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Formulation Flashcards

1
Q

For psychiatric history, what needs to be noted? (10)

A
  1. Presenting complaint
  2. History of presenting complaint
  3. Past psychiatric history
  4. Personal history (include here family, thoughts on school, childhood etc.)
  5. Family history (e.g. mental illness in the family)
  6. Social history (e.g. employment, relationship status)
  7. Drugs/alcohol/smoking
  8. Physical health problems/Medications
  9. Forensic history
  10. Premorbid personality
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2
Q

What are the key areas to discuss with the mental state examination

A
  1. Appearance and behaviour
  2. speech
  3. Mood (subj, obj and bio symptoms)
  4. Thoughts - form and content
  5. Perceptions
  6. cognition
  7. insight
  8. Risk (to or from others, to self)
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3
Q

What are the three Ps and what do they mean?

A

Predisposing: prior making them vulnerable
Precipitating: Trigger
Perpetuating: Keeps it going

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4
Q

What is the diagnosis for alcohol dependency?

A

Need to have three of the following for at least one month (or if less than a month then needs to occurred repeatedly within 12 months)

  1. Desire or strong of compulsion to take the drug
  2. Difficulty controlling the amount consumed
  3. Experience withdrawal effects when discontinuing
  4. Tolerance to the drugs effects heightens, need more to feel an effect
  5. Alternatives in life are neglected due to preoccupation with substance
  6. Persistent use despite evidence of harmful consequences
  7. ONLY alcohol: Narrowing of repertoire
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5
Q

What possible differentials can be used for substance misuse?

A
  • Change what the ‘mental and behavioural disorder due to…’ to drugs or alcohol
  • GAD
  • Social phobia
  • Emotionally unstable personality disorder
  • Hypoglycaemia
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6
Q

What are the biological explanations which may underlie substance misuse?

A
  • Moderate heritability 30-36%
  • Male more likely
  • High tolerance to alcohol
  • Low facial flushing
  • Physical health comorbidities
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7
Q

What are the psychological explanations which may underlie substance misuse?

A
  • Childhood trauma
  • external locus of control
  • premorbid dissocial personality
  • High impulsivity/thrill-seeking
    Precipitating:
  • High levels of stress
    Perpetuating:
  • Dissocial personality
  • Lack of insight
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8
Q

What are the social explanations which may underlie substance misuse?

A 
predisposing:
- Close family member with dependency
- Early drinking age
Precipitating:
- Partner/Social support who drink alot
- Regular drinking, including binge drinking
Perpetuating:
- Unemployment
- Poor housing
- Financial worries
- Non-engagement with support
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9
Q

What are the general prognostic factors for substance abuse?

A
  • 1.3% UK adults dependent on alcohol
  • Continual alcohol use reduces life expectancy by 10 years
  • Risk of suicide increased by 3-15%
  • Longer abstinence, the better prognosis
  • After one year: 25% remain dependent, 27% partial recovery, 12% asymptomatic drinkers, 36% recovered (however mostly low risk)
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10
Q

What are ‘asymptomatic drinkers’?

A

Previously dependent individuals who are currently drinking to harmful levels (over the recommended level
but without dependency symptoms) are asymptomatic drinkers. They remain at elevated risk of relapse into
dependency.

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11
Q

What are the positive prognostic factors for substance abuse?

A 
Stable employment
Stable relationship
Older age at treatment
Motivation to change/insight
Care co-ordination
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12
Q

What are the negative prognostic factors for substance abuse?

A 
Lower social-economic status
Lower education levels
Severe problems
Complex co-morbidities
Poor insight
Premorbid dissocial personality
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13
Q

What is the ICD code for dependency disorder?
What is the code for mental and behavioural disorder due to….
- Alcohol use
- Opioid use
- Cocaine use

A

F1x2

Alcohol F10
Opioids F11
Cocaine F14

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14
Q

What is salience in regard to substance abuse?

A

the property of being noticeable or important; in dependency increased salience to alcohol, or other substance of abuse, leads to neglect of alternative activities or needs.

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15
Q

What is formication?

A

sensation of small insects crawling on, or under, the skin. Also known as Ekbom’s Syndrome, a feature of cocaine use

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16
Q

What is othello syndrome?

A

a type of delusional jealousy, marked by suspecting a faithful partner of infidelity, with accompanying jealousy, attempts at monitoring and control, and sometimes violence. Associated with alcohol dependence

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17
Q

What is delirium tremens?

A

a psychotic condition typical of withdrawal in chronic alcohol dependency, involving tremors, hallucinations, anxiety, and disorientation.

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18
Q

What is a lilliputian hallucination?

A

a hallucination in which things, people, or animals seem smaller than they would be in real life.

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19
Q

What is confabulation?

A

a disturbance of memory, defined as the production of fabricated, distorted, or misinterpreted memories about oneself or the world, without the conscious intention to deceive. Feature of Wernicke-Korsakoff Syndrome.

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20
Q

What is narrowing of repertoire?

A

Instead of consuming a variety of drinks, or modifying drinking behaviour to suit the situation, the types of alcoholic beverage is restricted.

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21
Q

What is anterograde amnesia?

A

loss of memory for events occurring after the onset of a brain injury. Associated with the inability to learn and repeat simple pieces of information or learn new tasks. Often causes disorientation in time and place. Feature of Wernicke-Korsakoff Syndrome

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22
Q

What is the diagnostic criteria for panic disorder? and How many of the general anxiety criteria is needed?

A

[F41.0]
- Panic attacks need to be recurrent and not associated with a specific situation, they appear spontaneously
- Panic attacks are characterised by the following:
A) episode of intense fear or discomfort
B) starts aruptly
C) Reachs maximun in a few minutes and lasts at least some minutes
D) Need at least of the four of the anxiety symptoms

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23
Q

For an anxiety disorder, what is the general criteria needed?

A 
Arousal symptoms
1. sweating
2. trembling or shaking
3. dry mouth
4. palpitations/pounding heart/accelerated heart rate
Chest and Abdomen
5. difficulty breathing
6. feeling of choking
7. chest pain or discomfort
8. nausea or abdominal distress
Mental state:
9. dizzinesss, unsteady, faint, light-headed
10. derealisation, depersonalisation
11. fear of loosing control 'go crazy'
12. fear of dying
General symptoms:
13. hot flush or cold chill
14. numbness or tingling sensation
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24
Q

What is the diagnostic criteria for generalised anxiety disorder? and How many of the general anxiety criteria is needed?

A 
[F41.1]
- Must worry on more days than not with persistent worry or tension for at least 6 months
- Additional to the main criteria need one of the following:
Tension
15. muscle tension or aches or pains
16. restlessness
17. feeling on edge, mentally tense
18. lump in throat, difficulty swallowing
Other non-specified
19. exaggerated response to minor 
20. difficulty concentrating
21. persistent irritability
22. difficulty to get to sleep
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25
Q

What are the diagnostic criteria for social phobia disorder? and How many of the general anxiety criteria is needed?

A

[F40.1]
Must have one of the two following:
1) fear of being the focus of attention, or fear of behaving in an embarrassing way
2) Avoidance of being focus of atttention, or avoidance of social situations where behaviour may be embarrassing

Also, need at least two of the main criteria with either
A) Blushing or shaking
B) Fear of vomiting
C) urgency or fear of micturition or defecation

26
Q

What are the diagnostic criteria for agoraphobia disorder? and How many of the general anxiety criteria is needed?

A 
[F40.0]
Fear and avoidance of:
1. crowds
2. public places
3. travelling alone
4. travelling away from home
  • Plus four of the main anxiety symptoms
  • Agoraphobia can be with or without panic disorder
27
Q

What are the diagnostic criteria for specific isolated phobia disorder? and How many of the general anxiety criteria is needed?

A

[F40.2]
Neither one of below
1. fear of specific object / situation
2. Avoidance of specific object / situation

Need to have symptoms of anxiety main criteria

Can be split into 4 subtypes: Animal type, nature forces, blood/injection/injury type, situational type (e.g. lifts)

28
Q

.What is the ICD code for GAD? and panic disorder?

A

GAD F41.1

Panic F40.0

29
Q

What are the biological explanation for anxiety disorders?

A

Predisposing:
- Genetic heritability approx. 30% GAD (Dellava et al, 2011)
- Serotonin, norepinephrine and GABA implicated
- Female gender (more likely - however mixed evidence with GAD - Moreno-Peral et al, 2014)
Precipitating and perpetuating:
- physical illness
- drug abuse
- middle aged, fragility of life

30
Q

What are the psychological explanation for anxiety disorders?

A 
Predisposing:
- Personality traits e.g. harm advoidance, behavioural inhibition, neuroticism (Kessler et al, 2008)
- Childhood trauma (Edwards et al, 2003)
- Attachment issues
- High levels of stress
Precipitating:
- High stress 
- Stressful life event
- co-morbidity (e.g. depression 50% comorbidity or cluster C PDs)
Perpetuating:
- Low self-esteem
- High stress
31
Q

What are the social explanation for anxiety disorders?

A 
Predisposing:
- Low SES (Moreno-Peral, 2014)
Precipitating:
- Financial difficulties (Beesdo et al, 2009)
- Major life event e.g. bereavement
Perpetuating:
- Smoking and substance misuse
- High stress situations e.g. housing issues
- Low social support = social isolation
32
Q

What are the general prognostic factors for anxiety disorders?

A
  • UK prev. 5.9% (Stansfeld et al, 2016)
  • Only 48% of sufferers in treatment (Lubian et al, 2016)
  • More prevalent in woman
  • GAD chronic and low remission, 1 in 4 symptomatic remission with average illness duration of 20 years (Yonkers et al, 1996) however hospital sample
  • Tyler et al (2004) 40% of GAD sample had fully recovered within 12 years.
  • Social functioning poor, 30% reduction in work productivity
33
Q

What are the positive individual prognosis factors for anxiety disorders?

A
  • Social support
  • Insight
  • Positive engagement with treatment
  • employment
  • quicker engagement in treatment
  • Quicker diagnosis
34
Q

What are the negative individual prognosis factors for anxiety disorders?

A
  • comorbid depression or other illness
  • Physical comorbidity
  • financial difficulties
  • lack of insight
  • social isolation
  • childhood trauma exposure
  • traumatic life events
35
Q

What differential diagnosis could be given for anxiety disorder?

A
  • Depression
  • Eating disorder
  • Personality disorders cluster C
  • Autoimmune thyroiditis
  • Psychosis
  • Somantization disorder
  • Drug or alcohol withdrawal symptoms
  • Drug or alcohol induced
  • Medication-induced
36
Q

What is the ICD code, and criteria, for Anorexia Nervosa?

A

[F50.0]

  1. Weight loss leading to body weight at least 15% below normal for age/height
  2. Weight loss is self-induced by avoidance
  3. Self-perception of being too fat, dread fatness leading to self-imposed low weight thresholds
  4. A widespread endocrine disorder involving HPA axis (hormones) e.g. amenorrhoea in woman, potency and sex drive in men
37
Q

What is the ICD code, and criteria, for Bulimia Nervosa?

A

[F50.2]

  1. Recurrent episodes of overeating (At least twice a week, for three months)
  2. Preoccupation with eating, strong desire or compulsion to eat
  3. Patient tries to counteract the eating via self-induced vomiting, self-induced purging, alternating periods of starvation, or use drugs (e.g. appetite suppressants or avoid insulin treatment)
  4. Self-perception of being too fat, dread of fatness
38
Q

What is the ICD code, and criteria, for Binge Eating Disorder?

A
  1. Recurrent episodes of binge eating with control loss plus three of the following:
    A) Rapid consumption of food
    B) Eating until unpleasantly full
    C) Eating without being hungry
    D) Frequent food intake causes embarrassment, disgust or feelings of guilt after binge
    E) Suffering pressure due to ones eating habits
    F) No compensatory measures for weight reduction
39
Q

What could be a differential diagnosis for an eating disorder?

A
  • Anxiety
  • Depression
  • Hyperthyroidism
  • Inflammatory bowel disease
  • OCD
  • Somatization disorder
  • PD cluster B is common with BN, cluster C common with AN
40
Q

Provide the biological explanation for EDs

A

Predisposing:
- AN heritability of 58% (Wade et al, 2000)
- Genetic overlap between AN and BN
- Gene-brain derived neurotrophic factor (BDNF)
- Specific at-risk chromosome e.g. 1p34 (Grice et al, 2002)
- Serotonin receptor abnormalities
- Phenotypes (Collier and Treasure, 2004)
Precipitating:
- Food allergies contribute to restrictive eating
- presence of type one diabetes
Perpetuating
- Neuroadaption
- Neuroprogression
- Structural brain changes e.g. loss of grey matter (Van den Eynde et al, 2011)

41
Q

Provide the psychological explanation for EDs

A 
Predisposing:
- CT
- Personality traits e.g. perfectionism, emotional dysregulation
- Anxiety disorder (esp. social anxiety)
- Depression
- OCD
- Poor attachment (Gander et al, 2015)
Precipitating
- High stress or anxiety
- Adverse life event
Perpetuating:
- Automated habits / rituals
42
Q

Provide the social explanation for EDs

A 
Predisposing: 
- Cultural promotion of thinness and 'ideal body type'
- Social difficulties
Precipitating:
- Significant life event
- size/weight prejudice discrimination
- dieting
Perpetuating;
- Lack of social support
- Experiences of prejudice and discrimination
- Interpersonal difficulties
- Lonilessness or social isolation (McKnight et al, 20090
43
Q

What is the general prognosis for EDs?

A
  • AN: 50% good outcomes, 30% intermediate, 20% poor
  • BN: 45% good, 18% intermediate, 21% poor (Herzog et al, 1996)
  • AN highest mortality rate of all psychiatric disorders (Yilmaz et al, 2015)
  • Prevelence AN and BN 1-2% across Europe, 3-10% BED
  • Longer duration of untreated illness = worse prognosis
  • High amounts of co-morbidity (depression up to 80%, OCD approx. 30%, substance abuse AN 12-18% BN 30-70%, Social anxiety 39%)
44
Q

What are the individual positive prognosis factors for EDs?

A
  • Quick diagnosis
  • Quickly engaged with treatment near onset
  • Good social support
  • If onset is during adulthood, later life
  • Treatment when in early stages of illness
  • Good vocational training
  • No comorbidity
  • Motivation
45
Q

What are the individual negative prognosis factors for EDs?

A
  • Long duration of untreated illness
  • delayed diagnosis
  • delayed treatment
  • Early onset (developmental stunting)
  • Social difficulties
  • premorbid
  • unemployed or poor vocational functioning
  • Entrenched habits which are hard to change
  • employment in certain industries
  • sense of mastery
46
Q

What is the ICD criteria for OCD? and the code?

A

F42
1. Obsessional symptoms or compulsive acts or both must be present on most days for at
least 2 successive weeks and be a source of distress or interference with activities
2. Symptoms must include the below four:
a. they must be recognised as the individual’s own thoughts or impulses.
b. there must be at least one thought or act that is still resisted unsuccessfully,
even though others may be present which the sufferer no longer resists.
c. the thought of carrying out the act must not in itself be pleasurable (simple
relief of tension or anxiety is not regarded as pleasure in this sense).
d. the thoughts, images, or impulses must be unpleasantly repetitive.

47
Q

What could be a differential diagnosis?

A
  • depression
  • GAD
  • Anakastic personality disorder
  • Substance abuse induce anxiety
48
Q

What is the biological explanation of OCD?

A

Predisposing:
- OCD occurs in first degree relatives of patients in ~10%
- Concordance on monozygotic twins in 68% compared to 31% for dizygotic twins.
Precipitating:
- paediatric autoimmune neuropsychiatric disorders associated with streptococcal
infection (PANDAS) - Believed to
be an autoimmune response causing damage to basal ganglia
- Childbirth
Perpetuating:
- Physical health co-morbidity

N.B 50% of individuals with Tourette’s syndrome have OCD.

49
Q

Provide the psychological explanation for OCD?

A 
Predisposing:
- CT
- Personality traits e.g. neat, meticulous and methodical people 
- generally anxious people
- People with strong sense of responsibility with perfectionist beliefs
Precipitating:
- High stress/anxeity
- Adverse life event
Perpetuating:
- Low self-esteem
High stress
50
Q

What are the social explanations for OCD?

A 
Predisposing:
- Migration
- Urbanity
Precipitating:
- significant life event
- financial problems
- Employment changes
Perpetuating:
- Stress from work
- Poor housing
- financial problems
- Lack of social support
51
Q

What are the general prognosis factors for OCD?

A
  • Annual prevalence rate of ~1%; Lifetime prevalence 2-3%
    • Mean age of onset is in late adolescence for men and early twenties for women but
    onset covers a wide range.
    • Often comorbidity with a range of disorders, especially depression
    • OCD can be a disabling and chronic condition.
    • Skoog and Skoog (1999) 40-year prospective study OCD:
  • approximately 60% of people with OCD displayed signs of general improvement
    within 10 years of illness, increasing to 80% by the end of the study
  • 20% achieved full remission
  • 60% continue to experience significant symptoms
  • 10% displayed no improvement
  • 10% deteriorated further
  • Retain a risk of relapse with 20% who have early, sustained recovery relapsing even
    after 20 years without symptoms
52
Q

What are the negative prognosis factors for OCD?

A
  • Early age of onset
  • Long duration
  • Male gender
  • Magical thinking (schizotypal PD)
  • Poor social adjustment
  • Early chronic course
53
Q

What are the positive prognosis factors for OCD?

A
  • Later age of onset
  • Supportive partner
  • Short duration of illness
  • Female gender
  • Engagement with psychological treatment and medication
54
Q

Define egosynstonic

A

thoughts and behaviour that are acceptable to the individual and
consistent with their fundamental personality and beliefs

55
Q

Define egodystonic

A
  • thoughts and behaviours that are in conflict with the person’s ideal
    self-image
56
Q

Define an Obbession

A

an idea or thought that continually preoccupies or intrudes on a
person’s mind.

57
Q

Define a compulsion

A

an irresistible urge to behave in a certain way

58
Q

What is a thought insertion?

A

a form of thought interference occurring when the individual
feels as if one’s thoughts are not their own but belong to someone else and have
been inserted into their mind (psychotic symptom – perceptual abnormality)

59
Q

What is meant by stereotyped behaviour?

A

repetitive, invariant behaviour pattern with no obvious goal

or function

60
Q

What is an intrusive thought?

A

an unwelcome involuntary thought, image or idea that is

distressing and can feel difficult to manage or eliminate

Formulation (3 decks)

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