Affective and Anxiety Disorders Flashcards
Risk Factors for suicide completion (scale)
"SADPERSONS" Sex (male) Age (15-25 and >59) Depression Previous attempt Excess ethanol or substance abuse Rational thinking loss Sickness Organized plan No spouse Social support lacking
NB: in US, access to firearms is the biggest risk factor
Biological aspect to depression
Neurochemical and endocrine theories.
E.g. 5HT, NE, Da all decreased; stress increases cortisol which decreases neurotrophin level expression and damages hippocampal neurons
Psychosocial aspect to depression
Childhood adverse events Vulnerability reduces resilience (e.g. unemployment, lack support) Life events Substance misuse Beck's triad
Beck’s triad (depression)
Worthlessness (self)
Helplessness (world)
Hopelessness (future)
Seasonal Affective Disorder
Depression with a seasonal pattern, often in winter
Tx: light therapy, CBT, anti-depressants
Atypical depression
Retain mood reactivity.
May have increased sleep and eating
Agitated depression
Depression with psychomotor agitation rather than retardation
MSE: Depression
A: signs neglect, dehydration, look miserable, disinterested, movements may indicate anxiety, poor eye contact, tearful,
S: Slow, quiet.
M: Restricted range of affect
P: in very severe, may have visuals of evil images, auditory hallucinations with unpleasant voices. Delusions-guilt, nihilistic (nothingness), persecutory
T: worthlessness, helplessness, hopelessness. Suicidal thoughts
C: psychomotor retardation or slowing of thoughts/speech can mimic cognitive impairment
Ddx-depression
Physical: hypothyroidism, head injury, cancer, quiet delirium, meds
Adjustment disorder (follows life event)
Bereavement (up to 6/12)
Chronic schizophrenia (blunted affect)
Bipolar disorder (always ask about periods energy–antidepressants dangerous if bipolar)
Postnatal blues/depression
Sementia
Dysthymia
Often co-morbid with panic dosorder, agoraphobia, OCD, eating/personality disorders
Depression criteria
5/9 of following for at least two weeks:
(“SIG E CAPS”)
Sleep (decreased, early morning awakening) Interest decrease (anhedonia) Guilt Energy decrease Concentration decrease Appetite change Psychomotor retardation or agitation Suicidal ideation
Ix-depression
TFT
FBC
Glucose/HbA1c
Beck Depression Inventory or Hospital Anxiety and Depression Scale
Treatment of subclinical depression
Watch and wait (F/U in 2/52)
Sleep hygiene advice
Information about depression (what to look out for)
If persistent-written/web-based/standalone CBT materials +/- therapist
Schedule activities that help engage in behaviours that increase energy levels and develop interests/achievement
Group-based CBT
Exercise
Side effects of antidepressants
D&V, weight change (gain), blurred vision, anxiety, agitation, insomnia, tremor….
Contraindicated in bipolar
Affected by P450 inducers/inhibitors
When to refer depressed pt to secondary care
High suicide risk
Severe depression
Unresponsive to tx
Bipolar-definition
Requires two episodes, one of which must be hypomanic, manic, or mixed.
Recovery usually complete between two episodes
Biological and social factors in bipolar
Bio:
Genetic: 1st degree relative increases risk 7x.
Increased E, NE, Da, 5HT –> mania
Social:
Stressful life events….PREGNANCY
Mania definition
Lasts at least one week, disturbs occupational/social functioning
"DIG FAST" Distractibility Irritability Grandiosity Flight of ideas Agitation/aggression Speech-pressured Talkative
May have psychotic symtpoms
Type I bipolar
Manic episodes interspersed with depressive episodes
Type II bipolar
Mainly recurrent depressive episodes, less prominent hypomanic episodes
Rapid cycling bipolar
Four or more affective episodes in a year
Women
Valproate
When to admit bipolar pt
High risk suicide/homicide
Severe psychotic/manic/depressive symptoms
Severe cylcing
Catatonic symptoms
Biological tx in bipolar
Lithium first line. Takes 2/52 to work so add benzo or antipsych in meantime
Valproate, benzos, carbamazepine
Severe behavioral disorder: haloperidol, clonazepam
If acute manic episode (severe/life-threatening): ECT
Psychosocial tx in bipolar
Psychoeducation CBT interpersonal and social rhythm therapy Family therapy Support groups
OCD-definition
Plus definitions obsessions and compulsions
Anxiety-producing obsessions which they try to relieve with rituals (compulsions)
Obsessions: involuntary thoughts, images, or impulses that are recurrent/intrusive, enter mind against conscious resistance, and pt recognizes obsessions product of owns mind even though involuntary and often repugnant
Compulsiosn-repetitive metntal operations or physical acts. Feel compelled to perform, and done to relieve anxiety through belief they will prevent dreaded event
OCD-biological aspects
Genetic risk
Neuro: basal ganglia implicated
NTs: 5HT dysregulation
OCD-psychosocial
Anankastic personality traits (rigidity, orderliness)
Stress may precipitate
Young age
Body dysmorphic disorder
Preoccupation with imagined defect in appearance.
Time consuming behaviors (e.g. mirror gazing, excessive camouflaging techniques, skin picking, reassurance-seeking)
Anankastic personality disorder
Aka obsessive compulsive personality disorder
Rigidity of thinking, perfectionism, orderliness, moralistic preoccupation with rules, tendency to hoard
Tx-OCD
CBT incl exposure therapy and relapse prevention
Behavioral therapy-response prevention
Psychotherapy
SSRIs high dose for at least 12/52 (escitalopram, fluoxetine, sertraline, paroxetine)
Clomipramine if above SSRIs don’t work
Antipsychotics if psychotic features, tics, or schizotypal traits (risperidone)
ECT if suicidal or severely incapacitated
Biological aspect to personality disorders
Henetic inheritance
Hx depression, EtOH dependence
Some NT disturbances or EEG findings (psychopathy)
Psychosocial causes of personality disorders
Cognitive and psychoanalytic theroeis: expectations tend to be fulfilled (open and confident people receive more friendly responses)
Maladaptive schema-formed in childhood
Narcissistic and borderline personalities display primitive defense mechs (splitting, projection, fantasizing, reaction formation)
Childhood temperament
Childhood experience (“people feel lovable because they were first loved”)
Clusters of personality disorders
“Weird, wild, and worried”
A (weird): odd/eccentric, paranoid, schizoid
B (wild): dramatic, erratic, emotional, histrionic, emotionally unstable, dissocial
C: (worried): anxious/fearful, anankastic, anxious/avoidant, dependent
Paranoid personality disorder
Unforgiving, suspicious, possessive/jealous of partners, excessive self-importance, conspiracy theories.
Schizoid personality disorder
“All alone”
Anhedonic, limited emotional range, little sexual interest, apparent indifference to praise/criticism, normal social conventions ignored, excessive fantasy world/introspection
“Schizoids avoid”–just not really into being around others
Dissocial personality disorder
FIGHTS
Can’t maintain relationships, irresponsible, guitless, heartless, always someone else’s fault
Evidence childhood conduct disorder
Emotionally unstable
Affective instability
Explosive behavior, impulsive, outburts of anger, unable to plan/consider consequences
Borderline type-self-image unclear, chronic empty feelings, abandonment fears, suicide attempts and self harm
Impulsive type-lack impulse control, outburt of threat/violence, sensitivity to being thwarted/criticized
Histrionic personality disorder
Attention seeking, concerned with appearance, theatrical, open to suggestion, racy/seductive, shallow affect
Manipulative behavior
Avoidant personality disorder
Avoid social contact–would like to be around people, but anxious
Doesn’t get involved unless sure of acceptance
Dependent personality disorder
Subordinate, undemanding, feels helpless when alone
Fears abandonment, encourages others to make decisions, reassurance needed
Clinging, excess need for care
Anorexia nervosa-definition
Morbid fear of gaining weight, deliberate weight loss, distorted body image, amenorrhea, BMI
Biological aspects to anorexia nervosa
Genetic
NTs: 5HT
Hypothalamic dysfunction
Neuro: pseudoatrophy with sulcal widening and ventricular enlargement
Psychosocial aspects to anorexia nervosa
Parental overprotectiveness, weak generational boundaries, lack of conflict resolution, rigidity.
Escape from problems in adolescence
Culture: Westerns “ideal body” is unusually thin
Past exposure to dieting behavior (childhood obesity, parental obesity)
Childhood feeding difficulties, picky eating, childhood perfectionism, OCD, negative self-evaluation
Complications anorexia nervosa
Highest mortality of psychiatric illnesses (including depression)
CVS: arrhythmias, cardiomyopathy, long QT, signif bradycardia. Common cause of death
Endo/GI: hypokalemia, hyponatremia, hypoglycemia, hypothermia, hypercortisolemia, amenorrhea, delayed puberty, osteoporosis
Repro: decreased fertility
Neuro: peripheral neuropathy, loss brain volume
Etc etc.
NB REFEEDING SYNDROME. If re-feed too quickly, electrolyte disturbances (K) and then death by arrhythmia
Subtypes of anorexia
Restricting type (restrict calories) Binge and purge type
NB: binge and purge may resemble bulimia, but MAIN DIFFERENTIATOR is the weight: anorexics are underweight, bulimics are normal or overweight
Tx-anorexia nervosa
Biological: fluoxetine
Psycho: family therapy, CBT, nutritional education, psychodynamic psychotherapy
Social: interpersonal therapy
Bulimia nervosa
Binging and excessive preoccupation with control of body weight. Binges followed by compensatory behavior, e.g. vomiting, fasting, excessive exercise
Etiology bulimia
Similar to anorexia
Genetics
Hx dieting, negative self-evaluation, parental obesity, weight-related criticism, EtOH and substance misuse, depression
Complications bulimia
Dental erosion and caries
Electrolyte disturbances: arrhythmias, metalbolic acidosis if laxative use, alkalosis if vomiting, ulcers, pancreatitis, constipation/steatorrhea
Tx-bulimia
Bio: fluoxetine, medical stabilization
Psycho: CBT, self-help
Social: support groups
SCOFF questionnaire
Screening for anorexia nervosa and bulimia.
- Do you make yourself SICK because you feel uncomfortably full?
- Do you worry you have lost CONTROL over how much you eat?
- Have you recently lost mrore than ONE stone in a 3-mo period?
- Do you believe yourself to be FAT when others say you are thin?
- Would you say that FOOD dominates your life?
Psychosocial causes anxiety
Childhood adversity
Life events can trigger
Classical conditioning
Negative reinforcement (e.g. running away relieves anxiety)
Cognitive theories: worrying thoughts repeated automatically which induce and maintain worry response
Attachment theory: insecure styles of attachment to parents become anxious adults
Sxs anxiety
Fear, poor concentration, irritability, depersonalization/derealization, insomnia, night tremors
Restlessness, fidgeting, feeling on edge
Trembling, tension HA, muscle aches
Dry mouth, difficulty swallowing, nausea, loose/frequent motions
Erectile dysfunction, amenorrhea, urinary frequency
Tight chest, palpitations
Generalized anxiety disorder
Not associated with specific external threat. Excessive worry or apprehension about many normal life events
>6/12
Has at least one sxs of autonomic arousal (e.g. tachy, sweating, shaking, dry mouth)
Agoraphobia
Fear of being unable to escape into a safe place (e.g. home)
May manifest in open spaces that are difficult to leave without attracting attention
95% have current or past dx of panic disorder
Social phobia
Fear of being criticized or scrutinized; worry that they will be embarrassed in public. Will tolerate anonymous crowd (unlike agorophobics) but small groups are intimidating.
Self-medication with alcohol or drugs =avoidance and perpetuates problem
Panic disorder
Episodic anxiety attacks, not restricted to certain situations or objective danger.
May have fear of having further attachs
Panic can persist until pts receive reassurance or reverts to “safety behaviors” e.g. calling ambulance, taking aspirin
Pts may think they are dying, having MI, or going mad which can further increase anxiety levels
Acute stress reaction
1-3 days
Anxious but may seem dazed, may have amnesia, depersonalization, derealization
PTSD
Persistent flashbacks, vivid memories, recurring dreams
Actual or preferred avoidance of circumstances remembling or associated with stressor
Inability to recall, partially or completely, some important aspects or period exposure to stressor
Adjustment disorder
Grief reaction
Anger, guilt, self-blame, searching and pining (vivid dreams dead person being alive, pseudohallucinations), sadness and despair, acceptance
Tx-GAD
Buspirone for psych sxs
BDZ for somatic sxs
CBT
Tx-agoraphobia
Antidepressants
Beta blockers
CBT
Tx-panic disorder
SSRIs
CBT
Psychodynamic psychotherapy
Tx-PTSD
Trauma-focused CBT and EMDR (eye movement desensitization and reprocessing)
Sleep disturbance: mirtazapine
Anxiety/hyperarousal: BDZ
Tx-adjustment disorder
Antidepressants, anxiolytics, or hypnotics
Supportive psychotherapy, practical support
Verbalization of feelings prevents maladaptive behavior
