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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 o Psych - (Anhedonia, poor concentration, guilt) o 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.g Thyrotoxicosis, 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? o Childhood o School o Occupations o 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 2 Assessment ASW or Relative 3 Treatment ASW or Relative 4 5(2) Emergency Detention of inpatient Detention of in patient Magistrate - police to enter home Admission by police ASW or Relative ASW or relative 5(4) 135 136 Max. Duration MH Nurse Med Recommendation 2 Dr’s (1 is section 12 approved) 2 Dr’s (1 is section 12 approved) Any Dr Dr in charge of pt care None Magistrate None 72 hrs Police None 72 hrs 28 days 6 months 72 hrs 72 hrs 6 hrs Schizophrenia Schneider’s First Rank Symptoms Auditory Hallucinations o Thought echo o Running commentary o 3rd person reference Thought alienation o Thought insertion o Thought withdrawal o Thought broadcasting Negative Sx Low mood Flattened affect Low IQ Somatic passivity Somatic Phenomena o Made feelings o Made impulses o Made actions Delusional Perception o Religious, Grandiose, Nihilistic etc Lack of energy Sleep disturbances Loss of motivation/drive Management Antipsychotics o Olanzapine, Risperidone – 2nd generation antipsychotics Psychosocial o Family therapy o CBT o Social skills rehabilitation Schizoaffective Disorder Schizophrenic Sx + Sx of 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: o Pervasive lowering of mood o Anhedonia o Reduced energy Further Symptoms: o Reduced self-esteem/confidence o Reduced concentration & attention o Ideas of guilt & worthlessness o Feelings of hopelessness o Thoughts of self-harm o Biological symptoms Pschological: o CBT o Interpersonal Psychotherapy Social: Financial, Housing problems etc Admit to hospital Mild: 2 core + 2 further Moderate: 2 core + 4 further Severe: 3 core + 5 further (or pyshchosis) Management Address underlying co-morbidities Biological: o SSRIs e.g. Fluoxetine o TCAs e.g. Amitriptyline o MAOIs e.g. Phenelzine o ECT-psychosis, catatonic state, refractory 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 weeks postnpartum. 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 o Antipsychotic’s o Benzodiazepine o Lithium Prophylaxis o Lithium o Carbamazepine & Sodium Valproate (if Lithium fails) Psychological o Family therapy o Social worker involvemnt o 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 Paranoid PD Schizoid PD Schizotypal PD Dissocial (antisocial) PD Emotionally unstable PD Features Suspicious Jealous Bears grudges Self-important Emotionally cold Detached Lacking enjoyment Prone to fantasy Don’t make intimate relationships Classified with Schizophrenia in ICD-10 Callous Transient shallow relationships Grossly irresponsible Lack guilt Fail to accept responsibility Low frustration and aggression threshold Borderline Uncertain self-image, Intense, unstable relationships Recurrent threat of self-harm Impulsive Impulsiv, Liability to anger and violence Quarrelsome Treatment Supportive to prevent accumulation of problems caused by suspiciousness or angry responses to others Often drop out after few sessions Therapy to help them to be more aware of their problems and respond to them Fluoxetine can reduce measures of aggression Individual psychotherapy can be useful Group therapy Therapeutic community 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 Anakastic PD Avoidant (anxious) PD Dependent PD Difficulty maintaining course of action Self-dramatization Suggestibility Labile affect Seek attention and excitement Over-concern with physical attractiveness Preoccupied with details and rules Inhibited by perfectionism Rigid and stubborn Excessively doubting and cautious Tension Feel socially inferior/inadequate Preoccupation with rejection or criticism Avoidance of risk Avoidance of social activity 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 May attempt to impose impractical conditions on treatment Set clear limits Treatment focuses on responding to stressful situations. Medication of little value Do not respond well to psychotherapy Treatment directed to avoiding situations that increase the pts difficulties and to coping with stressful situations. Providing a therapeutic relationship in which they feel valued Be alert to co-morbid depressive disorder. Problem-solving Should not be seen too frequently to avoid dependence. Avoid meds unless associated depression. Generalized Anxiety 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 Futher sx control: o TCAs o SSRIs o MAOIs o 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 compulsive behaviour. 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 Alzheimer’s Disease Symptoms Memory loss (short term) Dysphasia and Dyspraxia Persecutory beliefs Personality change Labile mood Preserved insight Flucuating Cognition Visual Hallucinations Parkinsonism Frontal lobe/executive function impairment Preserved memory Personality change SZ-like psychosis Depression Abnormal movements Dementia occurs later Seizures Cerebellar ataxia Myoclonic jerks Vascular Dementia Lewy Body Dementia Pick’s Disease Huntington’s Disease CJD Other Features Relentless progression 5-10 year survival Stepwise progression CVA risk factors Neuro sx Worsened by anti-psychotics FH Slow progression 20-40 yrs Strong FH Often presenile Rapid onset and progression Child & Adolescent Psychiatry Early Childhood (0-5yrs) Disorder Behaviour Disorders Sleep Disorders Temper Tantrums Enuresis / Encopresis Autism Features Active, attention-seeking, disobedient children Often found with negative parent attitudes and incongruous discipline Management is usually with support and behavioural advice or therapy Night-waking and severe sleep problems are relatively common Illness, stress and maternal depression contribute Management by behavioural techniques Medication is seldom used 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 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 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 selfesteem 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 Most common symptom is anxiety in anticipation of an unpleasant event Associated with tension, physical complaints, Emotional bed-wetting and soiling Association with introvert personality Linked to over-protective parenting More common in boys Antisocial behaviour usually with aggression Conduct Lying and disobedience Linked to social deprivation and broken homes Psychosomatic School Refusal Recurrent abdominal pain and headaches are the most common May be due to other physical illness, concern over academic issues and is linked to highachievers. More common in single and youngest children who are passive and introvert Usually due to separation anxiety and may be influenced by overprotection 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) Treatment Stress reduction Improving understanding of anxiety a Enhancing coping mechanisms Counselling or psychotherapy Behaviour modification through feedback Rarely tranquillisers Joint psychiatric and paediatric management Mainly dealt with by parents and teachers. Firmness and encouragement Dependence Withdrawal o 2h-4d o tremor / sweating / vomit [GABA hyperactivity] o Delerium tremens Long term use o Cerebellar atrophy o Dementia o Wernicke’s (acute confusion, lateral rectus palsy, peripheral neuropathy, horiz nystagmus, ataxia + encelphelopathy) o Korsakoffs Management Acute Withdrawal: o Monitor + Correct Hydration/Electrolytes o Reassure o Benzos if req o Parenteral thiamine o Prophylactic anticonvulsant if Hx of seizures Opiates Features Toxicity o Coma o CNS + resp depression 4-6bpm o Pupillary miosi o Bradycardia o Hypotension o Constipation o Analgesia Withdrawal o Dilated pupils o Insomnia o Ttachycardia o Hypertension o Piloerection o Lacrimation o Yawning Management Acute intoxication o Urine drug screen o Establish on detox Withdrawal o Symptomatic treatment Detox supervised patient contract Psychiatric Medications Anxiolytic medication Delirium Tremens: o Parenteral Thiamine o Rehydrate o Electrolyte Balance o Underlying Infection o Benzos if req Wernicke (MEDICAL EMERGENCY) o Parenteral Thiamine o Rehabilitation o o o o o o Reduced anxiety Euphoria Ventricular arrhythmia Seizures Hallucinations Psychosis o o o o o o o Sweating Rhinorrhea Nasal congestion Myalgia Emesis Diarrhoea Abdominal crampin o Intubate, Restrain & titrate up Naloxone o Opioids should be avoided 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 o Buspirone o Beta-blockers (eg propanolol) o Benzodiazepines Antipsychotic Medication Group Examples Haloperidol Chlorpromazine Clozapine Olanzepine ‘Typical’ ‘Atypical’ Unwanted Effects More Less Extrapyramidal side-effects: Acute dystonia (eg tongue protrusion, grimace, ocular spasm) Akathisia (inability to remain still) Parkinsonism (expressionless face, akinesia, rigidity, tremor) Tardive dyskinesia (chewing and sucking, grimacing) Antidepressant Medication Type Examples Tricyclic Antidepressants (TCAs) Amitriptyline Imipramine Selective Serotonin Reuptake Inhibitors (SSRIs) Paroxetine Fluoxetine Fluvoxamine Sertraline Monoamine Oxidase Inhibitors (MAOIs) Phenelzine Isocarboxazid Unwanted Effects Dry mouth Constipation Drowsiness Arrhythmia GI disturbance Insomnia Agitation Sexual dysfunction Dry mouth Constipation Headache Tremor TCAs - toxicity in overdose MAOIs - complex interactions with various chemicals and foods Mood Stabilisers Lithium Carbamazepine Sodium valproate Use Moderate/severe depression Mild/moderate depression Started by specialist