misuse

Alcohol

• Light/Moderate/Heavy
• Men 21/35/50
• Women 14/25/35

Features

• Acute Intoxication
• Harmful Use (social / psychiatric / psychological / physical)
• Dependence
• Withdrawal
• 2h-4d
• tremor / sweating / vomit [GABA hyperactivity]
• Delerium tremens

• Long term use
• Cerebellar atrophy
• Dementia
• Wernicke’s(acute confusion, lateral rectus palsy, peripheral neuropathy, horiznystagmus, ataxia + encelphelopathy)
• Korsakoffs

Management

• Acute Withdrawal:
• Monitor + Correct Hydration/Electrolytes
• Reassure
• Benzos if req
• Parenteral thiamine
• Prophylactic anticonvulsant ifHx of seizures

• Delirium Tremens:
• Parenteral Thiamine
• Rehydrate
• Electrolyte Balance
• Underlying Infection
• Benzos if req
• Wernicke (MEDICAL EMERGENCY)
• Parenteral Thiamine
• Rehabilitation

Opiates

Features

• Toxicity

• Coma
• CNS + resp depression 4-6bpm
• Pupillarymiosi
• Bradycardia
• Hypotension
• Constipation
• Analgesia
• Reduced anxiety
• Euphoria
• Ventricular arrhythmia
• Seizures
• Hallucinations
• Psychosis

• Withdrawal

• Dilated pupils
• Insomnia
• Ttachycardia
• Hypertension
• Piloerection
• Lacrimation
• Yawning
• Sweating
• Rhinorrhea
• Nasal congestion
• Myalgia
• Emesis
• Diarrhoea
• Abdominal crampin

Management

• Acute intoxication

• Urine drug screen
• Establish on detox
• Intubate, Restrain & titrate up Naloxone

• Withdrawal

• Symptomatic treatment
• Opioids should be avoided

• Detox supervised patient contract

Psychiatric Medications

Anxiolytic medication

• Reduce anxiety and at higher doses induce drowsiness (sedatives) and sleep (hypnotics)
• Prescribed for short periods to avoid tolerance and dependence
• Gradual withdrawal to prevent withdrawal effects

• Buspirone
• Beta-blockers (egpropanolol)
• Benzodiazepines

AntipsychoticMedication

Group / Examples / Unwanted Effects
‘Typical’ / Haloperidol
Chlorpromazine / More
‘Atypical’ / Clozapine
Olanzepine / Less

Extrapyramidal side-effects:

• Acute dystonia (eg tongue protrusion, grimace, ocular spasm)
• Akathisia (inability to remain still)
• Parkinsonism (expressionless face, akinesia, rigidity, tremor)
• Tardivedyskinesia (chewing and sucking, grimacing)

AntidepressantMedication

Type / Examples / Unwanted Effects / Use
Tricyclic Antidepressants (TCAs) / Amitriptyline
Imipramine / Dry mouth
Constipation
Drowsiness
Arrhythmia / Moderate/severe depression
Selective Serotonin Reuptake Inhibitors (SSRIs) / Paroxetine
Fluoxetine
Fluvoxamine
Sertraline / GI disturbance
Insomnia
Agitation
Sexual dysfunction / Mild/moderate depression
Monoamine Oxidase Inhibitors (MAOIs) / Phenelzine
Isocarboxazid / Dry mouth
Constipation
Headache
Tremor / Started by specialist

TCAs - toxicity in overdose

MAOIs - complex interactions with various chemicals and foods

MoodStabilisers

• Lithium
• Carbamazepine
• Sodium valproate