Formulation part two Flashcards
What is the ICD code and criteria for depression?
F32
- Need two out of three:
1. Persistent sadness/low mood most days for two weeks
2. Anhedonia (loss of pleasure)
3. Anergia (fatigue) - And any of the following symptoms;
4. disturbed sleep
5. Poor concentration/indecisiveness
6. loss of confidence/self-esteem
7. change in appetite with corresponding weight gain/loss
8. suicidal thoughts/behaviour
9. change in psychomotor activity with agitation or retardation (subj or obj)
10. unreasonable feelings of guilt or self-blame
What is the categorization system for depression?
Mild [F32]: 4 or more symptoms Moderate [F32.1]: 5-6 symptoms Severe: 7 or more symptoms Severe without psychosis [F32.2] Severe with psychosis [F32.3]
Recurrent depression disorder = at least one previous episode, at least two months free of symptoms before current episode [F.33]
Depression differentials?
- Different level of depression, depression with/without psychosis
- Bipolar
- Physical illness e.g. hypothyroidism
- Alcoholism
- Medication induced e.g. blood pressure meds or steroids
- Grief reaction (social circumstances)
What are the biological explanations of depression
Predisposing:
- Female (twice as common)
- 40-50% heritability from twin studies (Lohoff et al, 2010)
- 2-3x more likely to develop if first-degree relative does
- HPA axis abnormalities, elavated cortisol and cotricotropin-releasing hormone (Varghese and Brown, 2001)
Precipitating:
- Phsyical health e.g. chronic physical illness
- Drug and alcohol abuse
- Insomnia
- medications linked to depression
Perpetuating
- long-term, chronic illness
- Co-morbidity
- non-adherence with medication
- continued use of certain medications
What are the psychological explanations for depression?
Predisposing: - Childhood Abuse/Trauma - Insecure attachment as a child - attachment issues - Personality traits - Anxiety or Eating disorder - PTSD - Depression in childhood Precipitating: - High stress and anxiety - Stressful life events - co-morbid personality disorder Perpetuating; - High levels of stress and anxiety - low self-esteem
What are the social explanations for depression?
Predisposing: - Adverse childhood environment - Migration - Urbanicity Precipitating: - financial problems - major life events - Young children 3-15 yrs - work changes - seperation from partner Perpetuating - unemployment - Poor housing - single parenthood - non-engagement with support - substance or alcohol misuse - social isolation/lack of social support
General prognosis for depression
- For a severe depressive episode there is spontaneous remission in many cases in 6-12 months, however, 10-20% have symptoms that last more than 2
years. - If the patient is concordant with a treatment plan the length of illness can be reduced. e.g. ADs or psychotherapy
Positive prognostic factor for depression
- male gender
- SES
- Social support
- insight
- engagement in treatment
- employment
- availability of treatment
Negative prognostic factors for depression
- Finanical difficulties
- lack of social support
- being single parent
- lack of insight
- non-engagement in treatment
- unemployment
- no avaliable treatment
- physical health difficulties
- co-morbidity
- experiences of childhood adversity
- Poor and limited relationships
What is the ICD diagnostic criteria for Mania?
[F30.1]
Mood must be predominantly elevated and abnormal for the individual. Mood must be prominent and sustained for at least 1 week and must contain three of the below:
1. increased activity or physical restlessnesss
2. increased talkativeness
3. flight of ideas or subjective experience of thoughts racing
4. loss of normal social inhibitions resulting in inappropriate behaviour
5. decreased need for sleep
6. inflated self-esteem and grandoise
7. distractability or constant changes in plans/activities
8. fool hardy or reckless behaviour
9. marked sexual energy or sexual indiscretions
What is the diagnostic criteria for hypomania?
[F30]
Mood must be predominantly elevated and abnormal for the individual for at least four days. They must have 3 of the below symptoms:
1. increased activity or physical restlessnesss
2. increased talkativeness
3. distractability or difficulty in concentration
4. decreased need for sleep
5. increased sexual energy
6. mild overspending or reckless or irresponsible behavior
7. increased sociability or over-familiarity
What is the ICD criteria for Mania with psychosis?
[F30.2]
Must meet the criteria for mania AND experience delusions or hallucinations
Subcategories:
F30.20 mania with mood congruent psychotic symptoms
F30.21 mania with mood incongruent psychotic symptoms
What are the differentials for bipolar
- Manic episode
- Schizoaffective disorder
- physical illness
- Illicit drug induced e.g. amphetamines and cocaine
- Medication-induced e.g. ADs or steroid treatment
What are the biological explanations for bipolar
Predisposing: - High heritability: 80-85% - Heritability between MZ twins 50% and 5-10% 1st degree relatives - Gender risk is equal - Abnormalities in brain receptors - Abnormalities in HPA axis Precipitating: - Physical illness - AD use with no mood stablisers - steroid use - drug and alcohol abuse - insomnia - childbirth in females Perpetuating - long term illness - continued steroid use - non-concordence with meds/ interventions - co-morbid conditions
How would you say the diagnosis for bipolar affective disorder?
Bipolar Affective Disorder with current episode
e. g. Bipolar affective disorder, with hypomania current episode
e. g.2. Bipolar affective disorder, with mania current episode with/without psychotic symptoms
e. g.3. Bipolar affective disorder with severe depression current episode with/without psychotic symptoms
What is rapid cycling bipolar?
At least 4 episodes within 12 months
What are the psychological explanations for bipolar?
Predisposing: - CT - Anxiety disorder or ADHD onset before 20years (in childhood) Precipitating: - High levels of stress and anxiety Perpetuating - Low self-esteem - Ongoing stress
What are the social explanations for bipolar?
Predisposing: - Urbanity - migration Precipitating: - Major life events Perpetuating: - Unemployment - poor housing - finanical worries - non-engagement with interventions - no or limited social support
What is the general prognosis for someone with bipolar disorder?
- prev: 1%
- Woman and men equal risk
- Patients with bipolar disorder are symptomatic nearly half of their adult lives with depressive
symptoms predominating - Up to 50% of all individuals with bipolar disorder are estimated to have made at least 1 suicide
attempt in their lifetime - 10% to 15% of untreated patients with bipolar disorder commit suicide.
- Substance abuse prevelence in those with bipolar is 60%
- Within the first 2 years after initial diagnosis, 40-50% of patients experience a relapse in mania.
- Most individuals with BPAD experience approximately 8 relapses in their lifetime
- On lithium: 50-60% of patients with Bipolar who are lithium treatment gain control of symptoms
however only ~7% of these patients on treatment have complete resolution of symptoms - On lithium: 45% of patients experience more episodes but good recovery in between. - 40% go on to have a persistent disorder
- Lithium reduces your chance of relapse by 30–40%, but the more manic episodes you’ve
had, the more likely you are to have another one - Often, the cycling between depression and mania accelerates with age.
Positive prognosis factors for bipolar?
Short duration of manic episodes
- Late age of onset
- No suicidal ideation
- No psychotic symptoms
- Good physical health
Negative prognosis factors for bipolar
Poor employment history
- Substance abuse
- Psychotic features
- Depressive features between periods of mania and depression
- Evidence of depression
- Male sex
- Pattern of depression-mania-euthymia
What is the main criteria for personality disorder?
- Persons behaviour deviates from cultural norms with severe disturbance to cognition, affectivity, control over impulses/gratification needs, and/or interpersonal
- Pervasive, inflexible and maladaptive causing significant functioning problems (without a trigger)
- Associated significant personal distress
- Stable and long-enduring with onset in childhood/adolescence manifesting into adulthood
What is the specific criteria for paranoid personality disorder?
Need four of the following:
- excessive sensitivity to set backs
- persistently bear grudges
- suspiousness and pervasive tendency to distort experiences as hostile
- combative sense of personal rights out of keeping with actual situation
- recurrent suspicions without justification regarding partners fidelity
- persistent self-referential attitude (excessive self importance)
- preoccupation with conspiratorical explanations of events (patient and the world)
What is the specific criteria for anakastic personality disorder
Include four of the below:
- excessive doubt/caution
- preoccupation with rules, lists, schedules, details, etc.
- perfectionism
- excessive conscientiousness
- preoccupation with productivity (except pleasure or relationships)
- excessive pedantry and adherence to social conventions
- rigidity and stubbornness
What is a schizoid personality disorder?
General criteria plus four of the following:
- few activities provide pleasure
- emotional coldness, detachment
- limited capacity to express emotions (warmth or anger)
- indifferent to praise or criticism
- little interest in sexual experiences
- consitent choice of solidary activities
- excessive preoccupation with fantasy
- no desire for close friends
- marked insensitivity to prevailing social norms - unintentional disregard
What is histronic personality disorder specific criteria?
At least four of below:
- self-dramatisation, exagerrated emotions
- suggestability
- shallow and liable afffectivity
- continual seeking excitement and desire to be center of attention
- inappropriate seductiveness in appearance and behaviour
- overly concerned with physical attractiveness
What is the specific criteria for anxious avoidant personality disorder?
Need four of below:
- persistent tension and apprehension
- feel inferior to others/ see self as socially-inept
- unwillingness to be involved unless they will be liked
- excessive preoccupation with criticism or rejection in social situations
- restricted due to needs for physical security
- avoidance of activities which involve interpersonal contact due to fear of rejection, disapproval or criticism
What is the specific criteria for dissocial PD?
Need three of the below or more:
- callous unconcern for others
- gross attitude of disregard for social norms
- incapacity to maintain enduring friendships, but no difficulty establishing them
- low tolerance to frustration, low threshold for violence
- cant feel guilt
- proneness to blame others
What is the specific criteria for emotionally unstable personality disorder - Impulsive type?
Must have three of the below (must include #2)
- act expectantly and without consideration for others
- quarrelsome behaviour and often in conflicts
- outbursts of violence/anger without ability to control ‘explosion’
- difficulty maintaining actions which offer no immediate reward
- unstable moods
What is the specific criteria for emotionally unstable personality disorder - Borderline type?
Must have at least three of the criteria for the emotionally unstable personality disorder - impulsive type PLUS two of the below:
- uncertainty about self-image, aims and preferences
- intense and unstable relationships
- excessive efforts to avoid abandonment
- recurrent self-harm
- chronic feelings of emptiness
What differential diagnosis is there for PDs?
- Head injury
- schizophrenia
- depressive episodes
What is the biological explanations for PDs?
Predisposing:
- Gender bias, woman more likely to get EUPD diagnosis
- Changes in neurotransmitters may be a risk factor as serotonergic activity can reduce ability to modulate responses.
- Intellectual disability
- Hereditability is evident for traits i.e. impulsivity and emotional dysregulation, rather than EUPD specifically.
- Overall hereditability for all cluster C personality disorders is approx. 27-35%. This is relatively low.
Perpetuating:
- Physical health co-morbidity
- Low IQ
What psychological factors explanations for PDs?
Predisposing: - CT e.g. neglect - Insecure attachment: Only 6-8% people with EUPD were securely attached in childhood - Prospective studies in children have shown that parental emotional under-involvement contributes to a child’s difficulties in socialising and perhaps to a risk for suicide attempts (Johnson et al., 2002) Precipitating: - High levels of stress and anxeity Perpetuating: - Lack of insight - regular self-harm - co-morbid mental illnesses
What are the social explanations for PDs?
Predisposing: - close family or friend with mood disorder or substance misuse disorder Precipitating: - relationship breakdown - redundancy - job loss Perpetuating: - unemployment - social isolation - non-engagement with support - frequent hospital admission - lack of social support - frequent instability
What is the general prognosis for emotionally unstable personality disorder
- EUPD improves with age - as time progresses people are less likely to meet the criteria for the disorder, e.g. 91% at 27 years post diagnosis
- Longer periods between crises promote longer term recovery.
- At 10 years, 85% of people will have experienced remission of symptoms for more than 12 months
- Reoccurance remains a risk - 11% at 10 year follow up
- Symptoms of self-harm and suicidality tend to remit over time, but chronic feelings of emptiness and low self-esteem persist.
- Risk of suicide is increased in people with EUPD and increases with age and continued self-harm.
- Increased comorbidity: 71-83% comorbid depression, 88% comorbid anxiety, 34-48% comorbid panic disorder
Self harm
- 1 in 3 will repeat in one year
- 3 in 100 of people who self-harm will kill themself within 15 years (50x more than general pop.)
- Risk is higher for men
