OCD, PTSD, GAD, Drug SE & Somatisation Flashcards
Define somatisation
Disorders with multiple, recurring & changing physical symptoms that are not fully explained by other medical, neuro, psychiatric disorders
What are the causes of somatisation?
Chronic/acute emotional/psychological stress or conflict
Emotional processing deficit
Social, cultural, family taboos
What are risk factors for somatisation?
Female Alexithymia IBS Chronic pain Hx sexual/physical abuse (PTSD) Hx of unstable childhood Antisocial personality disorder Hx of trauma Neuroticism Pre poor dr-pt relationship
How is somatisation characterised?
- > 2y of multiple, variable physical symptoms w/no underlying cause: Inconsistent Ex findings, False sensory findings, Hoover’s sign
-Refusal to accept Dr’s reassurance
-Impairment of social function- adjusting lifestyle to anticipate illness
-Symptoms not intentionally produced: Hx vague/odd/ dramatic
Other:
Emotional processing problems: Inability to be aware of emotions or tendency to suppress/avoid emotions
Multiple illness behaviours: Avoiding perceived environmental triggers
How is somatisation investigated?
Often see multiple Dr’s in different specialities
Nature of illness- Pt usually undergone multiple investigations w/ -ve outcomes
Lab tests to rule out organic cause
Extensive Hx & Ex
How is somatisation managed?
Psychotherapy: Short course CBT Mindfulness therapy Psychiatric consultation Graded physical exercise Antidepressants: Duloxetine
What is defined as a generalised anxiety disorder?
At least 6months of excessive worry, apprehension, prominent tension about everyday issues that is disproportionate to any inherent risk causing distress or impairment
What is pathophysiology of a generalised anxiety disorder?
Increased levels of arousal
Overactivity of ascending noradrenergic neurones w/enhanced response to nerve stimuli by excessive activity of 5-HT neurones
Changes in cerebral blood flow in response to stress & hyper vigilance
How is GAD managed?
Stepped care model:
1) Educate & monitor, sleep hygiene
2) Low intensity psychological support, guided self-help
3) 2 interventions failed, CBT/ drug treatment, Applied relaxation
4) SSRI/Venlafaxine
Other:
Beta blockers (Propanolol): Autonomic peripheral symptoms (palpitations, tremor)
Diazepam: 2-10mg, rapid anxiolysis (only in very short term e.g flying)
What is a phobia?
Intense fears of specific objects or situations that are triggered upon actual or anticipated exposure to phobic stimuli.
How can phobias be managed?
CBT w/ gradual exposure
Benzos (Lorazepam)
Education & monitoring
In OCD what are obsessions & compulsions defined as?
O: Unwanted, recurrent, disturbing, intrusive thoughts, images, impulses generally seen as excessive/irrational/ego-alien
C: Repetitive useless behaviours & mental acts that neutralise obsessions & reduce emotional distress. Function is to prevent some objectively unlikely event (often harm/danger)
Thoughts have significance & meaning so cannot be dismissed.
What are the risk factors for OCD?
PANDAS
Pregnancy
Fhx
What are the signs & symptoms of OCD?
Person hears impulsion as self (they know they are their own thoughts not thoughts externally inserted) Simultaneous anxiety Obsessions Compulsions Tic disorder Poor motor co-ordination Schizotypal personality disorder
How is OCD investigated?
Hx & Ex:
-Do you wash/clean a lot?
-Do you check things a lot?
-Is there any thought that keeps bothering you that you’d like to get rid of but can’t?
-Do your daily activities take a long time to finish?
-Are you concerned about putting things in a special order/are you upset by mess?
SCID
Tale-Brown Obsessive Compulsive Scale
Diagnosis: Ruminations arise/persist in absence of depressive episode
How is OCD managed?
CBT
ERP exposure & response prevention (to stimulus): Learning how to cope with tension
Mass practise: Pt forced to repeat their rituals
Thought-stopping: Blocking undesired thoughts
Pharmacotherapy:
SSRI: Fluoxetine/Sertraline, TCA: Clomipramine
Psychosurgery: Cingulotom
What is PTSD?
A disorder that develops immediately or delayed following exposure to a exceptionally threatening or catastrophic event likely to cause pervasive distress in almost anyone.
Associated depression & suicidal ideation
What are the diagnostic factors of PTSD?
1) Experience of major traumatic event
2) Re-experiencing trauma: INTRUSION: Involuntary, aspects of the traumatic event in a vivid & distressing way (flashbacks, intrusive images, sensory impressions, dreams/nightmares)
3) AVOIDANCE: Persistent effortful avoidance of reminders of the trauma (avoid people, situations, circumstances, newspapers, TV programmes)
4) Inc arousal: Hypervigilant, insomnia, enhance startle, numbness, emotional blunting
5) Onset delayed: Within 6months, features lasting >1m
How is PTSD investigated?
Latency period of 1-6months PTSD Checklist PCL-5 IES-R Davidson Trauma Scale Trauma Screening Questionnaire SPAN
How is PTSD managed?
Watchful waiting & follow-up in 1 month
Trauma focused CBT
Mirtazipine
Pharmacotherapy: Fluoxetine usually to treat positive symptoms
Eye movement desensitisation & reprocessing
Define neuroleptic malignant syndrome
Idiosyncratic life-threatening complication of treatment with neuroleptic meds. Characterised by altered mental state, increased muscle tone and alterations in the autonomic NS
What is the pathophysiology of NMS?
Antipsychotic medications antagonise D2 (dopamine) receptors.
Dopamine depletion in the hypothalamus & nigrostriatal/spinal pathways
Elevated temperature set-point, impairment of normal thermal homeostasis & EP induced muscle rigidity.
What medications can cause NMS?
Use of high dose Depot preparations
Withdrawal of anti-parkinsonian meds
Antipsychotics: Haloperidol & Fluphenazine
Lithium
Metoclopramide
Anticholinergics
Atypical antipsychotics: Clozapine, Risperidone
What are the signs of NMS?
90% within 10days of drug/dose added/changed Gradual onset Fluctuating consciousness Difficulty walking (shuffling gait) Increasing tremor/ involuntary movements Altered mental state Muscle rigidity (lead pipe) Hyperthermia/pyrexia Dyspnoea Dysphagia Autonomic dysfunction (Pallor, tachy, diaphoresis, labile HTN, tachypnoea, urinary incontinence) RARE: oculogyric crises, opisthotonos, seizures, chorea.
How is NMS investigated?
FBC (leukocytosis(↑WCC ) ↑ Serum CK Coag studies LFT: ↑LDH, ↑transamines Basic metabolic panel (↓Ca) ABG (Metabolic acidosis) Urine myoglobin & too screen Urine & blood culture Other causes ruled out: LP/CXR/Brain CT/MRI
How is NMS managed?
Consider airway management
Withdraw medication
Hyperthermia: Cooling devices & antipyretics
Supportive therapy: IV fluids, monitoring
Agitated: IV 1-4mg Lorazepam
Severe: Dantrolene (Tx muscle spasm), Bromocriptine (Reverse dopamine blockade)
What is tardive dyskinesia?
Repetitive stereotyped movements of the face/tongue/body/limbs from chronic (months-years) treatment with neuroleptics
What is the pathophysiology of tardive dyskinesia?
Dopamine receptor supersensitivity as a result of chronic receptor blockade
What serious condition can be misdiagnosed as tardive dyskinesia?
Huntington’s
How is tardive dyskinesia managed?
Depends on patients psychiatric state if medication is withdrawn
Switch to atypical neuroleptics: Olanzapine, Clozapine
Tetrabenazine
What is the prognosis for tardive dyskinesia?
1/3 achieve resolution but can take months-years
May be indefinite
What are the signs & symptoms of GAD?
Chronic & fluctuating
- Psychological: Worry, apprehension, fear, persistent nervousness, irritable, poor conc, described as ‘free-floating’
- Arousal: hypervigilance, restlessness, inc startle response
- Motor: muscle tension, headaches, trembling, purposeless activity
- Autonomic: CVS (Palpitations, tightness, pains), Resp (SOB, difficulty inhaling), GI (Dry mouth, loose stools, epigastric discomfort, butterflies), GUS (Freq micturition), Neuro (blurred vision, light headed, dizzy)
- Others: sweating, sleep disturbance (Initial Insomnia), derealisation, depersonalisation
- Fears: patient/relative will become ill/accident, impending danger, unrealistic ideas of danger, negative thoughts , feeling they can’t cope
What is an acute stress reaction?
Transient disorder
No other apparent mental disorder
Response to exceptional physical/mental stress
Symptoms: Within mins- daze, panic, amnesia, disorientation, inability to process external stimuli
Subside: Hours-days
Long-term: May be amnesia of the event
What are the predisposing factors & risk factors for PTSD?
Predisposing: Genetic (oversensitive amygdala & hippocampus, decreased hippocampal size on MRI), personality traits, prevent Hx of neurotic illness
RF: Level of social support, scale of trauma, patients prevention experience
How is a panic disorder diagnosed? How is a panic attack characterised?
> 4 panic attacks within 1month
Sudden onset spontaneous attack not limited to one situation
Signs: Lasts few mins, fear of going mad/dying, hyperV, nausea, palpitations, chest pain, sweating, lightheaded
Mx: CBT
How is GAD diagnosed?
- > 6m excessive worry/anxiety occurring more days than not
- Difficult to control the worry
- Other causes of anxiety excluded (OCD, phobia)
- 3/6 symptoms associated worrying: restlessness/on edge; easily fatigued; difficulty concentrating; irritability; muscle tension; sleep disturbance
- > 4 physical symptoms (e.g SOB, palpitations)
How is NMS diagnosed?
- Neuroleptics within 1-4weeks
- Hyperthermia >38
- Muscle rigidity
- Plus 5 other symptoms
What are the complications of NMS?
AKI Cardiac arrest Rhabdomyolysis Seizure DIC Respiratory arrest Deterioration in psych condition due to med withdrawal
What are the signs & symptoms of tardive dyskinesia?
Jerky movements : Lip smacking, moving mouth or jaw, tapping or moving hands or feet, movement in hips, movement in upper body, blinking
Slow movements: Writhing, twisting fingers, arms, legs, neck or tongue
Muscle spasm: Hypertonia, grunting, dyspnoea
What is an adjustment disorder?
State of emotional distress that interferes with social functioning
Occurring <1m of a significant life event
