Deck 8 Flashcards
What is stress?
Stress is an imbalance between the demands made on us and our personal resources to deal with these demands.
Life events (LE): work problems or changes, debts, relationship difficulties, extended family problems, house move, examinations, diagnosis of physical illness.
It isn’t the LEs themselves that cause stress, but the interpretation and meaning to the individual.
LE > Appraisal > Stress
What is the difference between primary and secondary appraisal?
Primary Appraisal - appraisal of event.
Secondary Appraisal - appraisal of personal coping abilities or personal resources and also the resources external to them, mainly in the immediate social network.
What are the four types of stress response?
Emotional – feeling on edge, feeling sad, irritability, tearful, over-reacting
Cognitive – difficulty concentrating, difficulty switching off, sensitive to criticism, self-critical,
indecisive
Behavioural – Comfort eating, loss of appetite, drinking, smoking, over/under activity,
disturbed sleep
Physiological – Increased HR, increased RR, tense,
perspiration
People may misinterpret their physiological symptoms (e.g. increased heart rate > heart attack), leading to anxiety and increased stress (physiological) response.
What is a Medically Unexplained Symptom?
Medically Unexplained Symptoms are physical symptoms not explained by organic disease which cause distress and impair functioning and for which there is positive evidence or a strong assumption that the symptoms are linked to psychological factors e.g. (stress/distress/mental illness)
These symptoms are produced by unconscious mechanisms. Patients are not deliberately ‘putting them on’
Patients have varying degrees of insight or acknowledgement that a proportion of their symptoms are related to psychological factors
Most MUS are transient, but a substantial minority are more persistent and associated with medical consultation
MUS may also be referred to as psychosomatic illness, functional symptoms/overlay, somatoform disorders. They are given medically descriptive terms, such as:
Irritable bowel syndrome
Chronic fatigue syndrome
Fibromyalgia
Atypical non-cardiac chest pain
Non-epileptic seizures
Multiple chemical sensitivity syndrome
Irritable bladder
Explain the Biopsychosocial model of MUS.
Some MUS may arise from ‘normal’
bodily sensations (physiological processes) with misinterpretation (SEE STRESS RESPONSE)
Some MUS may arise from minor pathology and are exaggerated at times of stress
Other mechanisms at a neurobiological level
What is the indirect effect for chronic stress to affect disease?
- Poor compliance with medication.
- Increased alcohol intake.
- Increased smoking.
- Reduced excersise.
- Poor diet.
What is the direct effect that stress has on illness?
- Stress activates the hypothalamic-pituitary-adrenocortical axis (HPA) causing cortisol secretion and the sympathetic-adrenal-medullary system (SAM) causing catecholamine secretion.
- Plausible these systems are having dirrect effects at a cellular level but the final pathways are less clear.
What factors are you assessing in a mental state examination?
Appearance
Speech
Mood
Thought content
Abnormal beliefs and interpretations of events
Cognitive state
Insight
How do you assess appearance and behaviour in the mental state examination?
General appearance – self neglect, poorly fitting clothes, clothes not suitable for weather, flamboyant clothing.
Facial appearance – downcast eyes, vertical furrow forehead and downturned mouth may indicate depression. Manic patients look euphoric and less or more irritable. Relatively fixed faces may be parksonian side effects from medication or the disease itself.
Posture and Movements…. In schizophrenia you may see abnormal movements, e.g. echopraxia (imitation), posturing where the patient adopts a bizarre posture for a long time. Tics are repeated irregular movements involving a muscle group. Poor eye contact and hunched shoulders may indicate depression. Increased movements and inability to sit down may show mania. Restlessness is often a feature of anxiety.
Underactivity…. Stupor is when they are mute, immobile but fully conscious. Depressive retardation is a lesser form of psychomotor retardation seen in depression. Obsessional slowness is secondary to repeated doubts and compulsive rituals.
Overactivity is psychomotor agitation. It is usually not productive and leads to restlessness. Compulsion is repetitive and seemingly purposeful behaviour, e.g. cleaning, checking. Social behaviour
Try to establish a rapport. Is social behaviour within accepted social norms?
How do you assess speech in the mental state examination?
Rate may be increased in mania and reduced in depression. Quantity may be increased in mania and anxiety but reduced in dementia, schizophrenia and depression. Volume should also be noted.
Pressure of speech = increased rate and quantity. Poverty of speech = restricted amount of speech. Mutism = complete loss of speech. Dysarthria = difficulty in articulation of speech.
Forms of speech –
Flight of ideas. Accelerated thoughts, abrupt changes of topic, no central direction
Neologism. A new word constructed by a patient or a normal word used in an abnormal way.
Echolalia. Automatic imitation by patient of another person’s speech, even when they don’t
understand it.
Thought blocking. Sudden interruption in train of thought, leaving a blank and the patient
cannot recall what he/she had been saying or thinking.
Knights move thinking. Odd associations between ideas leading to disruptions in continuity
of speech.
All of the above changes in the form of speech can be described as a sign of thought disorder, which is a pattern of disordered language presumed to reflect disordered thinking. Psychosis is an abnormal condition of the mind, with a loss of contact with reality.
How do you assess mood in the mental state examination?
Mood can be defined as a persuasive and sustained emotion that, in the extreme, markedly colours the person’s perception of the world. Objective assessment based on history, appearance, behaviour and posture of patient. Subjective assessment as described by the patient.
Dysphoric mood is an unpleasant mood
Low or depressed mood may be accompanied by anhedonia, which is the loss of ability and
interest in regular and pleasurable activities.
Euphoria is a personal feeling of unconcern and contentment
Elation is an elevated mood or exaggerated feeling of well-being
Irritable mood presents with a tendency to be annoyed and provoked to anger
Anxiety
internal danger. There is phobic anxiety, free floating anxiety and panic attacks.
is a feeling of apprehension, tension or uneasiness owing to anticipation of an external or
An affect is a pattern of observable behaviours in that is in the expression of emotions. Inappropriate affect to the thought or speech expressed would occur, for example, if someone appeared cheerful when talking about recent bereavement. Flat affect is total or almost total absence of signs of expression of affect.
How do you assess thought content in the mental state examination?
Preoocupations – Note any thoughts, preoccupations and worries – e.g. hypochondriasis, the preoccupation with the fear of having a serious illness.
Obsessions – repetitive senseless thoughts that are recognised as irrational by patient and usually resisted.
Phobias – persistent irrational fear of an activity, object or situation, leading to avoidance. Fear out of proportion to real danger and cannot be reasoned away, being out of voluntary control.
Suicidal and homicidal thoughts.
Delusions – fixed, false personal belief based on incorrect inference about external reality firmly sustained in spite of what almost everyone else believes and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the culture. A primary delusion arises fully formed without any connection with previous events. Secondary delusion arises when a person is trying to make sense of their experiences. Passivity phenomena is a belief that an external agency is controlling oneself. This includes thought insertion, withdrawal and broadcasting. A delusional perception is when the patient attaches new and delusion significance to a familiar real perception, e.g. school bell rang, therefore I am the king.
Sensory deceptions such as illusion (a false perception of a real external stimulus) and hallucination (false sensory perception in the absence of a real external stimulus).
Pareidolia – vivid imagery occurs without conscious effort while looking at a poorly structured background such as a fire
Disorders of self-awareness - Disturbance of awareness of self-activity including depersonalisation – patient feels altered or not real; Derealisation – in which the surroundings do not seem real
How do you assess cognitive state in the mental examination?
Orientation – time, person and place
Attention and concentration – serial 7’s
Memory – immediate recall, registration and short term memory. Ask re recent events as
well as long term e.g. patient’s place and date of birth
General Knowledge – current prime minister, monarch, current news events
Mini-Mental State Examination - Scoring is out of 30 – to be used when there is memory loss
Orientation time and place 10 marks
Registration 3 marks
Attention and Calculation 5 marks
Recall 3 marks
Language and Praxis 9 marks
How do you assess insight in the mental state examination?
Degree of insight can be assessed by asking
“Do you think you are ill?”
“Do you think you have a mental illness?”
“Do you think that treatment is necessary?”
