Mental Health / Addiction medicine Flashcards
What are symptoms of abrupt cessation of antidepressant medication?
(6)
The symptoms of ‘antidepressant discontinuation syndrome,’ include: “FINISH”
Flu-like symptoms (lethargy, fatigue, headache, achiness, sweating)
Insomnia (with vivid dreams or nightmares)
Nausea (sometimes vomiting),
Imbalance (dizziness, vertigo, light-headedness)
Sensory disturbances (“burning,” “tingling,” “electric-like” or “shock-like” sensations) and
Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness).
How do you diagnose gender dyshoria?
(5)
Person needs to have 2 of the following present for at least 6 months:
- a significant difference between their own experienced gender and their secondary sexual characteristics
- strong desire to be rid of their secondary sexual characteristics or prevent their development
- wanting secondary sexual characteristics of the opposite gender
- wanting to be treated as the other gender
- the strong belief that they have the feelings/reactions of the opposite gender.”
What features of the history, in an adult, may make you consider ADHD as a diagnosis?
(3+4)
Lifelong history of:
>Impulsivity
>Inattention
>Hyperactivity
Specifically in adults:
-Relationship difficulties
-Dropping out of studies- especially if considered to be capable of higher achievement
-Driving accidents or offenses
-Greater addiction habits: drugs, alcohol, smoking or even computer gaming
What aspects of management do you need to consider in adult ADHD?
(5)
- Psychiatrist referral for trial of stimulant medication
- Psychologist referral to help develop strategies to manage symptoms
- Relationship counsellor to assist with relationship issues
- Consideration of the patient’s ability to drive safely
- Improve psychoeducation to help the patient understand their condition better
What questions can you ask to screen someone whom you suspect to have an eating disorder?
(5+2)
“SCOFF”
S (SICK) – Do you make yourself Sick because you feel uncomfortably full?
C (CONTROL) – Do you worry you have lost Control over how much you eat?
O (?) – Have you recently lost more than 6.35 kg in a three-month period?
F (FAT) – Do you believe yourself to be Fat when others say you are too thin?
F (FOOD)– Would you say Food dominates your life?
—> an answer of YES to more than 1 question prompts the need for a more detailed assessment.
A further two questions have been shown to indicate a high sensitivity and specificity for bulimia nervosa.
- Are you satisfied with your eating patterns?
- Do you ever eat in secret?
Investigations to order at baseline for an eating disorder …
(numerous answers)
This can get quite extensive given the nutritional deficiencies and potential dangerous sequelae.
B12/folate level
Calcium, magnesium, phosphate level
Complete blood count/FBC
Creatine kinase
Electrocardiogram
Electrolytes, Urea and Creatinine
Fasting blood sugar level
Iron studies
Liver function test
Vitamin C level
Vitamin D level
Zinc level
Why are the following important to correct in an eating disorder?
Zinc deficiency
Vitamin C deficiency
Vitamin D deficiency
zinc: is actually important for healthy growth.
more specifically– apparently low levels lead to a vicious cycle of more binging or altered eating habits in itself! So treating the deficiency can lead to an improved rate of recovery!
Vitamin C- more basically prevents things like scurvy
Vitamin D - bone loss, even osteoporosis, can occur with eating disorders.
What is the HEEADSSS screening tool?
What is it used for, and what do the letters stand for?
Used to screen adolescent behaviours and risky environments that can contribute to a poor physical or mental health
Home situation
Education/Employment
Eating (..screening for disorders..) +/- body image
Activities (peer group)
Drugs/alcohol
Sex life
Suicide and Depression
Safety from violence and bullying
Examination features of Anorexia Nervosa?
(7)
Muscle and fat wasting
Weakness
Slow tendon reflexes
Fine downy hair
Decreased peripheral circulation: low volume pulse, acral (finger tip like) cyanosis
Decreased blood pressure
Decreased pulse
List three drugs that can be used for long term management of alcohol dependence.
Disulfiram - best if highly motivated and physically fit
Acamprosate - best for protracted withdrawal symptoms (anxiety, insomnia, craving, irritability)
Naltrexone - best for binge or heavy drinkers
Specific strategies to help to curb alcohol dependence (non pharm)
(7)
Drink only with food
Have a glass of water between drinks
Switch to smaller glass sizes
Switch to low alcohol beer, or trial non-alcoholic beers/spirits etc
Avoid going to the pub after work
Avoid spending time with friends or family that drink heavily
When stressed do exercise or take a walk instead of drinking
Explore new interests
Spend time with friends who don’t drink
When managing alcohol dependence, who should get thiamine?
And what is the dose?
All dependent drinkers are prone to thiamine deficiency because of
poor diet and damage to the gastric lining, and impaired thiamine
utilisation. Current consensus is that thiamine should be given to
all dependent drinkers at a dose of at least 300 mg/day.
Loss of interest in previously pleasurable activities or depressed mood are the key features of depressive disorders.
What other somatic symptoms might you ask about?
(4)
PAFS
Somatic symptoms
-Psychomotor disturbance: can be agitated behaviour like tapping fingers/feet or pacing or rapid talking. Or can be the opposite- retardation: slowed speech and movements
-Appepite loss/ increased appetite / change in weight
-Fatigue
-Sleep deprivation/excessive sleep
Other than suicidal ideation, depressed mood and loss of interest, what are psychological features of depression?
FIELD
Feelings of helplessness/hopelessness
Irritability
Excessive Guilt
Low self esteem
Diminished concentration
What are the 5 main depressive disorders?
Major depressive disorder
Seasonal affective disorder
Perinatal depression
Substance or drug induced depressive disorder
Sub-threshold depressive symptoms
What is the diagnosis criteria for major depressive disorder. (DSM 5)
At least 2 weeks of either ..
A. Depressed mood or
B. Anhedonia
PLUS
four other features (somatic or psychological)
AND
These symptoms must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning.
AND
The symptoms must also not be a result of substance abuse or another medical condition
What are “static” risk factors for suicide?
(What does “static” mean and what are the exact risk factors?)
(6 main categories)
Static refers to fixed/historical risk factors
Previous self harm including suicide attempts
Diagnosis of a mental health disorder, especially MDD
Substance abuse- Especially alcohol
Family history of suicide
Recent stressor or loss
Demographics; age, gender, marital status; worse if older age, male, and divorced
What are dynamic risk factors for suicide?
(6)
Active suicidal ideation
Guilt
Hopelessness
Current substance use
Psychological stressors
Problem solving deficits
Which two aspects of suicidality/suicidal thoughts determine how dangerous it is?
- The lethality/potency of the planned act or damage caused by the suicide plan
- Degree of ideation: How far into planning it is, their desire to live or die and if plans have been made specifically to AVOID discovery
Example a person who has an advanced plan to drink Powerade only until they pass out, and has purchased the Powerade and made sure everyone is out of the house is still unlikely to complete suicide.
Whereas someone who hasn’t quite yet acquired a harmful illicit drug and has only made a half-wit plan might actually be higher risk.
What are some risk factors of harm to others?
HAPPy
history of substance abuse (esp alcohol)
antisocial personality disorder
previous violence
poor impulse control
Negative affect (anger, irritability, humiliation)
Social (conflict with others)
What are questions to ask when assessing SUICIDE risk. not depression.
(7)
Do you feel like giving up?
How does the future look to yoU?
Does life feel so bad that it makes you feel like you want to die?
How severe and how frequent are your thoughts?
Have you made any plans?
How close have you come to doing something?
What stops you from doing something?
What is one useful and one not so useful action you can do in clinic, to help mitigate suicide risk?
- writing down a safety plan,
may include involving close family or friends
can use resources like Lifeline, beyond blue - ’ no self harm contracts,’ have mostly been found to be ineffective.
What are the two main aspects of personality disorders that make up the dysfunction?
Problems with functioning views of oneself (self worth, accuracy of view, self direction and identity)
Interpersonal dysfunction (difficulty maintaining close and mutually satisfying relationships, impaired ability to understand other person’s perspective, and difficulty managing conflict in relationships)
The aetiology of a personality disorder (PD) is ___a_____.
There may be __b____ in the ____c_____ environment during infancy that lead to ongoing maladaptive responses.
__d____ life experiences are associated with a personality disorder, but there are some with a PD that have none.
PD affects _e__% of the Australian population.
Personality disorder does not have an ___f____ onset. You will need to distinguish disturbances in cognition, ___g____ and ____h____ that are part of the person’s usual self versus distinct periods of time.
Personality disorder is most evident during the transition from childhood to adulthood, when capacity for self reflection and life narrative is developed.
a- complex
b-deficits
c-caregiving
d-adverse
e- 10%
f- abrupt
g- emotions
h- behaviour
In order to diagnose a personality disorder traits disturbances in cognition, emotions and behaviour have to be:
(4)
- displayed across a range of situations and contexts
- associated with substantial distress or significant impairment in functional areas (family, occupational, educational, social)
- relatively stable traits across years i.e not abrupt
- distinct from periods of another mental state disorder (eg depressive or manic episodes, periods of intoxication).
What three sources of information can you utilise to provide a history into PD?
longitudinal history from the patient
previous clinician records/notes
collateral history from family, carers or significant others
How is the classification of PD changing and why?
It was previously based on categories e.g. anti-social, histrionic, schizotypical etc.
It is now changing to classifying PD on a spectrum of severity.
WHY?
This is because the previous classification has lots of overlap. It also lacked any validity and no clear threshold existed between the types and degrees of PD
In classifying the severity of PD, which factors should be taken into account?
(5)
the number of areas of personality functioning affected (eg personal, familial, social, educational, occupational)
The amount of interpesonal relationships affected
Person’s ability to perform social and occupational roles
Likelihood of inflicting harm on themselves or others
The level of distress or impairment experienced in areas of functioning
The therapeutic relationship between the patient and clinician is central to personality disorder management and can provide an environment that allows change. However, it can be challenging because, by definition, people with personality disorder have difficulties with interpersonal relationships.
List at least 5 key principles of working with these people. There is a large list.
-Be compassionate.
-Demonstrate empathy.
-Listen to the person’s current experience.
-Validate the person’s current emotional state.
-Take the person’s experience seriously, noting verbal and nonverbal communications.
-Maintain a nonjudgemental approach.
-Stay calm.
-Remain respectful.
-Remain caring.
-Engage in open communication.
-Be human and be prepared to acknowledge both the serious and funny side of life where appropriate.
-Foster trust to allow strong emotions to be freely expressed.
-Be clear, consistent and reliable.
-Remember aspects of challenging behaviours have survival value given past experiences.
-Convey encouragement and hope about their capacity for change while validating their current emotional experience.
Patients with PD usually present in or after an acute crisis. You might be pressured to prescribe pharmacotherapy, but this is not indicated.
What strategies can you use?
(3)
Verbal de-escalation
Psychoeducation
Psychological intervention
What is the mainstay of long term management of PD?
Psychological interventions
Mainly dialectical behaviour therapy
also mentalisation based therapy
When might you consider pharmacotherapy for personality disorder, and what would you use?
If they are acutely distressed and not responding to de-escalation. then
Diazepam 5-10mg, orally, twice a day, for up to 2 weeks. reduce dose over 4 weeks
OR lorazepam 0.5-1mg, orally, BD, for up to 2 weeks. reduce dose over 4 weeks.
if they are agitated AND If they are likely to harm themselves or others then:
-Diazepam 10-20mg, oral, immediately, can be repeated in 30 minutes. max 60mg before consulting
-Olanzapine 5-10mg, orally, repeated in 30 minutes if needed to max 30mg before consulting an expert.
-also lorazepam 1-2mg, orally, 30 minutely, max 6mg before consulting
If suffering from insomnia then
temazepam 10-20mg, orally, 30 minutes before needed. not more than 2 weeks, preferably not on consecutive nights
zolpidem IR 5-10mg, orally, at bedtime for the shortest duration, but not more than 2 weeks.
What is the classification of nicotine dependence?
any of:
1. Smoking within 30 minutes of waking up
2. Smoking more than 10cigarettes a day
3. Experiencing withdrawal symptoms upon smoking cessation
What are signs of nicotine withdrawal?
(6)
Anxiety
Frustration
Craving
Restlessness
Insomnia
Increased appetite
What are some strategies to deal with perceived barriers to quitting smoking?
Belief they can quit at any time. Explore previous attempts and what made it successful or more so why it didn’t last
Feel like health isn’t affected -Explain the health benefits of quitting at any stage, and refer to the timeline of when benefits begin to kick in
Weight gain- only 10% of people gain weight and there are plenty of ways to deal with that
Feeling needing help is a sign of weakness- explain the nature of addiction and withdrawal. And that success is vastly improved with support.
Peer pressure- explore environments and how to avoid high risk social situations
What are TGA approved items for smoking cessation?
All nicotine
Vareniciline
Bupropion
For someone that smokes within 30 minutes of waking and smokes more than 10 a day, what nicotine replacement options are there?
nicotine patch 21mg/24 hours patch
AND
4mg gum
Or
4mg Lozenge
or 1mg Spray or 15mg inhaler
When starting varenicline, what are the specifics around prescribing it?
Patient has to be enrolled in a conselling program
Has to be ready to quit at the time
Cannot be used for more than 24 weeks in a given year
Can only be using this medication ALONE for cessation efforts
What is the dosing instruction for varenicline?
varenicline 0.5 mg orally, daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily for the remainder of a 12-week course
What is the goal quit date after starting either Zyban or Champix?
2 weeks
arrange a follow up at the 2 week mark
What are the dosing instructions for Zyban (Bupropion)?
bupropion 150 mg orally, once daily for 3 days, then 150 mg twice daily for the remainder of a 9-week course
What are contraindications to using bupropion?
Seizures are the only contraindication
Use discretion with eating disorders
Also use discretion if using MAOi’s
What are non pharmacological strategies to deal with smoking cessation?
- Conselling
- Cognitive and behavioural techniques
deep breathing
drink a glass of water
do something else
QuitBuddy distraction
Other online/paper distractsion - Written information
- Quitline referral
- Arrange follow up
What is the preferred way to administer Nicotine replacement therapy?
As a combination
e.g. patch + lozenge.
When should the first follow up occur after starting on pharmacotherapy for smoking cessation?
2 weeks
What conditions do you have to consider when prescribing pharmacotherapy for smoking cessation?
- Varenciline - psychiatric and cardiovascular (though the incidence is quite low and furthermore the risk of smoking poses a bigger cardiovascular risk than trying to use this medication to stop smoking)
- Bupropion- seizures. Still very tiny and almost insignificant evidence.
- NRT- cardiovascular risk. but again risk of smoking is even worse.
What is it important to let patients know about diagnosing ADHD ?
That it is time consuming taking up to 2-3 hours.
It requires a longitudinal view of that patient’s life including home and school or work, and the exclusion of other health and mental health conditions that can mimic ADHD
Children with ADHD either have ___(a)___ – cannot sit still and are always squirming – or ___(b)____ – where they daydream and tune-out – or a mixture of both. Another characteristic is ____(c)____
a. hyperactivity
b. inattentiveness
c. impulsivity.
What is the estimated proportion of children and adults suffering from ADHD?
apparently 10% of children and 5% of adults.
about 25% of children with ADHD also have an autism spectrum disorder
What are two main aspects of oppositional defiant disorder.
Negative attitude, hostile, aggressive – temper outbursts, bullying
Baseline mood appears lower
than normal
What does a patient need to display specifically, in order to diagnoses ADHD.
ADHD cannot be diagnosed simply in terms of fulfilling a certain number of listed criteria.
Though they should display certain symptoms the key to diagnosis is that the symptoms are associated with functional impairment. This should be across two or more settings, usually home and either at work, school or preschool.
Over what domains in life does ADHD cause functional impairment.
Remembering you need at least 2 different settings that display impairment for diagnosis.
Is considered capable of higher achievement – could/should do better
Behaviour presents unreasonable stress or disruption in school/work
Behaviour presents unreasonable stress or disruption in the family
Behaviour significantly affects
peer relationships
Person is aware of having difficulties and has low self-esteem
It can be hard to diagnose ADHD in preschoolers as some behaviours may be normal. Hence if so, they majority also have ODD (oppositional defiant disorder).
The peak age of ADHD diagnosis is between 5-10 years old. Teachers are quite good at recognising those with hyperactive tendencies as displayed by…. (A)
Functional impairment at home may manifest as (B)
Part A
A child who is unable to concentrate for long may become bored and disruptive.
However teachers are not as good at recognising innattention.
Part B
Functional impairment at home may manifest as disorganisation requiring numerous reminders for getting dressed and ready.
Because of under-diagnosis in childhood an adult may end up with untreated ADHD.
This can lead to a lifetime of underachievement, disorganisation and impulsive behaviour and associated poor self-esteem.
What issues can further arise from there?
(3)
May progress to anxiety, depression or substance abuse
What key questions can you ask in an initial consult to help begin clarifying a suspected ADHD diagnosis?
Remember you won’t be-able to diagnose it in a single consult, and will need a psychiatrist to make the diagnosis at this stage.
(5)
- Ask about functioning. at school or work
- Ask about a life long nature of it, in an adult or adolescent
- Ask about their concentration. How long they can focus on a task
- Ask about mood. Which may be better off coming from an observer. Parent or significant other
- Specific questions (see another slide)
What specific disruptions may you ask about when considering ADHD as a diagnosis?
(6)
- Relationship breakdowns
- Being dismissed from work
- Dropping out of courses
- Substance abuse
- Driving offences/accidents
- Criminal activity
What medication (no dosing required) can GPs prescribe for ADHD treatment?
Firstly GPs can only prescribe ADHD stimulants after a psychiatrist has done the initial assessment and prescription.
Options include
Methylphenidate (long or short acting)
Dexamphetamine
Lisdexamphetamine
Treating ADHD goes beyond medication alone, requiring a multimodal approach. What else should be implemented?
(4)
social and organisational skills training
cognitive training
parent behaviour training (for children)
classroom management measures (eg strategically positioning the child in the classroom, setting rules and expectations, using a daily report card). again for children.
Irrespective of severity of depression, which lifestyle factors should you address with the patient?
(7)
Sleep hygiene
Regular physical activity
Healthy diet
Minimise alcohol
Stress reduction. Recognise stressful events/factors and plan a way to reduce this
Social/community interaction. identify social supports and lean in on this.
Time in nature
Relaxation techniques
What are resources to provide patients for basic psychological intervention?
(6)
Though there could be others
Smiling mind app - mindfulness
Blackdog institute - relaxation strategies
Sleep- CBTi apps
This way up for cognitive training
Mindspot - cognitive training
Mood gym- skills for dealing with depression and anxiety
When might a mental health crisis plan entail?
(6)
- Implement relaxation strategies if stressed
- Implement minfulness strategies
- Phone a family member or friend
- Phone/chat with beyond blue/lifeline
- Present to GP clinic
- Present to E.D
What is the recommended initial follow up time frame after commencing ANY management for Major Depressive Disorder?
Initially 2-4 weeks
First line medical options to treat Major Depressive Disorder?
(4)
- Sertraline 50mg, oral, daily. up to 200mg
- Citalopram 20mg, orally, daily up to 40mg
- Mirtazpine, 15mg, orally, daily, max 60 mg. ideally taken at night
- Paroxetine 20mg, orally, daily up to 50mg
When reviewing a patient started on anti-depressants, if they haven’t responded what is the next step?
(2)
- Increase the dose if there has been some response and adjust every 2-4 weeks
- change medication if there has been no response or if, off course the medication caused too many/too severe side effects
What is the definition of treatment failure depression? and what does this imply needs to happen next?
- Trial of two different medications at their maximum dose for at least 4 weeks EACH.
- Referral to psychiatrist
What is the recommended time frames to consider medication cessation in MDD?
(2+1)
- after 12 months, start to taper the medication after an initial episode and treatment for depression
- after 3 years if there have been recurrent depressive episodes
- sometimes lifelong therapy is needed
If a patient has had 2 or more depressive episodes within 5 years, 3 or more cumulative episodes, psychotic depression or a serious suicide attempt, continue antidepressant therapy for 3 to 5 years—sometimes lifelong therapy is required.
What are two complimentary medical options for treating mild-moderate depression?
what are things to keep in mind
(2 +info)
St Johns Wort, Do not use with warfarin, digoxin or HIV medication
Omega 3- useful in the acute treatment of major depression but there is no evidence for prophylactic or long term use
What classification of medical health conditions do these fall under?
Adjustment disorder
PTSD
Acute stress disorder
Trauma/Stress related disorders
(yes, PTSD is not an anxiety disorder)
What is the definition of adjustment disorder?
(4)
Onset is within 3 months of acute stressor
Disproportionate symptoms to stressor itself
Significant social/occupational functional impairment
Symptoms resolve within 6 months
What are tools/aspects of management for adjustment disorder?
(5)
- problem recognition and solving
- Relaxation strategies
- Guidance; financial, accomodation (not really the GP realm to directly be involved in this, but can refer)
- Short term conselling or CBT or psychodynamic psychotherapy
- Short term use of benzodiazepines if anxiety is crippling
e.g. diazepam 2 to 5 mg orally, as a single dose. If required, repeat once after 2 hours. Use for up to 2 weeks
what is the difference between psychodynamic psychotherapy and CBT?
PDPT - longer term. focuses on gaining insight. focus on understanding thoughts and patient’s past
CBT- shorter term. focused on maladaptive behaviours. change focused
What is the definition of acute stress disorder and /vs. PTSD?
acute stress disorder - significant distress or functional impairment after a traumatic event. Symptoms last for more than 2 days but less than 1 month.
PTSD characterised by symptoms lasting for more than 1 month.
What are symptoms of PTSD?
(4)
- Intrusive thoughts
- Persistent avoidance of stimuli associated with the event
- Negative thoughts or feelings about the event
- Marked alterations in reactivity and arousal: irritability, aggression, difficulty concentrating
What are first line therapies for PTSD?
EMDR - eye movement desensitisation and reprocessing
Trauma focused CBT
Note
Medication, whilst can be used, is NOT first line .
What are some adjunctive medications that can be used in conjunction with psychotherapies for PTSD?
- Sertraline 50mg up to200mg, oral, daily. adjust by 25mg each time.
- Escitalopram 10mg up to 20mg, oral, daily. Adjust by 5mg each time.
- Paroxetine 20mg up to 50mg, oral daily. adjust by 10mg each time.
- Citalopram 20mg t0 40mg, oral, daily. Adjust by 10mg.
Review and adjust every 2-3 weeks
There is little evidence to support mirtazapine and TCAs but can be used if treatment fails for with SSR/SNRIs
What are early interventions following trauma exposure?
(3)
What is not recommended?
(2)
Recommended:
Encourage use of social supports
Encourage coping strategies
Provide advice on good sleep practices
Not recommended:
No need for structured interventions (like psychological debriefing)
No role for pharmacotherapy
What are questions to ask yourself if there is apparent failure to treat PTDS or even MDD when initiating a first line anti-depressant ?
(7)
- Do you have the correct diagnosis?
- Are there possible medical causes for the diagnosis
- Have alcohol or other substance issues been addressed?
- Have relevant psychosocial factors been addressed?
- Is the medication at an adequate dose, and treated for an adequate time to have effect
- Is there a drug reaction reducing the response?
- Is the patient adherent to therapy?
-stigma?
-side effects?
-forgetfulness/hard to remember?
Recurrent nightmares are common in PTSD.
What are three types of management that could be used?
(if medication no dosing required)
- imagery rehearsal therapy
- CBT
- Prazosin <- yes prazosin. proven to be safe and effective in managing sleep in PTSD
What are some anxiety specific disorders?
(6)
Agoraphobia
Generalised anxiety disorder
Panic disorder
Separation anxiety disorder
Social anxiety disorder
Specific phobias
What are the three “obsessive compulsive disorders”
Body dysmorphic disorder
Hoarding disorder
Obsessive compulsive disorder
What needs to be included in the diagnosis of GAD?
and assume there is already
1. social or occupational impairment and
2. not due to substance misuse
Needs to have 3+ of the following symptoms with at least one present for 6 months:
Restlessness
Difficulty concentrating
Easily fatigued
Irritable
Muscle tension
Sleep disturbance
First line treatment for GAD, panic disorder and social anxiety disorder and adult separation anxiety?
(2)
- CBT and psychotherapies including psychoeducation
- always address lifestyle factors
What are the 4 key aspects of providing psychoeducation to patients?
- education about their disorder
- education about the mental health care system, including different types of clinicians and relevant health legislation
- Maintaining physical health
- Principles of caring for one-self
In providing pyschoeducation, as a GP, what should you cover when educating the patient about their disorder?
(6)
- Cause and symptoms
- Treatment
- Prognosis
- alleviating and aggravating factors
- characteristic early symptoms/signs of relapse
- Strategies to prevent relapse
What is the difference between agoraphobia and social anxiety disorder?
Agoraphobia tends to develop in response to panic attacks. So it is a fear that develops to being in spaces where they fear of losing control or not being able to escape. It doesn’t have to be large public places only and is not restricted to social interactions, more so ‘places’. Usually you have to treat the panic disorder- short term benzos and longer term CBT.
Social anxiety is the fear of being judged or criticised and risk embarrassment in social situations or even basic interactions such as paying for a bus ticket (though this is a poor example, even now you don’t need to even interact with anyone at the supermarket).
What is the difference between having a panic attack and panic disorder?
A single panic attack usually occurs due to some kind of stimulus/stress/event.
Whereas panic disorder is when there are repeated panic attacks without a clear trigger.
What are two potential psychological therapies for an acute panic attack whether a single episode or panic disorder?
Breathing techniques
eg.
Box breathing
4-7-8 breathing
Distraction
e.g. 3-3-3 rule (3 sounds, 3 things you see, 3 things you can touch by moving)
What are second line (medical) treatments for GAD and panic disorder?
SSRI’s/SNRI’s similar to MDD
however with panic disorder the doses are halved.
E.g. citalopram 10mg but still up to 40mg, oral, daily. review and adjust 2-4 weekly.
What disorder class does body dysmorphic disorder fall into?
Obsessive compulsive disorder
NOT an eating disorder
What is the definition of body dysmorphic disorder? (DSM-5)
(5)
Has to have..
- Appearance preoccupation: person preoccupied with non existent or slight flaws (presumed to be at least 1 hour - accumulative - a day)
Note; if there is an obvious appearance flaws this is NOT body dysmorphic disorder. but can still be a disorder.
- repetitive behaviours: usually observable by others, mirror checking, seeking reassurance, excessive grooming, skin picking or clothes changing. Or mental acts: comparing to others
- Significant social or occupational or other functional impairment
- Not better explained by an eating disorder e.g. fear of gaining weight or guilt about weight gain.
- Specifiers
- muscle dysmorphia- feeling they are too small. Why specify? because this type is related to worse quality of life and high suicide.
-also specify level of insight. i.e. how aware they are that this is true or not. ranges from: good insight, poor insight, no insight. (no insight would not classify as a psychotic disorder however).
What is the best therapy option for treating the OCD and body dysmorphic disorder?
A combination of psychological and pharmacotherapy.
e.g. CBT with exposure and response training and SSRIs (at MDD dosing)
What are symptoms of mania?
(6)
Elevated mood and euphoria
Increased energy/activity
Reduced need for sleep
Grandiosity
Increased subjective speed of thoughts
Enhanced perceptual experiences (more harmonious more vivid)
What is it most important to ask or inform, during the first presentation of suspected major depressive disorder, in assessing differentials and why?
Ask or educate about manic symptoms for assessment for bipolar disorder.
Why?
1. because bipolar presents as depression first.
2. those with bipolar have a 30x risk of suicide (than general) so you want to catch it
3. treatment for MDD, if started, can exacerbate or cause or manic episode.
For an acute management of mania, what 3 medications will be started in combination?
No dosing needed.
Mood stabiliser: valproate or lithium
+
Anti-psychotic: quetiapine or olanzapine
+
Anxiolytic: benzo like diazepam.
