Lectures Flashcards
What is the most common group of mental disorders in ICD-10?
Mood disorders
What are mood disorders?
Disorder of mental status and function where altered mood is the (or a) core feature
Refers to states of depression and of elevated mood-mania
How can mood disorders present?
Primary problem or consequence of other disorders or illness e.g cancer, dementia, drug misuse or medical treatment
What symptoms are mood disorders often associated with?
Anxiety disorders
What is dysthymia?
Below threshold version of depression, carry out normal activities but low mood.
What is depression?
Symptom = emotion within the range of normal experience
Syndrome = a constellation of symptoms and signs
Recurrent illness = recurrent depressive disorder
When does depression become a disorder?
- Persistence of symptoms (at least 2 weeks)
- hypervasiveness of symptoms
- degree of impairment
- presence of specific symptoms or signs
What are the 3 categories for the symptoms of depressive illness?
Psychological
Physical
Social
List psychological symptoms of depressive illness.
Change in mood: depression, anxiety, perplexity, anhedonia
Change in thought content: built, hopelessness, worthlessness, neurotic (e.g obsessive thoughts, panic attacks), delusions and hallucinations
List physical symptoms of depression.
Change in bodily function e.g energy, sleep, appetite, libido, constipation, pain
change in psychomotor functioning e.g agitation, retardation
Give an example of an idea of reference.
E.g group of people are laughing and you assume they are laughing at you.
What is a delusion?
belief or impression maintained despite being contradicted by reality or rational argument
e.g feel like you are rotting inside
List social symptoms of depressive disorders.
Loss of interest
irritability
apathy
withdrawal, loss of confidence, indecisiveness, loss of concentration, registration, memory
How long does a patient need to have symptoms to diagnose a depressive disorder?
2 weeks
What is anhedonia?
loss of ability to derive pleasure from experience
What is apathy?
Loss of interest in own surroundings
According to the ICD-10, what is required to confirm depressive disorder?
2 weeks
no hypomanic or manic episodes
not linked to psychoactive substance
What is somatic syndrome.
Can occur without feelings of sadness/low mood
Lack of interest/pleasure/emotional reactions.
Depression worst in morning
Loss of appetite, weight loss and loss of libido.
What do you need to diagnose mild depression and moderate depression.
2 of……
- abnormal depressed mode most of day almost everyday for past two weeks
- loss of interest or pleasure
- decreased energy/increased fatigue
Mild - 4 out of the list of symptoms. Moderate - 6 out of the list of symptoms
When is there an increased risk of postpartum depression?
30 days after childbirth up to 24 months
What are differentials for depressive disorders?
normal reaction to life event SAD Dysthymia Cyclothymia Bipolar Stroke Tumour Dementia Hypothyroidism Addison's Hyperparathyroidism Infections e.g influenza, hepatitis, HIV Drugs
What is the first line treatment for depressive disorders?
SSRIs
Apart from SSRIs, what are other antidepressants used for depressive disorders?
TCAs, monoamine oxidase inhibitors
Apart from meds, what else can be used to treat depressive disorders?
Psychological e.g CBT
Physical e.g ECT, psychosurgery, vagus nerve stimulation
How do you measure depressive disorders?
SCID
SCAN
What is mania?
Elevated mood often associated with grandiose ideas, disinhibition, loss of judgement, similarities to stimulant drugs e.g cocaine.
What are 4 key points of mania?
Persistence of symptoms
pervasiveness of symptoms
degree of impairment
presence of specific signs or symptoms
What is hypomania?
Lesser degree of mania with no psychotic symptoms (hallucinations, delusions)
List symptoms of mania.
elevated mood increased energy overactivity pressure of speech decreased need for sleep disinhibition grandiosity alteration of senses extravagant spending can be irritable
1 week of symptoms severe enough to disrupt work and social activities
List differential diagnoses for mania.
Mixed affective state Schizoaffective disorder Schizophrenia Cyclothymia ADHD Drugs and alcohol Stroke Tumour Epilepsy AIDS Neurosyphilis Cushings Hyperthyroidism SLE
What tools can you use to measure mania?
SCID, SCAN
What are treatment options for mania?
Antipsychotics
Mood stabilisers
Lithium
ECT
List examples of antipsychotics.
Olanzapine
Risperidone
Quetiapine
Give examples of mood stabilisers.
Sodium valproate
Lamotrigene
Carbamazepine
What is bipolar affective disorder?
Repeated (2+) episodes of depression and mania or hypomania
What is the epidemiology of bipolar disorder?
Early onset (15-19) usually with positive FH M=F Mean age of onset is 21
What is the epidemiology of depression?
Mean age = 27
F:M = 2:1
Less common in those employed and financially independent
Associated with lower educational attainment
First episode can be linked to adverse life event
What is the clinical course and outcome of major depression?
4-6 month duration
around half recover in 26 weeks
80+% have further episodes
What is the clinical course and outcome of bipolar/mania?
1-3 months
60% recover at 10 weeks
90% have further episodes
What is the most common type of affective disorder?
Depression
List three common mental health disorders.
Affective/anxiety
Substance misuse
Disorders of reaction to psychological stress
Give examples of affective/anxiety disorders.
Major depressive disorder
Generalised anxiety disorder
Panic disorder and phobic anxiety
OCD
Give examples of substance misuse disorders.
Due to drugs, tobacco, opioids/benzo/stimulants
Give an example of disorders of reaction to stress.
PTSD
What is cognitive behavioural therapy?
Show how thoughts affect/are related to feelings and behaviour
Patient centred
Goal orientated
Can involve exposure therapy
What is CBT useful for?
Depression Anxiety Phobias OCD PTSD
Give examples of ‘thinking errors’.
Automatic negative thoughts Unrealistic beliefs Cognitive distortions Catstrophizing Balck and white/all or nothing thinking Perfectionism
What is behavioural activation?
Activities function as avoidance and escape from aversion, thoughts, feelings and external situations
Client taught to analyse unintended consequences of the way they are responding
Collaborative/empathic/non-judgemental
Small changes –> long term goals
What is interpersonal psychotherapy?
Focussed on present
Time limited
Treatment for depression/anxiety
Depression often follows a disturbing change in or contingent with significant I-P event
Construct interpersonal map and focus area
List 4 therapies used for common mental health disorders.
CBT
Behavioural activation
IPT
Motivational interviewing
What are benefits of interpersonal psychotherapy.
No homework
Can continue practising skills
What are disadvantages of IPT?
Requires reflection
Limited interpersonal support if poor social networks
What is motivational interviewing?
Promotes positive behaviour change
Used where behaviour change is being considered when patient may be unmotivated or ambivalent to change
More effective than advice giving
Shows empathy, avoids argument, support self-efficacy
What are the stages of change?
Pre-contemplation -> contemplation -> planning -> action -> maintenance
What is stigma?
Devalues people due to distinguishing characteristic
List approaches to reduce stigma in mental illness.
Societal Individuals Good medication management CBT Consider own attitudes and awareness Influence of celebs
What are controversies in mental health?
Diagnosis, social control, treatment without consent, rising rates of antidepressant prescription, security, detention, ECT
List indications for antidepressants.
Unipolar and bipolar depression
Organic mood disorders
Schizoaffective disorder
Anxiety disorders (OCD, panic, social phobia, PTSD)
How long does it take for antidepressants to reach their maximum effect?
3-6 weeks
List classifications of antidepressants.
TCAs MAOIs SSSRIs SNRIs Novel antidepressants
What are the unacceptable side effects of TCA?
Antihistaminic (sedation and weight gain)
Anticholinergic (dry mouth, eyes, constipation, memory defects)
Antiandrenergic (orthostatic hypotension, sedation, sexual dysfunction)
QT lengthening
What are tertiary TCAs?
Amine side chains
Give examples of tertiary TCAs.
Imipramine, amitriptyline
What are the differences between tertiary and secondary TCAs?
Tertiary - block serotonin
Secondary - block noradrenaline, less severe side effects
What are side effects of MAOIs?
Orthostatic hypotension, weight gain, dry mouth, sedation, sexual dysfunction, sleep disturbance
What can develop when MAOIs are taken with tyramine-rich food or sympathomimetics?
CHEESE REACTION - Hypertensive crisis
What can causes serotonin syndrome?
If taking MAOI with meds that increase serotonin or have sympathomimetic actions.
What are symptoms of serotonin syndrome?
Abdo pain, diarrhoea, sweats, tachycardia, HTN, myoclonus, irritability delirium
How do SSSRIs work?
Block serotonin pre-synaptic re-uptake
What are SSRIs used for?
Anxiety and depression
What are most common SEs of SSRIs?
GI upset, sexual dysfunction, anxiety, restlessness, nervousness, insomnia, fatigue, sedation, dizziness
Give examples of SSRIs.
Paroxetine Sertraline Fluoxetine Citalopram Escitalopram Fluvoxamine
What is discontinuous syndrome?
Coming of SSRIs - lasts about 1 week - 10 days (agitation, nausea, dysphoria)
What is activation syndrome?
Serotonin reuptake inhibitors (SSRI) have been associated with a state of restlessness, lability, agitation, and anxiety termed “activation syndrome”. In some people, this state change can increase suicidal tendencies, especially in those under age 25 and during the initial weeks of treatment.
How do SNRIs work?
Inhibit serotonin and noradrenergic reuptake like the TCAS but without anthistamine, antiadrenergic or anticholinergic side effects
Give examples of SNRIs.
Venlafaxine
Duloxetine
Mirtazapine
Susie has a non psychotic unipolar depression with no history of hypomania or mania. She has depressed mood, hyperplasia, psychomotor retardation and hyper somnolence. What agent would you use to treat her?
SSRI
Citalopram, Fluoxetine or Sertraline
less sedating
55yo DM, mild HTN, painful diabetic neuropathy, previous depressive episodes and one suicide attempt. Treated with paroxetine, sertraline and bupoprion. What would you treat him with?
Duel reuptake inhibitor as ge had not achieved remission with two SSRIs.
Don’t give venlafaxine since HTN.
Duloxetine good since indication for neuropathic pain, depression and anxiety.
Don’t give TCA since lethality in overdose.
How do you treat resistant depression?
SSRI –> SNRI
Combine antidepressants e.g SSRI or SNRI + Mirtazepine
Adjunctive Rx with lithium
Adjunctive Rx with atypical antipsychotic]
ECT
Discuss prophylaxis of antidepressants.
1st episode - 1 year
2nd episode - 2 years
3rd episode = lifelong
What are indications for mood stabilisers?
Bipolar
Cyclothymis
Schizoaffective
List classes of mood stabilisers.
Lithium, anticonvulsants, antipsychotics
What is the only medication that has been shown to reduce suicide rate?
Lithium
What is lithium used for?
Long-term prophylaxis of mania and depressive episodes in 70%+ of bad.
What do you need to get a baseline of before starting lithium?
U&E and TSH
since hypothyroidism and small vessel damage in kidneys
Why should you do a pregnancy test before prescribing lithium?
Ebstein’s anomaly
What are the most common side effects of lithium?
GI distress, reduced appetite, N&V, diarrhoea, thyroid abnormalities, nonsignificant leukocytosis, polyuria, hair loss, acne, intention tremor, convulsions
Give examples of anticonvulsants used as mood stabilisers.
Valproic acid
What tests do you need to do before starting valproic acid?
Baseline LFTs, FBC and pregnancy test
List SEs of valproic acid
N&V Sedation Tremor Hair loss Platelet dysfunction Thrombocytopenia
What is carbamazepine prescribed for in psychiatry?
First line for acute mania and mania prophylaxis
What tests do you need to carry out before taking carbamazepine?
FBC, ECG, LFTs
What are SEs of carbamazepine?
Rasg
N&V&D
Sedation, dizziness, ataxia, confusion, aplastic anaemia, agranulocytosis, water retention
What are SEs of lamotrigine?
N&V Sedation Dizziness Confusion Stevens Johnson's Syndrome
What is lamotrigine used for?
Bipolar depression
What are antipsychotics prescribed for?
Bipolar affective disorder
Give examples of antipsychotics
Ariprazole
Risperdone
Quetiapine
Olanzapine
33 year old woman, hospitalised with first episode of mania, no previous history of a depressive episode, no drug or ETOH history and has no medical issues. What medication would you start?
Lithium
Remember to check for pregnancy, TFT and U&Es
You start Mary on a 800mg dose of lithium when she comes to see you in one week, she I complaining of stomach irritation and diarrhoea. What do you think is going on and what should you do?
GI irritation including diarrhoea is common particularly in early treatment
encourage to drink
27yo male admitted secondary to manic episode. Review history and find he has 5 to 6 manic or depressive episodes a year. Also struggled on and off with ETOH abuse. What medication would you like to start?
Depakote since rapid cycler (4 or more depressive or mani episodes/year) and because of comorbid ETOH abuse
A patient on Depakote has raised LFTs, what happened and what do you do?
Not unusual for anticonvulsants to increase LFTs and as long as they don’t triple, no change in therapy indicated.
What is psychosis?
An inability to distinguish between symptoms of delusion, hallucination and disordered thinking form reality
What are hallucinations?
Have the full force and clarity of true perception, no external stimulus, not willed or controlled, located in external space
Sensory - x5 (auditory/visual, tactile, olfactory and gustatory)
What is a delusion?
An unshakeable idea or belief which is out of keeping with the person’s social and cultural background; it is held with extraordinary conviction.
What illnesses may have psychotic symptoms?
Schizophrenia
Delirium
severe affective disorder (e.g depressive episode with psychosis, manic episode with psychosis)
What is schizophrenia?
Severe mental illness affecting thinking, emotion and behaviour. Most common cause of psychosis.
What are symptoms of schizophrenia?
Hallucinations, delusions, disordered thinking
Apathy, lack of interest, lack of emotions
According to the ICD-10, what are the symptoms/signs of schizophrenia?
For more than a month in the absence of organic or affective disorder, at least one of:
- Alienation of thought
- passivity
- hallucinatory voices
- persistent delusions
AND/OR 2 of:
- persistent hallucinations
- breaks or interpolations in the train of thought
- catatonic behaviour
- “negative” symptoms e.g apathy
How many types of schizophrenia are there? Give examples of 2.
9
Paranoid
Residual
What are risk factors for psychosis?
- Biological: genetics, neurochemistry e.g “dopamine hypothesis”, obstetric complications, maternal influenza, substance misuse, malnutrition and female
- Psychological
- Social: occupation, social class, migration, social isolation, life event precipitants
- Evolutionary theories e.g Jung’s concept of collective unconscious
What would suggest delirium or acute organic brain syndrome psychosis?
Consequence of brain or systemic disease, prominent visual hallucinations and illusions affect of terror, delusions are prosecutors and evanescent, worse at night
What would suggest depressive episode psychosis?
Delusions of guilt, worthlessness and persecution, derogatory auditor hallucinations
What would suggest manic episode psychosis?
Delusions of grandeur, special powers or messianic roles, gross overactivity, irritability and behavioural disturbance, manic excitement
What are signs of schizoaffective disorder?
Mix of affective and schizophrenia like features.
What early intervention services should be in place for the diagnosis of the first episode of schizophrenia?
Family involvement
Psychological interventions
Vocational/educational interventions
Antipsychotic medication
If there is no response to a medication despite dose optimisation, how long should you wait before changing antipsychotics for schizophrenia?
4 weeks
What medication should be considered first for acute exacerbations or recurrence of schizophrenia??
Amisulpride
Olanzapine
Risperidone
alternative = chlorpromazine
What should be considered for maintenance treatment of schizophrenia?
Amisulpride
Olanzapine
Risperidone
alternative = chlorpromazine
How long should maintenance treatment for schizophrenia be offered for?
2 years
How do you treat treatment resistant schizophrenia (not responded to 2)?
Clozapine
Then Clozapine + second SGA
Then dozapine augmentation with lamotrigine
What psychological therapies can be used for schizophrenia?
CBT
Cognitive remediation
Family intervention
Social skills training
Who should not take clozapine?
Women who are breast feeding.
Pregnancy
List good prognostic factors for schizophrenia.
Absence of family history, good premorbid function
acute onset
mood disturbance
prompt treatment
What are poor prognostic factors for schizophrenia?
Slow onset
Prominent negative symptoms
Comorbidity
What are the principles of the mental health (care and treatment) (Scotland) act 2003?
Non-discrimination Equality Respect Reciprocity Informal care Participation Child welfare
What does section 328 define a mental disorder as?
Any mental illness, personality disorder or learning disability, however caused or manifested
List four key civil compulsory powers to detain.
EDC - 72 hours
STDC - 28 days
CTO - 6 months
Nurses holding power - 3 hours
Who can detain with a STDC or EDC?
Medical practitioner
What is the process for a compulsory treatment order?
Application to mental health tribunal made by mental health officer. Mental health report ( GP + approved medical practitioner or 2 medical practitioners)
What are the principles for detaining a patient?
Mental disorder and as a result patient’s decision making impaired, necessary for Rx that is available, risk to individual and/or others, order necessary
Who does the adults with incapacity (Scotland) act 2000 protect?
Individuals incapable of acting, making decisions, communicating decisions, understanding decisions, retaining memory of decisions
When applying for the adults with incapacity act, what must be considered?
Intervention must benefit, least restrictive option, consider past/present wishes of individual, relatives, guardians, attorneys etc.
What do you assume with regards to capacity?
It is present unless proven otherwise
What are the two powers regarding the adults with incapacity act?
Intervention order or guardianship order
What powers do the police have for mentally disordered offenders according to the criminal procedure (Scotland) act 1995?
Removal from public place if an immediate need of care/Rx, removal to safe place
Can detain for 24 hours
According to the criminal justice and licensing (Scotland) act 2010, is a person with a mental disorder criminally responsible?
No, unless personality disorder with abnormally aggressive or seriously irresponsible conduct.
What are the forensic roles according to the criminal justice and licensing (Scotland) act 2010?
Restriction, assessment, treatment, interim and compulsion orders
Transfer for treatment
What mental health facilities are available in Scotland?
State Hospital (Carstairs) - high security on account of dangerous, violent or criminal propensities
Medium secure unit - less security
Low security unit - patients have more access to the community
List different types cluster A personality disorders.
Paranoid personality disorder
Schizoid personality disorder
Scizotypical personality disorder
What is the diagnostic criteria for paranoid personality disorder?
Pervasive distrust and suspiciousness of others such as their motives are interpreted as malevolent, beginning in early adulthood and present in different contexts.
- Suspects
- Preoccupied with unjustified doubts
- reluctant to confide in others
- reads hidden demeaning or threatening meanings
- persistently bears grudges
- perceives attacks on his or her character
- recurrent suspicion of fidelity of sexual partner
What is the diagnostic criteria for schizoid personality disorder?
Pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood.
- neither desires nor enjoys close relationships (including family)
- almost always chooses solitary activities
- Little interest in sexual experiences
- pleasure from few activities
- Lacks close friends
- indifferent to praise/criticism
- detached
What is the diagnostic criteria for schizotypical personality disorder?
Pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as cognitive or perceptual distortions and eccentrics of behaviour
- ideas of reference
- odd beliefs/magical thinking
- unusual perceptual experiences
- odd thinking and speech
- suspicious/paranoid ideation
What are the prominent problems with cluster B personality disorder?
With keeping feelings tolerable without criticism
List 4 examples of cluster B personality disorders.
Antisocial
Narcissistic
Borderline
Histrionic
What is antisocial personality disorder?
Pattern of disregard for and violation of the rights of others, occurring since 15 years.
At least 18 years old
Antisocial behaviour not exclusive during course of schizophrenia or bipolar disorder
What is borderline personality disorder?
Pervasive pattern of instability of interpersonal relationships, self image and affects and marked impulsivity, beginning early adulthood, present in various contexts
List signs of borderline personality disorder.
- Frantic efforts to avoid real or imagined abandonment
- unstable/intense interpersonal relationships (extremes of idealisation and devaluation
- identity disturbance
- impulsivity in at least 2 areas
- recurrent suicidal behaviour
- chronic feelings of emptiness
- inappropriate intense anger, difficult to control
- transient stress related paranoid ideation
- marked reactivity of mood
What are signs of narcissistic personality disorder?
Pattern of grandiosity, need for admiration and lack of empathy.
Fantasies of unlimited success/power
Sense of entitlement
Envious of others and believes others are envious of him
What is histrionic personality disorder?
Excessive emotional and attention seeking
Uncomfortable if not centre of attention
Inappropriate sexual seductive or provocative behaviour
Self dramatised/theatrically/exaggerated emotions
What are the prominent problems of cluster C personality disorders?
Relate to anxiety and how it is managed (in relationships)
Give examples of cluster C personality disorders?
Obsessive-compulsive (Anankastic) personality disorder
Avoidant personality disorder
Dependent personality disorder
How do you treat borderline personality disorder?
Dialectic behavioural therapy
Mentalization-based treatment
Symptomatic prescribing
Co-occuring mental illness
What is dependent personality disorder?
excessive need to be taken care if that leads to submissive and clinging behaviour and fears of separation
What is obsessive compulsive personality disorder?
Preoccupation with orderliness, perfectionism and mental and interpersonal control, at expense of flexibility, openness and efficiency
What is avoidant personality disorder?
Pattern of social inhibition, feeling of inadequacy and hypersensitivity to negative evaluation
List indications for use of antipsychotics?
Schizophrenia, schizoaffective disorder, bipolar disorder - for mood stabilisation and/or when psychotic features are present, psychotic depression
What pathways ate affected by dopamine?
Mesocortical, mesolimbic, nigrostriatal, tuberoinfundibular
What can dopamine hypoactivity cause?
Parkinsonian movements
Blocking dopamine in the tuberoinfundibulnar pathway can cause what?
Hyperprolactinameia
What are the two main types of antipsychotics?
Typicals and atypicals
What are typical antipsychotics?
D2 dopamine receptor antagonists
Which type of antipsychotic cause more side effects?
Typicals
What extrapyramidal side effects are caused by typical antipsychotics?
tremor, slurred speech, akathesia, dystonia, anxiety, distress, paranoia, and bradyphrenia,
List typical antipsychotics that have extrapyramidal side effects?
Fluphenazine, haloperidol, primozide
What are atypical antipsychotics?
serotonin-dopamine 2 antagonists
List examples of atypical antipsychotics.
Risperidone
Olanzapine
Aripiprazole
List examples of atypical antipsychotics.
Risperidone Olanzapine Aripiprazole Quietiapine Clozapine
What are side effects of Risperidone?
Weight gain, sedation, EPSE
What antipsychotic is used for treatment resistance?
Clozapine
What are serious adverse effects of antipsychotics?
Tardive dyskinesia (TD)
Neuroleptic malignant syndrome
Extrapyramidal side effects
List Neuroleptic malignant syndrome symptoms.
severe muscle rigidity, fever, altered mental status, autonomic instability, elevated WBC, CPK and LFTs, fatal
What is the inly drug to be beneficial in treatment resistance?
Clozapine
What agents are used for extrapyramidal side effects?
Anticholinergics - benztropine, trihexyoheidyl, diphenhydramine
Dopamine facilitators
Beta blockers
What are side effects of clozapine?
Weight gain, sedative, agranulocytosis, seizures
What prophylaxis is given for schizophrenia.
Life long, compliance issues, lack of insight, long acting IM injection, may need to use mental health act.
What happens with recurrent episodes of schizophrenia?
Negative symptoms develop with recurrent episodes of schizophrenia
What is the only neuropsychiatric emergency?
Neuroleptic malignant syndrome
21 yo male, schizophrenia, admitted for profound psychotic symptoms, treatment naive. What bloods should you take?
LFT, Glc, fasting lipid, CBC
If a schizophrenic patient has mildly elevated total cholesterol and a low HDL. What meds would you choose?
Risperidone, Aripiprazole, Ziprasidone
Name two antipsychotics which have an increased risk of dyslipidaemia.
Olanzapine, Quetiapine
How do you treat akathisia which is a common side effect of risperidone?
Propranolol
What are anxiolytics used to treat?
Panic disorder, generalised anxiety disorder, substance-related, withdrawal, insomnias and parasomnias.
What are anxiolytics often combined with?
SSRIs or SNRIs
What are side effects of benzodiazepines?
Somnolence, cognitive deficits Amnesia Disinhibition Tolerance Dependence
Name 3 models of stress.
Biomechanical
Medicophysiological
Psychological
Name 2 coping mechanisms.
Problem focussed
Emotion focussed
What are normal “fight or flight” response and symptoms of anxiety?
Psychological arousal Autonomic arousal Muscle tension Hyperventilation Sleep disturbance
List psychological arousal reactions to stress producing anxiety.
Fearful anticipation Irritability Sensitivity to noise Poor concentration Worrying thoughts
List autonomic arousal reactions to stress producing anxiety.
GI: dry mouth, swallowing difficulties, dyspepsia, nausea, wind, frequent loose motions
Resp: tight chest, difficulty inhaling
CVS: palpitations, chest pain
GU: frequency/urgency of micturition, amenorrhoea, ED
CNS: dizzy/sweaty
What are physiological and psychological reactions to stress?
Muscle tension
Hyperventilation
Sleep disturbance
What is the difference between phobic anxiety disorders and general anxiety disorder.
Phobias (occur in particular circumstance)
GAD = occur persistently
List differentials for anxiety disorders.
Psychiatric: depression, detention, schizophrenia, substance misuse
Physical: thyrotoxicosis, pheochromocytoma, hypoglycaemia, asthma and/or arrhythmias
What is GAD?
Persistent (several months)
Psychological arousal, autonomic arousal, muscle tension, hyperventilation, sleep disturbance
What is the cause of generalised anxiety disorder?
Stressor acting on a personality predisposed to the disorder by a combination of genetic and environmental factors in childhood.
How are GADs managed?
Counselling
Relaxation training
Medication (sedatives, SSRIs or TCA)
CBT
What are the key features of phobic anxiety disorders?
Same as core GAD features
Only in specific circumstances
“Phobic avoidance”
Anticipatory anxiety
List three clinical important syndromes of phobic anxiety disorders.
Specific phobias
Social phobia
Agoraphobia
What is agoraphobia?
Fear of being in situations where escape might be difficult or that help wouldn’t be available if things go wrong.
May be scared of: travelling on public transport
visiting a shopping centre
leaving home
What is social phobia?
Fear of exclusion - inappropriate anxiety in situation where person feels observed or could be criticised - restaurants, shops, public speaking
How do you manage social phobia?
CBT
Education and advice
Medication - SSRI antidepressants
What is OCD?
Recurrent obsessional thoughts or compulsive acts
What are obsessional thoughts?
Ideas, images, impulses Occur repeatedly Unpleasant and distressing Recognised as own thoughts Usual key anxiety symptoms
What are risk factors for OCD?
Genetic - gene coding for 5HT receptors - abnormalities in serotonin
How is OCD managed?
Good history and MSE
General measures - education and explanation, involve partner/family
Serotonergic drugs (SSRI - fluoxetine, clomipramine)
CBT
Psychosurgery (if treatment resistant)
What is PTSD?
Delayed and or protracted reaction to a stressor of exceptional severity e.g combat, natural disaster, rape, assault, torture
What are the key elects to PTSD?
- Hyperarousal cdp
- Re-experiencing phenomena
- Avoidance of reminders
How is PTSD managed?
Survivors of disasters screened at one month
Mild symptoms = watchful waiting and reviews further month
Trauma-focussed CBT
Eye-movement desensitisation and reprocessing
Risk of dependence with sedatives but patient may prefer SSRI or TCA
