Mental disorders, dependency and abuse Flashcards
What is family violence?
- Coercive and controlling behavior by a family member
What can family violence cause?
Physical, sexual , and or emotional damage to others in the family, including causing them to live in fear and threatening to harm people, pets or property. Wether it is physical, sexual, or emotional it may have long term detrimental effects
What kind of abuse are most common?
By one partner towards another (domestic violence/ intimate partner abuse) and/or by an adult towards a child/children
What are other kinds of abuse?
Elder abuse and sibling abuse
What is interpersonal abuse and violence
It is very common, with the main perpetrators of such violence being men, but women can also be perpetrators
What kinds of abuse are there?
- Physical
- Emotional
- Child sexual
- Neglect
- Adult sexual
- Economic
- Social
Abuse are most prevalent in populations of..
Are across populations and ages, however all involve abuse of power
How often is abuse ass w alcohol?
Involved in about 45% of partner violence. Increase the risk of abuse
What are the GP role in abuse?
- Identidy predisposing risk factors
- Noting early signs and symptoms
- Assessing for violence and safety within family
- Mx of consequences of abuse to minimize morbidity and mortality
- Advocating for changes that promote a violence free society
What are signs of physical abuse?
- Bruising on chest and abdomen
- Multiple injuries
- Minor laceration
- Injuries during pregnancy
- Ruptured eardrums
- Delay in seeking medical attention
- Patterns of repeated injury
What are ass. signs of abuse?
Anxiety, panic attacks, stress, depression, drug abuse, chronic headache, vague pains, asthma, abd. pain, chronic diarrhea, sexual dysfunction, vaginal discharge, joint/muscle pain, sleeping/eating disorder, suicide attempts, psych illness, miscarriages, gyn - problems, chronic pelvic pain
How to document abuse?
- Describe physical injuries, type, extent, age and location
- Consider taking photo
- Record what pat has said and relevant behavior
How to display clinic awareness of abuse?
- Posters in waiting area
- Pamphlets available
- Folder of articles in waiting room
- Appointment cards printed w phone numbers of domestic violence and sexual assault services
What is the law regarding abuse?
- Doctors are responsible for medical care, not legal advice, but have an understanding of legal issues
- Assault occurring btw family members is a criminal offense
- Document any physical injuries and specific description of violence, but leave any interpretation of physical and other observations to a suitably qualified expert
“Handlingsplan mot vold i nære relasjoner 2014-2017”
Speaking to someone that has been abused
○ Listen: Being listened to can be an empowering experience for a woman who has been abused.
○ Communicate belief: “That must have been very frightening for you.”
○ Validate the decision to disclose: ‘It must have been difficult for you to talk about
this.’ ‘I am glad you were able to tell me about this today.’
○ Emphasise the unacceptability of violence:‘You do not deserve to be treated this
way.’
What are the types of addiction?
Substance and behavior
Wha is addiction?
Using a drug or alcohol consistently to excess, behavior can be personally destructive to a person. It concerns jobs, home, money, friendship, family relationships and contact with the normal world
How is an addicts view of the world?
They have a desperate view of the world, in which the only priority is securing the next high.
How is an addiciton developed?
An activity initially enjoyed by a person like eating, drinking, drugs etc. W repeated use and higher amounts needed to achieve a similar high that can become life threatening for the persons level of work and life responsibility
What may contribute to addiction?
May be in individuals w a combo of genetic makeup and poor social skills. This is why offsprings of addicts are prone to becoming addict. Child of a parent w drug or alcohol addiction is 8 x more likely to develop addiction.
What is dependence?
A term used to describe a persons physical and psychological loss of control due to substance abuse.
What is the difference btw addiction and dependence?
- Addiction is physical reliance on substance
- Dependence is psychological reliance on addictive behavior.
What are addictive behaviors? ‘
- Compulsive gambling
- Compulsive shopping and borrowing
- Work addiction
- Exercise addiction
- Internet
- Sexual
- Multiple
What is compulsive shopping and borrowing=
- Are on average 23000$ in dept
- Can happen in cycles
- Shopping frequently leads to compulsive borrowing from family, friends or institutions
What is healthy work?
- Provide a sense of identity
- Develops our strengths
- Is a means of satisfaction, accomplishment, and mastery of problems
What is work addiction ?
- Compulsive use of work and work personalia to fulfill needs of intimacy, power and success
- Is a major source of marital discord and breakup
- Often affects those who come from alcoholic/ dysfunctional homes
What is exercise addiction?
- Use exercise compulsively to meet needs of intimacy, nurturance, self-esteem and self-competency
- Are traditionally woman but also seen in men (steroid abuse and over exercising)
What are the negative consequences of exercise addiction ?
- Alienation of friends and family
- Injuries from overdoing
- Cravings for more
What is muscle dysmorphia?
Sometimes called “bigorexia”, is a pathological preoccupation w being larger and more muscular.
What is internet addiction ?
- Cyber sex and cyber relationship
- Net compulsions
- Information overload
- Addiction to interactive games: 15% of collage students report internet use/ computer games interfere w their academic performance
What is sexual addiction ?
- Compulsion of the intensity of physical arousal w intimacy
- Are incapable or nurturing another bc sex is the object of their affection
- Frequently have episodes of depression and anxiety
- Have high suicide rates
- Often were in a dysfunctional family during childhood
What is multiple addiction ?
Tends to have a favorite substance. In 60 % of people in Tx have problems w more than one.
What is the prevalence of smoking in US?
- 20% of adults / 46 million
- Everyday 4000 new smokers aged 12 - 17
- 20 % of smokers are non- daily or do not identify as smokers
What are the tobacco alternatives?
E-cig, cigars, pipers, snuff. Second hand smoke also counts
Tobacco dependence, how many want to quit?
- 70% of adult users report wanting to quit each year
- 44% try to quit each year, most w/o aid of counseling or cessation products, and most unsuccessful
- Only 4-7% of tobacco users who attempt to quit are successfull
How can tobacco dependence be reflected?
- Need to reflect the chronicity of the dependence
- Expectation that pat may have periods of relapse and remission (chronic disease model)
- Need ongoing tx and care, the importance of continued pat education, counseling and adivice over time
What are the risk factors with smoking?
- May cause over 40 diseases
- Stroke
- Class A carcinogen
Exposure to second hand smoke can cause
- Middle ear effusion
- Increase risk of croup, pneumonia and bronchiolitis by 60% before 18m
- Increase frequency and severity of asthma episode
- Is a risk factor for asthma in asymptomatic child
What is the existing barriers to effective treatment of tobacco dependence?
- Clinician lack knowledge about: 1) how to identify smoker quickly and easily 2) types of treatments available 3) Delivery of treatments 4) The relative effectiveness of the treatment
- Inadequate support of routine assessment and treatment
- Time constraints
- Limited training in tobacco cessation interventions
What is the evidence for effectiveness in treatment of smoking cessation?
- Cochrane review found that simple advice from doctor had significant effect on cessation rates
- Doctors/other health profesionals using multiple types of intervention to deliver individualized advice on multiple occasion produce the best results
- Frequent and consistent intervention over time are more important than the type of intervention
What is the intervention model for smoking cessation?
The 5 As
- Ask about smoking
- Advice smokers to quit
- Assess readiness to quit
- Assist with pats smoking cessation efforts
- Arrange for follow up visit or contact
Physician should use this intervention model to encourage smoking cessation
Which test is used to assess nicotine dependence?
Fagerstrøm
What will one day of quitting smoking help with ?
Decrease chance of heart attack
What will two days of smoking cessation help with ?
Enhance smell and taste
What wil 2w to 3m of smoking cessation help with?
Improve circulation and improve lung function by up to 30%
Excess risk of heart disease are reduced by half after ..
One years abstinence from smoking
After 10-15 years of smoking abstinence, the risk of dying…
Are almost reduced to those who never smoked
Smoking cessation in all ages, including older..
Reduce risk of premature death
Men who smoke are..
17 x more likely to develop lung cancer
What can smoking during pregnancy cause?
Small birth weight (IUGR)
What are the average weight gain after smoking cessation?
3kg + psychological effects
How to Assist a patient to quit smoking?
- Make plan
- Reccomend medication
- Provide practical counseling
- Provide int-treatment social support
- Provide supplementary material, including information on quitlines
What are first line medication in smoking cessation?
- Burpropion SR
- NRT ( nicotine replacement therapy)
- Varenicline
What are the second line medication in smoking cessation?
Clonidine and nortryptiline
There is insufficient evidence for recommending cessation meds to ..
Certain populations, like pregnant women, smokeless tobacco users, light smokers and adolescents
NRT
- Nicotine replacement therapy
- Used to relieve sy,toms of nicotine withdrawal while smoker breaks smoking habits
- Available as patch, lozenge, gum, nasal spray, inhaler
- Efficacy: combo (gum + patch) showed greater efficacy than single
Varenicline
- Partial agonist of nicotinic acetylcholine receptors
- Produce reinforcing effects of nicotine and lead to the development of nicotine dependence
- Reduce withdrawal symptoms
- Blocks nicotine from binding to the reception, thereby reducing rewarding aspects of smoking
How is varenicline excreted?
Via kidneys, no liver metabolism
What are the AE of varenicline?
Nausea, stomach pain, indigestion, constipation, weakness, tiredness, headache, insomnia, unusual dreams
What is bupropion
- Enhance CNS norepi and dopamine release which helps w smoking cessation
- Started 1 w before quit date (12w tx)
What are AE of bupropion?
Nausea, stomach pain, headache, dizziness, tinnitus, decreased sex drive, muscle pain, change in appetite, weight loss or gain
What is the efficacy of varenicline?
23,6% at 26w
What is the efficacy of bupropion ?
22% at 26w
What is the efficacy of NRT?
22.8% at 26w ( 2x better than placebo)
When should you consider second line agents?
For pats unable to use 1st line med bc of CI or pats for whom the group of 1st line meds has not been helpful.
What should you use in patients particularly concerned about weight gain?
Bupropion SR and NRT ( 4mg gum and 4 mg lozenge) delay but do not prevent weight gain
What to use in pat w past history of depression?
Bupropion and nortryptiline, NRT
What supplementary materials can you provide?
- Federal agencies
- Nonprofit agencies
- National/ state quitline network or local / state / tribal health departments/ quiting
When should follow up be?
- Soon after quit date, preferably during the first week
- Second follow up contact is recommended within the first month
What can you do with the patient unwilling to quit?
Motivational interviewing (MI):
- Express empathy
- Develop discrepancy
- Roll with resistance
- Support self- efficacy
What is the prevalence of depression?
- 5% of general population
- 10-15% of primary care pat
- 10- 14% of in-hospital patient
What are the screening tools for major depression disorders ?
PHQ - 9
PHQ - 2
Becks inventory
(MADRS)
What are the dx criteria for MDD?
A major depressive sd or episode manifest w five or more ( at least 1 sx is either depressed mood or loss of interest or pleasure) of the following sx, present most of the day, nearly every day for a minimum of two consecutive weeks
- Depressed mood
- Loss of interest or pleasure in most or all activities
- insomnia or hypersomnia
- change in appetite or weight
- psychomotor retardation or agitation
- low energy
- poor concentration
- thoughts of worthlessness or guilt
- recurrent thoughts about death and suicide
Pat w MDD w somatic problem
- Parkinsons > 50%
- Chronic pain 50%
- Malignant disease 40%
- DM/ MI / stroke 25-27%
- Chronic heart disease 17%
- Alzheimers disease 11%
- HIV / AIDS 10%
(5% of general population)
What er the TX of MDD?
- Psychotherapy w CBT
- Drugs: TCA, SSRI (1st choice), SNRI, MAOI, others
- Other: ECT, receptive transcranial magnetic stimulation, vagal nerve stimulation, phototherapy, St. Johns wart (induce cytokrom) , omega3 fatty acids
What are the cues of drug use in elderly w MDD?
- 2/3 of regular dose
- Mianserin (tolvon), SSRI, Tianeptin (Stablon, Coaxil) , venlafaxine, mirtazepin ( Remeron), trazodon
What are the cues of drug use in epilepsy + MDD?
SSRI, moclobemid (Amira, Aurorix, Clobemix) , reboxetin, Avoid maprotilitn (Ludiomil) as it has high risk of seizures
What are the cues of drug use in Parkinsons disease + MDD?
TCA, moclobemid, bupropion, venlafaxine, SSRI
What are the cues of drug use in females w MDD?
- SSRI bu NB! weight gain
- venlafaxine, trazodone, tianeptin, moclobemid
What are the cues of drug use in coronary heart disease + MDD?
- SSRI (sertralin, fluvoxamin)
- tianeptin, venlafaxine, moclobemid
With who should you avoid TCA?
Elderly and CVD pats
If there is acute coronary incident w MDD
SSRI, mirtazepin, bupropion
What should be avoided in pat w impaired coagulation treatd w ASA and NSAIDS?
SSRI and SNRI
What drug should you choose in pat who is breast feeding?
A drug not cumulating in childs organism ( sertralin, nortriptilin)
What is the relapse risk in MDD?
40% of pat in 1 year
1st episode: 50% chance of 2nd, 2 episodes 70%
3rd: 90%, consider long term therapy
What are indications for referral w MDD?
- Suicidal ideation
- Dx uncertain
- ass w substance abuse
- lack of response to antidepressants
- need for psychotherapy to achieve optimal response
- psychotic features: delusions, hallusinations
- bipolar disorder
- need for ECT
- MD combo w sever PD, borderline, narcisstic, antisocial
What are the prevalence of suicide?
10th cause of death in US. Highest risk are white men. Women and teens have more attempts
Can therapy and meds help with the issue of suicide?
Can help most people who have suicidal thoughts. Treating mental illness and substance abuse can reduce the risk of suicide
What are the risk factors of suicide?
- Depression and other mental disorders,
- Substance abuse disorder (often combo w mental disorder)
= 90% who die have these risk factors - prior attempt
- family history of mental disorder or substance abuse
- family history of suicide
- family violence, including physical or sexual abuse
- firearms in the home, method used in more than half of suicide
- incarceration
- exposure to the suicidal behavior of others, such as family members, peers, or media figures
What are the features of the patients who die in suicide?
- Sex M: F 4:1
- Age: elderly (highest rate >85y), young adults 20-24y
- ethnicity: american indian, alaska natives, non-hispanic whites
Non-hispanic white men > 85y have the highest rate
What are the risk factors for nonfatal suicide attempts in adults?
- 11 attempts per 1 deaths
- men and elderly are more likely to have fatal attempts than women and young
Adults:
- depression and other mental illness
- alcohol and other substance abuse
- separation or divorce
What are the risk factors for nonfatal suicide attempts in youth?
Youth:
- depression
- alcohol, drug use disorder
- physical, sexual abuse
- disruptive behavior
What are most attempts expressions of?
Extreme distress. A person who appears suicidal should not be left alone and needs immediate mental health tx
What are the stressors in PTSD
The person was exposed to 1) death 2) threatened death 3) actual threatened serious injury 4) actual or threatened sexual violence
What are the types of exposure in PTSD?
- witnessing in person
- indirectly, learning that a close relative/friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental
- repeated or extreme indirect exposure to aversive details of the events, usually in the course of professional duties
What are the Sx in PTSD?
- intrusion sx eg flashbacks
- avoidance: 1) people 2) places 3) activities, situations 4) objects
- negative alterations in cognitions and mood: 1) dissociative amnesia 2) persistent negative belief about oneself or the world
- alterations in arousal and reactivity: irritable, aggressive behavior, self-destructive reckless behavior, exaggerated startle response
- duration persistence of sc ( in criteria B, C, D and E) for more than 1 month
Prevalence of eating disorder
Do not discriminte btw gender and age. You cannot tell by someones weight that they have an eating disorder
What factors influence on eating disorders?
Both genetic and environmental factors.
