Adult Psychiatry 2 Flashcards
How many adults in the UK have ‘broadly defined neurosis’ at any one time?
15%
Most common anxiety disorders in the UK
Mixed anxiety-depression
GAD
How many GP consultations are for anxiety related sx?
25%
Mean age of onset of GAD
30
Mean age of onset of panic disorders
22-25
Mean age of onset of OCD
20
Mean age of onset of social phobia
15
Mean age of onset of phobia of blood injury injection or environmental types
5-9 years
Mean age of onset of situational phobias
20 years
What has been noted about the dx of anxiety disorders and age?
With each generation, anxiety disorders are diagnosed at a younger age than previous
Lifetime prevalence of blood-injection-injury phobia
3.5%
What do subjects with blood-injury-injection phobia have a higher lifetime hx of?
Fainting
Seizures
In which groups is prevalence of blood-injury-injection lower?
Elderly
In which groups is prevalence of blood-injury-injection higher?
Females
Less education
Which anxiety disorder is most common in boys?
OCD
Which anxiety disorder has equal distribution between men and women?
OCD
In which anxiety disorder do men outnumber women in attending health centres?
Social phobia
What do NICE recommend is needed first before treating anxiety disorders?
Comprehensive assessment considering distress, functional impairment, effect of co-morbid MI, substance misuse or medical conditions and previous response to treatment
First line treatment for anxiety disorders
Psychological therapy first
Which pharmacological therapy is advised for anxiety disorders?
SSRIs
When to consider combination therapy for anxiety disorders?
Complex anxiety disorders refractory to treatment
Point prevalence of OCD in adults
1-3%
Point prevalence of OCD in children
1-2%
Lifetime prevalence of OCD
2-3%
Most commonly prevalent psychiatric disorders?
Phobias Alcohol misuse Depression OCD (in that order)
Gender ratio of OCD in community
1.5:1 female:male
Why is it thought that there is a greater ratio of women with OCD in the community despite equal gender ratio of the disease?
Men have more severe psychopathology
Difference in OCD between males and females
Men show earlier onset and trend more towards tics and poorer outcome
Who created the four factor model of OCD?
Castle & Phillips 2006
What is the four factor model of OCD?
Aggressive, sexual and religious obsessions and checking compulsions
Symmetry and ordering obsessions and compulsions
Contaminatino obsessions and cleaning compulsions
Hoarding obsessions and compulsions
Which obsessions & compulsions are often chronic and treatment resistant?
Symmetry ordering often chronic and Rx resistant
Hoarding often Rx resistant
Which obsession/compulsion may be neurobiologically ditinct?
Hoarding
What neurobiology has been reported in OCD?
Hypermetabolism of basal ganglia structures i.e. caudate
Which medications can cause OCD sx?
D2 antagonists such as clozapine and other antipsychotics
Which children have higher rates of OCD?
Children with autoimmune reactions
What can OCD spectrum disorders be classified into?
Somatic preoccupation e.g. anorexia
Neurological disorders e.g. Tourettes
Impulse control disorders e.g. paraphilias
Anankastic PD
What does PANDAS stand for?
Paediatric autoimmune neuropsychiatric disorders associated with strep infection
What is PANDAS?
Thought to be secondary to streptococcal infection and mediated by autoantibodies binding to basal ganglia.
What sx does PANDAS produce?
Tics
Fluctuating OCD sx
Anxiety
NIMH diagnostic criteria for PANDAS
Presence of OCD or a tic disorder
Onset between 3 years of age and beginning of puberty
Abrupt onset of sx or a course characterised by dramatic exacerbations of sx
Onset of exacerbation of sx temporally related to infection with GABHS
Abnormal neuro exam during exacerbation
What is GABHS?
Group A beta-haemolytic strep infection
What is found to be elevated in those with PANDAS?
AntiDNAseB or Antistreptolysin O titres
Some may have autoantibodies to neurons in basal ganglia; called basal ganglia antibodies
Treatment for mild-moderate OCD (first line)
Self-help
2nd line treatment for mild-moderate OCD
CBT with ERP (Exposure and response prevention)
3rd line treatment for mild-moderate OCD
SSRIs +/- CBT
1st line treatment for severe OCD
SSRIs+/-CBT
How long do people with severe OCD need to continue SSRIs if they respond well?
1-2 years +/- booster CBT
2nd line treatment for severe OCD
Switch to different SSRI or clomipramine
What is exposure and response prevention?
Element of CBT for OCD
What happens in exposure and response prevention?
Patients are trained to confront (directly or imaginative) anxiety-provoking situations while abstaining from compulsive behaviours in response.
Evidence for ‘booster’ sessions of ERP for OCD?
Can reduce risk of relapse and provide more durable remission than pharmacotherapy alone
What type of medications does OCD respond well to?
Serotonergic medications i.e. SSRIs, clomipramine.
How many patients with OCD show some sort of improvement to SSRI?
60-70%
NNT for SSRI for OCD?
6-12
When is antipsychotic augmentation with SSRI considered for OCD?
If no response after 3 month trial of maximal dose of SSRI.
Particularly useful if tics.
What has happened to PTSD diagnosis in DSM V?
Criteria changed
Moved from anxiety disorders into ‘trauma and stressor-related disorders’
Clinical subtype ‘dissociative sx’ added
Diagnostic criteria for PTSD for DSM V
Hx of exposure to traumatic event that meets specific stipulations and sx from each of 4 clusters:
Avoidance
Negative alterations in cognitions and mood
Alterations in arousal
Reactivity
Point prevalence of PTSD
1%
Incidence of PTSD worldwide?
Varies
Lifetime prevalence of PTSD in America for adults?
6.8%
Lifetime prevalence of PTSD in men vs women
Men: 3.6%
Women: 9.7%
Which gender is more likely to be exposed to traumatic events?
Men: 60%
Women: 50%
How many people exposed to trauma will develop PTSD?
30%
Most frequently experienced trauma?
Witnessing someone being badly injured/killed Exposure to fire/flood/natural disaster Involved in life-threatening accident Combat exposure (in that order)
Which gender is molestation more common in?
Females
Which gender is mugging more common in?
Males
In which type of trauma do men develop more PTSD?
Rape
Which age group is more likely to develop PTSD?
Younger
In which type of patients is PTSD more common?
Younger
Those with higher anxiety response to initial event
Those who perceive external locus of control
What does NICE recommend re PTSD initially?
Primary care diagnosis and screening as likely underdiagnosed
Who did research into factors associated with PTSD?
Bisson 2007
Pre-traumatic factors of PTSD?
Previous psychiatric disorder Female Personality - external locus of control Lower socioeconomic & educational status Etnic minotiry Cluster B PD
Peritraumatic factors for PTSD?
Higher severity of trauma
Perceived threat to life
Peritraumatic dissociation
Post-traumatic factors for PTSD?
Perceived lack of social support
Subsequent life stress or physical illness - especially chronic pain
Protective factors for PTSD?
High IQ
Higher social class
Opportunity to grieve for loss
Which areas of the brain show abnormalities in PTSD?
Hippocampus
Amygdala
What type of metabolic disturbance is shown in PTSD?
Hypocortisolaemia
What features predict chronicity in PTSD?
Strong avoidance features
Which interventions have been shown to be beneficial for PTSD?
Multiple-session CBT to prevent PTSD in people with acute stress disorder
Which interventions are unlikely to be beneficial in PTSD?
Single-session individual debriefing to prevent PTSD
Supportive counselling to prevent PTSD
NICE guidelines for initial management of PTSD in primary care
Watchful waiting if sx are mild and present for <4 weeks after trauma
When does NICE recommend px of non-benzo sleeping tablet for PTSD in primary care?
After 4 consecutive nights sleep disturbance
NICE Guidelines for PTSD in secondary care
Psychological treatment regularly and continuously (once a week) by the same person
What does NICE specifically not recommend for PTSD management in secondary care?
Non-trauma focused interventions such as relaxation/non-directive therapy
NICE guidelines for PTSD management in secondary care if sx present within 3 months of trauma
Trauma-focused CBT
What does trauma-focused CBT include?
Exposure therapy
Cognitive therapy
Stress management
When should trauma-focused CBT be offered?
Those with severe PTSD
Those with severe PTSD in first month after traumatic event
Those with PTSD within 3 months of event
How is trauma-focused CBT delivered?
OP; 8-12 sessions (5 if treatment starts within 1 month of event)
Guidance for long-term use of sleeping medication for PTSD
Antidepressant
NICE guidelines for PTSD if sx present for more than 3 months after trauma
Trauma-focused CBT or EMDR
How many sessions of trauma-focused CBT or EMDR are offered for PTSD sx >3 months after trauma?
12 sessions
What to offer if treatment failure or limited improvement with therapy and sx >3 months after trauma?
Alternative form of trauma-focused psychological treatment; if no further improvement, consider pharmacological treatment
Pharmacological treatment for general use for PTSD
Paroxetine
Mirtazapine
Pharmacological treatment for specialist use for PTSD
Amitriptyline
Phenelzine
Which medication is licensed for females only with PTSD?
Sertraline
NICE second line options for PTSD (pharmacotherapy)
Paroxetine
Mirtazapine
Which medication has evidence of good effect if used as augmentation for PTSD?
Olanzapine
Evidence re psychological debriefing after trauma?
Equivalent to or worse than control or educational interventions in preventing PTSD and general psychological morbidity post-trauma.
May increase risk of PTSD & depression.
Evidence re psychological therapies for PTSD?
No difference between trauma-focused CBT and EMDR
Both are superior to stress management
Stress management superior to other therapies
What happens in exposure therapy as part of trauma-focused CBT?
Repeated confrontation of traumatic memories and repeated exposure to avoided situations take place together with relaxation and anxiety reduction
When happens in the cognitive component of trauma-focused CBT?
Modification of misinterpretations that lead to overestimation of current threat and modification of other beliefs related to trauma experience and individuals behaviour during trauma (such as guilt) are attempted via cognitive restructuring.
Who discovered EMDR and how?
Shapiro; used it on herself
What theory is EMDR based on?
Bilateral stimulation in the form of eye movements allows processing of traumatic memories.
What happens during EMDR?
While patient focuses on specific images, negative sensations and associated cognitions, bilateral stimulation is applied to desensitise the individual to these memories and more positive sensations and cognitions are introduced.
Outcome results for PTSD with treatment?
More than a third of people report having the disorder after 6 years.
Remission of PTSD?
50% at 2 years
Diagnostic criteria for acute stress disorder?
Immediate and clear temporal connection between impact of stressor and onset of sx
Sx usually appear within minutes and disappear within 2-3 days (often hours)
Partial or complete amnesia for episode may be present.
Further sx required for acute stress disorder?
Sx show mixed and changing picture
Sx resolve rapidly (hours) when removal of stressful situation is possible; when continued, sx diminsh in 24-48h.
What type of sx are seen in acute stress disorder?
Initial state of ‘daze,’ depression, anxiety, anger, withdrawal.
When should dx of acute stress disorder not be used?
To cover sudden exacerbation of sx in individuals already showing sx that fulfull criteria for any other psychiatric disorder
Which sx is not needed for GAD which is usually needed for other anxiety disorders?
Avoidance
Lifetime prevalence of GAD
5%
Point prevalence of GAD
2-3%
MZ vs DZ concordance of GAD?
41% vs 4% (MZ vs DZ)
Risk factors for GAD?
Exposure to civilian trauma Bullying Higher number of life events Being first-degree relative of GAD patient Female
What is Hamilton anxiety scale?
14-item scale
Emphasises somatic sx
Definition of treatment response for GD
50% reduction in baseline score on Hamilton anxiety scale
Definition of clinical recovery of GAD
<7 on Hamilton anxiety scale
Acute treatment of GAD
SSRI TCAs Benzos CBT Venlafaxine, Duloxetine & Buspirone
Which SSRIs can be used for GAD?
Escitalopram
Paroxetine
Sertraline
Which TCAs can be used for GAD?
Imipramine
Which Benzos can be used for GAD (Short-term)?
Alprazolam
Diazepam
Treatment for long-term management/prevention of GAD?
CBT Paroxetine Escitalopram Venlafaxine Pregabalin
Adjuncts for non-response for GAD
Olanzapine/Risperidone at low dose
First line treatment for GAD as per NICE?
SSRI or SNRI or Pregabalin
Which type of CBT is recommended for GAD?
Education
Relaxation training
Exposure and cognitive restructuring
Guidance re combination of medication and psychological therapy for GAD?
Insufficient evidence but can be used if initial treatment fails
Outcome for GAD
42% patients recover after 12 years
Which patients show poorer outcomes for GAD?
Those with another anxiety disorder
Which herbal drug has been shown to be effective for GAD?
Kava shrub (Piper methysticum)
How does kava work?
Due to kavapyrones which in animals act as muscle relaxants and anticonvulsants and reduce limbic system exciability
How might kava work?
Inhibition of voltage-dependent Na channels
Increase GABAA receptor densities
Block norepinephrine reuptake
Suppress release of glutamate
Research re kava for GAD
Kava is more effective than placebo in reducing HAM-A scores, effect is detectable for 1 week
Why is kava not recommended for clinical use for GAD in the UK?
Associated with hepatotoxicity
Which medications can Kava interact with?
Levodop
Alprazolam
Can cause EPSEs or lethargy
Which medications can the herb Valerian interact with?
Loperamide and fluoxetine, causing delirium
Which medications can evening primrose oil interact with?
Phenothiazides, causing epileptic seizures
Point prevalence of social phobia?
2.8%
Who recognised two types of social phobia?
Schneier 2003
What are the two types of social phobia?
Generalised
Situational
What is generalised social phobia?
Fear occurs in most social situations
What is situational social phobia?
Fear occurs in public speaking or performance anxiety
First line pharmacotherapy for Social phobia?
Paroxetine Sertraline Fluoxetine Fluvoxamine Escitalopram Venlafaxine
Duration of medication for social phobia (first line)
12 weeks
How long should drug treatment continue if good response for social phone?
6-12 months
2nd line treatment for social phobia?
Phenelzine
3rd line treatment for social phobia?
SSRI + Clonazepam combination
Gabapentin
Pregabalin
Which social phobia can beta blockers be used for?
Performance anxiety
How does DSM categorize panic disorder?
Primary dysfunction
How does ICD categorize Panic Disorder?
Agoraphobia
Point prevalence of panic disorder
0.9%
Lifetime prevalence of panic attacks
28%
Lifetime prevalence of panic disorder
4.7%
Mean age of onset of any panic attack
22 years
Mortality rate of panic disorder
All-cause mortality increased by 1.9 times
How does ICD 10 classify panic disorder?
Recurrent, unpredictable panic attacks with sudden onset of palpitations, CP, choking sensation, dizziness and feelings of unreality, often associated with fear of dying/losing control but w/o requirement for sx to have persisted >1 month.
Heritability estimate of panic disorder
30-40%
Cognitive theory of patients with panic disorder?
Patients have heightened sensitivity to internal bodily sensations.
What does neuroimaging suggest re panic disorder?
Involvement of fear network: amygdala, orbitofrontal cortex and hyporthalamus
First line drug treatment for panic disorder
SSRI
First line treatment for panic disorder
7-14 weeks of CBT (weekly 1-2 hours) completed within 4 months
SSRI
Bibliotherapy
Recommendation if no effect with 12 week course of SSRI for panic disorder
Imipramine
Clomipramine
Benzo use in panic disorder?
Associated with worse outcome; should not be used
BAP recommendation for panic disorder
CBT All SSRIs Clomipramine, Imipramine Venlafaxine Reboxetine Benzos
Which benzos does BAP recommend for panic disorder?
Alprazolam
Clonazepam
Diazepam
Lorazepam
Efficacy of meds vs therapy for panic disorder?
Both have equal efficacy
How long do SSRIs need to be continued for panic disorder to assess efficacy?
12 weeks
Long-term treatment for panic disorder?
Cognitive therapy with exposure
Drug treatment for 6 months if good response
Best treatment to reduce relapse of panic disorder?
Cognitive therapy with exposure
First line drug treatment for long term treatment of panic disorder
SSRI
2nd line drug treatment for long term treatment of panic disorder
Imipramine
Recommendations if initial therapy fails for panic disorder
Add Paroxetine or Buspirone to psychological treatment if partial response
Add Paroxetine while continuing CBT if no response
How is Hypochondriasis classed in ICD 10?
Preoccupation with fear of having a serious disease based on misrepresentation of bodily sx.
How is hypochondriasis classed in DSM V?
Removed due to pejorative perception; now diagnosd as Somatic Symptom Disorder or Illness Anxiety Disorder
Prevalence of Hypochondriasis
0.8-4.5%
Treatment for Hypochondriasis
CBT
Group CBT
SSRIs
What happens to patients with Body dysmorphic disorder (BDD)?
Patient is convinced that part of their body has a defect or is flawed.
Patient engages in repetitive behaviours or mental acts in response to preoccupations about perceived flaws.
What can BDD be divided into?
Psychotic
Non-psychotic
What can BDD be classified into in DSM V?
With or w/o delusional component; characterised by spectrum of insight
Factors that predispose an individual to BDD
Low self-esteem
Critical parents and significant others
Early childhood trauma
Unconscious displacement of emotional conflict
What do patients with BDD also tend to have?
Earlier onset of depression (26%) Social phobia (16%) OCD (6%) Pyschotic disorder Higher rates of substance use in first-degree relatives.
How many patients with BDD seek cosmetic surgery?
7-15%
Treatment for BDD
High dose SSRIs for longer than usual antidepressant trial
Best medication therapy for BDD?
Fluoxetine
Treatment for treatment-resistant BDD?
Fluoxetine with CBT
Outcome of BDD
Poor, with waxing/waning course.
Preserved psychosocial functioning in line with persistent delusional disorders
Prevalence rate of somatisation disorder
1-2%
Gender ratio of somatisation disorder
2:1 female:male
What do patients with medically unexplained symptoms also have high prevalence of?
Undiagnosed mental disorder
What did Rohricht and Elanjithara (2009) find re MUS?
42% of patients with MUS have primary diagnosis of somatoform disorder
36% had depression medicated by effect of somatic sx
What is emphasis of diagnosis of somatic symptom disorder on?
Maladaptive thoughts and feelings and behaviours associated with somatic symptoms
Who did a review into treatment of somatic symptom disorder?
Sumathipala et al 2007
Treatment options for somatic symptom disorder
Antidepressants
CBT
Nonspecific inerventions
Which treatment option has best evidence for somatic symptom disorder?
CBT
What type of somatic symptom disorder is CBT best for?
MUS
How does CBT help in MUS?
Reduces physical sx, psychological distress and disability
Treatment recommendation for somatic symptom disorder in primary care?
Collaborative care models
Which type of therapy is recommended for somatic symptom disorder?
CBT
Body-oriented psychological therapy
Mentalization-based CBT
Brief psychodynamic interpersonal therapy
What does ICD 10 classify conversion dsorder as?
Dissociative disorder
What does DSM V list as dissociative disorders?
Dissociative identity disorder
Dissociative amnesia
Depresonalisation/dereleaisation disorder
What is Dissociative fugue classed under in DSM V?
Dissociative amnesia
What is dissociative identity disorder?
Distinct alternation of two or more distinct personality states with impaired recall between these states
What is dissociative amnesia?
Temporary loss of recall memory (specifically episodic) due to traumatic or stressful event
What is dissociative fugue
Reversible amnesia for personal identity, usually involving unplanned travelling sometimes established by new identity
Prevalence of dissociative disorder in adults
10%
Who is dissociative disorder more common in?
Females
Those with anxiety, mood and substance misuse disorders
Childhood trauma
Aim of treatment for dissociative disorders
To integrate feelings, perceptions, thoughts and memories
Recommendation for treatment of dissociative disorder?
Individual psychotherapy; especially structured therapy such as Acceptance and Commitment therapy & DBT
