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Psychiatry. Dr N Fernando 2 nd May 2006. 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) )

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psychiatry

Psychiatry

Dr N Fernando

2nd May 2006

content
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 )
psychiatric history
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
psychiatric history1
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
mental state examination
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
model for managing treatment1
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
multi disciplinary team work mdt
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
community psychiatric nurses cpn
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
psychiatric social workers
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
occupational therapists ot
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)
impact of mental health on relatives
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)
delusions definition
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…
hallucinations definition
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)
schizophrenia
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
schizophrenia1
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
schizophrenia2
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

schizophrenia types
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
schizophrenia3
Schizophrenia

Negative symptoms

6 A’s

- Attention reduced

- Avolition

- Anhedonia

- Affective blunting

- Apathy

- Alogia

schizophrenia management1
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)

schizophrenia antipsychotics
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)

affective disorders
Affective Disorders
  • Depression
  • Bipolar Affective Disorder (BPAD)
  • Hypomania
  • Mania
  • Persistent Mood Disorders
    • Cyclothymia
    • Dysthymia
depression
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
depression use of antidepressants
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
bipolar affective disorder bpad
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
bipolar affective disorder bpad1
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

bipolar affective disorder bpad2
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

bipolar affective disorder bpad3
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

bipolar affective disorder bpad4
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..

persistent mood disorders
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

anxiety disorders
Anxiety Disorders

- Agoraphobia

- Social phobia

- Specific phobia

- Panic Disorder

- GAD

- OCD

- PTSD

agoraphobia
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

social phobia
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

specific phobias
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

panic disorder
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)

generalised anxiety disorder gad
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

obsessive compulsive disorder ocd
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

post traumatic stress disorder ptsd
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)

dementia
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)

dementia1
Dementia

Types

Alzheimer's

Vascular

Lewy Body

HIV

Parkinson’s

Pick’s

Huntington’s

Creutzfeldt-Jakob

Normal Pressure Hydrocephalus

dementia alzheimer s disease
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

dementia2
Dementia

Reversible causes of dementia

These need to be excluded

Hypothyroidism

Hypercalcaemia

Vitamin B12 deficiency

Niacin Deficiency (Folate)

Normal pressure hydrocephalus

Subdural haematoma

Syphilitic

dementia management
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

dementia mmse
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)

acute confusional state delerium
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

acute confusional state delerium1
Acute Confusional State (Delerium)

Management

Dialogue with family, carers, ward staff

Safety – consider admission

Nurse separately if possible, well lit, approach away from blind spots

Full Examination – in detail

Investigations

Common causes – infections, constipation, overmedication, TIAs

Look actively for physical basis

Bloods, ECG, Radiology if appropriate

Treat as found

anorexia nervosa
Anorexia Nervosa

Features

- Deliberate weight loss – induced and sustained by patient

- Adolescent girls/young women (peak age 13-16yrs) F >> M

- An independent syndrome (Inter-observer reliability, chronic form similar)

- Aetiology unclear – increasing evidence of socio-cultural, biological and vulnerable personality. Less evidence of specific psychological mechanisms

- Associated with under-nutrition  Secondary biological features

- Incidence 5:100,000 pa; Prevalence approx 1% of young females

- Diagnosis: - Body wt maintained <=15% below expected or BMI <=17.5

- Wt loss is self induced – avoid fat, vomiting, purging, exercise, appetite suppressants +/- diuretics

- Body image distortion

- Widespread endocrine disorder of H-P-Gonadal axis

- Amenorrhoea, Reduced sexual interest, Increased levels of GH & cortisol, changes in peripheral metabolism of thyroid hormones, abnormalities of insulin secretion

- Onset before puberty

- Pubertal changes can be delayed/arrested

- Prognosis: 1/3rd better in 3y, 1/3rd better in 3-6y, 1/3rd better in 6-12y

4% chronic

Mortality = 15%

anorexia nervosa1
Anorexia Nervosa

Management

Cornerstone of therapy is talking therapy

<18y  Family Therapy – to reduce EE, loosening of bonds (help with failure of individuation)

>18y  Interpersonal Therapy

Self help and CBT does not work well

- BUT behavioural structure similar for managing Bulimia Nervosa can be helpful if AN has improves

Treat any comorbid condition – i.e. depression

bulimia nervosa
Bulimia Nervosa

Features

- Preoccupation with control of body weight  extreme measure to reduce fattening effects of food

- Age and sex distribution similar to Anorexia Nervosa

- May be sequel to persistent AN

- Vomiting  electrolyte imbalance & physical problems (Tetany, etc..)

- Incidence 2-15/100,000; Prevalence of approx 1%

- Diagnosis:- Persistent preoccupation with eating and irresistable craving for food – with strict dieting for ‘control’  Succumb to bingeing

- Counteract fattening effects – self induced vomiting, purgative abuse, alternative periods of starving, drug use (suppressants, thyroid prep., diuretics)

- Psychopathology – morbid dread of fatness

- Pt sets sharply defined wt threshold

- +/- earlier episode of AN

-Prognosis: - 50% improve

- 50% relapsing

bulimia nervosa1
Bulimia Nervosa

Management

Cornerstone is CBT

- ‘All or nothing thinking’

- Work to change this and other harmful cognitions  use of diary keeping and homework setting (Survey of friends, Are fat people unhappy/unsuccessful?, Are fat perople lonely?)

- Behaviour modification

- Food dairy

- Tight shopping list (Only what’s on it)

- Limiting food (in home)

- Set meal to set plan

- Leave a little at end of meal  throw to signify end of meal

- Self help books ‘Getting better bite by bite’ - 50% improve

- Group therapy – for support

- Interpersonal therapy

self harm dsh
Self Harm - ‘DSH’

Definition:

- ‘a non-fatal act in which an individual deliberately causes self- injury or ingests a substance in excess of any prescribed or generally recognised dose’

Kreitman (1977)

Associations

- FOUR times as many stressful events in last 6/12

- Early parental loss, history of parental neglect/abuse, Childhood sexual abuse

- Personality factors (poor i/p problem solving skills)

- Hopelessness & impulsiveness

- Long term probs in marriage, kids, work, health

- Unemployment (esp. in men but also women now)

- Poor physical health (esp. epilepsy)

- Psychiatric illness

- Depression (high rates: up to 90+ percent)

- Psychotic (between 5-15%)

- Alcohol & drug misuse

- About 50% had contact with NHS in the preceding week

self harm dsh1
Self Harm - ‘DSH’

After DSH episode; outcomes

1. Repeat DSH (15-25% in first 12 months)

Lots of Associated factors; Previous attempt, personality disorder, alcohol and drug misuse, previous psychiatric tx, etc….

2. Risk of suicide (1-2% risk )

This is x 100 higher than in general population

10,000% increased risk than general population

At 8 years f/up  3% have committed suicide

 This is TWICE the expected no. from natural causes (unclear why)

IMPORTANT to assess at time of presentation to prevent repetition and increased morbidity and mortality

self harm dsh2
Self Harm - ‘DSH’

- Increasing since 1960s

- Current rate of 3 per 1000 per year

- 180,000 casesper year (60m pop)

- Higher rates in UK than other Western European countries

- Most common in young people

- Male:Female = 1:1 (Peak age for men is older)

- High rates in

- Divorced (men & women)

- teenage wives

- lower social classes

- high unemployment

- overcrowding

- many children in care, etc…

self harm treatments
Self Harm - Treatments

Studies have demonstrated that some treatments

may be of benefit

- Problem-solving therapy

- Emergency contact card (controversial)

- Behavioural therapy

Also delivery of well organized care has benefits of

- Recognition & treatment of major mental illness

- Recognition & help for personal & social difficulties

risk assessment
Risk assessment

Inform / predict / safety / legal / best practice

Mandatory & done by all (not recognised)

If done following incident

Look at factors -

- Before incident

- Incident

- After incident

If predicting  Can use rating scale (TAG Score)

risk assessment method guidelines only
Risk assessment - method (Guidelines only….)

Before incident

  • Depressed? Suicidal thoughts? If so when, freq, last
  • What steps taken towards these plans? When? Where?
  • Did you act on it before? If so what was done and where?
  • (If not, what stopped you?)
  • Any pre-planning? Left any notes behind?
  • Use of any substances such as alcohol?
  • Harm to others? Elaborate…

Incident

  • How were you found and by whom? How did you get to A&E?
  • What did you do and how?
  • What did you expect to happen?

After incident

  • What are your thoughts about the attempt?
  • How does talking about this make you feel?
  • Future plans, thoughts of further self harm? If so, intent?
  • What help would make it easier?
alcohol history guidelines
Alcohol History - Guidelines
  • How long – From what age? Years?
  • Daily consumption?
    • What time is first drink of day?
    • What do you drink and where?
    • How much do you drink and rate?
    • What time is last in day?
    • Any days without alcohol?
    • When did you start to drink daily?
  • Other daily activities?
  • Presence of withdrawal symptoms?
    • In morning or after abstinence?
    • Craving for alcohol?
    • What helps?
  • Alcohol use – out of control?
  • Tolerance – need to drink more to have the same effect?
  • Medical complications? (esp. related to alcohol)
    • Aware that alcohol is causing physical harm
  • Past history of alcohol detox’s and contact with services
  • Patient’s attitude towards drinking
  • (Depressive symptoms & DSH/suicidality)
substance misuse alcohol
Substance Misuse - Alcohol

Is this a problem?

- Alcohol misuse  drinking that causes mental, physical or social harm to the individual

- CAGE questionnaire

- if >=2 positive then important to consider for

DEPENDENT and HARMFUL use of alcohol

and consider referral to ALCOHOL/DRUG services

substance misuse alcohol1
Substance Misuse - Alcohol

Dependent use (>= 3 in last year)

  • Craving
  • Uncontrolled drinking – difficulty controlling consumption
  • Physiological withdrawal state
  • Tolerance
  • Salience of drinking – loss of other interests
  • C/t drinking despite evidence of harmful consequences
substance misuse alcohol2
Substance Misuse - Alcohol

Harmful use – criteria

  • Clear evidence alcohol is causing harm
    • Physical, psychological, Dysfunctional behaviour
  • Nature of harm clearly identified
  • Persistent use of alcohol
    • At least 1 month or repeatedly over 1 year
substance misuse alcohol3
Substance Misuse - Alcohol

Management

- Raise awareness of problem

- Increase motivation to change

- Withdraw alcohol (or controlled drinking)

- Support and advice

- CBT – social skills, relapse prevention

- Marital therapy

- Medication – disulfiram, acamprosate (reduce craving)

- Community Alcohol Team (CAT)

- Community detox – Community Teams

- Inpatient detox – Springfield, Wentworth

- Community follow-up

- Support services – Alcoholic Anonymous, CAT