Clinical Handbook - Main Conditions 2 Flashcards
Define neurosis
collection of psychiatric disorders characterized by distress, that are non- organic, have a discrete onset and where delusions and hallucinations are absent
Give some common features that may appear in any anxiety disorder
Psychological:
Anticipatory fear of impending doom, worrying thoughts, exaggerated startle response, restlessness, poor concentration and attention, irritability, depersonalization and derealization
Cardiovascular:
Palpitations, chest pain
Respiratory:
Hyperventilation, cough, chest tightness
Gastrointestinal:
Abdominal pain (butterflies), loose stools, nausea and vomiting, dysphagia, dry mouth
Genitourinary:
1 Frequency of micturition, failure of erection, menstrual discomfort
Neuromuscular:
Tremor, myalgia, headache, paraesthesia, tinnitus
What categories can anxiety disorders be split into
continuous anxiety - GAD
paroxysmal anxiety:
situation dependent - phobic anxiety disorder ( specific phobia, social phobia, agoraphobia )
situation independent - panic disorder
Give some medical conditions associated with anxiety
Hyperthyroidism, hypoglycaemia, anaemia, phaeochromocytoma, Cushing’s disease, chronic obstructive pulmonary disease (COPD), congestive cardiac failure, malignancy
Give some substance-related conditions associated with anxiety
Intoxication: e.g. alcohol, cannabis, caffeine
Withdrawal: e.g. alcohol, benzodiazepine, caffeine
Side effects: e.g. thyroxine, steroids, adrenaline
Give some other psychiatric conditions associated with anxiety
Eating disorders, somatoform disorders, depression, schizophrenia, OCD, PTSD, adjustment disorder, anxious (avoidant) personality disorder
Define Generalised Anxiety Disorder
Generalized anxiety disorder (GAD) is a syndrome of ongoing, uncontrollable, widespread worry about many events or thoughts that the patient recognizes as excessive and inappropriate. Symptoms must be present on most days for at least 6 months duration.
Common features of presentation specific to GAD?
‘WATCHERS’:
Worry (excessive, uncontrollable)
Autonomic hyperactivity (sweating,
↑ pupil size, ↑ HR)
Tension in muscles/Tremor
Concentration difficulty/Chronic aches
Headache/Hyperventilation
Energy loss
Restlessness
Startled easily/Sleep disturbance
How could you investigate a patient with anxiety?
Blood tests: FBC (for infection/anaemia), TFTs (hyperthyroidism), glucose (hypoglycaemia)
ECG: may show sinus tachycardia
Questionnaires: GAD-2, GAD-7, Beck’s Anxiety Inventory, Hospital Anxiety and Depression Scale.
What are the differentials for anxiety?
Other neurotic disorders: panic disorder, specific phobias, OCD, PTSD
Depression
Schizophrenia
Personality disorder (e.g. anxious PD, dependent PD)
Excessive caffeine or alcohol consumption
Withdrawal from drugs.
Organic: anaemia, hyperthyroidism, phaeochromocytoma, hypoglycaemia
How should GAD be managed?
Biological: SSRI (sertraline), then SNRI (venlafaxine or duloxetine), then pregabalin
Psychological: low intensity interventions e.g. psychoeducational groups, high intensity interventions e.g. CBT and applied relaxation
Social : self help methods (e.g. journalling) and support groups
Give 10 somatic features that GAD may present with
dry mouth
chest pain
difficulty breathing
nausea, loose bowel habits
hot flushes or cold chills
numbness or tingling
headache
muscle tension
restlessness
sensation of lump in
throat (globus hystericus)
Define phobia
an intense, irrational fear of an object, situation, place or person that is recognized as excessive (out of proportion to the threat) or unreasonable.
Define agoraphobia
What is the ICD-10 criteria for diagnosis?
It is a fear of public spaces or fear of entering a public space from which immediate escape would be difficult in the event of a panic attack.
ICD-10:
A. fear in, or avoidance of, at least two of the following:
Crowds, Public spaces, Travelling alone, Travelling away from home
B. Symptoms of anxiety in the feared
situation with at least two symptoms present together (and at least one symptom of autonomic arousal)
C. Significant emotional distress, Recognized as excessive or unreasonable.
D. Symptoms restricted to (or predominate in) feared situation.
Define social phobia
What is the ICD-10 criteria for diagnosis?
A fear of social situations which may lead to humiliation, criticism or embarrassment.
A. Marked fear / avoidance of being the focus of attention, or fear of acting in a way that will be embarrassing.
B. At least two symptoms of anxiety in the feared situation plus one of the following:
Blushing , Fear of vomiting, Urgency or fear of micturition/defecation
C. Significant emotional distress due to the avoidance or anxiety symptoms.
D. Recognized as excessive or unreasonable.
E. Symptoms restricted to (or predominate in) feared situation.
Give some risk factors for phobias
Aversive experiences (prior experiences with specific objects or situations)
Stress and negative life events
Other anxiety disorders
Mood disorders
Substance misuse disorders
Family history
What features distinguish phobic disorders from GAD?
SS, AA, AA
Specifc situtaions
Anticipatory Anxiety
Attempted Avoidance
Questionnaires for phobic disorders?
Social Phobia Inventory and Liebowitz Social Anxiety Scale
DDx for phobic disorders?
Psychiatric:
Panic disorder
PTSD
anxious personality disorder
somatoform disorders
adjustment disorder
depression
schizophrenia (may avoid socializing because of paranoid delusions)
Organic
Mx of agoraphobia?
CBT - exposure and desensitisation
SSRIs
Mx of social phobia?
CBT
SSRIs, SNRIs, or if no response then MAOI
Mx of specific phobia?
exposure using self help methods or CBT
Benzos can be used as an anxiolytic short term e.g. for claustrophobic patient having CT
Define panic disorder
recurrent, episodic, severe panic attacks, which are unpredictable and not restricted to any particular situation or circumstance.
What are the risk factors for panic disorder?
Age (20–30) , female
White ethnicity
Family history
Major life events / recent trauma
Other mental disorders
Asthma
Cigarette smoking
Give some of the key features of panic disorder
PANICS Disorder
Palpitations
Abdominal distress
Numbness/Nausea
Intense fear of death
Choking feeling/Chest pain
Sweating/Shaking/Shortness of breath
Depersonalization/Derealization
DDx for panic disorder?
Psychiatric: GAD , phobic anxiety disorder, dissociative disorder, bipolar affective disorder, depression, schizophrenia, adjustment disorder
Organic: Phaeochromocytoma, hyperthyroidism, hypoglycaemia, carcinoid syndrome, arrhythmias, alcohol/substance withdrawal
Mx of panic disorder?
SSRIs are first-line but if they are not suitable, or there is no improvement after 12 weeks, then a TCA, e.g. imipramine or clomipramine may be considered
Benzodiazepines should not be prescribed
CBT is the psychological intervention of choice
Give 3 differences between GAD, panic disorder and phobic anxiety
when they occur:
GAD= peristent, panic = episodic, phobic = situational
associated behaviour
GAD= agitation, panic= trying to escape, phobic= avoidance
cognition
GAD = constant worry, panic = fear of sxs, phobic = fear of situation
Define PTSD
an intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event
Define abnormal bereavement
Abnormal bereavement has a delayed onset, is more intense and prolonged (>6 months). The impact of their loss overwhelms the individual’s coping capacity.
Define adjustment disorder
Normal adjustment refers to psychological reactions involved in adapting to new circumstances
Adjustment disorder is when there is significant distress (greater than expected), accompanied by an impairment in social functioning
Give some risk factors for PTSD
Exposure to traumatic events - at risk groups e.g. armed forces, medics, refugees
Pre-trauma: history of mental illness, females, low socio- economic background, childhood abuse
Peri-trauma: Severity of trauma, perceived threat to life, adverse emotional reaction during or immediately after event.
Post trauma:Concurrent life stressors, absence of social support.
Give 4 key features of PTSD
reliving - flashbacks, nightmares
avoidance
hyperarousal - difficulty with concentration, sleep, exaggerated startle response
emotional numbing
How could you investigate someone with suspected PTSD?
Questionnaires: Trauma Screening Questionnaire (TSQ), Post-traumatic diagnostic scale
CT head: if head injury suspected
DDx for PTSD?
Psychiatric: Adjustment disorder, acute stress reaction, bereavement, dissociative disorder, mood or anxiety disorders, personality disorder
Organic: Head injury (result of traumatic event), alcohol/substance misuse.
How can you distinguish between PTSD and adjustment disorder?
adjustment disorder requires a non-catastrophic event, whereas PTSD involves an exceptionally traumatic event
The symptoms in adjustment disorder must occur within 1 month of the event whereas PTSD must occur within 6 months
Mx of PTSD?
SSRI (most commonly paroxetine), mirtazipine, SNRI
CBT, EMDR
Define obsessions
Unwanted intrusive thoughts, images or urges that repeatedly enter the individual’s mind. They are distressing for the individual who attempts to resist them and recognizes them as egodystonic and a product of their own mind.
Define compulsions
Repetitive, stereotyped behaviours or mental acts that a person feels driven into performing. They are overt (observable by others) or covert (mental acts not observable).
Obsessions and compulsions must share all of the following features:
FORD Car
Failure to resist: At least one obsession or compulsion is present which is unsuccessfully resisted.
Originate from patient’s mind
Repetitive and Distressing
Carrying out the obsessive thought (or compulsive act) is not in itself pleasurable, but reduces anxiety levels.
What is the ICD-10 criteria for diagnosis of OCD?
A. Either obsessions or compulsions (or both) present on most days for a period of at least 2 weeks.
B. Obsessions (thoughts, ideas or images) or compulsions have all of the clinical features (FORD Car)
C. The obsessions or compulsions cause distress or interfere with the subject’s social or individual functioning, usually by wasting time.
How can you investigate OCD?
Questionnaires: Yale–Brown obsessive–compulsive scale (Y-BOCS) → 10-item questionnaire with each item graded from 0–4; e.g. Time occupied by obsessive thoughts (0 = none, 4 = extreme, >8 hours/day).
What are the DDx for OCD?
Anankastic personality disorder
Eating disorders - AN and BN
Body dysmorphic disorder (time consuming behaviours e.g. mirror gazing)
Anxiety disorders
Depressive disorder
Hypochondriacal disorder
Organic: dementia, epilepsy, head injury
How can OCD be managed?
CBT : ERP - patients are repeatedly exposed to the situation which causes them anxiety (e.g. exposure to dirt) and are prevented from performing the repetitive actions which lessen that anxiety (e.g. washing their hands)
SSRIs : fluoxetine, paroxetine, sertraline, citalopram
What are somatoform disorders?
a group of disorders whose symptoms are suggestive of, or take the form of, a physical disorder but in the absence of a physiological illness
e.g. Somatization disorder, hypochondriacal disorder, undifferentiated somatoform disorder, persistent somatoform pain disorder
What are dissociative (conversion) disorder?
characterized by symptoms which cannot be explained by a medical disorder and where there are convincing associations in time between symptoms and stressful events, problems or needs.
What is the sequence of events in dissociative (conversion) disorders?
distressing event
emotional distress
dissociation (separating distressing event from normal consciousness)
conversion (conversion of emotional distress into physical sxs)
gain (primary gain = stress relief, secondary gain = financial benefits)
Risk factors for somatoform and dissociative disorders?
CRAMPS
Childhood abuse
Reinforcement of illness behaviours
Anxiety disorders
Mood disorders
Personality disorders
Social stressors
Somatoform disorders are usually a dx of exclusion. What features would point towards a somatoform disorder?
(1) Multiple symptoms, often occurring in different organ systems
(2) Vague symptoms that exceed objective findings
(3) Chronic course
(4) Presence of a mental health disorder (5) History of extensive diagnostic testing
(6) Rejection of previous physicians.
How could you investigate a patient with a suspected somatoform disorder?
Blood tests: FBC (anaemia, infection), U&Es (electrolyte disturbance), LFTs (liver or biliary pathology), CRP (infection, inflammation), TFTs (thyroid dysfunction)
Further investigations:
A. Gastrointestinal symptoms: AXR, stool culture, OGD, colonoscopy, diagnostic
laparoscopy
B. Cardiovascular symptoms: ECG, 24 hr tape, ECHO, angiogram
C. Genitourinary symptoms: urine dipstick, MSU, cystoscopy
DDx for somatoform disorders?
Dissociative (conversion) disorder.
Factitious disorder
Malingering
Other psychiatric disorders: Mood disorder, psychotic disorder, anxiety disorder, PD
Multi-systemic disease
What is malingering?
Patient seeks advantageous consequences of being diagnosed with a medical condition. For instance, evading criminal prosecution or receiving government benefits (i.e. secondary gain).
What is factitious disorder?
(Munchausen’s syndrome): The individual wishes to adopt the ‘sick role’ in order to receive the care of a patient, for internal emotional gain (i.e. primary gain).
Mx of somatoform and dissociative disorders?
SSRIs
CBT
interventions reducing specific causes of stress (e.g. marriage counselling)
How could you explain the dx to a patient with somatoform disorder?
Many people like yourself have physical symptoms that we cannot find a reason for. We usually call these ‘medically unexplained symptoms’ or ‘functional illness’
I would like to reassure you however, that there are still ways we can help you.
Relate to a disorder they are more familiar with → ‘We know that most physical illnesses get worse if the patient feels tense or down, for example stress makes asthma worse, and therefore I feel that if we manage other problems in your life you will automatically feel better within yourself. How do you feel about this?’
Give some predisposing factors for anorexia nervosa
fam hx
female, early menarche
low self esteem
premorbid anxiety/depression
obsessional / anankastic personality
bullying at school
stressful life events
Give some precipitating factors for anorexia nervosa
adolescence
criticism regarding eating / body shape
occupational pressure to be slim e.g. models, ballet dancers
Give some perpetuating factors for anorexia nervosa
Starvation leads to neuroendocrine changes that perpetuate AN
perfectionism, obsessional personality
ICD-10 criteria for diagnosis of AN?
FEEDD
Fear of weight gain
Endocrine disturbance resulting in amenorrhoea in females and loss of sexual interest and potency in males
Emaciated (abnormally low body weight): >15% below expected weight or BMI <17.5 kg/m2
Deliberate weight loss with ↓ food intake or ↑ exercise.
Distorted body image
Must be for at least 3 months with no binge eating episodes
How should you investigate a patient with suspected AN?
Blood tests: FBC (anaemia, thrombocytopenia, leukopenia), U&Es (↑ urea and creatinine if dehydrated, ↓ potassium, phosphate, magnesium and chloride), TFTs (↓ T3 and T4), LFTs (↓albumin), lipids (↑ cholesterol), cortisol (↑), sex hormones (↓ LH, FSH, oestrogens and progestogens), glucose (↓), amylase (pancreatitis is a complication)
VBG: Metabolic alkalosis (vomiting), metabolic acidosis (laxatives)
DEXA scan: To rule out osteoporosis
ECG: Arrhythmias such as sinus bradycardia and prolonged QT are associated with AN patients
Questionnaires: e.g. eating attitudes test (EAT)
Give some complications of AN
Gastro - enlarged salivary glands, pancreatitis, constipation, peptic ulcers, hepatitis
Cardio - cardiac failure, arrythmias, low bp, bradycardia
Renal - renal stones, renal failure
MSK - proximal myopathy, osteoporosis
Mx of AN?
biological:
tx of medical complications e..g electrolyte disturbance
SSRIs for co-morbid depression / OCD
psychological:
CBT
cognitive analytic therapy
family therapy
Social:
self help groups
voluntary organisations
What is refeeding syndrome?
A potentially life-threatening syndrome that results from food intake after prolonged starvation or malnourishment, due to changes in phosphate, magnesium and potassium.
It occurs as a result of an insulin surge
The phosphate depletion causes reduction in cardiac muscle activity which can lead to cardiac failure.
How can refeeding syndrome be prevented?
Measure serum electrolytes prior to feeding and monitor refeeding bloods daily, start at 1200 kcal/day and gradually increase every 5 days, monitor for signs such as tachycardia and oedema.
What is bulimia nervosa?
an eating disorder characterized by repeated episodes of uncontrolled binge eating followed by compensatory weight loss behaviours and overvalued ideas regarding ‘ideal body shape/weight’.
What is the ICD-10 criteria for dx of bulimia nervosa?
‘Bulimia Patients Fear Obesity’
binging (2 episodes per week over 3 months of overeating)
purging
fear of fatness
(pre)occupied with eating
What features may a patient with bulimia nervosa present with?
Normal weight: Usually the potential for weight gain from bingeing is counteracted by the weight loss/purging behaviours.
Depression and low self-esteem.
Irregular periods.
Signs of dehydration: ↓ blood pressure, dry mucous membranes, ↑ capillary refill time, ↓ skin turgor, sunken eyes.
Consequences of repeated vomiting and hypokalaemia
Risk of low potassium (<3.5 mmol/L) ?
muscle weakness, cardiac arrhythmias and renal damage.
How could you investigate a patient with suspected BN?
Blood tests: FBC, U&Es, amylase, lipids, glucose, TFTs, magnesium, calcium, phosphate
Venous blood gas: May show metabolic alkalosis
ECG: Arrhythmias as a consequence of hypokalaemia (ventricular arrhythmias are life threatening), classic ECG changes (prolongation of the PR interval, flattened or inverted T waves, prominent U waves after T wave)
DDx for BN?
Anorexia nervosa – with bulimic symptoms.
EDNOS (Eating Disorder Not Otherwise Specified)
Depression
Obsessive–compulsive disorder
Organic causes of vomiting, e.g. gastric outlet obstruction.
Give 6 complications of BN
erosion of dental enamel
Russel’s sign (calluses on hands)
Mallory-Weiss tears
arrhythmias
renal stones / renal failure
amenorrhoea
How can BN be managed?
Biological: A trial of antidepressant should be offered and can ↓ frequency of binge eating/purging. Fluoxetine (usually at high dose, 60 mg) is the SSRI of choice. Treat medical complications of repeated vomiting, e.g. potassium replacement.
Psychological: Psychoeducation about nutrition, CBT-BN
Social: Food diary to monitor eating/purging patterns, techniques to avoid bingeing (eating in company, distractions), small, regular meals, self-help programmes.
Define personality disorder
A deeply ingrained and enduring pattern of inner experience and behaviour that deviates markedly from expectations in the individual’s culture, is pervasive and inflexible, has an onset in
adolescence or early adulthood, is stable over time and leads to distress or impairment
Give some risk factors for personality disorders
low socioeconomic status
family hx
poor parenting
abuse during childhood
How can you remember the 3 clusters of personality disorders?
WWW: Cluster A = ‘Weird’; Cluster B = ‘Wild’; Cluster C = ‘Worriers’
Give key features of Cluster A - Paranoid PD
SUSPECTS
Suspicious of others
Unforgiving (bears grudges)
Spouse fidelity questioned
Perceives attack
Envious (jealous)
Criticism not liked/Cold affect
Trust in others reduced
Self-reference
Give key features of Cluster A - schizoid PD
DISTANT
Detached (flattened) affect
Indifferent to praise or criticism
Sexual drive reduced
Tasks done alone
Absence of close friends
No emotion (cold)
Takes pleasure in few activities
Give key features of Cluster B - Emotionally Unstable PD
AM SUICIDE
Abandonment feared
Mood instability
Suicidal behaviour
Unstable relationships
Intense relationships
Control of anger poor
Impulsivity
Disturbed sense of self (identity)
Emptiness (chronic)
Give key features of Cluster B - Antisocial PD
CORRUPT
Callous
Others blamed
Reckless disregard for safety Remorseless (lack of guilt)
Underhanded (deceitful)
Poor planning (impulsive) Temper/Tendency to violence
Give key features of Cluster C - Anankastic / obsessional PD
LAW FIRMS
Loses point of activity (due to preoccupation with detail)
Ability to complete tasks compromised
Workaholic at the expense of leisure
Fussy (excessively concerned with minor details)
Inflexible
Rigidity
Meticulous attention to detail
Stubborn
DDx for AN?
Bulimia nervosa
Depression
Obsessive–compulsive disorder
Schizophrenia: Delusions about food
Organic causes of low weight: Diabetes, hyperthyroidism, malignancy
Alcohol or substance misuse.
