Psychiatry is big Depression Suicide Bipolar disorder Generalised Anxiety Disorder Panic Disorder Post traumatic stress disorder Obsessive compulsive disorder Addiction Dementia Delirium ID: 931926
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Slide1
Psychiatry for 3a
Emily Alsworth and George Huntington
Slide2Psychiatry is big…
Depression
Suicide
Bipolar disorder
Generalised Anxiety Disorder
Panic Disorder
Post traumatic stress disorder
Obsessive compulsive disorder
Addiction
Dementia
Delirium
Schizophrenia
Personality disorders
Eating disorders
Sleep disorders
Functional illness
Body dysmorphic disorder
Hysteria
Dissociative identity disorder
Sexual disorders
Attention deficit hyperactivity disorder
Autistic spectrum disorder
Conduct disorder
Slide3Psychiatry is big…
Depression
Suicide
Bipolar disorder
Generalised Anxiety Disorder
Panic Disorder
Post traumatic stress disorder
Obsessive compulsive disorder
Addiction
Dementia
Delirium
Schizophrenia
Personality disorders
Eating disorders
Sleep disorders
Functional illness
Body dysmorphic disorder
Hysteria
Dissociative identity disorder
Sexual disorders
Attention deficit hyperactivity disorder
Autistic spectrum disorder
Conduct disorder
Slide4Pattern recognition
Pattern recognition
Pattern recognition
Slide5Depression
Slide6ICD-10 Criteria
A)The episode must last at least 2 weeks
A)The episode cannot be attributed to psychoactive substance abuse or to an organic mental disorder
B)At least two of the following must be present
Abnormal depressive mood present during most of the day and almost every day
Marked loss of interest in previously pleasurable activities – ANHEDONIA
Increase in fatigability - ANERGIA
Slide7ICD-10 Criteria cont.
C)One or more of the following symptoms
Loss of confidence and self esteem
Feelings of excessive guilt
Recurrent thoughts of death, suicide, or suicidal behaviour
Decrease in ability to concentrate
Changes in psychomotor activity- agitation or inhibition
Sleep alteration
Change in appetite
Slide8ICD-10 Criteria cont.
Mild
At least 2 symptoms from B, total of 4 symptoms
Moderate
At least 2 symptoms from B, total of 5 to 6 symptoms
Severe
All 3 symptoms of B, total of 8 symptoms, with or without psychosis
Slide9Questionnaires
PHQ-9
Patient Health Questionnaire 9
HADS
Hospital Anxiety and Depression Scale
BDI-II
Beck Depression Inventory II
Slide10Differentials
Dysthymia
Bipolar disorder
Adjustment disorder
Substance abuse
Dementia
Sleep related disorders
Chronic fatigue syndrome
Lupus
Lyme disease
Syphilis
Anaemia
Addison’s disease
Hypoparathyroidism
Hypoglycaemia
Hypothyroidism
Epstein-Barr virus
Slide11Treatment
Psychoeducation
Cognitive Behavioural Therapy (
eg
through IAPT)
Antidepressants
SSRIs
eg
citalopram or sertraline first line
TCAs
dangerous in overdose!
Electroconvulsive therapy
Severe and complex depression with risk to life and/or severe self-neglect
Slide12Bipolar Disorder
Slide13Symptoms of mania/hypomania
Feelings of intense happiness
Increased irritability
Increase self esteem
Reduced need for sleep
Pressure of speech
High energy
Exaggerated sense of self importance
Lack of concentration
Risky behaviour
Decreased inhibitions
Poor judgement
Grandiose delusions (mania)
Slide14Bipolar disorder
Must have had 2 episodes of mood disturbance
At least one of these must have been mania or hypomania
Bipolar I
with mania
Bipolar II with hypomania
Slide15Treatment
Acute mania
Consider admission, either voluntary or involuntarily under the Mental Health Act
Atypical antipsychotics
Olanzapine, quetiapine, risperidone
Chronic
Mood stabilisers
Lithium
Remember to monitor kidneys and thyroid
Beware toxicity
Anti-convulsants can also be used
eg
valproate, lamotrigine, carbamazepine
Slide16Suicide
Slide17Risk Assessment
Directly ask about suicidal thoughts/intent:
Do you feel that life is hopeless?
Do you think about suicide?
Have you made plans?
Have you got the means?
What has stopped you?
Identify risk factors
Assess social support and current personal circumstances
Identify factors reducing risk
Also remember risk to self, risk of exploitation, risk to others
Slide18Risk Factors for Suicide
Male
<30 years
Advanced age
Single/living alone
Prior suicide attempt
FHx
of suicide
History of substance/alcohol abuse
Recently started on antidepressants
Hopelessness
Psychosis
Anxiety
Concurrent physical illness
Severe depression
DSH
Unemployed
Slide19Generalised Anxiety Disorder
Slide20ICD-10 Criteria
A) A period of at least six months with prominent tension, worry and feelings of apprehension about everyday events and problems
B) At least four symptoms, one of which must be of autonomic arousal:
Slide21ICD-10 Criteria cont.
Autonomic arousal symptoms
Palpitations
Sweating
Trembling
Dry mouth
Chest and abdo symptoms
Difficulty breathing
Choking sensation
Chest pain or discomfort
Nausea
Neuro/
Ψ
symptoms
Dizzy/faint/light-headed
Derealisation or depersonalisation
Fear of losing control
Fear of dying
General symptoms
Hot flushes or cold chills
Numbness or tingling sensations
Symptoms of tension
Muscle tension or aches and pains
Restlessness
Feeling ‘on edge’
Difficulty swallowing
Other non-specific symptoms
Exaggerated response to minor surprises
Difficulty concentrating
Persistent irritability
Difficulty sleeping
Slide22ICD-10 Criteria cont.
C) Disorder must not meet criteria for panic disorder, phobic anxiety disorder, OCD, or hypochondriacal disorder
D) Common exclusion criteria: not sustained by a physical disorder
eg
hyperthyroidism, and organic mental disorder, or psychoactive substance related disorder
eg
use of amphetamines or benzo withdrawal
Slide23Differentials
Panic disorder
PTSD
OCD
Phobias
Social phobia
Acute stress disorder
Schizophrenia
Dementia
Depression
Alcoholism,
esp
withdrawal
Hyperthyroidism
Phaeochromocytoma
Hypoglycaemia
Slide24Treatment
Stepped care
1
Education about GAD, active monitoring
2
Low intensity CBT, individual self-help, group psychoeducation
3
High intensity CBT/applied relaxation OR drug treatment(SSRI, sertraline is first line, or SNRI
eg
venlafaxine – NOT BENZOS)
4
High intensity
Ψ
treatment AND medication, crisis services, admission
Slide25Panic Disorder
Slide26ICD-10 Criteria
Recurrent panic attacks that are NOT consistently associated with a specific situation or object
Panic attack
discrete episode of intense fear or discomfort, starts abruptly, reaches a crescendo within a few minutes
Moderate
at least four panic attacks in four weeks
Severe at least four panic attacks a week over four weeks
Slide27Treatment
Self help (bibliotherapy based on CBT, exercise etc.)
Psychological treatment
CBT
Weekly sessions of 1-2 hours over 4 months
Medication
Usually an SSRI (citalopram is licensed)
NOT BENZOS
Slide28Post Traumatic Stress Disorder
Slide29ICD-10 Criteria
A) exposure to a stressful event or situation of exceptionally threating or catastrophic nature
B) persistent remembering or ‘reliving’ the stressor by intrusive flashbacks, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or related to the stressor
C) actual or preferred avoidance of circumstances resembling or associated with the stressor
Slide30ICD-10 Criteria cont.
D) Either inability to recall some of the period of exposure to the stressor or persistent symptoms of increased psychological sensitivity and arousal shown by 2 of the following:
Difficulty sleeping, outbursts of anger, difficulty concentrating, hyper-vigilance, exaggerated startle response
E) Criteria B, C and D all occurred within 6 months of the event
Slide31Treatment
Symptoms <3 months
Trauma-focused CBT
Symptoms >3 months
Trauma focused CBT
or eye movement desensitisation and reprocessing
Drug treatment is not first line
Paroxetine (SSRI) is the only medication with a UK licence for PTSD
Slide32Phobias
Slide33ICD-10 Criteria
A) Either marked fear of a specific object or situation not included in agoraphobia or social phobia, or marked avoidance of such objects or situations
B) Symptoms of anxiety in the feared situation
C) Significant emotional distress due to the symptoms or the avoidance and a recognition that these are excessive or unreasonable
D) Symptoms are restricted to the feared situation or when thinking about it
Slide34Treatment
Exposure therapy/desensitisation therapy
Medication can be given on a short-term basis, usually an SSRI or a beta-blocker
Slide35Obsessive Compulsive Disorder
Slide36ICD-10 Criteria
A) Either obsessions or compulsions (or both) present on most days for a period of at least two weeks
B) Obsessions and compulsions share the following – all must be present
Acknowledged as originating in the mind of the patient
Repetitive and unpleasant
Subject tried to resist them
The though/act is not in itself pleasurable
Slide37ICD-10 Criteria cont.
C) The obsessions or compulsions cause distress or interfere with the person’s social or individual functioning
D) Common exclusion criteria – not due to other mental disorders, such as schizophrenia or related disorders, or mood disorders
Slide38Treatment
Mild impairment – low intensity CBT (including exposure response prevention)
Moderate impairment – more intensive CBT OR an SSRI
Severe impairment – high intensity CBT AND an SSRI
Slide39Addiction
Slide40ICD-10 Criteria for Dependence Syndrome
Three or more of the following for at least one month
A strong desire or sense of compulsion to take the substance
Impaired capacity to control substance-taking
eg
taking it for longer than intended, inability to stop
A physiological withdrawal state or use of the substance to avoid or relieve withdrawal symptoms
Tolerance to the effects of the substance
Preoccupation with substance use
Persisting with substance use despite clear evidence of harmful consequences
Slide41Symptoms of Delirium Tremens
Nightmares
Agitation
Confusion
Disorientation
Hallucinations – formication
Fever
High BP
Sweating
Seizures
This can be fatal!
Slide42Treatment of DT
Benzodiazepines
Haloperidol may be used
Control the environment,
eg
well-lit, to minimise distress and visual hallucinations
Slide43Wernicke’s encephalopathy
Korsakoff’s
psychosis
Wernicke’s
due to thiamine (B1) deficiency
Classic triad of
ophthalmoplegia
, ataxia and confusion
There may also be seizures, hearing loss, irritability, dysphagia
Korsakoff’s
(irreversible)
Six major symptoms
Anterograde amnesia
Retrograde amnesia
Confabulation
Minimal content in conversation
Lack of insight
Apathy
Slide44Dementia
Slide45Types
Alzheimer's
Beta-amyloid plaques and neurofibrillary tangles
Vascular
Symptoms depend on location of infarcts
Dementia with Lewy Bodies
Lewy bodies are abnormal aggregations of the protein alpha-
synuclein
Often have visual hallucinations and parkinsonian symptoms
Frontotemporal
Often have personality changes
CJD
Rapidly fatal
Normal Pressure Hydrocephalus
Huntington’s Disease
Defective gene on chromosome 4
Wernicke-
Korsakoff
Syndrome
Slide46Dementia vs Delirium
Features
Delirium
Dementia
Onset
Acute
Insidious
Course
Fluctuating
Progressive (usually)
Duration
Hours to weeks
Months
to years
Consciousness
Altered
Usually
clear
Attention
Impaired
Normal
Psychomotor
changes
Altered
(increased or decreased)
Often
normal
Reversibility
Usually
Irreversible
Slide47Case Studies
Slide48Case Study 1 - Max
60 year old man seen on inpatient
Ψ
unit
Admitted 8/52 ago with persistent low mood after his GP noticed he had deliberately burnt himself with a lighter
He describes having these feelings shortly after he lost his job and his wife passed away a year ago of breast ca – he believes this was his fault
Whilst on the ward he had a 3/52 course of fluoxetine which was switched to venlafaxine when this didn’t work
He describes feeling constantly tired and having no appetite
He no longer enjoys playing the piano nor walking his dog
Whilst you interview him, he seems to be under the impression his house has burnt down in his absence (you know this is not true) and that the world is going to end
He has now stopped eating and drinking
Slide49Case Study 1 - Max
What condition does Max suffer from?
Depression
What type of antidepressants was he given?
SSRI (fluoxetine) and SNRI (venlafaxine)
What type of delusions does he have?
Nihilistic
What are his risk factors for suicide?
Male, advancing age, DSH, recent inpatient admission, unemployed, widowed
What treatment should be considered?
ECT – with consent!
Slide50Case Study 2 - Josephine
Josephine is a 25 year old lady who has come to see you in clinic
Ever since she can remember she has been afraid of buttons
Initially the sight of a button caused her great discomfort, but over the last year her problem has progressed to take over her life
She cannot go out because some people’s clothes have buttons on and she has taken all of her clothes with buttons and disposed of them
She is now housebound and has intense dizzy spells and difficulty breathing whenever she thinks about a button or someone talks about them on the radio (probably on BBC4)
Slide51Case Study 2 - Josephine
What type of illness is Josephine suffering from?
Phobia
How is this best treated?
Exposure therapy via systematic desensitisation
CBT may also be beneficial
What are her dizzy spells known as?
Panic attacks
Slide52Case Study 3 - Thomas
Thomas is a 24 year old man who was found running down Division Street semi-nude in the middle of winter, ranting about his vastness of purpose and a divine prophesy which he must fulfil
He is sectioned by two doctors under the mental health act to a specialty
Ψ
ward
When you see him he is wearing brightly coloured clothes which are covered in scribbles
You ask him to describe what has happened, but he instead hands you a large sheaf of papers covered in writing and collages
He tells you he has everything sorted out and he finally sees how everything fits together. God is telling him he must speak to Jeremy
Corbyn
if he wants to save the world, which only Thomas is capable of
The conversation leaps around and becomes hard to follow, partially because he is speaking so quickly- you can’t seem to get a word in edgeways
Slide53Case Study 3 - Thomas
What type of illness does Thomas probably suffer from? What are the differentials?
Mania – probably due to bipolar disorder
Schizophrenia, drug-induced psychosis, thyrotoxicosis
What type of delusion is he suffering from?
Grandiose
What section of the MHA is he being held under, what is it’s purpose, and how long does it last for?
Section 2 for assessment, lasts 28 days
How would you treat this acute episode? How would you manage him in the long term?
Acute
anti-psychotic,
eg
olanzipine
, risperidone, quetiapine
Long term mood stabiliser -lithium
What needs to be monitored for his long term treatment and why?
Blood tests to monitor serum lithium - narrow therapeutic range
U+Es, TFTs
Slide54Take Home Messages
Pattern recognition!
Learn ICD-10 criteria for the major conditions
Have an idea of them for the minor conditions
Know the first line treatments
Be able to differentiate Wernicke’s vs
Korsakoff’s
, dementia vs delirium, GAD vs panic disorder vs OCD vs PTSD
etc
Breathe! You’ll be fine!
Slide55Any questions?