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Mental Health Conditions (Other (Self-harm (Differential - head trauma,…
Mental Health Conditions
Mood disorders
Depression
Diagnosis: Mild (2+2), Moderate (2+3), Severe (3+4, possible psychosis) (Psychosis presents as auditory, guilt, inadequacy, or disease delusions)
Differential: anxiety, bipolar, classify mild/ moderate/ severe as separate diagnoses, alcohol hypoglycaemia, hypothyroidism, anaemia, DYSTHYMIA (low mood not meeting criteria)
"CLAWS" - Concentration, Libido, Appetite, Weight loss, Sleep (+ Bowel Habit)
Investigations
Bedside
Obs, Urine drug screen, ECG (long QT), BM (low mood), assessment (PHQ-9/ HAD)
Bloods
FBC (anaemia, MCV in alcohol), U&E, LFT (alcohol), TFT (hypothyroidism), Ca (hypertyroidism psychic moans), HbA1c
"HELP" - Hobbies (Anhedonia), Energy (low/ tiredness), Low mood, Physical (CLAWS) (Low mood must be present for >2 weeks) (Presents more as apathy in older people)
Management
Acute
Collateral history, crisis team
ECT - severe only, when urgent improvement needed
Chronic
Psychological
CBT, counselling, self-help, family therapy and education
Social
GP involvement, CPN involvement, prevent isolation
Biological
Exercise, 1st line SSRI, 2nd line different SSRI, 3rd line SNRI/NASSA/ TCA/ MAOI
Pathway
Mild - psychoeducation, psychological interventions, no drugs
Moderate/ severe - drugs straight away, interpersonal therapy, ECT if severe only
Risk factors (AFFECT) - Anxious, Female, Family hx, Events, Chronic illness, Trauma (emotional)
Mania/ Bipolar Disorder
Depression is mania, hypomania, depression, psychosis
Investigations
Bedside - obs, urine dip/ drug screen, ECG (long QT), BM
Bloods - FBC, U&E, LFT TFT, Ca, HbA1c
Hypomania = 3 symptoms for 4 days, some ADL interference. Mania = 3 symptoms for 1 week, severe ADL interference. Psychotic symptoms = always mania
Management
Psychological
Psychoeducation, relapse prevention (recognising warning symptoms), CBT, family therapy
Social
Crisis team, DVLA, social services (finances), GP involvement, OT
Biological
Mania (type 1) - 2 or 3 of mood stabiliser (lithium/ valproate), antipsychotic (2nd gen ideally), benzodiazepine for a few days (lorazepam). Zopiclone if struggling with sleep
Hypomania (type 2) - mood stabiliser only (lithium), can still give zopiclone
Stop antidepressants (make bipolar worse)
Monitor lithium 3 monthly, U&E/ TFT 6 monthly. Note lithium teratogenic
Increased activity/ restlessness, flight of ideas, pressure of speech, decreased need for sleep, loss of normal social inhibitions, distractability, grandiosity/ inflated self esteem, reckless behaviour (e.g. spending sprees), increased sexual energy
Anxiety
Differential
Phobic disorder - response to object/ situation, can be anticipatory
OCD/ Depression
Panic disorder = 3 attacks in 3 weeks, asymptomatic in between
GAD = most days for >2w with no trigger
Investigations
Bloods
FBC, U&E, LFT, TFT, Ca, HbA1c
Bedside
Urine dip/ drug screen, ECG (antipsychotics/ chest pain), BM
Physical
Chest pain, SOB, palpitations, sweating, dry mouth. Also crossover with depression (fatigue/ concentration/ sleep)
Management
Psychological
Psychoeducation, mindfulness, CBT, self-help, EDMR (PTSD), thought stopping (OCD), systematic desensitisations. Mild GAD is psychological treatment only
Social
Crisis referral, driving, family education, GP/ social services, housing support, support groups to prevent isolation
Biological
1st line SSRI (lower dose than depression), 2nd line TCA. Benzodiazepines short term (diazepam/ lorazepam is more sedative), beta-blockers, breathe in bag (panic disorder)
Psychological
Feeling anxious/ frightened, avoiding certain things/ situations
Psychosis (dopamine-driven)
Schizophrenia
Investigations
Bloods
FBC, U&E, LFT, TFT, Ca, HbA1c
Imaging
Brain imaging (SOL)
Bedside
Obs, urine drug screen, ECG (arrhythmias, long QT in antipsychotics), BM (depression symptoms as a SE of antipsychotics), EEG (epilepsy - catatonic behaviour)
Management
Chronic
Psychoeducation, CBT, explore alcohol abuse, family therapy, art therapy
MDT approach, volunteering (avoid isolation), finances
Biological - long term low dose antipsychotics (1st gen if two 2nd gen don't work). Clozapine last resort due to agranulocytosis risk
Acute
Psychological
Relapse prevention (home stressors)
Biological
ORAL 2nd gen antipsychotics (Risperidone, Olanzapine)
Can give short acting benzodiazepine for tranquilisation if aggressive
Social
Early referral, crisis team, OT assessment
1 first rank symptom or 2 second rank symptoms
1st rank (3 by 3)
Delusions
Of control (feeling controlled)
Persecutory/ paranoid
Reference/ perception (e.g. on TV) or any special abilities/ powers
Thought alienation
Withdrawal
Broadcasting
Insertion
Hallucinations (SIP)
Inside/ outside head
Person (second/ third)
Saying - what, any commands
2nd rank
Neologisms (breaks in train of thought)
Catatonic behaviour (waxy flexibility, mutism)
Negative symptoms - apathy, social isolation, paucity of speech, incongruent emotion
Differentials
Bipolar, severe depression, neurodegenerative (Alzheimer's), SOL, delirium, encephalitis, thyrotoxicosis, steroids, recreational drug use (alcohol, cocaine, cannabis, amphetamines
Cognitive Impairment
Delirium
PINCH ME
Pain, Infection, Nutrition, Constipation, Hydration/ Hypoxia, Medication, Environment
Medication examples are antihistamines, steroids, antispasmodics, opiates, L-DOPA, anticonvulsants, sedatives, recreational
Differentials
Dementia, substance abuse, withdrawal states, psychosis, depression, non-convulsive epilepsy
Symptoms deteriorate towards evening, sleep-wake cycle is reversed - nocturnal insomnia, day drowsiness
Investigations
Delirium screen
FBC (infection, anaemia), U&E (drug use, deranged electrolytes), LFT (liver failure/ alcohol), CRP, INR, TFT, Ca (hypercalcaemia), B12/ folate, Glucose (common cause)
Bedside
Urine drug screen, EEG for epilepsy, obs for haemodynamic stability, ECG for arrythmias, MSU for infection, cognitive assessment, BM
Imaging
CXR for pneumonia, head CT for intracranial haemorrhage
Rapid onset acute confusional state with evidence of physical cause
Agitation, confusion, disorientation in time/ place, short term memory loss (confabulate to fill in gaps), withdrawal, illusions, visual hallucinations (e.g. Lilliputian so things seem smaller than they really are)
Management
Conservative
Correct cause - hydration, nutrition, infection, thiamine (alcohol), stop relevant medication
Re-orientate patient in a well lit room, communicate clearly and regularly
Medical
Antipsychotics - lowest possible dose for shortest possible time (<1 week)
1st line haloperidol IM or Olanzapine
2nd line lorazepam, especially if short term sedation
Dementia
Vascular Dementia
Atherosclerosis causing multiple mini strokes - focal neurology, step-wise deterioration
2nd most common, treat/ prevent with aspirin
Lewy Body Dementia
Treat with Rivastigmine
Males, earlier onset, fluctuant (good and bad days) - depression, visual hallucinations, delusions, parkinsonism
Alzheimer's Disease
Donepezil to treat
5A's - Amnesia, Agnosia, Apraxia, Aphasia, Associated behaviours (depression, persecution delusions, antisocial behaviour, aggression, wandering, sleep disturbance)
Senile plaques (beta amyloid deposits), Tau proteins (neurofibrillary tangles) and atrophy of brain, all causing cell loss, reduced synapses and reduced neurotransmitter function
Short term memory affected first, can't lay down new memories, agnosia is inability to process sensory information, apraxia is unable to perform tasks, more likely to get expressive (Broca's) aphasia than receptive (Wernicke's)
Frontotemporal Dementia
Repetitive and stereotyped behaviours e.g. rocking, marching, singing/ dancing. hoarding
Hyperorality (Kluver-Bucy syndrome) - ingesting inedible objects
Treatable dementias
Vitamin B12/ folate deficiency, depression (pseudodementia), hypothyroidism, normal pressure hydrocephalus, alcohol (Wernicke's/ Korsakoff's), syphilis
Presentation
Memory loss, impaired cognition, dysfunction in daily living
ADLs must be affected to differentiate from delirium, must be present for at least 6 months
Investigations
Bloods
FBC (anaemia, infection), U&E, B12/folate, HbA1c (vascular), lipid screen (vascular), TFT (hypothyroidism), calcium (falls risk with osteoporosis, psychic moans in hypercalcaemia)
Imaging
CT/ MRI Head for vascular dementia/ SOL
Bedside
Obs (BP for vascular), ECG (drug SEs), urine dip, cognitive assessment
Management
Conservative
Exercise, hearing, family therapy, memory aids, home care including social services, OT help to stay at home, gas safety, power of attorney
Medical
1st line - Acetylcholinesterase - "Forgot About DRG" (Donepezil/ Rivastigmine/ Galantamine)
2nd line - NMDA receptor antagonist e.g. Memantine
Acute
Assess capacity, OT assessment, DVLA, collateral history
Other
Alcohol/ Substance misuse
Alcohol - symptoms 6-12h, seizures 36h, delirium tremens 72h
Investigations
Bedside
Obs, urine drug screen, ECG (arrhythmias, long QT in antipsychotics), BM (low mood/ irritability)
Bloods
FBC (raised MCV), U&E, LFT, TFT (hypothyroidism)
Dependency - "CaNT StOP" - Compulsion, neglect, tolerance, symptoms on withdrawal, out of control use, persisting despite knowing harms
Management
Chronic
Medical
Substitution - methadone, buprenrphine, nicotine replacement
Relapse prevention - naltrexone, acamprosate (both reduce cravings)
Psychological/ social (relationship, finances, prevent isolation, therapy, support groups
Acute
Alcohol withdrawal syndrome - treat with decreasing doses of benzodiazepines (chlordiazepoxide 1st line, diazepam 2nd line)
Delirium tremens - oral Lorazepam
Harmful use (damage to physical/ mental health and criticism from others
Personality Disorders
Borderline - impulsive, shifting moods, chaotic relationships
Histrionic (dramatic), narcissistic (grandiosity, need for admiration)
Schizotypal - socially and emotionally attached, oddities of belief/ thought, fantasies
Paranoid, antisocial, anxious/ avoidant, dependent, obsessive
Schizoid - loners, emotionally detached
Eating disorders
Anorexia Nervosa - can precipitate hypothyroidism, up to 10% patients eventually die as a result
Hypokalaemia, reduced FSH/ LH, oestrogen/ testosterone/ T3, increased cortisol/ GH/ cholesterol, impaired glucose tolerance, hypercarotinaemia
Bulimia Nervosa - hypokalaemia (1st degree heart block, tall P, flattened T. Metabolic alkalosis
Management - individual focused CBT, specialist clinical management, family therapy if younger, MANTRA
Reduced BMI, bradycardia, hypotension, enlarged salivary glands, failure of secondary sexual characteristics, lanugo hair
Self-harm
Differential - head trauma, meningitis, metabolic abnormalities, liver disease, post-ictal state
Investigations - ECG, BM, ABG, urinalysis, U&E, LFT, glucose, anion gap, clotting, paracetamol level, CXR, CT head
High risk - effort to avoid discovery, planning, leaving a written note, final acts e.g. finances, violent method
Management - resuscitation, decrease absorption, antidotes, future prevention, specific history
Self-cutting, ingesting in excess, ingesting illicit with intent, ingesting non-edible, omitting medication/ food
Antidotes for: Paracetamol (activated charcoal <1h, N-acetylcysteine), Salicylates (sodium bicarbonate), Opioids (naloxone), TCAs (sodium bicarbonate), Benzodiazepine (flumezanil), Iron (deferoxamine)