Psychiatry for ISCE PDF

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Description

Vascular Dementia

Alzheimer’s disease EXPLANATION OF CONDITION

EXPLANATION OF CONDITION

Dementia is a term used to describe a loss of memory that keeps getting worse – progressive. The most common cause of dementia is Alzheimer’s disease. It typically begins with memory problems and slowly gets worse. Damaged tissue build up in the brain to form deposits called ‘plaques’ and ‘tangles’ which cause brain cells around them to die.

Dementia is a term used to describe a loss of memory that keeps getting worse – progressive. Vascular dementia is usually caused by the blood vessels supplying the brain becoming damaged or blocked. This can lead to small strokes as they are starved of oxygen and nutrients. This dementia can come on more quickly than Alzheimer’s.

SYMPTOMS

SYMPTOMS

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Inability to remember recent events Difficulty in recalling words, naming objects Forget names of people and places Hard to learn new things Subtle changes in personality Later stages – wandering, disorientation, psychiatric symptoms (hallucinations, delusions), behavioural problems (disinhibition, aggression), altered eating habits, incontinence

AETIOLOGY AND RISK FACTORS     

Increased age Family history More common in women Head injury RF associated with vascular disease – high lipids, high BP and diabetes

INVESTIGATIONS    

Tools to screen for cognitive impairment Bloods – rule out treatable cause MRI SPECT – single photon emission CT

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Stepwise – fluctuating/abrupt deterioration Cognitive impairment – orientation to time, place, person Attention and concentration ability Memory loss Focal neurological deficits Seizures Disturbance in gait, unprovoked falls Bladder symptoms – incontinence Emotional lability/depression

AETIOLOGY AND RISK FACTORS  Multi-infarct – series of small strokes  Small vessels disease – subcortical  CADASIL – inherited form (rare and younger) RF include:  Hx of stroke or TIA  AF  HTN, coronary heart disease  DM  Smoking  Hyperlipidaemia  Family history

MANAGEMENT

INVESTIGATIONS

General/Conservative:  Person-centred, support carer  Local care and support services  Structured group cognitive stimulation programme  Memory enhancement strategies – reminder notes, lists  CBT – if depression or anxiety  Therapeutic use of music and danc e  Multi-sensory stimulation  Exercise and massage Medical:  AChE-I: Donepezil, rivastigmine (titrated)  Memantine – second line for moderate AD or severe  Avoid antipsychotics – risperidone if needed  Antidepressants – avoid TCA Palliative:  Encourage oral nutrition  PEG if transient dysphagia  DNACPR

As per Alzheimer’s MRI Head

MANAGEMENT General/conservative:  As per Alzheimer’s Medical:  Non for vascular dementia  Medication for emotional and challenging behaviour – IM lorazepam, haloperidol, olanzapine Prevention:  Modifiable and preventable  Hypertension!!

ADHD

Lewy Body Dementia EXPLANATION OF CONDITION

EXPLANATION OF CONDITION

Dementia is a term used to describe a loss of memory that keeps getting worse – progressive. LBD seems to be caused by protein deposits building up in the brain. Symptoms often overlap with AD and Parkinson’s.

ADHD is a behavioural disorder which often becomes obvious in early childhood. The behaviours are due to underlying problems of poor attention, hyperactivity and impulsivity. Many children especially under-fives are inattentive and restless. This does not mean necessarily mean they are suffering from ADHD. The inattention or hyperactivity becomes a problem when they are exaggerated, compared with other children of same age, and that they affect the child and his life.

SYMPTOMS       

Dementia – memory loss, decline in problem solving ability, spatial awareness difficulties Fluctuating levels of awareness and attention Signs of mild Parkinsonism – tremor, rigidity, poverty of facial expression, festinating gait Frequent falls Visual hallucinations Sleep disorders – REM sleep disorder, restless legs syndrome Fainting spells

AETIOLOGY AND RISK FACTORS Increasingly common

INVESTIGATIONS    

Diagnosis usually clinical Basic dementia screen – bloods, MSU, CXR, ECG CT/MRI – exclude other cause of dementia SPECT

MANAGEMENT Conservative:  As per Alzheimer’s  Care plan for ADL – maximise independence  Building in exercise and OT  Involve psychiatric social worker early to help with initial risk assessment  Driving – must not drive Medical:  Avoid antipsychotics  Anti-parkinsonian Rx may worsen psychosis  Rivastigmine – helpful in treating cognitive decline

FRONTOTEMPORAL DEMENTIA EXPLANATION OF CONDITION This dementia seems to affect the front of the brain more than other areas. It often starts in people in their 50s and 60s. Because it affects the front of the brain, it is more likely to cause personality and behavioural changes. A person who is usually very polite and proper may start to become irritable or rude. Memory can remain good for a long time.

SYMPTOMS Can present with different behaviours depending on age and setting. Before age of 12, Sx present for 6months  Attention – forgetful, distracted, not seeming to listen, disorganised  Hyperactivity – restless, fidgety, full of energy, loud, noisy with a continuous chatter  Impulsivity – do things without thinking, difficulty waiting for their turn in games or queue, interrupt people in conversation

AETIOLOGY AND RISK FACTORS      

Do not know exactly what causes it Can run in families – genetics More likely in children with significant traumatic experience as a child Obstetrics and antenatal problems No evidence of poor parenting directly cause ADHD Parents however can play a crucial role in helping and managing a child with ADHD

INVESTIGATIONS Confirm by doing assessments – no simple test. Discussion with you and your child, physical examination. School report. Sometimes brain scan to rule out other causes.

MANAGEMENT Conservative:  Parent-training programme – simple instructions, break up tasks, healthy lifestyle with activities  Support group for parents  Child – group treatment programme to improve behaviour, CBT  Family therapy  Diet – avoid additives Medical:  Stimulant – methylphenidate or dexamphetamine  Non-stimulant – atomoxetine  Stimulant make people feel more alert, energetic, helps improve attention and reduce hyperactivity  SEs – loss of appetite, difficulty falling asleep, light headedness, tics or twitches, tummy pain or feeling sick, anxiety and nervousness  Monitoring – HR, BP, weight and height on regular basis

AUTISTIC SPECTRUM DISORDER

EMOTIONALLY UNSTABLE PD

EXPLANATION OF CONDITION

EXPLANATION OF CONDITION

ASD are neurodevelopmental disorders – which means they are caused by abnormalities in the way the brain develops and works. (Presence of impaired development manifested before age of 3) Asperger’s syndrome is a term used for some higher functioning people on the autism spectrum who have intellectual ability in the average range and no delays in learning to talk.

In mental health, the word ‘personality’ refers to the collection of characteristics or traits that we have developed as we have grown up and which make each of us an individual. These include the ways that we think, feel and behave. Usually our personality allows us to get on reasonably well with other people. For some of us, this doesn’t happen. Parts of your personality can develop in ways that make it difficult for you to live with yourself and other people. This may make you distressed and often upset other people.

SYMPTOMS Children and young people with ASD have particular difficulties in:  Communicating  Being around people socially (reciprocal social interaction)  Repetitive, stereotyped behaviour Communication:  Difficulties in both verbal and non-verbal communication inc. sustaining social conversation Social interaction:  Difficulties in recognising and understanding self and others’ feelings – hard to make friends  Prefer to spend time alone  Appears insensitive Behaviour, interest and activities:  Prefer familiar routines – distress if changed  Unusual intense specific interest  Sensitive to sound or feeling certain material against their skin

AETIOLOGY AND RISK FACTORS Exact cause is still unknown.  Genetics – defects  Increase risk in children with siblings with ASD  Environmental factors – prenatal factors (advance parental age, exposure to teratogens, maternal infections), perinatal (low birth weight), post-natal (infection, autoimmune)

INVESTIGATIONS Clinical diagnosis by paediatric neurologist. Comprehensive assessment of speech, language and communication.

MANAGEMENT Conservative:  MDT – doctor, speech, physio, OT, educational psychologist  Early intensive behavioural intervention (EIBI)  CBT  Speech and language therapy  Specialist courses on parenting, parent support group  Independent organisation – advice about benefits  Education – special support or mainstream school with extra help Medical:  Medication usually not indicated, but may be prescribed if there is a need.

SYMPTOMS These feelings may have lasted for a long time or have a big impact on your daily life:  Impulsive – do things on the spur of the moment  Find it hard to control emotions  Feel bad about yourself  Often self-harm  Make relationships quickly but easily lose them  May become paranoid and experience hearing voices when very stressed  Feels empty May associate with other mental health conditions – more vulnerable

AETIOLOGY AND RISK FACTORS 

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Upbringing – physical/sexual abuse in childhood, violence in family, parents who drink too much, difficult environment Triggers – drugs or alcohol, money, anxiety or depression, important events, stressful situations, loss of loved ones

INVESTIGATIONS   

Toxicology screen – substance abuse HIV, STI screen – impulsive acts and risk Psychological testing to support clinical diagnosis

MANAGEMENT Conservative:  MDT approach  Psychotherapy – long term o Mentalisation based (MBT) o Dialectical behaviour (DBT) o CBT o Schema focused therapy  Identify short and long term goals  Community mental health services  Crisis management  Self-help – identify trigger, good sleep, physical health, exercise, take up interest Medical:  Mood stabilisers  Atypical antipsychotics  Antidepressants  Sedatives – short term in crisis

BULIMIA NERVOSA

ANOREXIA NERVOSA EXPLANATION OF CONDITION

EXPLANATION OF CONDITION

We all have different eating habits. There are large number of eating styles which can allow us to stay healthy. However, they are some which are driven by an intense fear of becoming fat which actually damage our health. There are called eating disorders and involve eating too much or too little and using harmful ways to get rid of calories.

We all have different eating habits. There are large number of eating styles which can allow us to stay healthy. However, they are some which are driven by an intense fear of becoming fat which actually damage our health. There are called eating disorders and involve eating too much or too little and using harmful ways to get rid of calories.

SYMPTOMS

SYMPTOMS

People affected by an ED are constantly worried about their weight  You eat less and less – calorie counting  Exercise more and more – burn off calories  Use slimming pills  Can’t stop yourself from wanting to lose weight even when you are well below a safe weight for your age and height  Obsessively check your weight, shape or reflection  Menstrual periods become irregular or stop Vomit/Purge:  Lose enamel on teeth  Puffy face – salivary glands swell up  Palpitations – imbalance salt Laxatives:  Persistent stomach pain  Swollen fingers Affect:  Psychological – sleep badly, inattention, depressed  Physical – tired, weak and cold, constipated, hair loss, dry skin, brittle bones, extreme cases – die

People affected by an ED are constantly worried about their weight  Worry more and more about weight  Binge eat (raid the fridge or go out and buy lots of fattening food that you would normally avoid. Then eat it all quickly. Afterwards feel stuffed and bloated, guilty and depressed, purging with laxatives or vomit) Trap in a vicious cycle  Make yourself vomit and/or use laxatives  Feel tired and guilty  Stay normal weight in spite efforts to diet  Menstrual periods become irregular or stop Vomit/Purge:  Lose enamel on teeth  Puffy face – salivary glands swell up  Palpitations – imbalance salt Laxatives:  Persistent stomach pain  Swollen fingers

AETIOLOGY AND RISK FACTORS       

Genetics – runs in families Feel good for being able to control in a clear way Puberty, family Social pressure Depression Low self-esteem Emotional distress – adverse life events

AETIOLOGY AND RISK FACTORS       

Genetics – runs in families Feel good for being able to control in a clear way Puberty, family Social pressure Depression Low self-esteem Emotional distress – adverse life events

INVESTIGATIONS As per Anorexia Nervosa

INVESTIGATIONS Clinical diagnosis, physical exam Blood tests, ECG – complications of anorexia

MANAGEMENT Conservative:  Family therapy if under 18 – months or years  CBT, interpersonal therapy Hospital treatment:  Regular weight checks  Dietician – healthy eating, supplements  Medication – anxiety (Olanzapine) Compulsory treatment:  Unusual – only if someone has become so unwell that they cannot make proper decisions for themselves, needs to be protected from serious harm

MANAGEMENT Conservative:  Psychotherapy – weekly sessions over 20 weeks  CBT or Interpersonal Therapy  Eating advice – regular and healthy eating Medication:  High dose fluoxetine can reduce urge to binge eat, can reduce symptoms in 2-3 weeks and provide a kick start to psychotherapy

DEPRESSION

BIPOLAR DISORDER

EXPLANATION OF CONDITION

EXPLANATION OF CONDITION

We all feel fed up, miserable or sad at times. These feelings don’t usually last longer than a week or two and they don’t interfere too much with our lives. We usually cope by talking to a friend or family, but don’t otherwise need any help. In depression however, your feelings and mood don’t lift after a few days, they carry on for weeks or months. They may be so bad that they interfere with your life.

We all have normal highs and lows in life. Bipolar disorder is a mental health condition where people are at the extreme ends of the scale and have severe mood swings. These usually last several weeks or months and are far beyond what most of us experience. When they are low or depressive, there is feelings of intense depression and despair. On the other hand, when they are high or manic, there is feelings of extreme happiness and elation.

SYMPTOMS You feel unhappy most of the time, may be better in the evenings  Loss interest in life and can’t enjoy anything  Find it harder to make decisions  Utterly tired  Can’t cope with things you used to  Restless and agitated  Loss of appetite and weight or reverse of that  1-2 hrs to get off to sleep, waking up earlier than usual  Loss interest in sex  Lose your self-confidence  Feel useless, inadequate and hopeless  Think of suicide  Headache, palpitations, chest pain, general aches Symptoms every day and last at least two weeks Severe depression – may interfere with normal function and some may have fixed beliefs/thoughts that may be distressing and experience hearing or seeing unusual things 

AETIOLOGY AND RISK FACTORS      

Things that happen in our lives – bereavement, divorce, losing a job Circumstances – alone, no friends, stressed, other worries, physically run down Physical illnesses – long and painful, cancer, hormonal, viral infection Alcohol Genes Gender (women more than men)

Type 1 BP: at least one manic epi lasted for more than 1/52 + depressive episodes Type 2 BP: more than one epi of severe depression but mild manic epi (hypomania)

SYMPTOMS When depressive:  Unhappiness that don’t go away  Losing interest in things, unable to enjoy  Tired, restless and agitated  Hopeless, suicidal  Hard to concentrate  Losing appetite and weight  Difficulty in getting to sleep, waking earlier When Manic:  Intense sense of well-being, energy and optimism  Very happy and excited, feeling very important  New exciting ideas, moving from one idea to another, talk quickly  Hearing voices that other can’t hear  Believe strange things about yourself  Make bad decisions – reckless spending  Over familiar with other people  Behave in embarrassing or dangerous way  Sleeping very little

AETIOLOGY AND RISK FACTORS   

Runs in families – genetic rather than upbringing Physical problem with brain systems Mood swings can be brought on by stressful experiences or physical illnesses

MANAGEMENT Conservative:  Self-help – talk to people, may even cry. Do something, keep yourself physically active, and eat well, sleep well.  Try not to drown your sorrows with drink and cannabis – alcohol make depression worse  Counselling – mild depression  CBT – group or computerised  Problem-solving therapy  Support groups Antidepressants:  Help you feel less anxious and agitated, feel and cope better so that you can enjoy life and deal with problems effectively again  Fluoxetine in young people – in addition to talking therapy Electroconvulsive therapy ECT – severe/Rx resistant

MANAGEMENT Medical treatment for prophylaxis:  Mood stabilisers – lithium, sodium valproate or olanzapine – long term  Lithium reduces chance of relapse  Continue for at least 2 years after one episode of BPAD, up to 5 years if frequent relapses, psychotic, alcohol or substance misuse, continuous stress Psychological Rx: 6-9 months -16 1-hr sessions  Psycho-education  Mood monitoring  CBT Depressive episodes: antidepressant (if manic stop meds) Mania: stop antidepressant, mood stabiliser or antipsychotics Looking after children – may temporarily not be able to look after them – organise children’s care in advance

ANXIETY & PANIC ATTACK

OBSESSIVE-COMPULSIVE DISORDER

EXPLANATION OF CONDITION

EXPLANATION OF CONDITION

Anxiety is a feeling we all get in a situation that is threatening or difficult. The anxiety stops when you get used to the situation, when situation changes, or if you just leave. But if you feel anxious all the time for no obvious reason, it can make life difficult. Anxiety feels like fear, which a lot of the time caused by a problem in our life, we call it worry. Although they are unpleasant, they can be helpful in keeping us alert and make our body ready for action. These feelings become a problem when they are too strong or when they carry on even when we don’t need them anymore. They can make you uncomfortable, stop you from doing things.

OCD is an anxiety disorder. Obsessions are unwelcome thoughts, images, urges or worries that repeatedly appear in your mind. They can make you feel very anxious. Compulsions are repetitive activities that you do to reduce the anxiety caused by the obsession. Many people experience minor obsessions (worry gas is on, door is locked) and compulsions but they are often short lived. In OCD, it is likely that your obsessions and compulsions will have a big impact on your life, cause disruption to your dayto-day life and relationship...