MH fifth yr Flashcards
What is acute stress disorder?
occurs in the first 4 weeks after a person has been exposed to a traumatic event
PTSD > 4wks
Features of acute stress disorder?
intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance
Management of acute stress disorder?
Trauma-focused CBT
BDZs sometimes for agitation. sleep disturbance
Stages of grief?
5 stages:
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: this is commonly directed against other family members and medical professionals
Bargaining
Depression
Acceptance
Epidemiology of atypical grief reaction?
Women
If death sudden and unexpected
problematic relationship before death
patient has not much social support.
Features of atypical grief reaction?
delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
Features of PTSD?
> 4wks since traumatic event
Sx present for one month
re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
avoidance: avoiding people, situations or circumstances resembling or associated with the event
hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
emotional numbing - lack of ability to experience feelings, feeling detached
depression
drug or alcohol misuse
anger
unexplained physical Sx
Management of PTSD?
watchful waiting may be used for mild symptoms lasting less than 4 weeks
trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
not first line - If drug treatment is used then venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used
What is Cotard syndrome?
where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent
difficult to treat
problems - neglecting self (not E+D) as don’t deem it necessary
associated with severe depression and psychotic disorders
What is De Clerambault’s syndrome?
also known as erotomania
form of paranoid delusion with an amorous quality.
The patient, often a single woman, believes that a famous person is in love with her.
What is delusional parasitosis?
Delusional parasitosis is a relatively rare condition where a patient has a fixed, false belief (delusion) that they are infested by ‘bugs’ e.g. worms, parasites, mites, bacteria, fungus.
may occur with other psychiatric conditions or by itself
Factors suggesting depression over dementia?
short history, rapid onset
biological symptoms e.g. 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 recent memory loss)
Management of less severe depression?
reach shared decision with patient - least intrusive and least resource intensive first
anti-depressants not first-line unless persons preference
Treatment options, listed in order of preference by NICE:
guided self-help
group cognitive behavioural therapy (CBT)
group behavioural activation (BA)
individual CBT
individual BA
group exercise
group mindfulness and meditation
interpersonal psychotherapy (IPT)
selective serotonin reuptake inhibitors (SSRIs)
counselling
short-term psychodynamic psychotherapy (STPP)
Management of more severe depression?
shared decision
Treatment options, listed in order of preference by NICE
a combination of individual cognitive behavioural therapy (CBT) and an antidepressant
individual CBT
individual behavioural activation (BA)
antidepressant medication
selective serotonin reuptake inhibitor (SSRI), or
serotonin-norepinephrine reuptake inhibitor (SNRI), or
another antidepressant if indicated based on previous clinical and treatment history
individual problem-solving
counselling
short-term psychodynamic psychotherapy (STPP)
interpersonal psychotherapy (IPT)
guided self-help
group exercise
Screening for depression?
The following two questions can be used to screen for depression:
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
A ‘yes’ answer to either of the above should prompt a more in depth assessment.
Assessment of depression?
Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9).
DSM-IV criteria
Staging of depression?
‘less severe’ depression: encompasses what was previously termed subthreshold and mild depression
a PHQ-9 score of < 16
‘more severe’ depression: encompasses what was previously termed moderate and severe depression
a PHQ-9 score of ≥ 16
Epidemiology of anorexia nervosa?
Most common cause of admissions to child and adolescent psychiatric wards
Majority female patients
Teenage and young adult females
Criteria of anorexia nervosa?
BMI and amenorrhoea not longer specifically mentioned!
- Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
- Intense fear of gaining weight or becoming fat, even though underweight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
Management of anorexia nervosa?
Adults:
individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
specialist supportive clinical management (SSCM).
Child and young people
first line - anorexia focused family therapy
second line - cognitive behavioural therapy
Features of anorexia nervosa?
reduced body mass index
bradycardia
hypotension
enlarged salivary glands
lanugo hair
amenorrhoea
hypothermia
feel overweight - restricting calorie intake, exercise, laxatives
solitude
Physiological abnormalities - low, except C’s and G’s
hypokalaemia
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3
cardiac complications - arrhythmia, cardiac atrophy, sudden cardiac death
What is bulimia nervosa?
a type of eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising.
Criteria for bulimia nervosa?
recurrent episodes of binge eating (eating an amount of food that is definitely larger than most people would eat during a similar period of time and circumstances)
a sense of lack of control over eating during the episode
recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
recurrent vomiting may lead to erosion of teeth and Russell’s sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting
the binge eating and compensatory behaviours both occur, on average, at least once a week for three months.
self-evaluation is unduly influenced by body shape and weight.
the disturbance does not occur exclusively during episodes of anorexia nervosa.
Management of bulimia nervosa?
Referral for specialist care
bulimia-nervosa-focused guided self-help for adults
If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, NICE recommend that we consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
children - bulimia-nervosa-focused family therapy (FT-BN)
Pharmacological - high-dose fluoxetine licensed - long term data lacking
Features of bulimia nervosa?
Alkalosis, due to vomiting hydrochloric acid from the stomach
Hypokalaemia
Erosion of teeth
Swollen salivary glands
Mouth ulcers
Gastro-oesophageal reflux and irritation
Calluses on the knuckles where they have been scraped across the teeth. This is called Russell’s sign.
What is binge eating disorder?
characterised by episodes where the person excessively overeats, often as an expression of underlying psychological distress.
This is not a restrictive condition like anorexia or bulimia, and patients are likely to be overweight.
Features of binge eating disorder?
A planned binge involving “binge foods”
Eating very quickly
Unrelated to whether they are hungry or not
Becoming uncomfortably full
Eating in a “dazed state”
Summary of refeeding syndrome?
people that have been in a severe nutritional deficit for an extended period, when they start to eat again
higher risk if they have a BMI below 20 and have had little to eat for the past 5 days
metabolism slows during periods of malnutrition. As starved cells start to process glucose, protein and fats again, they use up magnesium , potassium and phosphorus. Leads to:
hypomagnesaemia
hypokalaemia
hypophosphotaemia
risk of: cardiac arrhythmias, heart failure, fluid overload
Tx:
slowly reintroducing food with restricted calories
Magnesium, potassium, phosphate and glucose monitoring along with other routine bloods
Fluid balance monitoring
ECG monitoring may be required in severe cases
Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine
What is schizophrenia?
Long-term MH problem affecting thinking, perception and affect
Epidemiology of schizophrenia?
Affects 1 in 100 people
M=F
ages 15-35
earlier in men
high incidence in urban areas and among migrants, lower SES
Pathophysiology of schizophrenia?
combination of psychological, environmental, biological and genetic factors.
emotional life experiences can be trigger
physical changes to brain hypothesis - hypoxic brain injury, temporal lobe epilepsy, smoke cannabis while brain still developing = enlarged ventricles, small amounts of grey matter loss, smaller lighter brains
Neurotransmitter hypothesis - excessive of dopamine in mesocorticolimbic thought to cause positive Sx, less dopamine in mesocortiyal tracts causing negative Sx - why psychotic Sx are seen in people with Parkinsons overtreated with levodopa
Also increase in serotonin activity and decrease in glutamate activity
Sub types of schizophrenia?
Paranoid - paranoid delusions and auditory hallucinations
Hebephrenic - adolescents and young adults - mood changes, unpredictable behaviour, shallow affect and fragmentary hallucinations, negative Sx develop rapidly
Simple - characterised by -ve Sx, no +ve Sx
Catatonic - psychomotor Sx - posturing, rigidity, stupor
Undifferentiated - don’t fit into other subtypes
Residual - -ve Sx, +ve Sx burnt out
