1- Mental health conditions (Anxiety disorders 2/2) Flashcards
Obsessive–compulsive disorder (OCD)
is characterized by recurrent obsessional thoughts or compulsive acts, or commonly both. It is ranked by the WHO as one of the top ten most disabling illnesses in terms of impact upon quality of life.
Obsessions
Unwanted intrusive thoughts, images or urges that repeatedly enter the individual’s mind. They are distressing for the individual who attempts to resist them and recognizes them as absurd (egodystonic) and a product of their own mind.
Compulsions
Repetitive, stereotyped behaviours or mental acts that a person feels driven into performing. They are overt (observable by others) or covert (mental acts not observable).
To neutralise these obsessions people develop compulsions (aka neutralising rituals)
- ‘obsessional motor acts. May result from an obsessional impulse that leads directly to the action, or they may be mediated by an obsessional mental image or fear’
- e.g. ‘I need to turn the light switch on and off ten times or my family will die’
- Can lead to patients wasting a lot of time!
- Can also have mental compulsions e.g. repeating phrases
prevalence of OCD
- 0.8-3%
- Equally common in men and women
- More common in the relatives of OCD patients
risk factors for OCD
- Carrying out the compulsive act (e.g. washing) is likely to exacerbate the obsession and is thus a maintaining factor.
- Developmental factors such as:
o Neglect
o Abuse
o bullying and social isolation may have a role.
OCD pathophysiology theories
- Basal ganglia re-entrant circuits
- Reduced serotonin levels
- Altered activity in a range of cortical areas
- PANDA
basal ganglia re-entrant circuits- OCD
- The cortex projects to the basal ganglia, and these then project back up to the cortex via the thalamus
- This is an example of a ‘re-entrant’ loop, where obsessional thoughts can re-enter the cortex having entered the basal ganglia
- This may be due to overactivity in the direct pathway o Treatments that inhibit thalamic (and hence cortical) activity by reducing the direct pathway or increasing the indirect pathway may hold promise (e.g. subthalamic nucleus stimulation)
reduced serotonin levels and OCD
SSRIs help
PANDA
- There may be cross-reactivity with certain streptococcal antigens and the basal ganglia (PANDA)
OCD cycle
Obsessions create anxiety which continues to build until a compulsion is carried out in order to provide relief. This vicious cycle is known as the OCD cycle
presentation of obsessions and compulsions
Compulsions
- OVERT
Washing
Checking
Ordering/aligning
- COVERT
Praying
Counting
Repeating words
Obsessions (unwanted and recurring distressing and intrusive)
- E.g. most common is that of being contaminated e.g. HIV, behaving inappropriately, sexual imagery
features of obsessions and compulsions in OCD
1) Failure to resist: At least one obsession or compulsion is present which is unsuccessfully resisted.
2) Originate from patient’s mind: Acknowledged that the obsessions or compulsions originate from their own mind, and are not imposed by outside persons or influences.
3) Repetitive and Distressing: At least one obsession or compulsion must be present which is acknowledged by the patient as excessive or unreasonable.
4) Carrying out the obsessive thought (or compulsive act) is not in itself pleasurable, but reduces anxiety levels.
diagnosis/investigations for OCD
1) History
2) MSE
3) RIsk assessments
3) Invetigations
history for OCD
- ‘Do you have any distressing thoughts that enter your mind despite trying hard to resist them?’, ‘Is there any unwanted thought that keeps bothering you that you would like to get rid of but cannot?’ (obsessions)
- ‘Do you worry about contamination with dirt even after washing?’, ‘Do you repeatedly check things you have already done?’, ‘Do you find yourself having to touch, count and arrange things many times?’, ‘Do you wash or clean a lot? Do you check things a lot?’, ‘Are you concerned about putting things in a specific order, or do you get upset by not completing tasks?’ (compulsions)
- ‘Do your daily activities take a long time to finish?’ (due to carrying out compulsions)
MSE for OCD
risk assessment for OCD
suicide and self harm
investigations for OCD
management of OCD involves
psychological and pharmacological therapies
Psychological therapies for OCD
CBT (including ERP – exposure and response prevention)
Exposure and response prevention (ERP)
is a technique in which patients are repeatedly exposed to the situation which causes them anxiety (e.g. exposure to dirt) and are prevented from performing the repetitive actions which lessen that anxiety (e.g. washing their hands). After initial anxiety on exposure, the levels of anxiety gradually decrease.
pharmacological therapies for OCD
SSRIs are the drug of choice in OCD. NICE recommends fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram.
Clomipramine is an alternative drug therapy. Mild This can be combined with citalopram in more
severe cases. Alternatively, an antipsychotic can be added in with an SSRI or clomipramine.
define PTSD
- Is an intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event
prevalence of PTSD
- 3%
- More common in women 2:1
pathophysiology of PTSD
- Caused by exposure to event or situation of exceptionally threatening or catastrophic nature which would be likely to cause pervasive distress in almost anyone.
- Cognitive theories suggest that failure to process emotionally charged events causes memories to persist in an unprocessed form which can intrude into conscious awareness
PTSD vs bereavement
RF for PTSD
presentation of PTSD
PTSD symptoms must occur within 6 months of the event and can be divided into four categories:
1. Reliving the situation (persistent, intrusive, involuntary): Flashbacks, vivid memories, nightmares, distress when exposed to similar circumstances as the stressor.
2. Avoidance: Avoiding reminders of trauma (e.g. associated people or locations), excessive rumination about the trauma, inability to recall aspects of the trauma.
3. Hyperarousal : Irritability or outbursts, difficulty with concentration, difficulty with sleep, hypervigilance, exaggerated startle response.
4. Emotional numbing : Negative thoughts about oneself, difficulty experiencing emotions, feeling of detachment from others, giving up previously enjoyed activities.
Diagnosis/ investigations for PTSD
1) History
2) ICD-10 criteria
3) MSE
4) Risk assessment
5) Investigations
history for PTSD
- ‘Do you ever get any flashbacks, vivid memories or nightmares about the events that
- ‘Has there been any traumatic incident or event in your life recently which may account for how you are feeling?’ (exposure to stressful event) took place?’ (reliving the situation)
- ‘Do you find yourself constantly thinking about the same thing?’ (rumination)
- ‘Have you had any problems with sleep since the event?’, ‘Are you feeling more irritable or having trouble concentrating?’,
- ‘Do you get startled easily?’ (hyperarousal)
ICD-10 for PTSD
MSE for PTSD
risk assessment for PTSD
risk to self i.e. suicide and self harm
risk to others
investigations for PTSD
a. Questionnaires e.g. trauma screening questionnaire (TSG), post-traumatic diagnostic scale
b. CT head- if head injury suspected
management of PTSD can be split up into
PTSD where symptoms are present within 3 months of a trauma
PTSD where symptoms have been present >3 months after a trauma
Management: PTSD where symptoms are present within 3 months of a trauma
- Watchful waiting may be used for mild symptoms lasting <4 weeks.
- Military personnel have access to treatment provided by the armed forces.
- Trauma-focused CBT should be given at least once a week for 8–12 sessions.
- Short-term drug treatment may be considered in the acute phase for management of sleep disturbance (e.g. zopiclone).
- Risk assessment is important to assess risk for neglect or suicide.
Management: PTSD where symptoms have been present >3 months after a trauma
- All sufferers should be offered a course of trauma-focused psychological intervention.
- Drug treatment should be considered when: (1) little benefit from psychological therapy; (2) patient preference not to engage in psychological therapy; (3) co-morbid depression or severe hyperarousal which would benefit from psychological interventions.
- Paroxetine, mirtazapine, amitriptyline and phenelzine are licensed for treatment of PTSD in the UK. Evidence for paroxetine is weaker than the other three drugs. Practically, amitriptyline and phenelzine are rarely used as a result of their side effects and tolerability.
psychological interventions for PTSD
The two options for psychological intervention are
1) CBT
2) Eye movement desensitization and reprocessing (EMDR). The goal of EMDR is to reduce distress in the shortest period of time. It is a form of psychotherapy, with one technique involving eye movements to help the brain process traumatic events
define adjustment disorders
an emotional or behavioral reaction to a stressful event or change in a person’s life. The reaction is considered an unhealthy or excessive response to the event or change within three months of it happening.
adjustment disorders can occur in response to
Stressful events or changes in your life
- Death of a loved one
- Relationship issues
- Loss of job
- family move
- the parents’ divorce or separation
- or the birth of a sibling.
- A sudden illness or restriction to your child’s life due to chronic illness may also result in an adjustment response.
prevalence of Adjustment disorders
While adults can experience adjustment disorders, it is predominantly diagnosed in children and adolescents.
- Equal in men and women
causes and risk factors for adjustment disorders
- Anyone can develop AF
- Social skills and methods for coping with other stressors may determine whether or not you develop an AD
key features of adjustment disorders
In all adjustment disorders, the reaction to the stressor is excessive to what would be otherwise expected. Also, the reaction should significantly interfere with social, occupational or educational functioning. Additionally, age can have an effect: Differences are found in the symptoms experienced, how long they last, how strong they are and what effect they have. Adolescent symptoms of adjustment disorders can be more behavioral, such as acting out. Adults who experience adjustment disorders exhibit more depressive symptoms.
key features of adjustment disorders
In all adjustment disorders, the reaction to the stressor is excessive to what would be otherwise expected. Also, the reaction should significantly interfere with social, occupational or educational functioning. Additionally, age can have an effect: Differences are found in the symptoms experienced, how long they last, how strong they are and what effect they have. Adolescent symptoms of adjustment disorders can be more behavioral, such as acting out. Adults who experience adjustment disorders exhibit more depressive symptoms.
presentation of ADs
Last under 6 months
- physical
- psychological- split into 6 subtypes
physical symptoms of AD
- Insomnia
- Muscle twitches or trembling
- Fatigue
- Body pain
- Indigestion
6 subtypes of AD
1) Adjustment disorder with depressed mood.
Symptoms may include:
* Depressed mood
* Tearfulness
* Feelings of hopelessness
2) Adjustment disorder with anxiety. Symptoms may include:
* Nervousness
* Worry
* Jitteriness
* Fear of separation from major attachment figures
3) Adjustment disorder with anxiety and depressed mood. A combination of symptoms from both of these conditions are present.
4) Adjustment disorder with disturbance of conduct. Symptoms may include:
* Violation of the rights of others
* Violation of society’s norms and rules (truancy, destruction of property, reckless driving or fighting)
5) Adjustment disorder with mixed disturbance of emotions and conduct. A combination of symptoms from all of the above subtypes is present (depressed mood, anxiety and conduct).
6) Adjustment disorder unspecified. Reactions to stressful events that do not fit in one of the above subtypes are present. Reactions may include behaviors like social withdrawal or inhibitions to normally expected activities, like school or work.
6 subtypes of AD
1) Adjustment disorder with depressed mood
Symptoms may include:
* Depressed mood
* Tearfulness
* Feelings of hopelessness
2) Adjustment disorder with anxiety. Symptoms may include:
* Nervousness
* Worry
* Jitteriness
* Fear of separation from major attachment figures
3) Adjustment disorder with anxiety and depressed mood. A combination of symptoms from both of these conditions are present.
4) Adjustment disorder with disturbance of conduct Symptoms may include:
* Violation of the rights of others
* Violation of society’s norms and rules (truancy, destruction of property, reckless driving or fighting)
5) Adjustment disorder with mixed disturbance of emotions and conduct. A combination of symptoms from all of the above subtypes is present (depressed mood, anxiety and conduct).
6) Adjustment disorder unspecified. Reactions to stressful events that do not fit in one of the above subtypes are present. Reactions may include behaviors like social withdrawal or inhibitions to normally expected activities, like school or work.
management of adjustment disorders
Biopsychosocialc
Bio
o SSRIs or SNRis
o Benzodiazepine short term e.g. for sleep
Psychological
o CBT
o Psychotherapy
o Crisis intervention (emergency psychological care)
o Family and group therapies
Social
o Developing strong network of people
o Living healthy
o Establishing good self esteem
