OCD, PTSD, GAD, Drug SE & Somatisation Flashcards

1
Q

Define somatisation

A

Disorders with multiple, recurring & changing physical symptoms that are not fully explained by other medical, neuro, psychiatric disorders

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2
Q

What are the causes of somatisation?

A

Chronic/acute emotional/psychological stress or conflict
Emotional processing deficit
Social, cultural, family taboos

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3
Q

What are risk factors for somatisation?

A
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
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4
Q

How is somatisation characterised?

A
  • > 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
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5
Q

How is somatisation investigated?

A

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

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6
Q

How is somatisation managed?

A
Psychotherapy: Short course CBT
Mindfulness therapy
Psychiatric consultation
Graded physical exercise
Antidepressants: Duloxetine
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7
Q

What is defined as a generalised anxiety disorder?

A

At least 6months of excessive worry, apprehension, prominent tension about everyday issues that is disproportionate to any inherent risk causing distress or impairment

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8
Q

What is pathophysiology of a generalised anxiety disorder?

A

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

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9
Q

How is GAD managed?

A

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)

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10
Q

What is a phobia?

A

Intense fears of specific objects or situations that are triggered upon actual or anticipated exposure to phobic stimuli.

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11
Q

How can phobias be managed?

A

CBT w/ gradual exposure
Benzos (Lorazepam)
Education & monitoring

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12
Q

In OCD what are obsessions & compulsions defined as?

A

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.

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13
Q

What are the risk factors for OCD?

A

PANDAS
Pregnancy
Fhx

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14
Q

What are the signs & symptoms of OCD?

A
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
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15
Q

How is OCD investigated?

A

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

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16
Q

How is OCD managed?

A

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

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17
Q

What is PTSD?

A

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

18
Q

What are the diagnostic factors of PTSD?

A

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

19
Q

How is PTSD investigated?

A
Latency period of 1-6months 
PTSD Checklist
PCL-5
IES-R
Davidson Trauma Scale
Trauma Screening Questionnaire
SPAN
20
Q

How is PTSD managed?

A

Watchful waiting & follow-up in 1 month
Trauma focused CBT
Mirtazipine
Pharmacotherapy: Fluoxetine usually to treat positive symptoms
Eye movement desensitisation & reprocessing

21
Q

Define neuroleptic malignant syndrome

A

Idiosyncratic life-threatening complication of treatment with neuroleptic meds. Characterised by altered mental state, increased muscle tone and alterations in the autonomic NS

22
Q

What is the pathophysiology of NMS?

A

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.

23
Q

What medications can cause NMS?

A

Use of high dose Depot preparations
Withdrawal of anti-parkinsonian meds
Antipsychotics: Haloperidol & Fluphenazine
Lithium
Metoclopramide
Anticholinergics
Atypical antipsychotics: Clozapine, Risperidone

24
Q

What are the signs of NMS?

A
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.
25
Q

How is NMS investigated?

A
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
26
Q

How is NMS managed?

A

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)

27
Q

What is tardive dyskinesia?

A

Repetitive stereotyped movements of the face/tongue/body/limbs from chronic (months-years) treatment with neuroleptics

28
Q

What is the pathophysiology of tardive dyskinesia?

A

Dopamine receptor supersensitivity as a result of chronic receptor blockade

29
Q

What serious condition can be misdiagnosed as tardive dyskinesia?

A

Huntington’s

30
Q

How is tardive dyskinesia managed?

A

Depends on patients psychiatric state if medication is withdrawn
Switch to atypical neuroleptics: Olanzapine, Clozapine
Tetrabenazine

31
Q

What is the prognosis for tardive dyskinesia?

A

1/3 achieve resolution but can take months-years

May be indefinite

32
Q

What are the signs & symptoms of GAD?

A

Chronic & fluctuating

  1. Psychological: Worry, apprehension, fear, persistent nervousness, irritable, poor conc, described as ‘free-floating’
  2. Arousal: hypervigilance, restlessness, inc startle response
  3. Motor: muscle tension, headaches, trembling, purposeless activity
  4. 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)
  5. Others: sweating, sleep disturbance (Initial Insomnia), derealisation, depersonalisation
  6. Fears: patient/relative will become ill/accident, impending danger, unrealistic ideas of danger, negative thoughts , feeling they can’t cope
33
Q

What is an acute stress reaction?

A

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

34
Q

What are the predisposing factors & risk factors for PTSD?

A

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

35
Q

How is a panic disorder diagnosed? How is a panic attack characterised?

A

> 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

36
Q

How is GAD diagnosed?

A
  • > 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)
37
Q

How is NMS diagnosed?

A
  • Neuroleptics within 1-4weeks
  • Hyperthermia >38
  • Muscle rigidity
  • Plus 5 other symptoms
38
Q

What are the complications of NMS?

A
AKI
Cardiac arrest
Rhabdomyolysis
Seizure
DIC
Respiratory arrest
Deterioration in psych condition due to med withdrawal
39
Q

What are the signs & symptoms of tardive dyskinesia?

A

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

40
Q

What is an adjustment disorder?

A

State of emotional distress that interferes with social functioning
Occurring <1m of a significant life event