Anxiety and Schizophrenia Flashcards
(275 cards)
1
Q
What are some acute signs of anxiety?
A
Palpitations Sweating Tremor Dizziness Shortness of breath
2
Q
What are some chronic signs of anxiety?
A
Muscle pains
Weakness
3
Q
What is Globus hystericus?
A
Feeling of a lump in your throat
4
Q
When does anxiety become a problem?
A
If it results in isolation
5
Q
Under what heading does ICD-10 classify anxiety disorders? What does this include?
A
Neurotic disorders:
- PTSD
- Adjustment disorder
- OCD
- Hoarding disorder
6
Q
How are PTSD and Adjustment disorder classed in DSM-V?
A
Under trauma and stressor-related disorders
7
Q
How are OCD and Hoarding disorder classed in DSM-V?
A
OCD and Related Disorders (OCARD)
8
Q
Under ICD-10, what does F40 describe?
A
Phobic anxiety disorders:
- Agoraphobia (F40.0)
- Social phobia (F40.1)
- Specific phobies (F40.2)
9
Q
Under ICD-10, what does F41 describe?
A
Other anxiety disorders:
- Panic disorder (F41.0)
- Generalised Anxiety Disorder (GAD) (F41.1)
10
Q
Under ICD-10, what does F42 describe?
A
OCD
11
Q
Under ICD-10, what does F43 describe?
A
Reaction to severe stress and adjustment disorders:
- PTSD (F43.1)
- Adjustment disorder (F43.2)
12
Q
What is the full ICD-10 range which describes ‘Neurotic, Stress-Related and Somatoform Disorders’?
A
F40-F48
13
Q
Under the proposed ICD-11, what does OCARD also include?
A
Olfactory reference disorder
Hypochondriasis
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)
15
Q
What ICD-10 number is Generalised Anxiety Disorder?
A
F41.1
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
17
Q
What fraction of people with panic disorder develop agoraphobia?
A
2/3
18
Q
What is the other name for social phobia?
A
Social anxiety disorder
19
Q
What is agoraphobia?
A
Fear in places/situations in which:
- Escape might be difficult
- Help might not be available
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
21
Q
What are common physical symptoms of social phobia?
A
Blushing
Fear of vomiting
Urgency/Fear of micturition/defaecation
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
23
Q
What symptoms develop later in PTSD?
A
Intrusive symptoms (eg. Flashbacks)
Avoidance symptoms
Negative alterations in cognitions and mood
Hyperarousal
24
Q
What are the features of hyperarousal?
A
Disturbed sleep
Hypervigilance
Exaggerated startle response
25
How is OCD characterised?
Recurrent obsessive ruminations/images/impulses
+/or recurrent rituals
Symptoms are:
- Distressing
- Time consuming
- Interfering with social and occupational function
26
How is an obsession described?
Intrusive and inappropriate
| Excess and unreasonable (not in kids)
27
How is an obsession ego-dystonic?
Product of own mind but experienced as alien
| Outwith own control
28
What is a compulsion?
Repetitive behaviour/mental act
Aim to reduce anxiety
Not pleasurable in themselves
29
What is F40.00?
Agoraphobia without panic disorder
30
What if F40.01?
Agoraphobia with panic disorder
31
What is F40.8?
Other phobic anxiety disorders
32
What is F40.9?
Phobic anxiety disorder, unspecified
33
Marked and consistently manifested fear/avoidance of how many places is needed to diagnose agoraphobia? What sort of places?
>=2 of the following:
- Crowds
- Public spaces
- Travelling alone
- Travelling away from home
34
Apart from fear/avoidance of certain situations in agoraphobia, what other two features must be present?
- Anxiety in a situation with >=2 symptoms on >1 occasion from the key features symptoms of GAD
- Significant emotional distress due to avoidance/anxiety
35
To diagnose a social phobia, what insight should the patient have?
Recognising that the symptoms and avoidance are excessive or unreasonable
36
What percentage of patients with social phobia with abuse alcohol?
20%
37
How many symptoms of generalised anxiety disorder must be present for a panic attack to be classed as such?
```
>=4 symptoms
At least one from each of:
- Autonomic symptoms
- Thorax symptoms
- Brain/Mind symptoms
- General symptoms
```
38
How is general anxiety disorder diagnosed?
```
>=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
```
39
How is OCD diagnosed?
Obsessions +/or compulsions present on most days for >=2 weeks
40
In OCD, what features of obsessions and compulsions MUST be present to be diagnosed as such?
Acknowledged as originating from patient's mind
Repetitive and unpleasant
Subject tries to resist
Carrying out a compulsion is not pleasurable
41
In diagnosing PTSD, following an initial stressor event, when must criteria 2-4 be met?
Within 6 months of:
- Event OR
- The end of a period of stress
42
What kind of stressor event is associated with the highest incidence of PTSD?
Rape
43
When is the 'freeze' response initiated?
When limbic system judges that neither fight nor flight is possible and death/severe injury is inevitable
44
What happens during a 'freeze' response?
Altered state of reality
Body becomes immobile
Pain responses reduced
45
What are the types of trauma?
Type 1 = Simple
| Type 2 = Complex
46
What symptoms can run alongside typical PTSD symptoms to classify it as complex PTSD?
```
Cognitive disturbance
Mood/Emotional disturbances
Somatisation
Identity disturbance
Chronic interpersonal difficulties
Dissociation
Tension reductive activities
```
47
How is the stress response resolved?
PNS kicks in:
- Muscles relax
- Skin warms
- Pupils constrict to normal (SNS dilates them)
- Refocusing
- HR slows
- BP reduces
- Eat, digest and rest
48
What part of the brain is responsible for locating memories in the right time, place and context?
Hippocampus
49
What part of the brain stores emotionally charged memories?
Amygdala
50
Where does the limbic brain connect to?
Medial prefrontal cortext
51
What to the limbic connections enable it to do?
Regulate emotional and fear responses
52
How many connections are there from limbic brain to medial prefrontal cortex?
Many
53
How many connections are there from the medial prefrontal cortex to the limbic brain?
Fewer
54
How do sense of danger and logic interact?
Sense of danger overrides logic
55
What can potentially trigger flashbacks in PTSD?
Insomnia
Tiredness
Stress
56
Why can nightmares result in insomnia?
Delay in going to sleep
Bedroom associated with nightmares:
- Bedroom avoidance
- Poor sleep hygeine
57
When is dissociation more likely to occur in PTSD?
If trauma is:
- Severe
- Prolonged
- Repeated/Horrific/Shaming
- Affecting a very young victim
58
How does dissociation present in PTSD?
```
Patient may feel like they're watching themselves
May feel like it isn't happening
Dissociative flashbacks
Fugue states
Dissociative Identity Disorders
```
59
What can indicate dissociation?
```
Things look strange
Changes in sound
Rocking/Tapping
'Slow-motion'
Feel like a robot/observer
```
60
When does an acute stress reaction occur following trauma?
48 hours after
61
When does an acute stress disorder occur following trauma?
Up to 4 weeks
62
When does acute PTSD occur following trauma?
Up to 3 months
63
When does chronic PTSD occur following trauma?
Over 3 months
64
How can acute stress disorder be diagnosed?
The following symptoms occurring within 1 months of the trauma and lasting at least 2 days:
- Dissociative symptoms
- Persistent re-experiencing
- Increased arousal
65
What treatment should not be undertaken in acute stress disorder?
Debriefing
66
When is watchful waiting and monthly reviewing appropriate in an acute stress disorder?
If symptoms are mild and present for <4 weeks
67
What psychotherapeutic models can be employed in the treatment of acute stress disorder/PTSD?
Trauma focused CBT
Eye Movement Desensitisation and Re-Programming
Prolonged exposure
Cognitive processing therapy
68
What drugs are licensed for use in PTSD?
Antidepressants:
- Paroxetine
- Other classes if SSRIs don't work
69
What specialist alternative drugs can be used in PTSD?
Prazosin
Atypical antipsychotics
Mood stabilisers
70
Under DSM-V, what is included under OCARD?
Excoriation
Hoarding
Body dysmorphic disorder
Tic disorder
71
What is the most common comorbid condition in OCD?
Anxiety disorders
72
What is the mean age of onset of OCD?
20 years
73
What is the median age of onset of OCD?
19 years
74
When is the peak incidence of OCD in males?
13-15 years
75
When is the peak incidence of OCD in females?
24-25 years
76
What populations have an increased incidence of OCD?
General hospital populations
77
What autoimmune conditions may contribute to developing OCD?
Beta-Haemolytic Strep. infection (PANDAS)
| Autoantibodies to basal ganglia
78
What does neuroimaging show in OCD?
Increased metabolism and blood flow in:
- Orbitofrontal cortex
- Caudate nucleus
- Cingulate cortex
79
What five screening questions can be used for OCD?
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?
80
When would benzodiazepines be used in anxiety disorders?
Specific occasions (eg. flights)
81
What anxiety disorders can graded exposure be used to treat?
```
Simple phobias (eg. spiders)
Agoraphobia
```
82
How would the exposure in graded exposure be described?
Gradual and progressive
83
What is flooding?
Full exposure to feared stimulus and staying with it until fear reduces
84
What are the issues with flooding?
Generally less popular
| Fear may spontaneously reoccur
85
What are the principles of CBT?
Suggest that underlying thoughts affect emotions which then affect behaviour
Involve patient in questioning/testing their thoughts
86
What BZDs can be used in PTSD?
Bromazepam
| Clonazepam
87
What anticonvulsants can be used in PTSD?
Gabapentin
Pregabalin
Onlanzapine
88
What form of CBT is used in PTSD?
Trauma-Focused CBT
89
What are the typical first line medications used in OCD?
Serotonergic antidepressants:
- SSRIs
- Clomipramine (TCA)
90
What antipsychotics can be used to augment treatment in OCD?
Risperidone
| Aripiprazole
91
What anticonvulsant might be used in OCD?
Lamotrigine
92
What psychological therapies are very frequently employed in OCD?
Exposure and Response Prevention >=20 hours
CBT:
- Heavy emphasis on exposure
93
How would OCD with mild functional impairment be treated?
Brief CBT (+ERP); <10 therapist hours
94
How would OCD with moderate-severe functional impairment OR when patients with mild impairment cannot engage with CBT/it fails, be treated?
Offer choice of:
- More intensive CBT (+ERP); >10 therapist hours
- Course of SSRI
95
Following treatment of OCD with moderate-severe functional impairment, when would it be upgraded to definite severe impairment?
If there is inadequate response at 12 weeks an MDT review is carried out
96
How is OCD with severe functional impairment treated?
Offer combo of:
- CBT (+ERP) AND
- SSRI
97
If first line treated of OCD with severe functional impairment fails, how can it be treated?
Offer either:
- Different SSRI
- Clomipramine
(Continue CBT [+ERP])
98
If second line treated of OCD with severe functional impairment fails, how can it be treated?
Refer to MDT with OCD experience
99
If third line treated of OCD with severe functional impairment fails, how can it be treated?
```
Additional CBT (+ERP) or cognitive therapy
Add antipsychotic to SSRI/Clomipramine; combine clomipramine and citalopram
```
100
What dose of fluoxetine is used in OCD?
60mg/day
101
What dose of paroxetine is used in OCD?
60mg/day
102
What dose of citalopram is used in OCD?
60mg/day
103
What dose of sertraline is used in OCD?
>=200mg/day
104
What dose of fluvoxamine is used in OCD?
300mg/day
105
What dose of escitalopram is used in OCD?
>=20mg/day
106
What dose of clomipramine is used in OCD?
>=250mg/day
107
How does ERP work?
```
Repeatedly keeping anxiety in check:
- Provides powerful reinforcement for avoidance
- Sustains avoidance
Conversely:
- Increase exposure to feared stimulus
- Develops habituation to anxiety
```
108
What is the first line pharmacological treatment for Generalised Anxiety Disorder?
SSRIs
109
What is the second line pharmacological treatment for Generalised Anxiety Disorder?
SNRIs:
- Venlafaxine
- Duloxetine
110
What is the third line pharmacological treatment for Generalised Anxiety Disorder?
Pregabalin
111
What psychological therapies can be used in Generalised Anxiety Disorder?
Guided self-help (if mild)
CBT
Relaxation (usually short-term)
112
What medications can be used to treat social phobia?
Most SSRIs
Venlafaxine, Phenelzine
Some BZDs (Bromazepam, Clonazepam)
Anticonvulsants (Gabapentin, Pregabalin)
113
What psychological therapies can be used to treat social phobia?
CBT with emphasis on exposure
Cognitive restructuring
Social skills training
114
When would an SSRI be used in management of a specific phobia?
If anxiety is moderate-severe and hasn't responded to behavioural therapy
115
What psychological therapies are used frequently in management of a specific phobia?
Exposure therapy:
- Graded exposure
- Flooding
116
What medications can be used to treat panic disorder +/- agoraphobia?
All SSRIs
Some TCS (Clomipramine, Imipramine)
Venlafaxine (SNRI)
Some anticonvulsants (Gabapentin, Pregabalin)
117
What psychological therapies are used frequently in management of panic disorder +/- agoraphobia??
CBT
| Graded exposure therapy if agoraphobia present
118
How long is maintenance treatment continued for in responders in GAD?
>=18 months
119
How long is maintenance treatment continued for in responders in panic disorder?
>=6 months
120
How long is maintenance treatment continued for in responders in social phobia?
>=6 months
121
How long is maintenance treatment continued for in responders in PTSD?
>=12 months
122
How long is maintenance treatment continued for in responders in OCD?
>=12 months
123
What are the worldwide suicide rates?
15 per 100,000 per annum
124
What are the suicide incidence rates in England and Wales?
15. 9/100,000 in men
| 4. 5/100,000 in women
125
What are the suicide incidence rates in Scotland?
26. 8/100,000 in men
| 7. 4/100,000 in women
126
Levels of what are lower in patients with a history of deliberate self-harm?
CSF 5-HIAA (5-Hydroxyindoleacetic acid)
127
There is reduced binding of 5-HT transporter sites in deliberate self-harm; where in the brain does this occur?
Ventral Prefrontal Cortex-PM
128
In the PM there is an increase in what receptors in deliberate self-harm?
Post-synaptic 5-HT1a
129
What does neuroimaging show in deliberate self-harm patients?
In high lethality patients:
- Different prefrontal cortex activity
SPECTs of recent deliberate self-harm patients showed reduced frontal activity
130
In what populations is deliberate self-harm more common?
Northern Europe
Women
Low socio-economic status
131
How do deliberate self-harm patients die prematurely?
```
Suicide
IHD
Cancer
RTAs
Homicide
```
132
In what European country is deliberate self-harm more common in males?
Finland
133
What is the initial stage of managing deliberate self-harm?
```
Calm the patient; emotional release is good:
- Crying is good; Aggression is not
- Be supportive but firm
Direct interview:
- Privacy
- Distract
- Deep breathing
```
134
What is it important to ask about in deliberate self-harm?
Antecedants
The episode of DSH
Mental state then and now
135
How can self-esteem be bolstered and problem-solving be initiated in deliberate self-harm?
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
What may a manipulative patient use as a threat?
Threat of suicide to change environment:
- Powerlessness
- Compromise
- Boundaries
137
What are the types of manipulative patients?
1. Dependent clingers
2. Entitled demanders
3. Manipulative help-rejecters
4. Self-destructive deniers
138
How else can deliberate self-harm be referred?
Passive death wish
| Suicidal ideation vs. Suicidal intention
139
What are the positive symptoms of Schizophrenia?
Delusions
Hallucinations
Thought disorder
140
What are the negative symptoms of Schizophrenia?
Apathy
Lack of volition
Social withdrawal
Cognitive impairment
141
When are negative symptoms in Schizophrenia prominent?
Prior to illness atrting
142
What symptoms in Schizophrenia respond better to treatment?
Positive symptoms
143
What symptoms in Schizophrenia have more impact on functioning and QoL?
Negative symptoms
144
Schizophrenia can be diagnosed by ONE of what symptoms (according to ICD-10)?
```
Thought interference
Passive phenomena
Hallucinatory voices:
- Running commentary OR
- Third person
Impossible, persistent delusions
```
145
Schizophrenia can also be diagnosed by TWO of what symptoms (according to ICD-10)?
Formal thought disorder
Catatonic behaviour
Negative symptoms
Loss of interest/Idleness/Self-absorbed/Social withdrawal
146
How long must either of the ONE symptoms or the TWO symptoms last to diagnose Schizophrenia?
>=1 month
147
What are Schneider's First Rank Symptoms of Schizophrenia?
```
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
What is the typical kind of delusion in Schizophrenia?
Bizarre
149
Are delusions in Schizophrenia mood-congruent or mood-incongruent?
Congruent
150
What are delusions often related to in Schizophrenia?
Current affairs
151
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?
Development of new delusions
152
How can flow of thought be affected in Schizophrenia?
Disruption of association
Thought blocking
Crowding (Flight of ideas with passivity)
Neologisms
153
What sort of affect is seen in Schizophrenia?
Blunted:
- Limited range of emotion
- Lack of sensitivity/connection to surroundings
154
Is the affect of a patient with Schizophrenia congruent or incongruent with surroundings?
Incongruent
155
What is catatonia (as seen in Schizophrenia)?
Increased tone at rest (abolished by voluntary movement)
Other motor activity and posture abnormalities:
- Stupor
- Hyperactivity
- Mutism
- Stereotypes
- Waxy flexibility
156
What is the peak incidence of onset of Schizophrenia in men?
15-25 years
157
What is the peak incidence of onset of Schizophrenia in women?
25-35 years
158
What is the incidence of Schizophrenia?
15/100,000
159
What is the suicide rate in Schizophrenia?
10-15%
160
What factors contribute to a good prognosis in Schizophrenia?
Older onset
Female
Marked mood disturbance (esp. elation)
FHx of mood disorder
161
What factors contribute to a poor prognosis in Schizophrenia?
```
Longer duration of untreated psychosis
Poor premorbid adjustment
Insidious onset
Earlier onset
Cognitive impairment
Enlarged ventricles
```
162
What does psychosis involve?
Inability to distinguish between subjective experience and reality
163
What is psychosis characterised by?
Lack of insight
164
Why is it important to recognise the importance of the experience in consulting with a psychotic patient?
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
In consulting with a psychotic patient, it is important to think of creative ways to challenge their beliefs. How can this be done?
"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
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?
"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
What is Schizophrenia typified by?
Prodromal symptoms and gradual functional decline
168
How present are depressive and manic symptoms in Schizophrenia?
Absent or minimal
169
What is F20.0?
Paranoid Schizophrenia
170
What is F20.1?
Hebephrenic Schizophrenia
171
What is F20.2?
Catatonic Schizophrenia (catalepsy catatonia)
172
What is F20.3?
Undifferentiated Schizophrenia
173
What is F20.4?
Post-Schizophrenic depression
174
What is F20.5?
Residual Schizophrenia
175
What is F20.6?
Simple Schizophrenia
176
What is F20.8?
Other Schizophrenia
177
What is F20.9?
Schizophrenia, unspecified
178
What is Simple Schizophrenia?
```
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
What is F10?
Mental and behavioural disorders due to the use of alcohol
180
What is F11?
Mental and behavioural disorders due to the use of opioids
181
What is F12?
Mental and behavioural disorders due to the use of cannabinoids
182
What is F13?
Mental and behavioural disorders due to the use of sedatives or hypnotics
183
What is F14?
Mental and behavioural disorders due to the use of cocaine
184
What is F15?
Mental and behavioural disorders due to the use of other stimulants (including caffeine)
185
What is F16?
Mental and behavioural disorders due to the use of hallucinogens
186
What is F17?
Mental and behavioural disorders due to the use of tobacco
187
What is F18?
Mental and behavioural disorders due to the use of volatile substances
188
What is F19?
Mental and behavioural disorders due to the use of multiple drug use and use of other psychoactive substances
189
When any disorder under F10-F19 is followed by a .0, what does this indicate?
Acute intoxication
190
When any disorder under F10-F19 is followed by a .1, what does this indicate?
Harmful use
191
When any disorder under F10-F19 is followed by a .2, what does this indicate?
Dependence
192
When any disorder under F10-F19 is followed by a .3, what does this indicate?
Withdrawl
193
When any disorder under F10-F19 is followed by a .4, what does this indicate?
Withdrawal with delirium
194
When any disorder under F10-F19 is followed by a .5, what does this indicate?
Psychotic disorder
195
When any disorder under F10-F19 is followed by a .6, what does this indicate?
Amnesic syndrome
196
When any disorder under F10-F19 is followed by a .7, what does this indicate?
Residual and late-onset psychotic disorder
197
What delusions are seen in depressive psychosis?
Worthlessness
Guilt
Hypochondriasis
Poverty
198
What hallucinations are present in depressive psychosis?
```
Accusing/Insulting/Threatening
2nd person (usually)
```
199
What is F32.2?
Severe depressive episode with psychotic symptoms
200
How is F32.3 defined?
```
An episode as described in F32.2
But with:
- Hallucinations
- Delusions
- Psychomotor retardation
- Stupor
```
201
What may the symptoms of F32.3 result in that can be life-threatening?
Suicide
Dehydration
Starvation
202
Are psychotic symptoms in depressive psychosis congruent or incongruent?
Congruent
203
Are psychotic symptoms in mania with psychosis congruent or incongruent?
Congruent
204
What kind of delusions are seen in mania with psychosis?
Grandeur
Special ability
Persecution
Religiosity
205
What sort of hallucinations are seen in mania with psychosis?
Auditory
206
How is F30.2 (mania with psychosis) described according to ICD-10?
```
An episode as in F30.1
But with:
- Delusions (usually grandiose)
- Hallucinations
- Flight of ideas
- Excitement
- Excessive motor activity
```
207
What is Schizoaffective Disorder?
Presence of both symptoms typical of:
- Schizophrenia AND
- Affective disorder
208
Can mood-incongruent psychotic symptoms in an affective disorder justify a diagnosis of Schizoaffective Disorder?
No
209
What is F25.0?
Schizoaffective Disorder, manic type
210
What is F25.1?
Schizoaffective Disorder, depressive type
211
What is F25.2?
Schizoaffective Disorder, mixed type
212
What is F25.3?
Other Schizoaffective Disorder
213
What is F25.9?
Schizoaffective Disorder, unspecified
214
What are affective symptoms superimposed on a pre-exisiting schizophrenic illness classified under in ICD-10?
Somewhere else in F20-F29
215
What sort of delusions are seen in delirium?
Persecutory
216
When is clouding of consciousness worse in delirium?
At night
217
What hallucinations are seen in delirium?
Visual
| +/- auditory (often threatening)
218
What is the ICD-10 for delirium (not induced by alcohol/psychoactive substances)?
F05
219
Delirium can also include acute or subacute conditions. Give examples.
Brain syndrome confusional state (non-alcoholic)
Infective psychosis
Organic reaction
Psycho-organic syndrome
220
What is the ICD-10 for delirium tremens?
F10.4
221
What is F05.0?
Delirium not superimposed on dementia
222
What F05.1?
Delirium superimposed on dementia
223
What is F05.8?
Other delirium:
- Of mixed origin
- Postoperative delirium
224
What are functional disorders?
Symptoms unexplained by conventional physical disease processes
225
Under ICD-10 and DSM-IV, what are functional disorders called?
Somatoform Disorders
226
What is the conversion process to a functional disorder referred to under ICD-10 and DSM-IV?
Somatisation
227
What dissociative disorders exist under ICD-10?
```
Dissociative amnesia
Dissociative fatigue
Dissociative stupor
Trance and possession disorders
Dissociative disorders of movement and sensation
```
228
How do dissociative disorders of movement and sensation present?
Like a physical disorder:
- Doesn't explain symptoms
- Can represent patient's concept of physical disorder
229
What are somatoform disorders? What is their ICD-10 number?
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
What is F45.0?
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
What GI symptoms can somatisation present with?
```
IBS:
- Low mood
- Abdominal pain
- Nausea
- Bloating
Dysphagia/GORD
```
232
What neurological symptoms can somatisation present with?
Non-epileptic attack disorder
| Weakness +/- sensory disturbance
233
What rheumatological symptoms can somatisation present with?
Fibromyalgia
| Chronic fatigue syndrome
234
What other symptoms can somatisation present with?
Cardiology - Atypical chest pain
Dermatology - Chronic vulval pain
Gynaecology - Chronic pelvic pain
Orthopaedics - Chronic lower back pain
235
What percentage of somatisation patients present with apparent status epilepticus?
50%
236
What impact do chronic somatisers have?
Spend an average 7 days/month in bed
Use 9 times more healthcare resources
Have ~22 abortive/unnecessary lifetime hospital admissions
237
In what populations is somatisation most common?
```
F > M
3rd to 6th decade
FHx of functional disorders
Allied Health Professionals
Patients with learning difficulties
```
238
What indicates poor prognosis in somatisation?
Long duration
Motor symptoms
Personality disorder
239
What is the biopsychological perspective of how IBS can result in symptoms?
1. Psychological distress
2. Stimulation of ANS
3. GI motility changes
4. Symptoms
240
What biological changes occur in chronic pain syndromes?
Adaptive changes in nervous system:
| - eg. Arborisation of dorsal horn cells
241
What psychosocial symptoms can occur in chronic pain syndromes?
Distress
Anxiety
Depression
242
What childhood experiences can predispose to somatisation?
```
Exposure to excessive family illness
Exaggerated family health concers
Hospitalisation
Parental neglect
Exposure to 'figure of identity'
Abuse
```
243
What stressful life events can precipitate somatisation?
Major threats to health
Personal losses
Psychiatric illness
244
What secondary gains can perpetuate somatisation?
Illness accrued benefits
Exemption from work
Manipulation of others
245
What SPECT abnormalities are seen in functional disorders?
```
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
What is Hoover's sign?
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
What does Hoover's sign indicate?
Inconsistency of examination
248
What external inconsistency may be seen in functional disorders?
Tubular field defect:
| - Inconsistent with laws of optics
249
What percentage of patients with Non-Epileptic Attack Disorder also have epilepsy?
10%
250
What can predispose to Non-Epileptic Attack Disorder?
Female
Traumatic experiences (in 90%):
- Esp. childhood abuse/neglect
251
What is Non-Epileptic Attack Disorder often comorbid with?
Depression
Anxiety
PTSD
252
How can Non-Epileptic Attack Disorder be differentiated from epilepsy?
Witness contact
| EEG
253
How can functional disorders be treated?
```
Positive diagnosis and explanation
Physical rehab (physio and OT)
Treat any anxiety/depression/PTSD
Psychological therapies
Laxatives/Antispasmodics
```
254
What symptoms can antidepressant treatment improvement in functional disorders?
Diarrhoea in IBS
Insomnia in chronic pain
Analgesia
255
What is hypochondriasis?
F45.2
Often called "health anxiety"
Focuses on diagnosis of serious and progressive physical disorders
256
What is Munchausen's Syndrome?
Factitious disorder (F68.1):
- Feigning symptoms for no reasons
- May self-harm to produce signs/symptoms
257
What is malingering?
Z76.5
Feigning illness for secondary aim:
- Often there is some actual structural/functional symptoms
258
What is the first line drug for severe anxiety for short-term use?
Diazepam (BZDs)
259
What pharmacological effects do BZDs have in anxiety?
```
Reduce anxiety and aggression
Hypnosis/Sedation
Muscle relaxation
Anticonvulsant effect
Anterograde amnesia
```
260
When are BZDs used?
```
Acute treatment of severe anxiety
Hypnosis
Alcohol withdrawal
Mania
Delirium
Rapid tranquilisation
Premedication before:
- Surgery
- During minor procedures
Status epilepticus
```
261
What substances all exhibit anxiolytic properties?
Ethanol
Neurosteroids
Barbituates
262
What drugs can have anxiogenic properties?
Inverse BDZ agonists:
- Beta-carbolines
Flumazenil
263
How can BZD overdose be treated?
Flumazenil
264
What are some side effects of BZD treatment?
Paradoxical aggression
Anterograde amnesia and reduced coordination (beware Rohypnol)
Tolerance and dependence
265
What can happen on BZD withdrawal?
Rebound anxiety:
- Confusion
- Toxic psychosis
- Convulsions
266
Why do the effects of BZD withdrawal occur?
Neuroadaptation of GABA response:
- Treatment reduces response to GABA
- Withdrawal results in anxiety/convulsions due to decreased density of BZD receptors
267
What is the process by with BZDs are withdrawn?
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
When can BZD withdrawal occur?
From ~4 weeks to >=1 year
269
In what anxiety disorders are SSRIs used?
Panic disorder, OCD, PTSD, phobias
GAD:
- Escitalopram
- Paroxetine
270
In what anxiety disorders are TCAs used?
2nd line for panic disorder
| OCD
271
What TCAs are usually used in anxiety disroders?
Clomipramine
| Imipramine
272
In what anxiety disorder is Venlafaxine used?
GAD
273
In what anxiety disorder is Moclobemide?
Social anxiety
274
What acute affect can SSRIs have in anxiety?
Anxiogenic
275
What effect do beta-blockers have in anxiety disorders?
Somatic symptoms:
- Palpitations
- Tremor
