33 Flashcards
Mental Health
4 types of anxiety disorders
- Phobia
- Obsessive Compulsive Disorder
- Panic disorder
- Generalised anxiety disorder
Somatic symptoms of anxiety
Main:
- Sweating
- Palpitations
- Dry mouth
- Tremor
Other:
- Dizziness
- Chest pain
- Breathlessness
- Globus hystericus
Psychological symptoms of anxiety
- Worry
- Apprehension
- Fear of impending disaster
- Catastrophizing
- Poor concentration
- Irritability
Generalised anxiety disorder definition
6 months + of excessive worry about everyday issues disproportionate to any inherent risk causing distress or impairment.
ICD-10
More than 6 months with 4 symptoms - one must be palpitations, tremour, sweating or dry mouth.
Risk factors for generalised anxiety disorder
Family history (4x increased if 1st degree family member)
Aged 33-54
Female
Being divorced, separated, living alone or lone parent
Childhood adversity
Stressors
Social isolation
Somatisation disorder
- Multiple physical SYMPTOMS present for at least 2 years
- Patient refuses to accept reassurance or negative test results
Hypochondrial disorder
- Persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
- Patient again refuses to accept reassurance or negative test results
Malingering
- Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Munchausen’s syndrome
- Also known as factitious disorder
- The intentional production of physical or psychological symptoms
Dissociative disorder
- Dissociation is a process of ‘separating off’ certain memories from normal consciousness
- In contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
- Dissociative identity disorder (DID) is the most severe form of dissociative disorder
Conversion disorder
- Typically involves loss of motor or sensory function
- The patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
- Patients may be indifferent to their apparent disorder (la belle indifference)
What investigations should be done if anxiety is suspected?
TFTs Urine drug screen 24 hour urine Pulmonary function tests ECG
What screening tool can be used for generalised anxiety disorder?
GAD2 or GAD7
Management of generalised anxiety
- Identification, assessment and education. Treat any alcohol or substance abuse
- Low intensity psychological interventions
- CBT OR drug treatment
- sertraline
- alternative SSRI or venlafaxine
- pregabalin
- benzodiazepine (short term only) - Specialist care
Comprehensive care and drug combinations
Consider propranolol for symptomatic control
Define phobia
Intense fears of specific objects or situations that are triggered upon actual or anticipated exposure to phobic stimuli
Incidence of phobias
- 8% of population
- Average of onset 7-10 years
- 2-3 times more common in women
- Increased in Caucasian
Risk factors for phobia
Female
Anxiety or mood disorders
Substance misuse disorders
Stress and negative life events
Treatment for phobia
- Recognition and diagnosis
2. Graded exposure
Describe graded exposure
Systematic desensitisation - deliberate confrontation of fear until anxiety reduces
Needs to be
- Repeated frequently
- Graded in steps
- Wait in situation until the anxiety reduced (otherwise reinforces)
- Clearly specified and planned
- Prolonged
- No artificial anxiolytic
Define panic disorder
ICD10
Recurrent panic attacks not consistently associated with a specific situation or object. Occur spontaneously.
Moderate = 4 or more attacks in 4 weeks
Severe = 4 or more attacks in 1 week for 4 weeks
Define panic attack
Discrete episode of intense fear or discomfort.
Starts abruptly.
Reaches a crescendo after a few minutes.
4 or more of the following symptoms;
- Palpitations, difficulty breathing, dizzy, hot flushes, sweating, derealisation, cold chills, trembling, chest pain, fear of losing control, numbness, dry mouth, tingling
Risk factors for panic disorder
Female 20-30 First degree relative Caucasian Smoking Major life disorders Asthma Caffeine
Treatment for panic disorder
- Recognition and diagnosis
- CBT or medication
- SSRI (citalopram or paroxetine) - Specialist care
Define obsessions
Unwanted intrusive thoughts, doubts, images or urges that repeatedly enter the mind
Define compulsions
Repetitive behaviours or mental acts that a person feels compelled to perform in response to an obsession. Involuntary.
Define rumination
Mental acts repeated endlessly in response to intrusive ideas and doubts
Incidence of OCD
1.6% of the population
Equal in gender
Age in men = late adolescent
Age in women = early 20s
Definition of OCD
Obsessional symptoms and compulsive acts
Most days for at least 2 weeks
Source of distress or interferes with activities
Treatment for OCD
Mild - low intensity psychological therapy or CBT. If no response SSRI
Moderate - choice between CBT and ERP (exposure and response prevention) OR SSRI
Severe - CBT and ERP and SSRI
Then can trial clomipramine alone
Then can add clomipramine to SSRI
Symptoms of depression
Depressed mood Energy Loss Pleasure loss (anhedonia) Retardation/Agitation Eating changes Sleep disturbance Suicidal thoughts I'm a failure (loss of self-esteem/confidence) Only me to blame (guilt) No concentration
Screening for depression
PHQ9 Patient health questionnaire
HAD - hospital anxiety and depression scale
Epidemiology of depression
25% women, 10% men Female PMHx of depression Significant physical illness causing disability or pain Other mental health problems African-Caribbean, Asian Refugees, asylum seekers Family history
Definition of depression
1 core symptom: low mood or anhedonia plus some of other symptoms
Mild - 4 symptoms
Moderate - 5 to 6 symptoms
Severe - 7+ symptoms or any psychotic symptoms
Causes of depression
Drugs = steroids, contraceptive pill, digoxin, beta blockers Hypothyroid Heart disease Stroke Cancer MS Dementia Alcohol abuse Illicit drug use Child birth (post-natal depression) Life events - unemployment, divorce, bereavement
Investigations in depression
U+Es LFTs TFTs Calcium FBC glucose inflammatory markers Magnesium Syphilis Drug screen
Treatment for depression
MILD
- low intensity psychological therapies
MODERATE
Antidepressant or CBT
SEVERE
Antidepressant and CBT
Antidepressant choice
- SSRIs- fluoxetine, sertraline, citalopram
- SNRI - venlafaxine
- TCAs (high risk in OD)
Note - increased risk of suicide in first 2 weeks
Define Bipolar disorder
Chronic illness associated with episodes of mania and depression
At least 2 episodes in which a persons mood are significantly disturbed (1 of which MUST be mania or hypomania)
What are the 2 types of bipolar disorder
Type 1 - manic episodes. they are severe and result in impaired functioning and frequent hospital admission
Type 2 - not full mania - hypomanic episodes. No psychotic symptoms
Define mania
At least 3 of the following symptoms:
- Grandiosity
- Decreased need for sleep
- Pressured speech
- Flight of ideas
- Distractibility
- Psychomotor agitation
- Excess pleasurable activity with no thought for consequences
Epidemiology of bipolar disorder
2%
Type 1 higher in males, type 2 in females
Onset between 13 and 30
Strong family history relation
Drug or alcohol use Major life changes Abuse in childhood Early onset depression Periods of high stress
Symptoms of mania
Grandiose ideas Pressure of speech Excessive energy Racing thoughts Flight of ideas Over activity Less sleep Easily distracted Unkempt Increased appetite Sexual disinhibition Recklessness financially
SEVERE
Auditory hallucinations
Delusions of persecution
Lack of insight
What is rapid cycling
4+ cycles of depression and mania in 1 year with no asymptomatic episodes
Associated with longer course of illness, earlier age of onset, increase suicide, increased drug and alcohol abuse
TEST THYROID FUNCTION
Management of acute manic episode
Increase antipsychotic dose to maximum if already taking
- Haloperidol, olanzapine,quetiapine, risperidone
- If one is not effective swap to another
- If the second doesn’t work - add lithium
STOP all antidepressants
Management of depressive episodes in bipolar disorder
Use antidepressants carefully as can tip into mania - only used with anti-mania medication
Don’t treat if mild
Moderate to severe
- Fluoxetine and olanzapine or quetiapine alone
- Lamotrigine alone
Management of rapid cycling
Stop all antidepressnats
Anti-mania therapy maximises
Lithium + valproate
Long term treatment of bipolar disorder
- Lithium
- Add valproate
Continue for 2 years but may need for 5 years.
ECT can provide rapid improvement in severe mania but is short lived
Prognosis of bipolar
Average 10 episodes in a lifetime
High risk of recurrence
Symptom free episodes get shorter with increased time
25-55% have at least 1 suicide attempt
Highest rate of suicides
Define psychosis
- Seeing or hearing things others do not
- Having unusual thoughts or beliefs
- Feeling confused or suspicious
Stages of psychosis
- Prodromal phase
Unclear, drop in functioning, sleep or mood disturbance - Psychosis and threshold
Frank symptoms of psychosis - can occur at any age but most likely to occur in late teens, women tend to be older - Remission
- Relapse
What is the early intervention rationale for psychosis?
Reduce the impact of psychosis by offering interventions at the earliest stage of condition as the longer the duration of the untreated psychosis = worse prognosis
Early intervention work with 14-35 year olds for first occurrence for up to 3 years
Reduce the impact
What risks should be assessed under mental health
Suicide Self-harm Aggressive behaviour Neglect Exploitation by others Self-neglect
Risk factors for suicide
Male Older age or teen Previous attempt Mental illness in 90% Divorced, single or widowed Bereavement Social isolation Physical ill health Unemployed
What are the 3 categories of suicide/self-harm
Failed suicide attempt - high risk of re-attempting. Likely to have mental health problems.
Impulsive self-harm with ambivalence to death = overdose taken after a stressful event. No real suicidal intent. Tend to be young and female.
Repeated self-harm without suicidal intent.
If a person presents with suicide - what questions need to be asked?
Events preceding the event
Details of the act themselves
Intentions
Current thoughts about suicide
Was it planned?
What happened after?
Any previous attempts?
What are the 5 stages of grief (Kubler-Ross)
Denial (and isolation) Anger Bargaining Depression Acceptance
What is complicated grief?
Pathological reaction to loss associated with long term physical and psychological dysfunction
Longer than 6 months and stuck in maladaptive state!
Significant deviation from cultural norm or increase intensity of impairment
Risk factors for complicated grief
Parental abuse Parental death controlling parents Close relationship with deceased Insecure attachment styles Emotional dependency Sudden death Death in hospital
Define adjustment disorder
Transient states of distress and emotional disturbance which arises in the course of adapting to a significant life change, serious physical illness or possibility of serious illness.
Stressor is not of unusual or catastrophic type.
- Must start within 3 months of stressful life event (usually within 1 month)
- Course does not exceed 6 months
- Depressive or anxiety symptoms that cause functional impairments
Aetiology of adjustment disorders
Relationship break up Unemployment Occupational dispute Bereavement Illness
Presentation of adjustment disorder
- Depressed mood
- Anxiety
- Worrying
- Feeling or irritability to cope, plan ahead or continue
- Difficulty in daily living
- Liable to dramatic behaviour or violence
- Palpitations, rapid breathing, diarrhoea, tremor
- Aggression, deliberate self-harm, alcohol abuse, drug misuse, social difficulties
ICD10 subtypes of adjustment disorders
Brief depressive reaction
Prolonged depressive reaction
Mixed anxiety and depressive reaction
Adjustment disorder - emotion/conduct/mixed
Prognosis of adjustment disorders
Usually resolve within a few months
Definition of schizophrenia
At least one must be present most of the time for 1 month:
- Thought echo, insertion, withdrawal or broadcast
- Delusions of control referred to body parts, actions or sensations
- Delusional perception
- Hallucinatory voices giving running commentary, discussing the patient or coming from a part of the patient’s body
- Persistent bizarre or culturally inappropriate delusions
OR 2 of the following for most of the time for 1 month:
- Persistent daily hallucinations accompanied by delusions
- Incoherent or irrelevant speech
- Catatonic behaviours - stooping and posturing
- Negative symptoms such as marked apathy, blunted or incongruous mood
Epidemiology of schizophrenia
15 per 100,000 incidence
7 per 1000 prevalence
Starts in adolescence and early 20s
Peak age of onset is later in women
More common in men
More common in Blacks and ethnic minorities
FHx association
Subtypes of schizophrenia
Paranoid - delusions or hallucinations prominent
Hebephrenic - sustained, flattened or incongruous affect, lack of goal directed behaviour, prominent thought disorder
Catatonic - sustained evidence over at least 2 weeks of catatonic behaviour including: stupor, excitement, posturing, rigidity.
Simple - considerable loss of personal drive, progressive deepening of negative symptoms
Management of schizophrenia
“Factors associated with poor prognosis
- Strong family history
- Gradual onset
- Low IQ
- Premorbid history of social withdrawal
- Lack of obvious precipitant
- Early intervention services
- MDT
- Health promotion
- Increased compliance with medication
Medical: usually risperidone or olanzapine
- Agree choice of antipsychotic
- Titrate as necessary to minimum effective dose
- Assess over 6-8 weeks
- If not suitable, change drug and repeat steps 1-3
- If not suitable use clozapine”
First rank symptoms of schizophrenia
First rank symptoms:
- Lack of insight
- Auditory hallucinations: thought echo, 3rd person commentary
- Thought disorder (insertion, withdrawal, interruption, broadcasting)
- Delusional perceptions (abnormal significance for normal event)
- External control of emotions
- Somatic passivity: thoughts, sensations and actions are under external control
Negative symptoms of schizophrenia
Negative symptoms:
- Underactivity
- Low motivation
- Social withdrawal
- Emotional flattening
- Self-neglect
Schizophrenia aetiology
Multifactorial: genetic, environmental and social
- Greatest risk factor is FHx (40% in monozygotic twins)
- NRG1 has some part
- Dopamine in mesolimbic system plays a key role
- Excessive dopamine adds salience to mundane and insignificant thoughts or perceptions
- Amphetamine misuse increases synaptic dopamine and can cause delusions and hallucinations
Signs of schizophrenia
“Appearance
Behaviours: withdrawal, suspicion, repetitive purposeless movements
Speech: interruptions to the flow of thought (thought blocking), loosing of associations, knight’s move thinking
Mood/affect: flattening, incongruous or odd
Thoughts: word salad, derailment, knights move thinking, thought insertion, thought withdrawal, thought broadcast
Beliefs: delusion perceptions, delusions regarding thought control or broadcasting, passivity of experiences
Hallucinations
Cognition: attention, concentration, orientation and memory should be assessed and is often impaired”
Risk factors for schizophrenia
“Risk factors:
- FHx
- Premature birth or low birth weight
- Perinatal hypoxia
- Intrauterine infection (influenza in 2nd trimester)
- Abnormal early cognitive neuromuscular development
- Social isolation
- Urban lifestyle
- Illicit drug use
- Migrants
- Abnormal family interactions
- Black and ethnic minority”
Investigations in schizophrenia
"FBC and LFTs Check for alcohol abuse Urine screening for drug misuse Serological tests for syphilis Check for intoxication or drug overdose
Rule out: Organic causes: - Drug induced psychosis: amphetamine, LSD, cannabis - Temporal lobe epilepsy - Encephalitis - Alcoholic hallucinosis - Dementia - Delirium - Cerebral syphilis
Psychiatric causes:
- Mania
- Psychotic depression
- Personality disorder
- Panic disorders
- Dissociative identity disorder”
Management of schizophrenia
“Factors associated with poor prognosis
- Strong family history
- Gradual onset
- Low IQ
- Premorbid history of social withdrawal
- Lack of obvious precipitant
- Early intervention services
- MDT
- Health promotion
- Increased compliance with medication
Medical: usually risperidone or olanzapine
- Agree choice of antipsychotic
- Titrate as necessary to minimum effective dose
- Assess over 6-8 weeks
- If not suitable, change drug and repeat steps 1-3
- If not suitable use clozapine”
Prognosis for schizophrenia
More than 80% of patients with their first episode will recover
20% will never have another episode
Worse prognosis with: poor premorbid adjustment, slow insidious onset, long duration of untreated psychosis, prominent negative symptoms
Differentials for schizophrenia
Organic
- Drug Induced Psychosis - Amphetamine, LDS, Cannabis
- Temporal Lobe Epilepsy
- Encephalitis
- Alcoholic Hallucinosis
- Dementia
- Delirium
- Cerebral Syphilis
Psychiatric
- Mania
- Psychotic Depression
- Personality Disorder
- Panic Disorders
- Dissociative Identity Disorder
Define psychosis
Severe mental disorder in which there is extreme impairment of ability to think clearly, respond with appropriate motion, communicate effectively, understand reality and behave appropriately.
Define delusions
False, fixed strange or irrational belief with is firmly held
Define hallucinations
Sensory perception without an appropriate stimulus
Delusional themes
Delusion of control - someone else controlling feelings, behaviours and thoughts
Delusional jealousy
Delusion of guilt
Thought insertion
Delusion of reference
Erotomania - belief that someone is in love with them
Grandiose
Grandiose religious - person is god or chosen to act as god
Persecutory - followed/harassed/cheated or conspired against
Cotard delusion
Thought or belief that they don’t exist or that they have died
Delusion of reference
Insignificant remarks or events have personal significance to patient
Types of hallucinations
Hallucinations:
- Visual: more common in organic illness e.g. TLE, epilepsy, Parkinson’s.
- Auditory: more common in functional psychiatric illness.
- Tactile: cocaine bugs, simple partial seizures, somatic passivity experiences.
- Olfactory: epileptic aura, tumours, schizophrenia.
- Gustatory: epileptic aura and attack, functional illness.
Lilliputian Hallucinations
Seen in TLE (temporal lobe epilepsy)
Size distortion
Alice in Wonderland syndrome
Also seen in migraines, brain tumours and EBV
Types of disordered thoughts
Paucity of thought
Thought block
Rapid uncontrollable thoughts
Formal thought disorders
- Derailment
- Loosening of association
- Knight’s move thinking
- Word salad
Organic causes of psychosis
Delirium - infections, electrolyte disturbance
Epilepsy
Medications - steroids, antibiotics, antivirals, dopamine agonists, stimulants
Cancer
MS
SLE
Neurodegenerative disorders e.g. Parkinson’s
Drug or alcohol withdrawal
Psychaitric causes of psychosis
Schizophrenia Schizoaffective disorder Bipolar disorder Major depression Acute psychosis Dementia Personality disorders
Risks in schizophrenia
Suicide rate is 10-15%
High in early stages of disease
Self-neglect
Risk to others - mild increased in minor aggressive acts.
Extrapyramidal side effects of antipsychotics
Dystonia
Pseudoparkinsonism
Akathisia
Tardive dyskinesia
Sedation
Hyperprolactinaemia
Decreased seizure threshold
Postural hypotension
Tardive dyskinesia
Late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw.
Akathisia
SEVERE RESTLESSNESS
Akathisia is a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting.
Dystonia
Dystonia is a movement disorder in which a person’s muscles contract uncontrollably.
The contraction causes the affected body part to twist involuntarily, resulting in repetitive movements or abnormal postures
E.g. torticollis, oculogyric crisis)
Dissociation (conversion) define
Psychological distress manifests as physical and mental signs
e.g. paralysis and amnesia
Relationship between physical and psychiatric illness
- Psychiatric symptoms can be a consequence of physical illness e.g. organic
- Physical symptoms are manifestations of psychiatric disorder e.g. MUS and somatisation
- Psychiatric symptoms that are manifestations of underlying physical illness
e. g. hypothyroid - Psychiatric symptoms precipitating physical illness
Anxiety, depression can precipitated seizures, MS relapses, pain
Define medically unexplained symptoms
Physical symptoms not explained by organic disease and there is positive evidence or assumption that the symptoms are linked to psychological factors
- Not a diagnosis of exclusion
- requires positive psychological factors
- Most are transient and not deliberately produced
Define illness denial
Behaviours to avoid the stigma
Inability to accept the physical or mental illness
Define illness affirmation
Behaviours that inappropriately affirm the illness
Disproportionate disability in relation to signs and symptoms
Define somatisation
Manifestation of psychological stress as physical complaints with medical consultation.
Can be acute or chronic
often associated with psychiatric diagnosis
Not a conscious process
ICD10 definition of medically unexplained symptoms
2 years of multiple and various physical symptoms
Persistent refusal to accept advice and reassurance that there is no physical aetiology
Some degree of impaired functioning
Temporal relationship to stresses
Features of chronic somatisation
Many unexplained symptoms (often pain)
Multiple investigations
Frequent consultations
Excessively disabled
Polypharmacy
Thick case notes
Dissatisfied with care
odd beliefs
Unrealistic expectations of care
Denial or minimise life problems
Define dissociative disorder
acute and dramatic onset
Psychological distress manifests as physical mental signs
Mental symptoms
e.g. amnesia, fatigue states
Caused by stressful life events, child hood neglect or abuse.
Define conversion disorders
acute and dramatic onset
Psychological distress manifests as physical signs
PHYSICAL symptoms
e.g. paralysis, blindness
Caused by stressful life events, childhood neglect or abuse.
Prevalence and outcome of medically unexplained symptoms
20% of general population
10-33% of GP presenting complaints
Secondary care 30-50%
50% recede in 12 months
2.5% persist and lead to repeated consultation
Conversion and dissociation disorders recover quickly
Clinical identification of MUS
- Symptoms do not fit with existing disease models
- Patient is unable to give clear and precise description of symptoms
- Symptom or disability seems excessive in comparison to pathology
- Temporal relationship to stressful life events
- Patient attends frequently with different symptoms
- Patient over anxious about the meaning of symptoms
- Patient complains of pain in various sites
Management of MUS
- Acknowledge that symptoms are genuine
- Provide clear explanation of investigations, results and conditions excluded
- Avoid extra investigations of referrals unless clinically indicated
- Address the patients concerns
- Set up brief regular meetings every 6-8 weeks (they need to feel they are being taken seriously)
- Symptom management e.g. analgesics, laxatives, antispasmodics, weight loss and exercise
- Treat any anxiety or depression if present +/- IAPT
- Counsellor if required
Aim for patient coping and decreased impact on life rather than symptom cure.
Ways of parents managing child stress
- Provide safe, secure, familiar, consistent environment
- Encourage the child to ask questions
- Listen to child without being critical
- Use encouragement and affection
- Use positive encouragement not punishment
- Allow child to make choices and have some control
- Recognise signs of unresolved stress
Methods of screening for dementia
Mini mental state exam (MMSE) MOCHA ACE-III DEMTECT AMTS
Diagnostic criteria for dementia:
- Affects ability to function in normal activities
- Represents a decline from a previous level of function
- Cannot be explained by delirium or other psychiatric disorder
- Has been established from history and cognitive assessment
- Involve impairment of at least 2 cognitive domains”
Describe MMSE
Out of 30
Cut off 24
- Most commonly used for complaints of problems of memory
- Used for diagnosis and assesses progression and severity
- Tests memory, attention and language
- Not good for mild impairment
X doesn’t test frontal function
X not designed to measure change
Describe MOCHA
Out of 30
Cut off 26
- Aimed at detection of mild cognitive impairment
- Relatively comprehensive but brief
- Not biased towards a particular cognitive domain
- Not suitable for patients in advanced stages
Describe ACE-III
Out of 100
Cut off 82-88
- Robust validation in various neurodegenerative conditions
- Appropriate for longitudinal studies
- Sensitive to subtle impairments
- Not sensitive to behavioural impairments
