13. AKT: Mental Health Flashcards
Describe obsessive compulsive disorder.
- It is characterised by obsessions and/or compulsions
- Obsessions are recurrent and persistent thoughts, impulses or images that experienced as intrusive an unwanted
- Compulsions are repetitive behaviours or mental acts that the person feels compelled to undertake in response to an obsessionIn order to prevent discomfort
- The person usually recognises their behaviour is excessive or unreasonable
What questions can you ask when you are suspecting obsessive compulsive disorder?
- Do you check things alot?
- Do you wash or clean a lot?
- Do your daily activities take a long time to finish?
- Do you have to do things over and over, even though you don’t want to?
- Are you concerned about putting things in a special order or are you very upset by miss?
- Is there any thought that keeps bothering you that you would like to get rid of, but cannot?
- Do you have any rituals or routines that you have to follow every day?
- Troubling thoughts can really affect our mood and way of life; do you think this could be the cause of your anxiety?
- Do other people often tell you that your home is cluttered or that you have problems with throwing things out?
- Do these problems trouble you?
What is the management for obsessive compulsive disorder?
First line: psychosocial interventions are first line but some patients require an issue pharmacotherapy to actively engage In psychological interventions
Pharmacotherapy:
* First line: SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline)
* Second line: SNRIs
* Clomipramine:
* Note: SSRI and SNRI doses for OCD are usually higher than for other indications
* Note: risk of QT propagation apiece would be higher with citalopram compared to other SSRIs
* Many patients relapse when antidepressants are withdrawn, so require long term pharmacotherapy
What are cluster A characteristics?
Individuals may appear odd an eccentric
* Paranoid
* Schizoid
* Schizotypal
What are cluster B characteristics?
Individuals often appear dramatic, emotional, or erratic
* Antisocial
* Borderline
* Histrionic
* Narcissistic
What are cluster C characteristics?
Individuals often appear anxious or fearful
* Avoidant
* Dependent
* Obsessive compulsive
Describe the dsm 5 criteria for borderline personality disorder.
A pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts.
5 or more of the following:
* Frantic efforts to avoid real or imagined abandonment
* A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation
* Identity disturbance: markedly and persistently unstable self image or sense of self
* Impulsivity in at least two areas that are potentially self damaging (eg spending, sex, substance abuse, reckless driving, binge eating)
* Recurrent suicidal behaviour, gestures, or threats, or self mutilating behaviour
* Affective instability /marked reactivity of mood
* Chronic feelings of emptiness
* Inappropriate, intense anger or difficulty controlling anger
* Transient, stress related paranoid ideationsOr severe dissociative symptoms
Differentials for borderline personality disorder (BPD)?
- Bipolar disorder: depressive or mood elevated syndromes in bipolar are longer; affective instability of BPD are usually triggered by stressors such as failure or rejection
- Major depressive disorder: sustained neurovegetative symptoms related to sleep, appetite and energy whereas BPD affective states fluctuate within a single day
- Antisocial personality disorder: wanting to gain power/material gratification whereas BPD wants concern of caretakers
- Histrionic personality disorder: does not have self destructive behaviour, frequent angry disruptions in relationships, and chronic feelings of emptiness
- Narcissistic personality disorder: does not have self destructive behaviour, impulsivity, and fear of abandonment that marks BPD
What is complex PTSD?
- A subtype of PTSD with complex symptoms often observed in response to prolonged trauma, occuring during crucial developmental periods
- Symptoms include dissociation, emotional dysregulation, somatisation, altered relationships/attachments, and alterations in systems of meaning (eg believing there is no purpose in life, losing faith in others)
Differences between complex PTSD and Borderline personality disorder?
cPTSD:
* Severe but stable negative self concept
* Relational difficulties are characterised by a tendency to avoid
BPD:
* Shifts in their self image vacillating between highly positive and highly negative self perceptions
* Associated with rapid engagement followed by ups and downs or idealisation and devaluation of relationships
* Has suicide attempts and gestures and self injurious behaviours
Which antidepressant has a long half life and rarely has discontinuation side effects because of this?
Fluoxetine
In what situations are discontinuation symptoms from antidepressant weaning more likely?
- A high dose of antidepressant
- After a longer duration of antidepressant treatment
- Paroxetine, venlafaxine, desvenlafaxine or duloxetine
- An antidepressant in a child or adolescent (reduce over 6 to 12 weeks)
- An antidepressant used for the treatment of an anxiety disorder
List some good sleep practises for adults
Sleep-wake activity regulation
* Go to bed and arise at regular times (including on weekends)
* Avoid lying in bed for long periods of time worrying about sleeping. If unable to sleep after 20 minutes, Get up and do something relaxing, then return to bed when sleepy
* Avoid over sleeping
* Avoid napping (if necessary, limit to an afternoon power nap of 15 to 30 minutes)
Sleep setting and influences
* Avoid exposure to bright lights (including screens) from late evening onwards
* Seek exposure to bright light after rising in the morning
* Avoid heavy meals within three hours of bedtime
* Undertake regular daily exercise, but avoid vigorous physical activity within three hours of bedtime
* Ensure quiet, cool, dark room to sleep
* Do not have electronic devices or a clock in the bedroom
* Avoid sleeping with children or pets in the bedroom
* Use a comfortable and supportive mattress and pillow
* Reserve bedroom for sleeping and intimacy
* Avoid stressful ruminations before or at bedtime; Allocate time earlier in the evening to reflect and address worries
* Avoid caffeine after midday
* Reduce excessive alcohol intake or avoid alcohol altogether
* Avoid tobacco, especially in the evening
* Avoid illicit drugs
Sleep promoting adjutants
* Have a light snack or a warm drink before bed
* Have a warm bath or shower before bed
What is your approach to insomnia management?
Psychological and behavioural interventions affectively treat insomnia and our first line therapy
- Good sleep hygiene practices
- Relaxation therapies: hypnosis, meditation, visualisation, mindfulness, deep breathing an progressive muscle relaxation
- Stimulus control: limit the amount of time spent awake in bed, conditioning the patient to associate their bed and bedroom with sleep
- Sleep restriction
- Other lifestyle interventions
Pharmacotherapy as adjunct, NOT sole treatment
Dsm 5 diagnostic criteria for a major depressive episode?
Five or more of the following symptoms have been present during the same two week (at least one of the symptoms is either depressed mood or loss of interest or pleasure):
* Depressed mood most of the day
* Markedly diminished interest or pleasure in most activities
* Unintentional weight loss OR change in appetite nearly everyday
* Insomnia or hypersomnia nearly everyday
* Psychomotor agitation or retardation nearly everyday
* Fatigue or loss of energy nearly everyday
* Feelings of worthlessness or excessive or inappropriate guilt
* Diminished ability to think or concentrate
* Recurrent thoughts of death, recurrent suicidal ideations without a specific plan Or a suicide attempt or a specific plan for committing suicide
How can you distinguish between depression and dementia?
Depression:
* Coincides with life changes, often abrupt
* Diana effects, typically worse in the morning, situational fluctuations for less than acute confusion
* Minimal impairment in attention but is distractible
* Selective or patchy memory impairment
* Thinking is intact but with themes of hopelessness, helplessness or self deprecation
* Early morning awakening
Dementia:
* Chronic, generally insidious
* Long, no diona affects, symptoms progressive
* Generally normal attention
* Recent and remote memory impaired
* Difficulty with abstract thought, thoughts impoverished, marked poor judgement, words difficult to find
* Often disturbed sleep, nocturnal wondering and confusion
Are antidepressants helpful in dementia?
- Depression may mimic dementia (ie pseudodementia)
- Antidepressants or talking treatments may be warranted
- Antidepressants do not work well for depression in the presence of dementia, although they may be helpful for agitation
- Of the SSRIs, citalopram is the most effective for the management of dementia
What is bulimia nervosa?
It is a common eating disorder characterised by recurrent episodes of binge eating followed by compensatory behaviour to prevent weight gain
What are some signs and symptoms of bulimia nervosa?
- Regular episodes of uncontrolled overeating over a discrete period of time (binge eating), followed by
- Regular extreme weight control methods to counteract the perceived and feared effects of over eating, such as purging (eg self induced vomiting, laxative or diuretic abuse), driven exercise, fasting
- Overvaluation of body weight or shape as an expression of self worth
- Body weights in the adequate to obese range
What screening questionnaire can be used to check for anorexia nervosa/bulimia nervosa?
SCOFF questionnaire (>1 = likely):
* Do you make yourself sick be cause you feel uncomfortably full?
* Do you worry you have lost control over how much you eat?
* Have you recently lost more than 635 kg in a three month period?
* Do you believe yourself to be fat when others say you’re too thin?
* Would you say that food dominates your life?
Approach to management of bulimia nervosa?
- Assess patients for medical complications, such as hyperkalemia, other metabolic disturbances or dehydration
- First line is psychological therapies
- For children and adolescents, bulimia nervosa focused family therapy is recommended
- Pharmaco therapy as an adjunct - SSRIs, particularly fluoxetine (effect on satiety and mood)
Management of performance anxiety?
- Similar to social anxiety but restricted to discrete performance situations
- Psychosocial interventions such as cognitive behavioural therapy with an expression component are essential
- Propranolol has a limited role and overdose must be considered
- Propranolol 10 to 20 mg, 30 to 60 minutes before performance PRN (max 60mg)
