1- Mental health conditions (Anxiety disorders 2/2)

Question 1

Obsessive–compulsive disorder (OCD)

Answer 1

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.

Question 2

Obsessions

Answer 2

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.

Question 3

Compulsions

Answer 3

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).

Question 4

To neutralise these obsessions people develop compulsions (aka neutralising rituals)

Answer 4

• ‘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

Question 5

prevalence of OCD

Answer 5

• 0.8-3%
• Equally common in men and women
• More common in the relatives of OCD patients

Question 6

risk factors for OCD

Answer 6

• 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.

Question 7

OCD pathophysiology theories

Answer 7

• Basal ganglia re-entrant circuits
• Reduced serotonin levels
• Altered activity in a range of cortical areas
• PANDA

Question 8

basal ganglia re-entrant circuits- OCD

Answer 8

• 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)

Question 9

reduced serotonin levels and OCD

Answer 9

SSRIs help

Question 10

PANDA

Answer 10

• There may be cross-reactivity with certain streptococcal antigens and the basal ganglia (PANDA)

Question 11

OCD cycle

Answer 11

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

Question 12

presentation of obsessions and compulsions

Answer 12

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

Question 13

features of obsessions and compulsions in OCD

Answer 13

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.

Question 14

diagnosis/investigations for OCD

Answer 14

1) History
2) MSE
3) RIsk assessments
3) Invetigations

Question 15

history for OCD

Answer 15

• ‘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)

Question 16

MSE for OCD

Answer 16

Question 17

risk assessment for OCD

Answer 17

suicide and self harm

Question 18

investigations for OCD

Answer 18

Question 19

management of OCD involves

Answer 19

psychological and pharmacological therapies

Question 20

Psychological therapies for OCD

Answer 20

CBT (including ERP – exposure and response prevention)

Question 21

Exposure and response prevention (ERP)

Answer 21

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.

Question 22

pharmacological therapies for OCD

Answer 22

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.

Question 23

define PTSD

Answer 23

• Is an intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event

Question 24

prevalence of PTSD

Answer 24

• 3%
• More common in women 2:1

Question 25

pathophysiology of PTSD

Answer 25

• 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

Question 26

PTSD vs bereavement

Answer 26

Question 27

RF for PTSD

Answer 27

Question 28

presentation of PTSD

Answer 28

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.

Question 29

Diagnosis/ investigations for PTSD

Answer 29

1) History
2) ICD-10 criteria
3) MSE
4) Risk assessment
5) Investigations

Question 30

history for PTSD

Answer 30

• ‘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)

Question 31

ICD-10 for PTSD

Answer 31

Question 32

MSE for PTSD

Answer 32

Question 33

risk assessment for PTSD

Answer 33

risk to self i.e. suicide and self harm

risk to others

Question 34

investigations for PTSD

Answer 34

a. Questionnaires e.g. trauma screening questionnaire (TSG), post-traumatic diagnostic scale
b. CT head- if head injury suspected

Question 35

management of PTSD can be split up into

Answer 35

PTSD where symptoms are present within 3 months of a trauma

PTSD where symptoms have been present >3 months after a trauma

Question 36

Management: PTSD where symptoms are present within 3 months of a trauma

Answer 36

• 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.

Question 37

Management: PTSD where symptoms have been present >3 months after a trauma

Answer 37

• 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.

Question 38

psychological interventions for PTSD

Answer 38

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

Question 39

define adjustment disorders

Answer 39

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.

Question 40

adjustment disorders can occur in response to

Answer 40

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.

Question 41

prevalence of Adjustment disorders

Answer 41

While adults can experience adjustment disorders, it is predominantly diagnosed in children and adolescents.
- Equal in men and women

Question 42

causes and risk factors for adjustment disorders

Answer 42

• Anyone can develop AF
• Social skills and methods for coping with other stressors may determine whether or not you develop an AD

Question 43

key features of adjustment disorders

Answer 43

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.

Question 44

key features of adjustment disorders

Answer 44

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.

Question 45

presentation of ADs

Answer 45

Last under 6 months
- physical
- psychological- split into 6 subtypes

Question 46

physical symptoms of AD

Answer 46

• Insomnia
• Muscle twitches or trembling
• Fatigue
• Body pain
• Indigestion

Question 47

6 subtypes of AD

Answer 47

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.

Question 47

6 subtypes of AD

Answer 47

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.

Question 48

management of adjustment disorders

Answer 48

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