Psychiatry

1. Psychiatry Dr N Fernando 2nd May 2006

2. Content • Psychiatric history • Mental state examination • Assess suicide risk • Multi-Disciplinary Team (MDT) ) • Community Psychiatric Nurse (CPN) ) Understand • Psychiatric Social Workers ) their roles • Occupational Therapists (OT) ) • Impact of mental illness on relatives • Schizophrenia ) • Affective disorders ) • Anxiety ) Clinical features • Dementia ) & • Delerium ) their management • Eating Disorders ) • Alcohol Misuse )

3. Psychiatric History • A story……Chronological……detailed • From before birth • Family history • ….through birth & early adulthood • Personal, Educational, Psychosexual, Work history • ….through life difficulties • Substance misuse, forensic • ….status before the current episode • PMH, PSH, PPH, pre-morbid personality • Medications, allergies, social circumstances • ….to the current presentation • PC & HPC

4. Psychiatric History • PC/HPC • PMH/PSH/PPH • MEDS/ALLERGIES • Personal History • Early • Schooling & Academic achievements • Sexual history & preferences/ Work history • Substance use incl. alcohol, caffeine, nicotine • Forensic history • Family History • Current social circumstances • Pre-morbid personality

5. Mental State Examination • Appearance & Behaviour • Speech • Mood (s) & (o) • Thoughts • Disorders of form, content, flow • Deliberate self harm/suicidality • Perceptions • Cognition • Conscious level Orientation A&C Memory - STM,LTM Abstract thinking • Insight

6. Model for Aetiology

7. Model for Aetiology

8. Model for managing treatment

9. Model for managing treatment Summary • Talk, negotiate, dialog (therapeutic alliance, psychoeducation) • Informal  formal (?MHA use) • Period of observation (best before initiating treatment) • Medication – if required • Least toxic, least dose, shortest length (as possible) • Talking therapies • Counselling, CBT, psychotherapy, IP therapy, Group • Follow up • Review, optimise therapy • Aftercare - CPA (Care Programme Approach) • maintain therapeutic alliance, psychoeducation

10. Prognostic factors

11. Multi-Disciplinary Team work (MDT) • Basis of psychiatric diagnosis, treatment and management • Consensual decisions (most times) • Good communication skills • Important to include patient & carer in decisions • All professional have stake in patient care • Doctors, ward staff, OT, psychologists, pharmacists, community staff, any other therapists working with patient • Their concerns and views to be considered & documented • Final decision – ALL to be in agreement (if possible) thereby sharing risk and responsibility • Care plan – jointly appraised, agreed and maintained • Medical staff have overall responsibility (RMO status) • This is currently under review by DHS

12. Community Psychiatric Nurses (CPN) • Work within community teams • ‘Key-worker’ to coordinate care & liaise with RMO/wards,etc • Have experience of dealing with mental illness • Have good communication & organisation skills • Ideally have psycho-social skills • Work with challenging patients & their families including psychoeducation • Have a good understanding of relapse signatures, particular stressors and behaviour patterns of their clients • Understanding of other services that may benefit patient & refer appropriately • Have confidence in managing & advising reg. medications • Give depot medications

13. Psychiatric Social Workers • Experience in social work • Emphasis on mental health issues & impact on social services • Appropriate use of services & benefits • Social history of patient • ASW work – Approved Social Worker (Section 12 approved) • Coordinating mental health act assessments • Makes application for detention under MHA 1983 • Aware of social circumstances that may impact on presentation in community at time of MH assessment • Be aware of next of kin & their views • At MHA no other disposal apart from hospital admission • Be aware of changes in mental health law • Furnish reports to tribunals – patients under MHA 1983

14. Occupational Therapists (OT) • Work within hospital or community • Have a wide range of OT background skills • Good communication & psycho-social skills to work with highly challenging group of patients • Understanding of mental health & impact on daily functioning • Understand medications and its similar impact • Assess patient’s level of activity and living skills • ADL assessment – Activities of Daily Living • Compare with patients needs/desires and abilities • Set up graduated activities to improve patient’s level of functioning in a manageable and sustainable programme • Advocate for patient if required (reg. their functioning)

15. Impact of mental health on relatives • Can be significant & prolonged • Stressful; • Concerns that they or their children may be affected • Dealing with someone not in touch with reality – constantly • Dealing with someone constantly breaching limits • Dealing with someone becoming ill & feeling unable to help • Dealing with disorganisation & aggression • Dealing with services not able to respond fast enough • Dealing with poor insight from affected relative & meds need • Concern for relative • Can be excessive  High expressed emotion (EE) • Increase risk of physical illness & mental illness • Stress related & depression (Carer assessment useful)

16. Delusions – Definition • Belief which is firmly held despite evidence to the contrary which is out with their religious, social and cultural experience • Different from ‘overvalued idea’ • Many themes • Paranoid, Persecutory, Grandiose, Delusions of reference, Guilt or worthlessness, Hypochondriachal, Religious, Sexual, etc…

17. Hallucinations - Definition • Perception in the absence of stimuli • Can be normal experience – hypnogogic/hymnopompic • Based on different senses • Auditory (2nd, 3rd person, running commentary, thought echo) • Visual (commonly underlying organic condition) • Gustatory • Olfactory • Somatic (tactile & deep)

18. Schizophrenia • Fundamental & characteristic distortions of thinking & perception • Inappropriate or blunted affect • Delusions (secondary) & Perplexity common • Onset Acute or gradual • M=F - Later onset in women • Genetic component • 1 parent affected  13% risk in kids • Both parents  46% risk in kids • 1 sibling affected  10% in other siblings • MZ twins  48% concordance • Life events & expressed emotions associated with relapses • CT changes – predate illness • Smaller temporal lobes by 15-20% & Enlarged ventricles • PET scans  functional disturbances in frontal & temporal structures • Cognitive changes – late feature generally

19. Schizophrenia First rank symptoms • 3rd person auditory hallucinations • Running commentary • Thought echo • Made feelings ) • Made impulses ) • Made actions ) Passivity • Thought insertion ) ) Phenomena • Thought withdrawal ) Thought ) • Thought broadcasting ) Alienation ) • Somatic passivity ) • Delusional perception

20. Schizophrenia Definition: ICD 10 criteria • At least 1 month duration of symptoms • 1 clear CORE symptom or >= 2 if less clear or >=2 from Secondary group CORE group - Thought echo, alienation Delusions of passivity, Delusional perception 3rd person, running commentary persistent delusions Secondary group - Persistent hallucinations – any modality Thought block/neologisms Catatonic behaviour/ Negative symptoms Significant & Consistent change in overall quality

21. Schizophrenia - Types • Paranoid • Commonest, hallucinations +/- delusions prominent • Hebephrenic • starts bet 15-25yrs, poor prog. • Affective changes, irresponsible, inappropriate behaviour • Catatonic • Prominent psychomotor disturbance, rarely seen in west • Post Schizophrenic depression • Negative symptoms prominent usually, ^risk of suicide • Residual Schizophrenia • At least one previous psychotic episode • Period of 1 year, where +ve  -ve symptoms • Simple Schizophrenia • Uncommon, insiduous and progressive • No previous psychotic episode, vagrancy may occur

22. Schizophrenia Negative symptoms 6 A’s - Attention reduced - Avolition - Anhedonia - Affective blunting - Apathy - Alogia

23. Schizophrenia - management

24. Schizophrenia - Management Summary Therapeutic alliance MHA use if appropriate MDT decisions Reduce stressors Support – psychological, psychoeducation, reduce EE Drugs: Antipsychotics Anxiolytics Antidepressants Hypnotics (to aid sleep)

25. Schizophrenia - Antipsychotics Summary Therapeutic alliance Most appropriate choice – clinical basis Atypicals 1st line in new cases (NICE) - Start low and increase as tolerated - Raise dose to therapeutic level - If no response in 4-6 weeks, consider change, seek help - Watch for side-effects Side-effects; - Drowsiness, wt gain ) Reduce dose, another - reduced blood pressure ) drug to counter effects, - EPSE ) change to another - Sexual dysfunction ) Non-compliance - Consider depot medication Treatment resistant (inadequate response to two a/p) - Clozaril (regular FBC, co-ordinated via CPMS – Clozaril Patient Monitoring Service)

26. Affective Disorders • Depression • Bipolar Affective Disorder (BPAD) • Hypomania • Mania • Persistent Mood Disorders • Cyclothymia • Dysthymia

27. Depression • Definition: ICD – 10 requirements • 2/52 duration of symptoms • 3 Core symptoms – Mood, Anhedonia, Anergia • 7 additional Sx. • A&C worthlessness appetite • DSH acts hopelessness sleep self esteem • Mild (at least 2 core + 2 other) • Distressed but able to function with ordinary work • Moderate (at least 2 core + 3 other) • Will have considerable difficulty c/t with work • Severe (All 3 core + 4 other or more) • Suicide a distinct risk & unlikely to continue with work • Need to look for psychotic symptoms

28. Depression - Management

29. Depression – Use of Antidepressants • Discuss choice of drug with the patient • Therapeutic effects, adverse effects, discontinuation effects • Start ANTIDEPRESSANTS • Titrate to recognised therapeutic dose • Assess efficacy over 4-6 weeks • Continue for 4-6 months at full treatment dose • Consider long-term treatment in recurrent depression • If no effect • Increase dose (to maximum dose if tolerated) & assess over 2/52 • Try another antidepressant from another class • Titrate as above • Little improvement  Treatments for refractory depression

30. Bipolar Affective Disorder (BPAD) • >=2 episodes of mood/activity changes • Recovery complete between episodes • M = F • Usually abrupt onset of mania • Manic episode – last median of 4 months • Depressive episode – last median of 6 months • Often follow stressful life events • First episode  occur at any age (Most freq bet 20-29 years) • Increasing age  Increased frequency & length of episodes • 1-2% of population at some point in their lives • Genetic predisposition • BPAD  11% risk of Depression (UP) in 1st degree relatives • BPAD  8% risk of BPAD in 1st degree relatives • Morbidity & mortality is HIGH  suicide/accidental deaths/concurrent illnesses

31. Bipolar Affective Disorder (BPAD) Features Elated mood Grandiose ideas & inflated self esteem Increased energy & activity Flight of ideas Pressure of speech Increased libido impaired judgement & impulsive behaviour Reduced need for sleep Increased creativity Impaired attention & concentration Psychotic symptoms

32. Bipolar Affective Disorder (BPAD) Diagnosis >=2 episodes At least one should be mania Manic episode >= 1/52 Depression >= 2/52 Rapid cycling = 4 or more episodes / year Severity Hypomania  Mania  Mania with psychotic features

33. Bipolar Affective Disorder (BPAD) Hypomania - Increased mood & activity for at least a few days - interfere with work/social activity Mania - Increased mood & activity for at least a week - Disrupt work/social activity Mania with psychotic features - As above with psychotic features - most severe form

34. Bipolar Affective Disorder (BPAD) MANAGEMENT - Same as for depression & table - Important to gain therapeutic alliance - Consider admission +/- use of MHA - Assess RISKS carefully and address to reduce impact - Commence drug treatment if appropriate - Sedation/mood stabilisation (Lithium)/Antipsychotic - Antidepressant (watch for rebound mania) - ECT - Talking therapy - CBT based - Psychoeducation including Relapse signature work - Social work involvement - reduce stressors – finances/housing, etc - Follow-up review (CMHT & key-worker allocation) - Optimise social skills - employment, self esteem, ADLs, etc..

35. Persistent Mood Disorders Cyclothymia Persistent instability of mood Onset in early life (teens) Chronic course Not severe to fulfill BPAD (Episodes <1/52 mania, <2/52 depres.) Dysthymia Chronic lowness of mood, prolonged periods of time usually able to cope with ADLs & demands Begins in early adulthood Last for several years Can be associated with bereavement

36. Anxiety Disorders - Agoraphobia - Social phobia - Specific phobia - Panic Disorder - GAD - OCD - PTSD

37. Agoraphobia Features - Most incapacitating of phobic disorders - F:M = 3:1 - Onset early in adult life (15-35 yrs) - Autonomic/psychological symptoms  secondary to anxiety - terrified of collapse/left helpless in public - Anxiety generally restricted to; crowds/public places/travelling alone/travelling away from home. - Avoidance of phobic situation is prominent, can become housebound - presence of other disorders  depression, obsessional symptoms, panic Management - Ongoing assessment - Psychoeducation - CBT – Work with cognitions (homework), Graded exposure with relaxation - Graded activity - Drugs: SSRIs

38. Social Phobia Features - 8% of all phobias - Centred around FEAR OF SCRUTINY by others - Lead to avoidance of social situation - Fear of vomiting in public - M = F - Associated with low self-esteem & fear of criticism - May present with blushing/hand tremor/nausea/urgency - Diagnosis: - Anxiety  cause of symptoms & restricted to certain situations - Avoidance of phobic situation Management - Ongoing assessment - Psychoeducation - CBT – Work with cognitions (homework), Graded exposure with relaxation - Drugs: SSRIs

39. Specific phobias Features - restricted to highly specific situations - persistent irrational fear of object - contact with this  immediate anxiety response - Avoidance of object - Fear/avoidance/distress  interfere with individual’s life - Fear is recognised as being irrational/excessive - start in childhood/early adulthood Management - Ongoing assessment - Psychoeducation - CBT – Graded exposure with relaxation - Drugs: SSRIs

40. Panic Disorder Features - Recurrent anxiety attacks, can be severe (panic) - Unpredictable & sudden onset - Almost always due to fear of dying/losing control/going mad - Attacks last for minutes only - 20% adults  at least once in life; 2% in 1 yr  freq to get P.D. diagnosis - Onset mid 20’s, 1st panic attack in late teens - Panic attack: Increase fear  autonomic symptoms  hurried exit If this occurs in a situation  avoid situation - Diagnosis: - Panic attacks not in background of another disorder - Several severe autonomic attacks in last 1/12 - No objective danger, not only in specific circumstances, relatively free from anxiety between attacks Management - Ongoing assessment - Psychoeducation - CBT – Recognise early warning signs, Relaxation, challenge avoidance - Hyperventillation  can induce panic in vitro (useful in training) - (SSRIs)

41. Generalised Anxiety Disorder (GAD) Features - Essential feature is anxiety, which is generalised, persistent and not restricted to any situation (‘free floating’) - +/- somatic symptoms - F > M, Variable course - Often related to chronic environmental stress - Diagnosis: - Primary symptom of anxiety (most days, for weeks/months) - To include apprehension, motor tension, autonomic overactivity Management - Ongoing assessment - Psychoeducation (Avoid caffeine) - CBT: Relaxation, Graded activity, assertiveness training - Drugs: Amitriptyline, Venlafaxine, Buspirone, Clonidine Benzodiazepines – NOT advocated, can be used for short course - Yoga

42. Obsessive Compulsive Disorder (OCD) Features - Essential features  Obsessive thoughts +/- Compulsive acts - Close relationship with depressive features - F = M - Prominent Anankastic features in personality - Onset childhood/early adulthood - Family history of OCD/Tourette Syndrome - Underlying the act is FEAR (of dirt, etc…)  Ritual is way of reducing fear - Diagnosis: Obsessional thoughts +/- Compulsive acts  most days 2/52 Be distressing/interfere with activities Obsessional symptoms – recognised as own, resisted unsuccessfully, NOT pleasurable, repetitive (impulses & thoughts) Compulsive acts – stereotyped behaviour, repeated, not enjoyable, no useful task completed, attempts to resist, recognised as pointless, seen as preventing an unlikely event (‘magical undoing’) Management - Ongoing assessment - Psychoeducation, distraction techniques (thought stopping) - CBT: Work with cognitions (homework), Exposure & response prevention - Drugs: SSRIs (at higher dose) Clomipramine (past, can still use) BEST effects when combined with CBT

43. Post Traumatic Stress Disorder (PTSD) Features - Delayed/protracted response to stressful situations - Excessive use of alcohol +/- drugs in majority - Recovery expected in majority; Small number  chronic  personality change - Diagnosis: - Within 6/12 (usually) - Traumatic, exceptional event - Repetitive intrusive recollections, flashbacks OR Re-enactment of events in memory/imagery/dreams (nightmares) Other Sx - Emotional numbing - Autonomic symptoms – hyperarousal, hypervigilence (startle reaction), insomnia - Anxiety & depression – suicidal ideation - ‘Cues’  Increase arousal  Avoidance of such cues Management - Ongoing assessment - Psychoeducation - CBT: Aim of tx.  Remove fear of situation/position Vitro: Graded exposure (in imagery) & relaxation Vivo: Systematic desensitisation with relaxation - Drugs: SSRIs (at higher dose)

44. Dementia Features - SYNDROME due to disease of brain - Chronic/progressive - Disturbance of multiple higher cortical function - Consciousness NOT clouded - Impaired cognition - Deterioration of emotional control/social behaviour/motivation - Memory - Affects registration, storage, retrieval of new information - Previously learned material may not be affected - Thinking - Processing of information is affected, difficult to attend more than one stimulus at a time - Reduced reasoning capacity - Reduced flow of ideas - Diagnosis: - Primary  Evidence of decline in both MEMORY and THINKING which is enough to affect ADLs - Clear consciousness - For at least 6/12 (for confident diagnosis)

45. Dementia Types Alzheimer's Vascular Lewy Body HIV Parkinson’s Pick’s Huntington’s Creutzfeldt-Jakob Normal Pressure Hydrocephalus

46. Dementia – Alzheimer’s Disease Features - Primary degenerative brain disease - Usually in later life, but can occur earlier - Early onset  +ve FH, rapid course, prominent features of temporal and parietal lobe dysfunction - Down’s Syndrome  increased risk of AD - May be associated with vascular dementia - Memory problem is main feature - 1% at 65y, 10% at 80y, 40% at 90y (Rule: doubling every 5 years) - Pathology: Marked reduction in population of neurones Neurofibrillary tangles Neuritic plaques Granullovacuolar bodies Marked reduction in enzyme choline acetyl-transferase - Diagnosis: - Presence of dementia (see previous slide for guide) - Insidious onset & slow deterioration - Absence of features of systemic & other brain disease - Absence of sudden onset

47. Dementia Reversible causes of dementia These need to be excluded Hypothyroidism Hypercalcaemia Vitamin B12 deficiency Niacin Deficiency (Folate) Normal pressure hydrocephalus Subdural haematoma Syphilitic

48. Dementia - Management • Refer Memory Clinic • Differentiate from delerium/depression/paranoid disorders • Look for treatable causes (previous slide) • Physical investigations • FBC/U&E/LFT/TFT/Gluc/VitB12&Folate/Syphilis serology/Ca&Phos/ESR • Urine analysis & culture • ECG & CXR • CT Brain • Mini Mental State Examination MMSE (Memory Clinic) • Treatment; Treatable causes Behavioural changes – non-pharmacological Drugs: Antidepressants Anxiolytics Antipsychotics Anti-cholinesterase Inhibitors (Memory Clinic) • Vascular Dementia – Reduce risk Manage BP Low dose aspirin (note bleeding potential) Surgical treatment of carotid stenosis

49. Dementia - MMSE • Yr, month, DoW, date, season 5 • Place, Floor, city, county, country 5 • 3 Objects to remember 3 • WORLD backwards, serial 7’s 5 • Recall 3 objects 3 • Pen, watch – identify 2 • Repeat phrase ‘No ifs ands or buts’ 1 • 3 stage command 3 • Read & follow instruction 1 • Write sentence (verb & noun) 1 • Interlocking pentagons 1 Total 30 26-30 normal, 20-25 mild, 13-20 moderate, <12 severe (These figures are guidelines only, correlate with clinical picture)

50. Acute Confusional State (Delerium) Features - Rapid onset - Can be diurnally fluctuating - Any age, most common > 60y - Transient, fluctuating intensity - most recover within 4/52 - BUT can last for 6/12 esp. with chronic liver disease, Carcinoma, SBE - Diagnosis: Impairment of consciousness & attention Global disturbance of cognition - Impairment of recent memory & recall - Disorientation in time, severely of place & person - Perceptual distortions; illusions, hallucinations esp. visual - +/- transient delusions Psychomotor disturbances – hypo or hyperactivity, enhanced startle reaction Disturbance of sleep-wake cycle Emotional disturbance