List I - Core Conditions Flashcards
1
Q
How is grief commonly organised into stages?
A
- Denial
- This may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual
- Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
- Anger
- Commonly directed against other family members and medical professionals
- Bargaining
- Depression
- Acceptance
People may not go through all 5 stages
2
Q
Who is more at risk of atypical grief?
A
- Women and if the death is sudden and unexpected
* Problematic relationship before death or if the patient has not had much social support
3
Q
What are the features of atypical grief?
A
- Delayed grief - said to occur when more than 2 weeks passes before grieving begins
- Prolonged grief - difficult to define, normal grief reaction that may take up to and beyond 12 months
4
Q
What is anxiety defined as?
A
- Excessive worry about a number of different events associated with heightened tension
5
Q
What are the important alternative diagnoses of anxiety?
A
- Hyperthyroidism
- Cardiac disease
- Medication induced anxiety
6
Q
Which medications can trigger anxiety?
A
- Salbutamol
- Theophylline
- Corticosteroids
- Anti-depressants
- Caffeine
7
Q
What is the step wise approach to the management of anxiety according to NICE?
A
- Step 1: education about GAD + active monitoring
- Step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
- Step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
- Step 4: highly specialist input e.g. Multi agency teams
8
Q
What is the drug treatment approach to the treatment of anxiety?
A
- Sertraline should be considered the first-line SSRI
- Patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month
9
Q
What is the step wise approach to the management of panic disorder according to NICE?
A
- Step 1: recognition and diagnosis
- Step 2: treatment in primary care - see below
- Step 3: review and consideration of alternative treatments
- Step 4: review and referral to specialist mental health services
- Step 5: care in specialist mental health services
10
Q
What is the recommended treatment of panic disorder in primary care according to NICE?
A
- Either CBT or drug treatment
- SSRI’s are first line - if contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
11
Q
What is the ICD10 definition of bipolar affective disorder?
A
- Two or more episodes in which a persons mood and activity levels are significantly disturbed
Consisting of on some occasions: - Elevation in mood and increased activity and energy levels (hypomania or mania)
- Lowering of mood and decreased activity and energy levels (depression)
Repeated episodes of hypomania or mania only are classified as bipolar
12
Q
What is the ICD10 of hypomania?
A
- Persistent mild elevation of mood including:
- Increased energy and activity
- Marked feelings of well-being
- Feelings of physical and mental efficiency
- Increased sociability
- Talkativeness
- Over-familiarity
- Increased sexual energy
- Decreased need for sleep
- Irritability, conceit, boorish behaviour may take the place of the more usual euphoric sociability
- Disturbances of mood are not accompanied by hallucinations and delusions
- Symptoms not to the extent that they lead to severe disruption of work or result in social rejection
13
Q
What is the ICD10 of manic episode?
A
- Elevated mood
- Increased energy
- Reduced concentration
- Reduced need for sleep
- Inflated self esteem grandiosity
- Reckless behaviour - overspending, promiscuity
- Increased libido
- Racing thoughts, pressured speech
- Irritability, aggression
- Psychomotor agitation
- Disinhibition
14
Q
What is the ICD10 for mania with psychotic symptoms?
A
- In addition to the mania described:
- Grandiose delusions
- Hallucinations (usually voices speaking directly to the patient)
- Excitement or excessive motor activity can be so extreme that the patient is incomprehensible
15
Q
What are the indications for prescribing lithium?
A
Indications
- Mania- treatment and prophylaxis
- Bipolar affective disorder
- Recurrent depression
- Aggressive or self mutilating behaviour
16
Q
What are the kinetics (ADME) of lithium?
A
- Absorption is rapid
- Excretion is via the kidneys - clearance depends on renal function, fluid intake, Na intake
- Levels after last dose (0.4-1.0) therapeutic range but guided by clinical response
17
Q
What are the baseline investigations for lithium before starting a patient on it?
A
- Physical examination and weight
- U&E’s, renal function, TFT’s, Ca
- ECG
- Pregnancy test - female
18
Q
What are the monitoring requirements for lithium?
A
- Aim for the therapeutic window of 0.4-1.0
- Monitor levels every 3/12 when the patient is stable
- Renal, thyroid, Ca2+, weight and ECG
- Avoid drugs which reduce renal excretion such as ACEi, NSAID’s diuretics, thiazides, etc
19
Q
What are the early side effects of lithium use?
A
- Dry mouth, metallic taste in mouth, fine tremor, fatigue, polyuria, polydipsia
20
Q
What are the late side effects of lithium use?
A
- Diabetes insipidus, hypothyroidism, arrhythmias, ataxia, dysarthria, weight gain
21
Q
What are the signs/causes of lithium toxicity?
A
- Drugs (NSAIDs, diuretics), renal failure, UTI, dehydration
- Levels - may occur if lithium >1.5 but treat the symptoms as well as the levels
- Symptoms
- Early - blurred vision, anorexia, nausea, vomiting, diarrhoea, coarse tremor, ataxia, dysarthria
- Late - confusion, renal failure, delirium, fits, coma, death
22
Q
What is the management of lithium toxicity?
A
- Medical emergency - A to E
- Stop the lithium
- Give fluids
- Start diuresis / dialysis
- Treat the cause - e.g. stop nephrotoxic drugs
23
Q
What is pseudodementia?
A
- Understood as a specific clinical entity, characterised by cognitive deficits, mimicking dementia occurring on a background of psychiatric disorders, especially depression
24
Q
How can depression be differentiated from dementia?
A
Factors suggesting a diagnosis of depression over dementia:
- Short history, rapid onset
- Weight loss, sleep disturbance
- Patient worried about poor memory
- Reluctant to take tests, disappointed with results
- Mini-mental test score variable
- Global memory loss (dementia characteristically causes memory loss)
25
What is the ICD10 definition of depression?
Core symptoms:
* Low mood - may be worse in the morning
* Anhedonia - inability to derive pleasure
* Anergia - reduced energy levels
Additional symtoms:
* Decrease in activity
* Concentration reduced
* Sleep disturbance
* Reduced appetite
* Self esteem reduced
* Self confidence reduced
* Ideas of guilt
* Ideas of worthlessness
* Psychomotor retardation
* Agitation
* Weight loss
* Loss of libido
26
How is a mild depressive episode classified?
* Two core symptoms + 2 additional symptoms
| * Distressing to the patient but they can usually continue with most activities
27
How is a moderate depressive episode classified?
* Two core + 3 additional symptoms
| * Patient is likely to have great difficulty continuing with their ordinary activities
28
How is a severe depressive episode classified?
* Three core + 4 additional symptoms
* Suicidal thoughts and acts are common
* A number of somatic symptoms are usually present
* May present with or without psychotic symptoms
29
When does NICE guidance indicate use of ECT as a form of treatment?
* For severe life threatening or treatment resistant depression, catatonia or severe mania
* For depression, when the patient has tried two different types of (antidepressants) treatment at the right dose and for the right length of time and they have made no difference
30
How successful is ECT?
* 8/10 people report significant improvement in their depressive symptoms
31
How long is ECT treatment?
* Patients usually undergo a course lasting around 2 weeks with 6-12 treatments throughout that period
32
What does the procedure involve?
* Patient cannot eat or drink anything from midnight the night before the procedure and stops any psychiatric medicine for the procedure
* Patient is under short acting general anaesthetic and given a muscle relaxant and O2
* Electrodes are placed either side of temples
* Observations HR, RR, temp, O2, BP, ECG monitored
* Electric current is passed through the brain by the clinician (who has been trained)
* This induces a controlled seizure
* Patient can eat and drink and continue with medication after the procedure
33
What are the risks of ECT?
* Possible headache after the procedure for 1 hour or so - patient can take paracetamol
* Problems with short term memory, although this usually improves over time, usually in weeks to months
* 1/50000 risk of death from the GA
34
Summarise the whole process of preparing a patient for ECT?
* Initial consultation - 2 ineffective treatments for depression have failed, doctor with explain the procedure and give the patient an information leaflet to consider the treatment
* Consent for the procedure, patient informed they can withdraw at anytime and made aware of risks and benefits
* Patient meets with anaesthetist to discuss medicines, physical examination, blood tests
* Procedure itself as described, no eating or drinking from midnight the night before
35
What is the biological theory of depression?
* Monoamine theory - depression associated with decrease in brain NAd (noreadrenaline) and/or 5HT (serotonin)
Antidepressants rapidly block NAd or 5HT uptake but clinical improvement takes up to 4-6 weeks
36
Which drug groups are included in the monoamine re-uptake inhibitors?
* Tricyclics - amytriptyline, lofepramine
* SSRI's - fluoxetine, citalopram, etc
* Noreadrenaline re-uptake inhibitors - reboxetine
* SNRI's - venlafaxine
* Noreadrenaline and specific serotonin antidepressant (NaSSa) - mirtazapine
37
What are the possible side effects of SSRI's?
* Agitation
* Nausea/loss of appetite
* Indigestion/diarrhoea/constipation
* Loss of libido/erectile dysfunction
* Dizziness/dry mouth/blurred vision/sweatiness/headaches
38
Why are monoamine oxidase inhibitors less frequently used?
Examples: Phenelzine, Moclobemide (RIMA-reversible inhibitor)
* Poorer tolerability, interactions and diet restrictions
* Monoamine breaks down tyramine in your gut
* If you eat food containing tyramine e.g. cheese, red wine, bovril it can be toxic
* Can lead to a hypertensive crisis
39
What are some of the problems with antidepressants?
Suicidal ideas - motivation improves before mood giving an increased risk period (all types) - possibly more with SSRI's therefore important to warn patients
* Some are very toxic in overdose - TCA's
Serotonin syndrome - excess serotonin via SSRI + TCA/MAOI/ST Johns Wort/ecstasy
* Side effects - restlessness, fever, tremor, myoclonus, confusion, fits, arrhythmias
* Supportive treatment - most are mild and are better within 24 hours
Hyponatraemia - greater risk in older, thin females in summer with poor renal function
* Can occur with all antidepressants but SSRI's worst, lofepramine/mirtazapine are best
40
Give an example of an alternative treatment that should be advised against taking for depression?
* St Johns Wort - has different potencies with potential serious interactions with other drugs such as oral contraceptives, anticoagulants and anti-convulsants
41
How long should patients be treated with antidepressants for?
* 6-9 months following recovery
* If multiple episodes consider for at least 2 years
* If starting an antidepressant it should be tried for at least 4-6 weeks
42
How should a patient be counselled if they report their antidepressant isnt working?
* Check they are taking it
* For a reasonable length of time for it to work
* Alcohol use may stop it working (as well as use of street drugs at the same time)
* Consider if the underlying diagnosis is correct
* Consider perpetuating factors
* Options are to switch or to augment
43
When does NICE recommend low intensity psychological interventions for depression?
* Mild to moderate depression
* Medication not indicated at this stage
* Patients can use the IAPT - improving access to psychological therapies
44
When does NICE recommend a combination of antidepressant and high intensity psychological intervention?
* Moderate to severe depression
* Antidepressant and high intensity psychological intervention - usually CBT or IPT
* If patients decline medication and high intensity psychological intervention they can consider counselling or brief psychodynamic therapy
45
What are examples of low intensity interventions for depression?
* Advice - improving sleep hygiene, taking regular exercise
* CBT based self help - books and computer packages targeting specific diagnoses
* Many have good evidence base - 30% of people with bulimia improve with self help alone
* 6-8 sessions/delivered by a trained practitioner, working through a book with patient
* Structured group Physical activity programme - 10-14 weeks
* Group CBT
46
What are examples of high intensity interventions for depression?
* Use an antidepressant or
* CBT 16-20 sessions over 3-4 months
* IPT - 16-20 sessions over 3-4 months
* Behavioural activation - 16-20 sessions over 3-4 months
* Behavioural couples therapy - not commonly used
47
What is the cognitive behaviour model?
* Model used to analyse thoughts, behaviours, moods, biology according to triggers
* Helps to review the way in which a person sees the world and challenges their thoughts to have a more constructive/positive outlook
48
What is the theory behind CBT?
* Early experiences can dictate how we appraise events and the world around us
* Its not the event that causes problems but how we appraise it
49
What is done in practice with CBT?
* Problem and goals are defined
* Map out the problem in terms of thoughts, behaviours, physiology, emotions
* Use diaries to monitor and identify problematic thoughts, or other problems
* Help the patient to learn to think in more helpful ways
* Patient does behavioural experiments - what will happen if i go to the party? will exercise lift my mood?
50
What is the role of interpersonal therapy?
* Time limited and structured psychotherapy for moderate to severe depression
* Psychological symptoms can be understood in response to current difficulties in our everyday interactions with others
* In turn the depressed mood can also affect the quality of our relationships
* Focuses on interpersonal difficulties, roles and grief
* When a person is able to interact more effectively, their psychological symptoms often improve
* IPT focusses on:
- Conflicts
- Life changes
- Grief and loss
- Relationship problems
51
What is behavioural activation?
* Depression can lead to isolation, avoidance and withdrawal from regular activities
* People wait until they are better to do things - unfortunately they never feel better so never do things
* BA works on small steps and building up - e.g. walking the dog everyday
52
What is considered in terms of the management and assessment of social problems?
* Often act as precipitating and/or perpetuating factors
* Important to assess
* Importance of occupation and function
- ADLs - take me through a typical day
- Where are you living
- Isolation
- Support at home
- Working
- Finances?
53
Which services can you direct patients to for social support?
* Debts - citizens advice
* Food banks
* Voluntary organisations - age UK, alzheimers society
54
How/when is referral to secondary care made for depression?
* Significant risk of self harm, danger to others, psychotic symptoms or severe agitation - patients should be referred as an emergency
* Significant depression with functional impairment persists despite adequate treatment in primary care setting
* When additional community support from community mental health team or day hospital staff are required
* Indication for specialist psychological treatment
55
What should always be assessed in any depressed patient but also any other psychiatric patient?
* Risk of harm to self, others, neglect
| * Psychotic symptoms
56
What is the stepped care for depression according to NICE?
```
STEP 1:
All known and suspected presentations
of depression
* Low-intensity psychological and
psychosocial interventions, medication
and referral for further assessment
and interventions
```
STEP 2:
Persistent sub-threshold depressive symptoms mild to moderate depression
* Low-intensity psychological and
psychosocial interventions, medication
and referral for further assessment and interventions
```
STEP 3:
Persistent sub-threshold
depressive symptoms or mild to
moderate depression with inadequate
response to initial interventions;
moderate and severe depression
* Medication, high-intensity
psychological interventions, combined
treatments, collaborative care and
referral for further assessment
and interventions
```
```
STEP 4:
Severe and complex
depression; risk to life; severe
self-neglect
* Medication, high-intensity
psychological interventions,
electroconvulsive therapy, crisis
service, combined treatments,
multi-professional and inpatient care
```
57
What are the short term biological treatments for depression?
* Exercise
| * ECT
58
What are the short term psychological treatments for depression?
* Exercise
* Behavioural activation
* Problem solving
* Self help/computer based CBT
* Psycho-education
* CBT/IPT
59
What are the short term social treatments for depression?
* Housing
* Financial assistance
* Exercise
* Socialisation
60
What are the medium/long term biological treatments for depression?
* Antidepressants
* Antipsychotics
* Mood stabilisers
61
What are the medium/long term psychological treatments for depression?
* CBT/IPT
| * Psychoanalysis if refusal of CBT/antidepressants
62
What are the medium/long term social treatments for depression?
* Improve social networks
* Increase daily activities
* Employment
* Housing
* Finances
63
What is the ICD10 for anorexia nervosa?
* Disorder characterised by deliberate weight loss, induced and sustained by the patient
* Occurs most commonly in adolescent girls and young women (males may also be affected)
* Associated with a specific psychopathology whereby a dread of fatness and flabbiness of body contour persists as an intrusive overvalued idea and the patients impose a low weight threshold on themselves
* Usually undernutrition of varying severity with secondary endocrine and metabolic changes and disturbances of bodily function
* Symptoms include restricted dietary choice, excessive exercise, induced vomiting and purgation, and use of appetite suppressants and diuretics
64
What is atypical anorexia nervosa according to the ICD10 classification?
* Fulfil some of the features of anorexia nervosa but in which the overall picture does not justify the diagnosis
e. g. marked dread of being fat may be absent in the presence of marked weight loss and weight reducing behaviour
65
What is bulimia nervosa according to the ICD10 classification?
* Syndrome characterised by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading to a pattern of overeating followed by vomiting or use of purgatives
* Shares many psychological features with anorexia nervosa, including an over-concern with body shape and weight
* Repeated vomiting is likely to give rise to disturbances of body electrolytes and physical complications
* Often but not always an earlier episode of anorexia nervosa (interval ranging months to years)
66
What is atypical bulimia nervosa according to the ICD10 classification system?
* Fulfil some of the features of bulimia nervosa but in which the overall picture does not justify the diagnosis
e. g. recurrent bouts of overeating and overuse of purgatives without significant weight change
67
What are the three main types of eating disorder?
* Anorexia nervosa
* Bulimia nervosa
* Other specified feeding and eating disorders
68
What are the main components of anorexia according to DSM 5?
* BMI <18.5
| * Core psychopathology
69
What are the main components of bulimia according to DSM 5?
* BMI >18.5
* Core psychopathology
* Regular binge/purge x1/week
70
What does core psychopathology refer to in terms of eating disorders?
* Fear of fatness
* Pursuit of thinness
* Body dissatisfaction
* Body image distortion
* Self evaluation based on weight and shape
71
What are the common behaviours associated with eating disorders?
* Dieting
* Fasting
* Calorie counting
* Excessive exercise
* Water loading
* Diet pills, thyroxine, diuretics, appetite suppressants
* Excessive weighing
* Body checking
* Culinary behaviours
* Avoidance
* Isolation
* Bingeing
* Purging
* Starve-binge-purge cycle
* Misuse of insulin
* Laxatives
* DSH
* Substance misuse
72
What are the CVS effects of starvation?
* Bradycardia
* Hypotension
* Sudden death
73
What are the CVS effects of bingeing/purging?
* Arrhythmias
* Cardiac failure
* Sudden death
74
What is the ironic name of the questionnaire for eating disorders?
* SCOFF questionnaire
* S - do you make yourself SICK because you feel uncomfortably full?
* C - do you worry you have lost CONTROL over how much you eat?
* O - have you recently lost more than ONE stone in a 3 month period?
* F - do you belief yourself to be FAT when others say you are too thin?
* F - would you say that FOOD dominates your life?
75
Which psychiatric disorder has the highest mortality rate of any?
* Anorexia nervosa
* Most deaths due to physical complications of dieting, bingeing and purging
* 20-40% deaths in AN due to suicide
76
What are the components of the physical risk assessment of a person who has an eating disorder?
1. Clinical history and physical assessment
2. Body mass index
3. ECG
4. Blood investigations
77
What are the features of the clinical history and physical assessment of a person with an eating disorder?
* Rapid weight loss
* Physical comorbidity e.g. diabetes
* CVS - chest pain, postural dizziness, palpitations, blackouts
* Excessive exercise
* Water loading
* Alcohol
* Infection
* Haematemesis
* Pregnancy
* Medication
* BMI
* Irregular pulse
* Brady cardia
* Hypotension
* Postural hypotension
* Hypothermia
* Proximal myopathy
78
What is BMI level below which is considered part of diagnosis for anorexia nervosa?
* <18.5
79
What are the cardiac abnormalities that can be seen in a patient with anorexia nervosa?
* Most AN deaths are due to cardiac arrest
* Cardiac abnormalities are present in up to 86% of patients with AN
* T wave changes (hypokalaemia)
* Bradycardia (<40 bpm)
* QTc prolongation (>450ms)
80
What are the blood investigations required for a person with an eating disorder?
* FBC
* U&Es
* LFTs
* Glucose
* CK
* Phos, Mg, Ca
* TFTs
* Zn
81
What is the main physiological consequence of starvation?
For a person with an eating disorder.
* Hypoglycaemia
82
What is the main physiological consequence of vomiting?
For a person with an eating disorder.
* Hypokalaemia
83
What is the main physiological consequence of water loading?
For a person with an eating disorder.
* Hyponatraemia
84
What is the main physiological consequence of laxative misuse?
For a person with an eating disorder.
* Hyperkalaemia
| * Hyponatraemia
85
What is the main physiological consequence of diuretics misuse?
For a person with an eating disorder.
* Hypokalaemia
| * Hyponatraemia
86
What is the main physiological consequence of thyroxine misuse?
For a person with an eating disorder.
* Increased T3/T4
| * Decreased TSH
87
What is the main consequence of bone marrow hypoplasia for a person with an eating disorder?
* Normocytic anaemia
| * Leucopenia
88
What are the common physiological problems associated with re-feeding sydrome?
* Hypophosphataemia
* Hypomagnesaemia
* Hypocalacaemia
* Hypokalaemia
89
What are the physiological problems associated with proximal myopathy in a person with an eating disorder?
* Increased creatine kinase
| * Increased LFTs
90
Which resource can be used to inform on the management of unwell patients with anorexia nervosa?
* MARSIPAN: Management of really sick patients with anorexia nervosa
91
What are the referral criteria for patients in Yorkshire with an eating disorder to the Yorkshire Centre for Eating Disorders?
* Moderate/severe AN (BMI <17)
* Severe BN (daily bingeing and purging)
* EDNOS with comorbid IDDM or pregnancy
92
Which medication regime is given to patients with bulimia nervosa?
* Fluoxetine 60 mg daily
93
What are the psychological treatments offered to patients with anorexia nervosa?
* MANTRA - manualised
* CBT
* SSCM
* Other therapies
94
What are the psychological treatments offered to patients with bulimia nervosa?
* CBT
* IPT
* Fluoxetine 60 mg BD
* Other therapies
95
What is motivational enhancement?
* Brief therapy usually lasting 4-6 sessions
* Aims to:
- Understand the psychological functions of the ED
- Weigh up how the individual feels about change
- Increase motivation to change
- Make an informed decision about whether this is the right time to change
* Beneficial in the initial phase of treatment with promotion of responsibility and a commitment to change
96
What kind of questions might be asked when conducting a motivational enhancement interview?
* What matters most to how you feel about yourself?
* Why change?
* Advantages/disadvantages
* What do you like about your ED?
* What do you dislike about your ED?
* Write a list of all the things you have stopped doing because of your ED?
* Barriers to change - what would stop me giving up ED?
97
Which resource can patients be given information on regarding adequate nutrition?
* Eatwell guide
98
What is the recommended amounts of carbohydrates, fats, protein and fluid to have per day?
* Carbohydrates - eat meal to stabilise blood sugars
* Fats - dairy required 2-3x daily to ensure appropriate calcium, vitamin D and phosphate intake
* Protein - required 2-3 meals for growth and repair
* Fluid - 6-8 glasses per day (30-35ml/kg) to ensure appropriate hydration levels
99
What is the NICE guidance for the treatment of a patient with anorexia nervosa?
Support should:
* Include psycho-education about the disorder
* Include monitoring of weight, mental and physical health and any risk factors
* Be multidisciplinary and coordinated between services
* Involve the persons family members or carers
100
What does NICE recommend as the psychological treatments for anorexia nervosa in adults?
Consider offering patients one of:
* Individual eating disorder-focused cognitive behavioural therapy
* Maudsley anorexia nervosa treatment for adults (MANTRA)
* Specialist supportive clinical management (SSCM)
101
What does individual CBT-ED programmes for adults with anorexia consist of?
* Up to 40 sessions over 40 weeks with twice weekly sessions in the first 2 or 3 weeks
* Aims to reduce the risk to physical health and any other symptoms of the eating disorder
* Aims to encourage eating and reaching a healthy body weight
102
What does MANTRA programmes consist of for adults with anorexia nervosa?
* Typically 20 sessions with:
- Weekly sessions for the first 10 weeks
- Up to 10 sessions for people with complex problems
- Motivate the person
- Encourage them to adopt a 'non-anorexic identity'
103
What does SSCM for adults with anorexia nervosa consist of?
* Typically 20 sessions or more weekly sessions
* Aim to help people recognise the link between their symptoms and their abnormal eating behaviour
* Aim to restore weight
* Establish a weight range goal
104
What does eating disorder focused psychodynamic therapy consist of for patients with anorexia nervosa?
* Typically 40 sessions over 40 weeks
* Make a patient centred focal hypothesis that is specific to address:
- What the symptoms mean to the person
- How the symptoms affect the person
- How the symptoms influence the person's relationships with others and with the therapist
- Phase 1 - building self esteem, addressing behaviour
- Phase 2 - focus on relevant relationships and how these affect eating behaviour
- Phase 3 - transferring therapy experience to situations in everyday life and address the concerns a person may have about what will happen when treatment ends
105
What does NICE recommend as the psychological treatments for bulimia nervosa in adults?
* Consider bulimia-nervosa-focused guided self help
- Use cognitive behavioural self help materials for eating disorders
- Supplement self help with brief supportive sessions
* If guided self help is inappropriate consider individual eating disorder focused cognitive behavioural therapy
- Typically 20 sessions over 20 weeks
106
What is the MHA assessment process?
* Patient is identified as needing an assessment under the MHA.
1) Assessed by two doctors and 1 AMHP (ideally all see the patient at the same time)
2) Each Dr must determine their own opinion regarding whether the person meets the criteria for detention
3) AMHP is always responsible for making the application to the receiving hospital (can disagree with the assessing Dr's recommendation)
(Does happen that 1 Dr sees a person independently and makes a recommendation and then asks for the AMHP to see the person with a 2nd Dr)
107
Who is qualified to make the MHA assessment process?
* Requires: 2 doctors and 1 AMHP
* 1 doctor must be section 12 approved
* 1 doctor should "have prior knowledge" of the patient e.g. GP
* AMHP is independent and makes the final decision regarding detention
* Persons nearest relative can also make the final decision in place of the AMHP (rare)
108
What is the criteria for detention under the MHA?
* Person must be suffering from a mental disorder = any disorder or disability of the mind, or a nature or degree which warrants detention in hospital
AND
* Must be at risk to own health AND/OR own safety AND/OR risk to others
AND
* Must be unwilling to go to hospital voluntarily
109
What is important to note when considering detention under the MHA?
* Willing patients who lack capacity to consent to admission can no longer be admitted voluntarily e.g. cognitive impairment or severely depressed mood
* Learning disability - for treatment must be associated with abnormally aggressive or seriously irresponsible conduct
110
Outline 4 important sections to be aware of?
* Section 2 - admission for assessment
* Section 3 - admission for treatment
* Section 5 - detention of informal patients already in hospital
* Section 136 - mentally disordered persons found in public place
111
What are the important features of a section 2?
* Warrants detention in hospital for assessment (or assessment followed by medical treatment)
* Interests of patients own health and safety with view to the protection of others
* Requires: AMHP and 2 doctors (1 Dr must be section 12 approved)
* Lasts up to 28 days
* Can be appealed within the first 14 days
112
What are the important features of a section 3?
* Warrants detention in hospital for the patient to receive medical treatment
* Interests of patients own health and safety with view to the protection of others
* Requires: AMHP and 2 doctors (1 Dr must be section 12 approved)
* Lasts up to 6 months
* Can be appealed (twice in the first 6 months and then yearly after this)
113
What kind of treatments can the patient receive under a section 3?
Treatment:
* Of the mental disorder
- antidepressant/antipsychotic/mood stabiliser
* Of the cause of the mental disorder
- treat underlying organic illness
* Of the consequences of the mental disorder
- DSH (parvolex) (acetylcysteine), self neglect, weight loss/nutritional deficiency
114
What are the important features of a section 5 (2): doctor's holding power?
* No rights to treat
* Cannot be used to treat physical health problems
* Application must be done by a consultant in charge of care or a nominated deputy (must be a registered medical practitioner - FY2 and above)
* Nurse's holding power section 5(4) - 6 hour duration, RGN cannot use this; must see a doctor who can either rescind or complete 5 (2) within the 6 hours
115
What is a section 135?
* Warrant to search for and remove a patient
| * To move them to a place of safety for the purpose of assessment
116
What are the important features of a section 136?
* For mentally disordered persons in areas that are not private dwellings
* If a police officer thinks that a person is suffering from a mental disorder and is in immediate need of care they can take them to a place of safety to be assessed after discussing the case with a mental health professional
* Lasts for up to 24 hours (or 36 if exceptional circumstances)
117
What are the 5 statutory principles of the MCA?
* Person is assumed to have capacity
* All practical steps must be taken to help the person to make a decision
* Do not treat people as unable to make decisions if they make an unwise decision
* Any actions or decisions made on behalf of a person who lacks capacity must be made in that person's best interests
* Before acting in a persons best interests it must be established there is no other less restrictive way to achieve the outcome
118
What is the process for assessing capacity?
* 2 stage process
1) Diagnostic test
2) Functional test
* Decision specific and time specific
119
What is the (1) diagnostic test of capacity?
* At the time of the decision the person has an impairment of, or disturbance in functioning of, the mind or the brain
120
What is the (2) functional test of capacity?
1) Understand the information relevant to the decision
2) Retain that information
3) Use or weigh that information as part of the process of making the decision
4) Communicate his decision
121
How would you determine a person's best "best interests"?
Consider:
a) Person's past and present wishes and feelings
b) Beliefs and values
c) Views or anyone named by the person
d) Anyone engaged in caring for the person or interested in their welfare
e) Any donee of a lasting power of attorney
f) Any deputy appointed for the person by the court
g) IMCA if appointed - Independent Mental Capacity Advocate
122
What are the features of deprivation of liberty safeguards (DOLS)?
* Applies to anyone who lacks capacity and is deprived of their liberty in their best interests
* Occurs in care homes, general hospital wards and mental health wards
* Capacity is assessed as defined by MCA
* Urgent lasts up to 7 days, standard is up to a year
123
What is obsessive compulsive disorder?
* Obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person's mind and that usually causes marked anxiety or distress
* Compulsions are repetitive behaviours or mental acts that the person feels driven by their obsessions to perform, a compulsion can either be overt and observable by others or a covert mental act that cannot be observed
* Obsessive compulsive disorder is characterised by recurrent obsessional thoughts or compulsive acts or commonly both which may cause significant functional impairment and/or distress
124
What are the risk factors for the development of OCD?
* Family history
* Age - bimodal onset 10 years and 21 years, onset over the age of 30 is rare
* Developmental factors - emotional, physical, and sexual abuse, neglect, social isolation, bullying
* Pregnancy and the postnatal period - worry about harming the baby
125
How common is OCD?
* Thought to be the 4th most common psychiatric illness after depression, alcohol/substance misuse, and social phobia
* Sex ratio is 1:1
126
What is the prognosis of OCD?
* Untreated, the course is usually chronic, often waxing and waning symptoms - without treatment, remission rates among adults are approximately 20%
* Psychological therapies can be effective in the treatment of OCD
* Pharmacotherapy with clomipramine or SSRI has also shown to be effective in the treatment of OCD
127
What are the complications of OCD?
* Reduced quality of life
* Dermatitis - due to excessive hand washing
* Self-harm and suicide - increased risk
128
How can people with OCD be identified?
* Screen people with symptoms of depression, anxiety, alcohol or substance misuse, body dismorphic disorder, or an eating disorder using the following questions:
- Do you wash or clean a lot?
- Do you check things a lot?
- Is there any thought that keeps bothering you that you would like to get rid of but cannot?
- Do your daily activities take a long time to finish?
- Are you concerned about putting things in a special order or are you upset by mess?
- Do these problems trouble you?
129
What is the ICD 10 criteria for OCD?
* Presence of recurrent, obsessional thoughts or compulsive acts:
* Obsessional thoughts are:
- Ideas, images, or impulses that enter the person's mind again and again in stereotyped form.
- Almost invariably distressing, and the person often tries, unsuccessfully, to resist them.
- Recognized as the person's own thoughts, even if they are involuntary or repugnant.
* Compulsive acts or rituals are:
- Stereotyped behaviours that are repeated again and again.
- Not inherently enjoyable, nor do they result in completion of inherently useful tasks.
- Performed to prevent some objectively unlikely event, often involving harm to, or caused by, the person, which he or she fears might otherwise occur.
- Usually recognized by the person as pointless or ineffectual and repeated attempts are made to resist them
130
How can severity of OCD be assessed?
* Using the Yale-Brown Obsessive Compulsive Scale or questions derived from it
131
How should adults with OCD with mild functional impairment be managed?
* Recommend a psychological intervention. This is accessed by referral or self-referral to IAPT
* Following assessment, a low intensity cognitive-behavioural therapy (CBT), including exposure and response prevention (ERP) may be offered
* Format for low-intensity CBT should be up to 10 therapist-hours per person, of one of the following:
- Brief individual CBT (including ERP) with structured self-help materials.
- Brief individual CBT (including ERP) by phone.
- Group CBT (including ERP) which may be for more than 10 hours.
132
How should adults with OCD with moderate functional impairment be managed?
* Offer the choice of intensive CBT including ERP (accessed by referral or self referral to IAPT), or a selective serotonin reuptake inhibitor (SSRI) (see below).
* Consider prescribing clomipramine (as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated
133
How should adults with OCD with severe functional impairment be managed?
* Refer to the secondary care mental health team for assessment
* Whilst awaiting assessment:
- Consider offering combined treatment with an SSRI (see below) and CBT (including ERP).
- Consider prescribing clomipramine (as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated
134
Which SSRI's are licensed for the treatment of OCD?
* Escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline are all licensed for the treatment of OCD in adults
135
What is schizophrenia?
* Changes in thinking
* Changes in perception
* Blunted or inappropriate affect
* Reduced level of social functioning
Cognitive symptoms are usually intact in the early stages
"Fragmentation of thinking"
136
What are Schneider's (11) first rank symptoms?
* Auditory hallucinations: voices repeating thoughts out loud
* Auditory hallucinations: discussing the subject in the third person
* Auditory hallucinations: running commentary
* Thought insertion - external thoughts inserted into head
* Thought withdrawal - own thoughts withdrawn
* Thought broadcast - thoughts read by others
* Made feelings - external control of feelings
* Made impulses - external control of impulses
* Made actions - external control of actions
* Somatic passivity - recipient of bodily sensations from external agency
* Delusional perception - real perception followed by delusional misinterpretation of the perception
137
What other ICD-10 symptoms are important for making diagnosis of schizophrenia?
* Positive symptoms:
* Other persistent delusions - religious or political identity
* Persistent hallucinations - accompanied by fleeting ideas
* Overvalued ideas
* Breaks in the train of thought
* Catatonic behaviour - stupor, akinetic, mute, posturing and excitement
* Motiveless resistance to be moved
* Negative symptoms (chronic schizophrenia) - apathy, poverty of speech, lack of drive, slowness and blunting, social withdrawal and lowered social performance (other causes of the negative symptoms should be excluded e.g. depression and antipsychotic medication)
138
What is paranoid schizophrenia?
* Dominated by paranoid symptoms
* Delusions of persecution - others plotting against
* Delusions of reference - strangers on the tv referring to them
* Delusions of exalted birth - e.g. born with a messianic role
* Delusions of bodily change
* Delusions of jealousy
* Hallucinatory voices
* Non-verbal auditory hallucinations
* Hallucinations in other modalities - smell, taste, vision, etc
139
What is hebephrenic schizophrenia?
* Irresponsible and unpredictable behaviour
* Rambling or incoherent speech
* Affective changes - incongruous affect and shallow mood
* Poorly organised delusions
* Fleeting and fragmentary hallucinations
Age of onset usually between 15 and 25, poor prognosis, associated with negative symptoms
140
What is catatonic schizophrenia?
* Stupor, akinetic, mute, posturing and excitement
* Patient may change between these two states
* Catatonia = abnormality of movement and behaviour
141
Which type of schizophrenia are positive symptoms more common?
* Acute schizophrenia
142
Which type of schizophrenia are negative symptoms more common?
* Chronic schizophrenia
143
What are the positive symptoms of schizophrenia?
* Delusions
* Hallucinations
* Thought disorder
144
What are the negative symptoms of schizophrenia?
* Poverty of speech
* Blunting/incongruity of affect
* Social withdrawal
145
What is Liddle's classification of schizophrenia?
Syptoms of schizophrenia classified into three syndromes:
* Psychomotor poverty syndrome - poverty of speech, flatness of affect, decreased spontaneous movement
* Disorganisation syndrome - disordered thought form and inappropriate affect
* Reality distortion syndrome - delusions and hallucinations
146
What is the incidence and prevalence of schizophrenia?
* Incidence = 15-20 new cases per 100,000 per year
| * Prevalence = less than 1%
147
What is the age of onset of schizophrenia?
* 15 to 45 years
* Males = 20-24
* Females = 25-29
148
What is the ICD10 for schizophrenia?
* Characterised by distortions of thinking and perception and affects that are blunted or inappropriate
* Clear consciousness and intellectual capacity are usually maintained although certain cognitive defects may evolve in the course of time
* Most important psychopathological phenomena include:
- Thought echo
- Thought insertion/withdrawal
- Thought broadcast
- Delusional perception
- Delusions of control
- Delusions of influence
- Delusions of passivity
- Hallucinatory voices 3rd person
- Thought disorders
- Negative symptoms
149
What is the ICD10 for schizoaffective disorder?
* Refers to episodic disorders in which both affective (mood) and schizophrenic symptoms are prominent but do not justify a diagnosis of either schizophrenia or depressive or manic episodes
150
What are the types of schizoaffective disorder?
* Manic type
* Depressive type
* Mixed type
151
What is the ICD10 for delusional disorder?
* Development of a single delusion or of a set of related delusions that are usually persistent and sometimes lifelong
* Content is very variable
* DOES NOT INCLUDE:
- Definite evidence of brain disease
- Persistent auditory hallucinations
Schizophrenic symptoms such as:
- Delusions of control
- Marked blunting of affect
152
What is psychosis?
* Umbrella term - experience of hallucinations, delusions and/or thought disorder
* Not confined to mental disorder
* Often described as the experience of being out of touch with reality, struggling to distinguish what is real from not
153
What is a delusion?
* A false unshakeable belief, despite evidence to the contrary, not held by others in the same culture and held with intense personal conviction and certainty
154
What is a hallucination?
* Can be auditory, visual, olfactory, tactile, gustatory, somatic
* A perceptual experience without an object or stimulus that appears subjectively real but uncontrollable by the patient
155
What is a thought disorder?
* An abnormality in the thinking mechanism of thinking such that to the observer the person doesn't make sense
156
In which conditions can psychosis present?
* Organic states - delirium, dementia, DT's, other brain disorders, metabolic disorders e.g. porphyria
* Psychoactive substance misuse (intoxication and withdrawal states, DT's)
* Schizophrenia
* Affective disorders
- Depression
- Mania
* Sleep or sensory deprivation
* Bereavement
157
How common is schizophrenia?
* M>F
* Incidence 0.55-1% lifetime or 200/100,000
* Up to 1% of the population
* 10-20 patients per average GP practice
158
What are the features of the positive symptoms of schizophrenia?
* Hallucinations (esp auditory)
* Delusions
* Thought disorder
* Most people dont experience
* Calls attention to the illness in the acute phase
* Focus of drug treatment
* Good prognosis
159
What are the features of negative symptoms of schizophrenia?
* Avolition - lack of motivation
* Anhedonia - unable to experience please
* Alogia - poverty of speech
* Asociality - lack of desire for relationships
* Affect blunt
- Part of continuum of normal traits
- Often a late feature
- Less treatment responsive
160
What is seen on a SPECT scan of a patient with schizophrenia?
* Greater occupancy of DA receptors
161
Which pathway in the brain leads to the positive symptoms of schizophrenia?
* Mesolimbic
162
Which pathway in the brain leads to the negative symptoms of schizophrenia?
* Mesocortical
163
How do antipsychotics mainly work?
* All are antagonists at post-synaptic DA receptors (5 types, mainly D2)
164
Which pathway can patients experience extra pyramidal side effects from taking antipsychotics?
* Nigrostriatal
165
Which pathway can patients taking some antipsychotics experience elevated prolactin levels?
* Tuberoinfundibular
166
What are the risk factors for schizophrenia?
* Monozygotic twins 50% chance of developing it if the other twin has it
* 15-20% risk of developing it dizygotic twins
* Environment - winter births, viral infections
* Life events - social exclusion, childhood trauma, migration, urban environment, negative attitudes
* Substance misuse - cannabis, amphetamines
* Peri-natal trauma - hypoxia, maternal stress
167
What is a delusional disorder?
* Long standing delusions constitute the only or the most conspicuous clinical characteristic
* Single delusion of set of related delusions may be very variable
* Content of the delusions may be very variable
(Presence of occasional or transitory auditory hallucinations more common in elderly)
168
Which additional features are incompatible with the diagnosis of a delusional disorder?
* Clear and persistent auditory hallucinations (voices)
* Delusions of control
* Marked blunting of affect
* Definite evidence of brain disease
169
What are the different types of delusional disorder?
* Persecutory
* Othello syndrome
* De Clerambault's syndrome
* Capgras syndrome
* Fregoli's syndrome
* Cotard's syndrome
* Ekbom's syndrome
* Folie a deux
170
What is De Clerambault's syndrome?
* Erotomania
* Delusional belief another (famous, higher social status person) is in love with them
* Can't declare love so done via secret signs/communication
171
What is Othello syndrome?
* Morbid jealousy
* Delusional belief that partner is having affair/sex with others
* No evidence/misinterprets minor evidence
* Associated with alcohol dependence/sexual dysfunction
* Risk of stalking and/or violence to partner
172
What is Capgras syndrome?
* Delusional misidentification
| * Relative/spouse/close relation/friend replaced by identical looking double or imposter M:F = 2:3
173
What is Fregoli's syndrome?
* Different people are a single person who changes appearance or is in disguise
* Often people believe they are being persecuted by that person
174
What is Cotards syndrome?
* Delusion of being dead, dying, non existent, rotting, lost body parts of organs
* Associated with depression
175
What is Folie a deux?
* Induced delusional disorder
* Psychosis shared by two people
* Usually one dominant, the other submissive
* If separated usually the submissive one will get better spontaneously
176
What is Ekbom's syndrome?
* Delusion of parasitosis
* Infested with parasites
* No evidence
* Associated with formication (sensation of insects crawling under the skin)
* Risk of self harm trying to get rid of parasites
* Presents to dermatologists
* House or home infested - delusional cleptoparasitosis
177
If a patient is in a catatonic state, what does it mean?
* Prominent psychomotor disturbances that may alternate between extremes such as hyperkinesis and stupor, or automatic obedience and negativism
* Constrained attitudes and postures may be maintained for long periods
* Episodes of violent excitement may be a striking feature
* May be combined with a dream-like (oneiroid) state with vivid scenic hallucinations
178
What is schizoaffective disorder?
* Characterised by prominent affective and schizophrenic symptoms in the same episode of illness
* Mood symptoms episodic rather than continuous
179
What are the positive prognostic factors for schizophrenia?
* Acute onset
* Late onset
* Precipitating factors
* Florid symptoms or associated mood disorder
* Female sex
* No family history
* No substance misuse
* Good premorbid functioning
* Good social support and stimulation
* Married
* Early treatment and compliance
* Good response to treatment
180
What are the negative prognostic factors for schizophrenia?
* Insidious onset
* Early onset
* No precipitating factors
* Negative symptoms
* Male sex
* Family history
* Substance misuse
* Poor premorbid functioning
* Poor social support and stimulation
* Unmarried (including separated)
* Delayed treatment and non-compliance
* Poor response to treatment
181
What is the acute medical management of schizophrenia?
* Antipsychotics
182
What is the acute psycho-social management of schizophrenia?
* Psycho education
| * CBT/Family interventions
183
What is the long term medical management of schizophrenia?
* Antipsychotic (oral/depot)
+/-
* Antidepressants
* Lithium
184
What is the long term psycho-social management of schizophrenia?
* CBT
* Supported employment
* Family interventions
* Reduce expressed emotion
* Relapse signature
* Art therapy
185
How should first episode of psychosis be managed from primary care?
* Urgently refer to secondary services
* Early assessment to decide which service is best for the patient
* Early intervention team, crisis team, in patient care
* Assessment
* MDT approach - psychiatric, medical, physical health and well being, psychological, occupational, social
* Care plan to reflect the above
* Crisis plan based on a full risk assessment
* Roles of primary and secondary care
* Key clinical contacts in case of emergency or impending crisis
186
Which antipsychotics can be used for depot administration?
* Risperidone
* Paliperidone
* Olanzapine
187
How should administration of depot antipsychotics be conducted?
* Give initial test dose, then usually fortnightly to monthly dose
* Usually oral medication is required until steady state is reached
188
Which tests are required before starting antipsychotics?
* Bloods - FBC, U&E, RBS/HbA1c, Prolactin, Lipids and Cholesterol
* Physical - Weight, BP, HR
* ECG - risk of prolonged QTc/arrhythmias
* Consider present physical health status such as cardiovascular, smoking status
189
What is akathesia?
* Inner restlessness
* Increased risk of suicide
* Symptoms can be managed with propanolol, procyclidine and benzodiazepines
190
What can tardive dyskinesia be managed with?
* Tetrabenzene
191
What is acute dystonia?
* Torticolis
* Occulogyric crisis = fixed upwards gaze
* Within 72 hours post treatment
* Involuntary muscle spasms due to effect on basal ganglia
192
What is the management of an acute dystonia?
* Procyclidine - antimuscarinic
| * 5mg tds oral or IV benzatropine
193
What are the risk factors for developing an acute dystonia?
* Young
* Female
* Antipsychotic naive
* Liver problems
194
What are the indications for the use of clozapine as an antipsychotic according to NICE?
* Offer clozapine to people with schizophrenia whose illness has not responded adequately to treatment despite the sequential use of adequate doses of at least two different antipsychotic drugs
* At least one of the drugs should be a non-clozapine second generation anti-psychotic
195
What are the potential side effects of clozapine?
* Agranulocytosis (regular FBC and part of treatment)
* Myocarditis
* Weight gain
* Salivation
* Seizures
* Sedation
196
What are the risk factors for relapse of schizophrenia?
* Presence of persistent symtoms
* Poor adherence to the treatment regime
* Lack of insight
* Substance use
* Sudden stop of anti-psychotic medication in people with schizophrenia dramatically increases the risk of relapse in the short to medium term
197
What are the psycho-social treatments available for schizophrenia?
* Psycho-education
* Relapse signature - recognising signs early so can seek help
* CBT
* Family interventions
* Art therapy
198
What is the evidence and rationale of CBT as a therapy for schizophrenia?
* Doesn't help reduce the voices or delusions but helps the distress they cause and associated depression and anxiety
* Helps patients develop individual understanding of their disorder
* Its not the voice that causes the problems but the meaning they attach to it
199
What is a somatoform disorder according to ICD10?
* Main feature is repeated presentation of physical symptoms together with persistent requests for medical investigations
* In spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis
* If any physical disorders are present, they do not explain the nature and extent of the symptoms or the distress and preoccupation of the patient
200
What is a somatization disorder according to ICD10?
* Main features are multiple, recurrent and frequently changing physical symptoms of at least two years duration
* Most patients have long and complicated history with medical services
* Course of the disorder is chronic and fluctuating and often associated with disruption of social, interpersonal and family behaviour
* Short lived less than 2 years should be classified under undifferentiated somatoform disorder
201
What is hypochondriacal disorder according to ICD10?
* Persistent feature is preoccupation with the possibility of having one or more serious and progressive physical disorders
* Persistent somatic complaints or a persistent preoccupation with their physical appearance
* Normal or commonplace sensations and appearances are often interpreted by patients as abnormal and distressing
* Attention is usually focused on one or two organ systems of the body
* Marked depression and anxiety are often present and may justify additional diagnoses
202
What is a dissociative/conversion disorder according to the ICD10?
* Partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements
* All types tend to remit after a few weeks or months, particularly if onset is associated with a traumatic life event
* Evidence that the loss of function is an expression of emotional conflicts or needs
* Symptoms may develop in close relationship to psychological stress and often appear suddenly
203
What is another name for somatization disorder?
* Briquet's syndrome
204
For a diagnosis of somatization disorder, ICD 10 suggests what needs to be present?
All of the following for at least 2 years:
* At least 2 years of symptoms with no adequate physical explanation found
* Persistent refusal by the patient to accept reassurance from several doctors that there is no physical cause for the symptoms
* Some degree of functional impairment due to the symptoms and resulting behaviour
205
What is somatisation?
* Multiple physical SYMPTOMS present for at least 2 years
| * Patient refuses to accept reassurance or negative test results
206
What is hypochondrial disorder?
* Persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
* Patient again refuses to accept reassurance or negative test results
207
What is a conversion disorder?
* Typically involves loss of motor or sensory function
* Patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
* Patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
208
What is a dissociative disorder?
* Dissociation is a process of 'separating off' certain memories from normal consciousness
* In contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
* Dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
209
What is a factitious disorder?
* Also known as Munchausen's syndrome
| * Intentional production of physical or psychological symptoms
210
What is malingering?
* Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
