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MRCPsych Part B - Al-Rashid Hospital > Adult Psychiatry 2 > Flashcards

Adult Psychiatry 2 Flashcards

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1
Q

How many adults in the UK have ‘broadly defined neurosis’ at any one time?

A

15%

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2
Q

Most common anxiety disorders in the UK

A

Mixed anxiety-depression

GAD

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3
Q

How many GP consultations are for anxiety related sx?

A

25%

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4
Q

Mean age of onset of GAD

A

30

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5
Q

Mean age of onset of panic disorders

A

22-25

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6
Q

Mean age of onset of OCD

A

20

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7
Q

Mean age of onset of social phobia

A

15

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8
Q

Mean age of onset of phobia of blood injury injection or environmental types

A

5-9 years

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9
Q

Mean age of onset of situational phobias

A

20 years

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10
Q

What has been noted about the dx of anxiety disorders and age?

A

With each generation, anxiety disorders are diagnosed at a younger age than previous

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11
Q

Lifetime prevalence of blood-injection-injury phobia

A

3.5%

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12
Q

What do subjects with blood-injury-injection phobia have a higher lifetime hx of?

A

Fainting

Seizures

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13
Q

In which groups is prevalence of blood-injury-injection lower?

A

Elderly

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14
Q

In which groups is prevalence of blood-injury-injection higher?

A

Females

Less education

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15
Q

Which anxiety disorder is most common in boys?

A

OCD

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16
Q

Which anxiety disorder has equal distribution between men and women?

A

OCD

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17
Q

In which anxiety disorder do men outnumber women in attending health centres?

A

Social phobia

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18
Q

What do NICE recommend is needed first before treating anxiety disorders?

A

Comprehensive assessment considering distress, functional impairment, effect of co-morbid MI, substance misuse or medical conditions and previous response to treatment

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19
Q

First line treatment for anxiety disorders

A

Psychological therapy first

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20
Q

Which pharmacological therapy is advised for anxiety disorders?

A

SSRIs

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21
Q

When to consider combination therapy for anxiety disorders?

A

Complex anxiety disorders refractory to treatment

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22
Q

Point prevalence of OCD in adults

A

1-3%

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23
Q

Point prevalence of OCD in children

A

1-2%

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24
Q

Lifetime prevalence of OCD

A

2-3%

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25
Most commonly prevalent psychiatric disorders?
``` Phobias Alcohol misuse Depression OCD (in that order) ```
26
Gender ratio of OCD in community
1.5:1 female:male
27
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
28
Difference in OCD between males and females
Men show earlier onset and trend more towards tics and poorer outcome
29
Who created the four factor model of OCD?
Castle & Phillips 2006
30
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
31
Which obsessions & compulsions are often chronic and treatment resistant?
Symmetry ordering often chronic and Rx resistant | Hoarding often Rx resistant
32
Which obsession/compulsion may be neurobiologically ditinct?
Hoarding
33
What neurobiology has been reported in OCD?
Hypermetabolism of basal ganglia structures i.e. caudate
34
Which medications can cause OCD sx?
D2 antagonists such as clozapine and other antipsychotics
35
Which children have higher rates of OCD?
Children with autoimmune reactions
36
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
37
What does PANDAS stand for?
Paediatric autoimmune neuropsychiatric disorders associated with strep infection
38
What is PANDAS?
Thought to be secondary to streptococcal infection and mediated by autoantibodies binding to basal ganglia.
39
What sx does PANDAS produce?
Tics Fluctuating OCD sx Anxiety
40
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
41
What is GABHS?
Group A beta-haemolytic strep infection
42
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
43
Treatment for mild-moderate OCD (first line)
Self-help
44
2nd line treatment for mild-moderate OCD
CBT with ERP (Exposure and response prevention)
45
3rd line treatment for mild-moderate OCD
SSRIs +/- CBT
46
1st line treatment for severe OCD
SSRIs+/-CBT
47
How long do people with severe OCD need to continue SSRIs if they respond well?
1-2 years +/- booster CBT
48
2nd line treatment for severe OCD
Switch to different SSRI or clomipramine
49
What is exposure and response prevention?
Element of CBT for OCD
50
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.
51
Evidence for 'booster' sessions of ERP for OCD?
Can reduce risk of relapse and provide more durable remission than pharmacotherapy alone
52
What type of medications does OCD respond well to?
Serotonergic medications i.e. SSRIs, clomipramine.
53
How many patients with OCD show some sort of improvement to SSRI?
60-70%
54
NNT for SSRI for OCD?
6-12
55
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.
56
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
57
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
58
Point prevalence of PTSD
1%
59
Incidence of PTSD worldwide?
Varies
60
Lifetime prevalence of PTSD in America for adults?
6.8%
61
Lifetime prevalence of PTSD in men vs women
Men: 3.6% Women: 9.7%
62
Which gender is more likely to be exposed to traumatic events?
Men: 60% Women: 50%
63
How many people exposed to trauma will develop PTSD?
30%
64
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) ```
65
Which gender is molestation more common in?
Females
66
Which gender is mugging more common in?
Males
67
In which type of trauma do men develop more PTSD?
Rape
68
Which age group is more likely to develop PTSD?
Younger
69
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
70
What does NICE recommend re PTSD initially?
Primary care diagnosis and screening as likely underdiagnosed
71
Who did research into factors associated with PTSD?
Bisson 2007
72
Pre-traumatic factors of PTSD?
``` Previous psychiatric disorder Female Personality - external locus of control Lower socioeconomic & educational status Etnic minotiry Cluster B PD ```
73
Peritraumatic factors for PTSD?
Higher severity of trauma Perceived threat to life Peritraumatic dissociation
74
Post-traumatic factors for PTSD?
Perceived lack of social support | Subsequent life stress or physical illness - especially chronic pain
75
Protective factors for PTSD?
High IQ Higher social class Opportunity to grieve for loss
76
Which areas of the brain show abnormalities in PTSD?
Hippocampus | Amygdala
77
What type of metabolic disturbance is shown in PTSD?
Hypocortisolaemia
78
What features predict chronicity in PTSD?
Strong avoidance features
79
Which interventions have been shown to be beneficial for PTSD?
Multiple-session CBT to prevent PTSD in people with acute stress disorder
80
Which interventions are unlikely to be beneficial in PTSD?
Single-session individual debriefing to prevent PTSD | Supportive counselling to prevent PTSD
81
NICE guidelines for initial management of PTSD in primary care
Watchful waiting if sx are mild and present for <4 weeks after trauma
82
When does NICE recommend px of non-benzo sleeping tablet for PTSD in primary care?
After 4 consecutive nights sleep disturbance
83
NICE Guidelines for PTSD in secondary care
Psychological treatment regularly and continuously (once a week) by the same person
84
What does NICE specifically not recommend for PTSD management in secondary care?
Non-trauma focused interventions such as relaxation/non-directive therapy
85
NICE guidelines for PTSD management in secondary care if sx present within 3 months of trauma
Trauma-focused CBT
86
What does trauma-focused CBT include?
Exposure therapy Cognitive therapy Stress management
87
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
88
How is trauma-focused CBT delivered?
OP; 8-12 sessions (5 if treatment starts within 1 month of event)
89
Guidance for long-term use of sleeping medication for PTSD
Antidepressant
90
NICE guidelines for PTSD if sx present for more than 3 months after trauma
Trauma-focused CBT or EMDR
91
How many sessions of trauma-focused CBT or EMDR are offered for PTSD sx >3 months after trauma?
12 sessions
92
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
93
Pharmacological treatment for general use for PTSD
Paroxetine | Mirtazapine
94
Pharmacological treatment for specialist use for PTSD
Amitriptyline | Phenelzine
95
Which medication is licensed for females only with PTSD?
Sertraline
96
NICE second line options for PTSD (pharmacotherapy)
Paroxetine | Mirtazapine
97
Which medication has evidence of good effect if used as augmentation for PTSD?
Olanzapine
98
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.
99
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
100
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
101
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.
102
Who discovered EMDR and how?
Shapiro; used it on herself
103
What theory is EMDR based on?
Bilateral stimulation in the form of eye movements allows processing of traumatic memories.
104
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.
105
Outcome results for PTSD with treatment?
More than a third of people report having the disorder after 6 years.
106
Remission of PTSD?
50% at 2 years
107
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.
108
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.
109
What type of sx are seen in acute stress disorder?
Initial state of 'daze,' depression, anxiety, anger, withdrawal.
110
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
111
Which sx is not needed for GAD which is usually needed for other anxiety disorders?
Avoidance
112
Lifetime prevalence of GAD
5%
113
Point prevalence of GAD
2-3%
114
MZ vs DZ concordance of GAD?
41% vs 4% (MZ vs DZ)
115
Risk factors for GAD?
``` Exposure to civilian trauma Bullying Higher number of life events Being first-degree relative of GAD patient Female ```
116
What is Hamilton anxiety scale?
14-item scale | Emphasises somatic sx
117
Definition of treatment response for GD
50% reduction in baseline score on Hamilton anxiety scale
118
Definition of clinical recovery of GAD
<7 on Hamilton anxiety scale
119
Acute treatment of GAD
``` SSRI TCAs Benzos CBT Venlafaxine, Duloxetine & Buspirone ```
120
Which SSRIs can be used for GAD?
Escitalopram Paroxetine Sertraline
121
Which TCAs can be used for GAD?
Imipramine
122
Which Benzos can be used for GAD (Short-term)?
Alprazolam | Diazepam
123
Treatment for long-term management/prevention of GAD?
``` CBT Paroxetine Escitalopram Venlafaxine Pregabalin ```
124
Adjuncts for non-response for GAD
Olanzapine/Risperidone at low dose
125
First line treatment for GAD as per NICE?
SSRI or SNRI or Pregabalin
126
Which type of CBT is recommended for GAD?
Education Relaxation training Exposure and cognitive restructuring
127
Guidance re combination of medication and psychological therapy for GAD?
Insufficient evidence but can be used if initial treatment fails
128
Outcome for GAD
42% patients recover after 12 years
129
Which patients show poorer outcomes for GAD?
Those with another anxiety disorder
130
Which herbal drug has been shown to be effective for GAD?
Kava shrub (Piper methysticum)
131
How does kava work?
Due to kavapyrones which in animals act as muscle relaxants and anticonvulsants and reduce limbic system exciability
132
How might kava work?
Inhibition of voltage-dependent Na channels Increase GABAA receptor densities Block norepinephrine reuptake Suppress release of glutamate
133
Research re kava for GAD
Kava is more effective than placebo in reducing HAM-A scores, effect is detectable for 1 week
134
Why is kava not recommended for clinical use for GAD in the UK?
Associated with hepatotoxicity
135
Which medications can Kava interact with?
Levodop Alprazolam Can cause EPSEs or lethargy
136
Which medications can the herb Valerian interact with?
Loperamide and fluoxetine, causing delirium
137
Which medications can evening primrose oil interact with?
Phenothiazides, causing epileptic seizures
138
Point prevalence of social phobia?
2.8%
139
Who recognised two types of social phobia?
Schneier 2003
140
What are the two types of social phobia?
Generalised | Situational
141
What is generalised social phobia?
Fear occurs in most social situations
142
What is situational social phobia?
Fear occurs in public speaking or performance anxiety
143
First line pharmacotherapy for Social phobia?
``` Paroxetine Sertraline Fluoxetine Fluvoxamine Escitalopram Venlafaxine ```
144
Duration of medication for social phobia (first line)
12 weeks
145
How long should drug treatment continue if good response for social phone?
6-12 months
146
2nd line treatment for social phobia?
Phenelzine
147
3rd line treatment for social phobia?
SSRI + Clonazepam combination Gabapentin Pregabalin
148
Which social phobia can beta blockers be used for?
Performance anxiety
149
How does DSM categorize panic disorder?
Primary dysfunction
150
How does ICD categorize Panic Disorder?
Agoraphobia
151
Point prevalence of panic disorder
0.9%
152
Lifetime prevalence of panic attacks
28%
153
Lifetime prevalence of panic disorder
4.7%
154
Mean age of onset of any panic attack
22 years
155
Mortality rate of panic disorder
All-cause mortality increased by 1.9 times
156
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.
157
Heritability estimate of panic disorder
30-40%
158
Cognitive theory of patients with panic disorder?
Patients have heightened sensitivity to internal bodily sensations.
159
What does neuroimaging suggest re panic disorder?
Involvement of fear network: amygdala, orbitofrontal cortex and hyporthalamus
160
First line drug treatment for panic disorder
SSRI
161
First line treatment for panic disorder
7-14 weeks of CBT (weekly 1-2 hours) completed within 4 months SSRI Bibliotherapy
162
Recommendation if no effect with 12 week course of SSRI for panic disorder
Imipramine | Clomipramine
163
Benzo use in panic disorder?
Associated with worse outcome; should not be used
164
BAP recommendation for panic disorder
``` CBT All SSRIs Clomipramine, Imipramine Venlafaxine Reboxetine Benzos ```
165
Which benzos does BAP recommend for panic disorder?
Alprazolam Clonazepam Diazepam Lorazepam
166
Efficacy of meds vs therapy for panic disorder?
Both have equal efficacy
167
How long do SSRIs need to be continued for panic disorder to assess efficacy?
12 weeks
168
Long-term treatment for panic disorder?
Cognitive therapy with exposure | Drug treatment for 6 months if good response
169
Best treatment to reduce relapse of panic disorder?
Cognitive therapy with exposure
170
First line drug treatment for long term treatment of panic disorder
SSRI
171
2nd line drug treatment for long term treatment of panic disorder
Imipramine
172
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
173
How is Hypochondriasis classed in ICD 10?
Preoccupation with fear of having a serious disease based on misrepresentation of bodily sx.
174
How is hypochondriasis classed in DSM V?
Removed due to pejorative perception; now diagnosd as Somatic Symptom Disorder or Illness Anxiety Disorder
175
Prevalence of Hypochondriasis
0.8-4.5%
176
Treatment for Hypochondriasis
CBT Group CBT SSRIs
177
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.
178
What can BDD be divided into?
Psychotic | Non-psychotic
179
What can BDD be classified into in DSM V?
With or w/o delusional component; characterised by spectrum of insight
180
Factors that predispose an individual to BDD
Low self-esteem Critical parents and significant others Early childhood trauma Unconscious displacement of emotional conflict
181
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. ```
182
How many patients with BDD seek cosmetic surgery?
7-15%
183
Treatment for BDD
High dose SSRIs for longer than usual antidepressant trial
184
Best medication therapy for BDD?
Fluoxetine
185
Treatment for treatment-resistant BDD?
Fluoxetine with CBT
186
Outcome of BDD
Poor, with waxing/waning course. | Preserved psychosocial functioning in line with persistent delusional disorders
187
Prevalence rate of somatisation disorder
1-2%
188
Gender ratio of somatisation disorder
2:1 female:male
189
What do patients with medically unexplained symptoms also have high prevalence of?
Undiagnosed mental disorder
190
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
191
What is emphasis of diagnosis of somatic symptom disorder on?
Maladaptive thoughts and feelings and behaviours associated with somatic symptoms
192
Who did a review into treatment of somatic symptom disorder?
Sumathipala et al 2007
193
Treatment options for somatic symptom disorder
Antidepressants CBT Nonspecific inerventions
194
Which treatment option has best evidence for somatic symptom disorder?
CBT
195
What type of somatic symptom disorder is CBT best for?
MUS
196
How does CBT help in MUS?
Reduces physical sx, psychological distress and disability
197
Treatment recommendation for somatic symptom disorder in primary care?
Collaborative care models
198
Which type of therapy is recommended for somatic symptom disorder?
CBT Body-oriented psychological therapy Mentalization-based CBT Brief psychodynamic interpersonal therapy
199
What does ICD 10 classify conversion dsorder as?
Dissociative disorder
200
What does DSM V list as dissociative disorders?
Dissociative identity disorder Dissociative amnesia Depresonalisation/dereleaisation disorder
201
What is Dissociative fugue classed under in DSM V?
Dissociative amnesia
202
What is dissociative identity disorder?
Distinct alternation of two or more distinct personality states with impaired recall between these states
203
What is dissociative amnesia?
Temporary loss of recall memory (specifically episodic) due to traumatic or stressful event
204
What is dissociative fugue
Reversible amnesia for personal identity, usually involving unplanned travelling sometimes established by new identity
205
Prevalence of dissociative disorder in adults
10%
206
Who is dissociative disorder more common in?
Females Those with anxiety, mood and substance misuse disorders Childhood trauma
207
Aim of treatment for dissociative disorders
To integrate feelings, perceptions, thoughts and memories
208
Recommendation for treatment of dissociative disorder?
Individual psychotherapy; especially structured therapy such as Acceptance and Commitment therapy & DBT

MRCPsych Part B - Al-Rashid Hospital (64 decks)

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