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Year 3 - Psychiatry (DP) > Anxiety and Schizophrenia > Flashcards

Anxiety and Schizophrenia Flashcards

1
Q

What are some acute signs of anxiety?

A 
Palpitations
Sweating
Tremor
Dizziness
Shortness of breath
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2
Q

What are some chronic signs of anxiety?

A

Muscle pains

Weakness

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3
Q

What is Globus hystericus?

A

Feeling of a lump in your throat

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4
Q

When does anxiety become a problem?

A

If it results in isolation

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5
Q

Under what heading does ICD-10 classify anxiety disorders? What does this include?

A

Neurotic disorders:

  • PTSD
  • Adjustment disorder
  • OCD
  • Hoarding disorder
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6
Q

How are PTSD and Adjustment disorder classed in DSM-V?

A

Under trauma and stressor-related disorders

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7
Q

How are OCD and Hoarding disorder classed in DSM-V?

A

OCD and Related Disorders (OCARD)

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8
Q

Under ICD-10, what does F40 describe?

A

Phobic anxiety disorders:

  • Agoraphobia (F40.0)
  • Social phobia (F40.1)
  • Specific phobies (F40.2)
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9
Q

Under ICD-10, what does F41 describe?

A

Other anxiety disorders:

  • Panic disorder (F41.0)
  • Generalised Anxiety Disorder (GAD) (F41.1)
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10
Q

Under ICD-10, what does F42 describe?

A

OCD

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11
Q

Under ICD-10, what does F43 describe?

A

Reaction to severe stress and adjustment disorders:

  • PTSD (F43.1)
  • Adjustment disorder (F43.2)
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12
Q

What is the full ICD-10 range which describes ‘Neurotic, Stress-Related and Somatoform Disorders’?

A

F40-F48

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13
Q

Under the proposed ICD-11, what does OCARD also include?

A

Olfactory reference disorder

Hypochondriasis

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14
Q

What are the key features of Generalised Anxiety Disorder?

A

Excessive and inappropriate woryring that is persistent
Not restricted to certain circumstances
Symptoms include:
- Autonomic arousal (eg. palpitations, sweating)
- Thorax symptoms (eg. SoB0
- Brain/Mind symptoms (eg. Dizziness)
- General symptoms (eg. Hot flushes)
- Symptoms of tension (eg. Aches and pains)

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15
Q

What ICD-10 number is Generalised Anxiety Disorder?

A

F41.1

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16
Q

How is a panic attack defined?

A

Discrete periods of intense fear alongside physical and psychological anxiety symptoms
Reach peak within 10 minutes
Last around 30-45 minutes

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17
Q

What fraction of people with panic disorder develop agoraphobia?

A

2/3

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18
Q

What is the other name for social phobia?

A

Social anxiety disorder

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19
Q

What is agoraphobia?

A

Fear in places/situations in which:

  • Escape might be difficult
  • Help might not be available
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20
Q

How is social phobia characterised?

A

A persistent and unreasonable fear of being evaluated negatively by others
This fear is in social/performance situations

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21
Q

What are common physical symptoms of social phobia?

A

Blushing
Fear of vomiting
Urgency/Fear of micturition/defaecation

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22
Q

What sort of history is present in PTSD?

A

Exposure to trauma:

  • Actual/Threatened death
  • Serious injury
  • Threats to physical integrity of self/others
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23
Q

What symptoms develop later in PTSD?

A

Intrusive symptoms (eg. Flashbacks)
Avoidance symptoms
Negative alterations in cognitions and mood
Hyperarousal

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24
Q

What are the features of hyperarousal?

A

Disturbed sleep
Hypervigilance
Exaggerated startle response

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25
Q

How is OCD characterised?

A

Recurrent obsessive ruminations/images/impulses
+/or recurrent rituals
Symptoms are:
- Distressing
- Time consuming
- Interfering with social and occupational function

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26
Q

How is an obsession described?

A

Intrusive and inappropriate

Excess and unreasonable (not in kids)

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27
Q

How is an obsession ego-dystonic?

A

Product of own mind but experienced as alien

Outwith own control

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28
Q

What is a compulsion?

A

Repetitive behaviour/mental act
Aim to reduce anxiety
Not pleasurable in themselves

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29
Q

What is F40.00?

A

Agoraphobia without panic disorder

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30
Q

What if F40.01?

A

Agoraphobia with panic disorder

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31
Q

What is F40.8?

A

Other phobic anxiety disorders

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32
Q

What is F40.9?

A

Phobic anxiety disorder, unspecified

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33
Q

Marked and consistently manifested fear/avoidance of how many places is needed to diagnose agoraphobia? What sort of places?

A

> =2 of the following:

  • Crowds
  • Public spaces
  • Travelling alone
  • Travelling away from home
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34
Q

Apart from fear/avoidance of certain situations in agoraphobia, what other two features must be present?

A
  • Anxiety in a situation with >=2 symptoms on >1 occasion from the key features symptoms of GAD
  • Significant emotional distress due to avoidance/anxiety
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35
Q

To diagnose a social phobia, what insight should the patient have?

A

Recognising that the symptoms and avoidance are excessive or unreasonable

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36
Q

What percentage of patients with social phobia with abuse alcohol?

A

20%

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37
Q

How many symptoms of generalised anxiety disorder must be present for a panic attack to be classed as such?

A 
>=4 symptoms
At least one from each of:
- Autonomic symptoms
- Thorax symptoms
- Brain/Mind symptoms
- General symptoms
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38
Q

How is general anxiety disorder diagnosed?

A 
>=6 months with prominent tension/worry/feeling of apprehension about every-day events
>=4 symptoms
At least one from each of:
- Autonomic symptoms
- Thorax symptoms
- Brain/Mind symptoms
- General symptoms
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39
Q

How is OCD diagnosed?

A

Obsessions +/or compulsions present on most days for >=2 weeks

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40
Q

In OCD, what features of obsessions and compulsions MUST be present to be diagnosed as such?

A

Acknowledged as originating from patient’s mind
Repetitive and unpleasant
Subject tries to resist
Carrying out a compulsion is not pleasurable

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41
Q

In diagnosing PTSD, following an initial stressor event, when must criteria 2-4 be met?

A

Within 6 months of:

  • Event OR
  • The end of a period of stress
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42
Q

What kind of stressor event is associated with the highest incidence of PTSD?

A

Rape

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43
Q

When is the ‘freeze’ response initiated?

A

When limbic system judges that neither fight nor flight is possible and death/severe injury is inevitable

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44
Q

What happens during a ‘freeze’ response?

A

Altered state of reality
Body becomes immobile
Pain responses reduced

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45
Q

What are the types of trauma?

A

Type 1 = Simple

Type 2 = Complex

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46
Q

What symptoms can run alongside typical PTSD symptoms to classify it as complex PTSD?

A 
Cognitive disturbance
Mood/Emotional disturbances
Somatisation
Identity disturbance
Chronic interpersonal difficulties
Dissociation
Tension reductive activities
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47
Q

How is the stress response resolved?

A

PNS kicks in:

  • Muscles relax
  • Skin warms
  • Pupils constrict to normal (SNS dilates them)
  • Refocusing
  • HR slows
  • BP reduces
  • Eat, digest and rest
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48
Q

What part of the brain is responsible for locating memories in the right time, place and context?

A

Hippocampus

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49
Q

What part of the brain stores emotionally charged memories?

A

Amygdala

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50
Q

Where does the limbic brain connect to?

A

Medial prefrontal cortext

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51
Q

What to the limbic connections enable it to do?

A

Regulate emotional and fear responses

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52
Q

How many connections are there from limbic brain to medial prefrontal cortex?

A

Many

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53
Q

How many connections are there from the medial prefrontal cortex to the limbic brain?

A

Fewer

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54
Q

How do sense of danger and logic interact?

A

Sense of danger overrides logic

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55
Q

What can potentially trigger flashbacks in PTSD?

A

Insomnia
Tiredness
Stress

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56
Q

Why can nightmares result in insomnia?

A

Delay in going to sleep
Bedroom associated with nightmares:
- Bedroom avoidance
- Poor sleep hygeine

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57
Q

When is dissociation more likely to occur in PTSD?

A

If trauma is:

  • Severe
  • Prolonged
  • Repeated/Horrific/Shaming
  • Affecting a very young victim
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58
Q

How does dissociation present in PTSD?

A 
Patient may feel like they're watching themselves
May feel like it isn't happening
Dissociative flashbacks
Fugue states
Dissociative Identity Disorders
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59
Q

What can indicate dissociation?

A 
Things look strange
Changes in sound
Rocking/Tapping
'Slow-motion'
Feel like a robot/observer
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60
Q

When does an acute stress reaction occur following trauma?

A

48 hours after

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61
Q

When does an acute stress disorder occur following trauma?

A

Up to 4 weeks

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62
Q

When does acute PTSD occur following trauma?

A

Up to 3 months

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63
Q

When does chronic PTSD occur following trauma?

A

Over 3 months

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64
Q

How can acute stress disorder be diagnosed?

A

The following symptoms occurring within 1 months of the trauma and lasting at least 2 days:

  • Dissociative symptoms
  • Persistent re-experiencing
  • Increased arousal
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65
Q

What treatment should not be undertaken in acute stress disorder?

A

Debriefing

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66
Q

When is watchful waiting and monthly reviewing appropriate in an acute stress disorder?

A

If symptoms are mild and present for <4 weeks

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67
Q

What psychotherapeutic models can be employed in the treatment of acute stress disorder/PTSD?

A

Trauma focused CBT
Eye Movement Desensitisation and Re-Programming
Prolonged exposure
Cognitive processing therapy

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68
Q

What drugs are licensed for use in PTSD?

A

Antidepressants:

  • Paroxetine
  • Other classes if SSRIs don’t work
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69
Q

What specialist alternative drugs can be used in PTSD?

A

Prazosin
Atypical antipsychotics
Mood stabilisers

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70
Q

Under DSM-V, what is included under OCARD?

A

Excoriation
Hoarding
Body dysmorphic disorder
Tic disorder

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71
Q

What is the most common comorbid condition in OCD?

A

Anxiety disorders

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72
Q

What is the mean age of onset of OCD?

A

20 years

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73
Q

What is the median age of onset of OCD?

A

19 years

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74
Q

When is the peak incidence of OCD in males?

A

13-15 years

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75
Q

When is the peak incidence of OCD in females?

A

24-25 years

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76
Q

What populations have an increased incidence of OCD?

A

General hospital populations

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77
Q

What autoimmune conditions may contribute to developing OCD?

A

Beta-Haemolytic Strep. infection (PANDAS)

Autoantibodies to basal ganglia

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78
Q

What does neuroimaging show in OCD?

A

Increased metabolism and blood flow in:

  • Orbitofrontal cortex
  • Caudate nucleus
  • Cingulate cortex
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79
Q

What five screening questions can be used for OCD?

A
  1. Do you wash or clean a lot?
  2. Do you check things a lot?
  3. Is there any thought that keeps bothering you that you wanna get rid of but can’t?
  4. Do your daily activities take a long time to finish?
  5. Are you concerned about orderliness/symmetry?
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80
Q

When would benzodiazepines be used in anxiety disorders?

A

Specific occasions (eg. flights)

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81
Q

What anxiety disorders can graded exposure be used to treat?

A 
Simple phobias (eg. spiders)
Agoraphobia
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82
Q

How would the exposure in graded exposure be described?

A

Gradual and progressive

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83
Q

What is flooding?

A

Full exposure to feared stimulus and staying with it until fear reduces

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84
Q

What are the issues with flooding?

A

Generally less popular

Fear may spontaneously reoccur

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85
Q

What are the principles of CBT?

A

Suggest that underlying thoughts affect emotions which then affect behaviour
Involve patient in questioning/testing their thoughts

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86
Q

What BZDs can be used in PTSD?

A

Bromazepam

Clonazepam

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87
Q

What anticonvulsants can be used in PTSD?

A

Gabapentin
Pregabalin
Onlanzapine

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88
Q

What form of CBT is used in PTSD?

A

Trauma-Focused CBT

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89
Q

What are the typical first line medications used in OCD?

A

Serotonergic antidepressants:

  • SSRIs
  • Clomipramine (TCA)
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90
Q

What antipsychotics can be used to augment treatment in OCD?

A

Risperidone

Aripiprazole

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91
Q

What anticonvulsant might be used in OCD?

A

Lamotrigine

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92
Q

What psychological therapies are very frequently employed in OCD?

A

Exposure and Response Prevention >=20 hours
CBT:
- Heavy emphasis on exposure

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93
Q

How would OCD with mild functional impairment be treated?

A

Brief CBT (+ERP); <10 therapist hours

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94
Q

How would OCD with moderate-severe functional impairment OR when patients with mild impairment cannot engage with CBT/it fails, be treated?

A

Offer choice of:

  • More intensive CBT (+ERP); >10 therapist hours
  • Course of SSRI
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95
Q

Following treatment of OCD with moderate-severe functional impairment, when would it be upgraded to definite severe impairment?

A

If there is inadequate response at 12 weeks an MDT review is carried out

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96
Q

How is OCD with severe functional impairment treated?

A

Offer combo of:

  • CBT (+ERP) AND
  • SSRI
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97
Q

If first line treated of OCD with severe functional impairment fails, how can it be treated?

A

Offer either:
- Different SSRI
- Clomipramine
(Continue CBT [+ERP])

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98
Q

If second line treated of OCD with severe functional impairment fails, how can it be treated?

A

Refer to MDT with OCD experience

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99
Q

If third line treated of OCD with severe functional impairment fails, how can it be treated?

A 
Additional CBT (+ERP) or cognitive therapy
Add antipsychotic to SSRI/Clomipramine; combine clomipramine and citalopram
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100
Q

What dose of fluoxetine is used in OCD?

A

60mg/day

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101
Q

What dose of paroxetine is used in OCD?

A

60mg/day

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102
Q

What dose of citalopram is used in OCD?

A

60mg/day

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103
Q

What dose of sertraline is used in OCD?

A

> =200mg/day

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104
Q

What dose of fluvoxamine is used in OCD?

A

300mg/day

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105
Q

What dose of escitalopram is used in OCD?

A

> =20mg/day

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106
Q

What dose of clomipramine is used in OCD?

A

> =250mg/day

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107
Q

How does ERP work?

A 
Repeatedly keeping anxiety in check:
- Provides powerful reinforcement for avoidance
- Sustains avoidance
Conversely:
- Increase exposure to feared stimulus
- Develops habituation to anxiety
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108
Q

What is the first line pharmacological treatment for Generalised Anxiety Disorder?

A

SSRIs

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109
Q

What is the second line pharmacological treatment for Generalised Anxiety Disorder?

A

SNRIs:

  • Venlafaxine
  • Duloxetine
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110
Q

What is the third line pharmacological treatment for Generalised Anxiety Disorder?

A

Pregabalin

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111
Q

What psychological therapies can be used in Generalised Anxiety Disorder?

A

Guided self-help (if mild)
CBT
Relaxation (usually short-term)

112
Q

What medications can be used to treat social phobia?

A

Most SSRIs
Venlafaxine, Phenelzine
Some BZDs (Bromazepam, Clonazepam)
Anticonvulsants (Gabapentin, Pregabalin)

113
Q

What psychological therapies can be used to treat social phobia?

A

CBT with emphasis on exposure
Cognitive restructuring
Social skills training

114
Q

When would an SSRI be used in management of a specific phobia?

A

If anxiety is moderate-severe and hasn’t responded to behavioural therapy

115
Q

What psychological therapies are used frequently in management of a specific phobia?

A

Exposure therapy:

  • Graded exposure
  • Flooding
116
Q

What medications can be used to treat panic disorder +/- agoraphobia?

A

All SSRIs
Some TCS (Clomipramine, Imipramine)
Venlafaxine (SNRI)
Some anticonvulsants (Gabapentin, Pregabalin)

117
Q

What psychological therapies are used frequently in management of panic disorder +/- agoraphobia??

A

CBT

Graded exposure therapy if agoraphobia present

118
Q

How long is maintenance treatment continued for in responders in GAD?

A

> =18 months

119
Q

How long is maintenance treatment continued for in responders in panic disorder?

A

> =6 months

120
Q

How long is maintenance treatment continued for in responders in social phobia?

A

> =6 months

121
Q

How long is maintenance treatment continued for in responders in PTSD?

A

> =12 months

122
Q

How long is maintenance treatment continued for in responders in OCD?

A

> =12 months

123
Q

What are the worldwide suicide rates?

A

15 per 100,000 per annum

124
Q

What are the suicide incidence rates in England and Wales?

A
  1. 9/100,000 in men

4. 5/100,000 in women

125
Q

What are the suicide incidence rates in Scotland?

A
  1. 8/100,000 in men

7. 4/100,000 in women

126
Q

Levels of what are lower in patients with a history of deliberate self-harm?

A

CSF 5-HIAA (5-Hydroxyindoleacetic acid)

127
Q

There is reduced binding of 5-HT transporter sites in deliberate self-harm; where in the brain does this occur?

A

Ventral Prefrontal Cortex-PM

128
Q

In the PM there is an increase in what receptors in deliberate self-harm?

A

Post-synaptic 5-HT1a

129
Q

What does neuroimaging show in deliberate self-harm patients?

A

In high lethality patients:
- Different prefrontal cortex activity
SPECTs of recent deliberate self-harm patients showed reduced frontal activity

130
Q

In what populations is deliberate self-harm more common?

A

Northern Europe
Women
Low socio-economic status

131
Q

How do deliberate self-harm patients die prematurely?

A 
Suicide
IHD
Cancer
RTAs
Homicide
132
Q

In what European country is deliberate self-harm more common in males?

A

Finland

133
Q

What is the initial stage of managing deliberate self-harm?

A 
Calm the patient; emotional release is good:
- Crying is good; Aggression is not
- Be supportive but firm
Direct interview:
- Privacy
- Distract
- Deep breathing
134
Q

What is it important to ask about in deliberate self-harm?

A

Antecedants
The episode of DSH
Mental state then and now

135
Q

How can self-esteem be bolstered and problem-solving be initiated in deliberate self-harm?

A

Tell patient that discussing personal matters is brave
Any relief indicates more discussions needed
Look at what resolved past episodes
Use family or friends

136
Q

What may a manipulative patient use as a threat?

A

Threat of suicide to change environment:

  • Powerlessness
  • Compromise
  • Boundaries
137
Q

What are the types of manipulative patients?

A
  1. Dependent clingers
  2. Entitled demanders
  3. Manipulative help-rejecters
  4. Self-destructive deniers
138
Q

How else can deliberate self-harm be referred?

A

Passive death wish

Suicidal ideation vs. Suicidal intention

139
Q

What are the positive symptoms of Schizophrenia?

A

Delusions
Hallucinations
Thought disorder

140
Q

What are the negative symptoms of Schizophrenia?

A

Apathy
Lack of volition
Social withdrawal
Cognitive impairment

141
Q

When are negative symptoms in Schizophrenia prominent?

A

Prior to illness atrting

142
Q

What symptoms in Schizophrenia respond better to treatment?

A

Positive symptoms

143
Q

What symptoms in Schizophrenia have more impact on functioning and QoL?

A

Negative symptoms

144
Q

Schizophrenia can be diagnosed by ONE of what symptoms (according to ICD-10)?

A 
Thought interference
Passive phenomena
Hallucinatory voices:
- Running commentary OR
- Third person
Impossible, persistent delusions
145
Q

Schizophrenia can also be diagnosed by TWO of what symptoms (according to ICD-10)?

A

Formal thought disorder
Catatonic behaviour
Negative symptoms
Loss of interest/Idleness/Self-absorbed/Social withdrawal

146
Q

How long must either of the ONE symptoms or the TWO symptoms last to diagnose Schizophrenia?

A

> =1 month

147
Q

What are Schneider’s First Rank Symptoms of Schizophrenia?

A 
Auditory hallucinations:
- Thoughts spoken aloud
- Third person voices
- Running commentary
Passivitiy:
- ?Explained by delusions
- Experience that acts are imposed by an outsider
Delusional perception
Though broadcasting, withdrawal and insertion
148
Q

What is the typical kind of delusion in Schizophrenia?

A

Bizarre

149
Q

Are delusions in Schizophrenia mood-congruent or mood-incongruent?

A

Congruent

150
Q

What are delusions often related to in Schizophrenia?

A

Current affairs

151
Q

Hallucinations in Schizophrenia are often believed to be public (ie. others can perceive them too). If a patient with Schizophrenia realises that others can’t perceive them, what might happen?

A

Development of new delusions

152
Q

How can flow of thought be affected in Schizophrenia?

A

Disruption of association
Thought blocking
Crowding (Flight of ideas with passivity)
Neologisms

153
Q

What sort of affect is seen in Schizophrenia?

A

Blunted:

  • Limited range of emotion
  • Lack of sensitivity/connection to surroundings
154
Q

Is the affect of a patient with Schizophrenia congruent or incongruent with surroundings?

A

Incongruent

155
Q

What is catatonia (as seen in Schizophrenia)?

A

Increased tone at rest (abolished by voluntary movement)
Other motor activity and posture abnormalities:
- Stupor
- Hyperactivity
- Mutism
- Stereotypes
- Waxy flexibility

156
Q

What is the peak incidence of onset of Schizophrenia in men?

A

15-25 years

157
Q

What is the peak incidence of onset of Schizophrenia in women?

A

25-35 years

158
Q

What is the incidence of Schizophrenia?

A

15/100,000

159
Q

What is the suicide rate in Schizophrenia?

A

10-15%

160
Q

What factors contribute to a good prognosis in Schizophrenia?

A

Older onset
Female
Marked mood disturbance (esp. elation)
FHx of mood disorder

161
Q

What factors contribute to a poor prognosis in Schizophrenia?

A 
Longer duration of untreated psychosis
Poor premorbid adjustment
Insidious onset
Earlier onset
Cognitive impairment
Enlarged ventricles
162
Q

What does psychosis involve?

A

Inability to distinguish between subjective experience and reality

163
Q

What is psychosis characterised by?

A

Lack of insight

164
Q

Why is it important to recognise the importance of the experience in consulting with a psychotic patient?

A

Don’t give the impression that it is “All in your head.”
Try and understand:
- “I want to check that I understand, I think what you’re saying is that…”

165
Q

In consulting with a psychotic patient, it is important to think of creative ways to challenge their beliefs. How can this be done?

A

“What would you say if someone said to you that [these beliefs] weren’t true?”

“Can you just explain to me how this is possible?”

166
Q

If it is clear that a psychotic patient will not accept that the delusions/hallucinations are not real (and they are becoming agressive/stubborn), what might it be necessary to say?

A

“I think this is evidence that you are unwell and I think you need to be in hospital and receive treatment - although I recognise you disagree with this.”

167
Q

What is Schizophrenia typified by?

A

Prodromal symptoms and gradual functional decline

168
Q

How present are depressive and manic symptoms in Schizophrenia?

A

Absent or minimal

169
Q

What is F20.0?

A

Paranoid Schizophrenia

170
Q

What is F20.1?

A

Hebephrenic Schizophrenia

171
Q

What is F20.2?

A

Catatonic Schizophrenia (catalepsy catatonia)

172
Q

What is F20.3?

A

Undifferentiated Schizophrenia

173
Q

What is F20.4?

A

Post-Schizophrenic depression

174
Q

What is F20.5?

A

Residual Schizophrenia

175
Q

What is F20.6?

A

Simple Schizophrenia

176
Q

What is F20.8?

A

Other Schizophrenia

177
Q

What is F20.9?

A

Schizophrenia, unspecified

178
Q

What is Simple Schizophrenia?

A 
Insidious progressive development of:
- Oddities of conduct
- Inability to meet societal demands
- Decline in total performance
Negative features develop without being preceded by overt psychotic symptoms
179
Q

What is F10?

A

Mental and behavioural disorders due to the use of alcohol

180
Q

What is F11?

A

Mental and behavioural disorders due to the use of opioids

181
Q

What is F12?

A

Mental and behavioural disorders due to the use of cannabinoids

182
Q

What is F13?

A

Mental and behavioural disorders due to the use of sedatives or hypnotics

183
Q

What is F14?

A

Mental and behavioural disorders due to the use of cocaine

184
Q

What is F15?

A

Mental and behavioural disorders due to the use of other stimulants (including caffeine)

185
Q

What is F16?

A

Mental and behavioural disorders due to the use of hallucinogens

186
Q

What is F17?

A

Mental and behavioural disorders due to the use of tobacco

187
Q

What is F18?

A

Mental and behavioural disorders due to the use of volatile substances

188
Q

What is F19?

A

Mental and behavioural disorders due to the use of multiple drug use and use of other psychoactive substances

189
Q

When any disorder under F10-F19 is followed by a .0, what does this indicate?

A

Acute intoxication

190
Q

When any disorder under F10-F19 is followed by a .1, what does this indicate?

A

Harmful use

191
Q

When any disorder under F10-F19 is followed by a .2, what does this indicate?

A

Dependence

192
Q

When any disorder under F10-F19 is followed by a .3, what does this indicate?

A

Withdrawl

193
Q

When any disorder under F10-F19 is followed by a .4, what does this indicate?

A

Withdrawal with delirium

194
Q

When any disorder under F10-F19 is followed by a .5, what does this indicate?

A

Psychotic disorder

195
Q

When any disorder under F10-F19 is followed by a .6, what does this indicate?

A

Amnesic syndrome

196
Q

When any disorder under F10-F19 is followed by a .7, what does this indicate?

A

Residual and late-onset psychotic disorder

197
Q

What delusions are seen in depressive psychosis?

A

Worthlessness
Guilt
Hypochondriasis
Poverty

198
Q

What hallucinations are present in depressive psychosis?

A 
Accusing/Insulting/Threatening
2nd person (usually)
199
Q

What is F32.2?

A

Severe depressive episode with psychotic symptoms

200
Q

How is F32.3 defined?

A 
An episode as described in F32.2
But with:
- Hallucinations
- Delusions
- Psychomotor retardation
- Stupor
201
Q

What may the symptoms of F32.3 result in that can be life-threatening?

A

Suicide
Dehydration
Starvation

202
Q

Are psychotic symptoms in depressive psychosis congruent or incongruent?

A

Congruent

203
Q

Are psychotic symptoms in mania with psychosis congruent or incongruent?

A

Congruent

204
Q

What kind of delusions are seen in mania with psychosis?

A

Grandeur
Special ability
Persecution
Religiosity

205
Q

What sort of hallucinations are seen in mania with psychosis?

A

Auditory

206
Q

How is F30.2 (mania with psychosis) described according to ICD-10?

A 
An episode as in F30.1
But with:
- Delusions (usually grandiose)
- Hallucinations
- Flight of ideas
- Excitement
- Excessive motor activity
207
Q

What is Schizoaffective Disorder?

A

Presence of both symptoms typical of:

  • Schizophrenia AND
  • Affective disorder
208
Q

Can mood-incongruent psychotic symptoms in an affective disorder justify a diagnosis of Schizoaffective Disorder?

A

No

209
Q

What is F25.0?

A

Schizoaffective Disorder, manic type

210
Q

What is F25.1?

A

Schizoaffective Disorder, depressive type

211
Q

What is F25.2?

A

Schizoaffective Disorder, mixed type

212
Q

What is F25.3?

A

Other Schizoaffective Disorder

213
Q

What is F25.9?

A

Schizoaffective Disorder, unspecified

214
Q

What are affective symptoms superimposed on a pre-exisiting schizophrenic illness classified under in ICD-10?

A

Somewhere else in F20-F29

215
Q

What sort of delusions are seen in delirium?

A

Persecutory

216
Q

When is clouding of consciousness worse in delirium?

A

At night

217
Q

What hallucinations are seen in delirium?

A

Visual

+/- auditory (often threatening)

218
Q

What is the ICD-10 for delirium (not induced by alcohol/psychoactive substances)?

A

F05

219
Q

Delirium can also include acute or subacute conditions. Give examples.

A

Brain syndrome confusional state (non-alcoholic)
Infective psychosis
Organic reaction
Psycho-organic syndrome

220
Q

What is the ICD-10 for delirium tremens?

A

F10.4

221
Q

What is F05.0?

A

Delirium not superimposed on dementia

222
Q

What F05.1?

A

Delirium superimposed on dementia

223
Q

What is F05.8?

A

Other delirium:

  • Of mixed origin
  • Postoperative delirium
224
Q

What are functional disorders?

A

Symptoms unexplained by conventional physical disease processes

225
Q

Under ICD-10 and DSM-IV, what are functional disorders called?

A

Somatoform Disorders

226
Q

What is the conversion process to a functional disorder referred to under ICD-10 and DSM-IV?

A

Somatisation

227
Q

What dissociative disorders exist under ICD-10?

A 
Dissociative amnesia
Dissociative fatigue
Dissociative stupor
Trance and possession disorders
Dissociative disorders of movement and sensation
228
Q

How do dissociative disorders of movement and sensation present?

A

Like a physical disorder:

  • Doesn’t explain symptoms
  • Can represent patient’s concept of physical disorder
229
Q

What are somatoform disorders? What is their ICD-10 number?

A

F45
Repeated presentation of physical symptoms WITH
Persistent requests for medical investigations:
- In spite of repeated negative findings
Usually resist attempts to discuss psychological basis
Any physical disorder present:
- Do not explain patient’s distress

230
Q

What is F45.0?

A

Somatisation disorder:

  • Repeated and changing physical symptoms
  • Present over >=2 years
  • Long + complicated Hx of medical contact
  • Any body part affected
  • Disruption of social and family functioning
231
Q

What GI symptoms can somatisation present with?

A 
IBS:
- Low mood
- Abdominal pain
- Nausea
- Bloating
Dysphagia/GORD
232
Q

What neurological symptoms can somatisation present with?

A

Non-epileptic attack disorder

Weakness +/- sensory disturbance

233
Q

What rheumatological symptoms can somatisation present with?

A

Fibromyalgia

Chronic fatigue syndrome

234
Q

What other symptoms can somatisation present with?

A

Cardiology - Atypical chest pain
Dermatology - Chronic vulval pain
Gynaecology - Chronic pelvic pain
Orthopaedics - Chronic lower back pain

235
Q

What percentage of somatisation patients present with apparent status epilepticus?

A

50%

236
Q

What impact do chronic somatisers have?

A

Spend an average 7 days/month in bed
Use 9 times more healthcare resources
Have ~22 abortive/unnecessary lifetime hospital admissions

237
Q

In what populations is somatisation most common?

A 
F > M
3rd to 6th decade
FHx of functional disorders
Allied Health Professionals
Patients with learning difficulties
238
Q

What indicates poor prognosis in somatisation?

A

Long duration
Motor symptoms
Personality disorder

239
Q

What is the biopsychological perspective of how IBS can result in symptoms?

A
  1. Psychological distress
  2. Stimulation of ANS
  3. GI motility changes
  4. Symptoms
240
Q

What biological changes occur in chronic pain syndromes?

A

Adaptive changes in nervous system:

- eg. Arborisation of dorsal horn cells

241
Q

What psychosocial symptoms can occur in chronic pain syndromes?

A

Distress
Anxiety
Depression

242
Q

What childhood experiences can predispose to somatisation?

A 
Exposure to excessive family illness
Exaggerated family health concers
Hospitalisation
Parental neglect
Exposure to 'figure of identity'
Abuse
243
Q

What stressful life events can precipitate somatisation?

A

Major threats to health
Personal losses
Psychiatric illness

244
Q

What secondary gains can perpetuate somatisation?

A

Illness accrued benefits
Exemption from work
Manipulation of others

245
Q

What SPECT abnormalities are seen in functional disorders?

A 
Functional hemiparesis
Increased activity in rCBF (when resting) bilaterally in:
- Frontal cortex
- Parietal cortex
Reduced rCBF to contralateral:
- Thalamus
- Basal ganglia
Hypoactivation resolved with recovery
246
Q

What is Hoover’s sign?

A
  1. Ask patient to push their “weak” heel down against hand -> No effect
  2. Do straight leg raise of “normal” leg against resistance -> “Weak” heel will press into hand as “weak” hip extends
247
Q

What does Hoover’s sign indicate?

A

Inconsistency of examination

248
Q

What external inconsistency may be seen in functional disorders?

A

Tubular field defect:

- Inconsistent with laws of optics

249
Q

What percentage of patients with Non-Epileptic Attack Disorder also have epilepsy?

A

10%

250
Q

What can predispose to Non-Epileptic Attack Disorder?

A

Female
Traumatic experiences (in 90%):
- Esp. childhood abuse/neglect

251
Q

What is Non-Epileptic Attack Disorder often comorbid with?

A

Depression
Anxiety
PTSD

252
Q

How can Non-Epileptic Attack Disorder be differentiated from epilepsy?

A

Witness contact

EEG

253
Q

How can functional disorders be treated?

A 
Positive diagnosis and explanation
Physical rehab (physio and OT)
Treat any anxiety/depression/PTSD
Psychological therapies
Laxatives/Antispasmodics
254
Q

What symptoms can antidepressant treatment improvement in functional disorders?

A

Diarrhoea in IBS
Insomnia in chronic pain
Analgesia

255
Q

What is hypochondriasis?

A

F45.2
Often called “health anxiety”
Focuses on diagnosis of serious and progressive physical disorders

256
Q

What is Munchausen’s Syndrome?

A

Factitious disorder (F68.1):

  • Feigning symptoms for no reasons
  • May self-harm to produce signs/symptoms
257
Q

What is malingering?

A

Z76.5
Feigning illness for secondary aim:
- Often there is some actual structural/functional symptoms

258
Q

What is the first line drug for severe anxiety for short-term use?

A

Diazepam (BZDs)

259
Q

What pharmacological effects do BZDs have in anxiety?

A 
Reduce anxiety and aggression
Hypnosis/Sedation
Muscle relaxation
Anticonvulsant effect
Anterograde amnesia
260
Q

When are BZDs used?

A 
Acute treatment of severe anxiety
Hypnosis
Alcohol withdrawal
Mania
Delirium
Rapid tranquilisation
Premedication before:
- Surgery
- During minor procedures
Status epilepticus
261
Q

What substances all exhibit anxiolytic properties?

A

Ethanol
Neurosteroids
Barbituates

262
Q

What drugs can have anxiogenic properties?

A

Inverse BDZ agonists:
- Beta-carbolines
Flumazenil

263
Q

How can BZD overdose be treated?

A

Flumazenil

264
Q

What are some side effects of BZD treatment?

A

Paradoxical aggression
Anterograde amnesia and reduced coordination (beware Rohypnol)
Tolerance and dependence

265
Q

What can happen on BZD withdrawal?

A

Rebound anxiety:

  • Confusion
  • Toxic psychosis
  • Convulsions
266
Q

Why do the effects of BZD withdrawal occur?

A

Neuroadaptation of GABA response:

  • Treatment reduces response to GABA
  • Withdrawal results in anxiety/convulsions due to decreased density of BZD receptors
267
Q

What is the process by with BZDs are withdrawn?

A
  1. Transfer to equivalent dose of diazepam/chlordiazepam (take at night)
  2. Reduce dose every 2-3 weeks in steps of 2 or 2.5mg (maintain dose until symptoms improve)
  3. Reduce dose further in smaller steps if necessary
  4. Stop completely
268
Q

When can BZD withdrawal occur?

A

From ~4 weeks to >=1 year

269
Q

In what anxiety disorders are SSRIs used?

A

Panic disorder, OCD, PTSD, phobias
GAD:
- Escitalopram
- Paroxetine

270
Q

In what anxiety disorders are TCAs used?

A

2nd line for panic disorder

OCD

271
Q

What TCAs are usually used in anxiety disroders?

A

Clomipramine

Imipramine

272
Q

In what anxiety disorder is Venlafaxine used?

A

GAD

273
Q

In what anxiety disorder is Moclobemide?

A

Social anxiety

274
Q

What acute affect can SSRIs have in anxiety?

A

Anxiogenic

275
Q

What effect do beta-blockers have in anxiety disorders?

A

Somatic symptoms:

  • Palpitations
  • Tremor

Year 3 - Psychiatry (DP) (4 decks)

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