OCD, PTSD, GAD, Drug SE & Somatisation

Question 1

Define somatisation

Answer 1

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

Question 2

What are the causes of somatisation?

Answer 2

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

Question 3

What are risk factors for somatisation?

Answer 3

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

Question 4

How is somatisation characterised?

Answer 4

• > 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

Question 5

How is somatisation investigated?

Answer 5

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

Question 6

How is somatisation managed?

Answer 6

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

Question 7

What is defined as a generalised anxiety disorder?

Answer 7

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

Question 8

What is pathophysiology of a generalised anxiety disorder?

Answer 8

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

Question 9

How is GAD managed?

Answer 9

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)

Question 10

What is a phobia?

Answer 10

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

Question 11

How can phobias be managed?

Answer 11

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

Question 12

In OCD what are obsessions & compulsions defined as?

Answer 12

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.

Question 13

What are the risk factors for OCD?

Answer 13

PANDAS
Pregnancy
Fhx

Question 14

What are the signs & symptoms of OCD?

Answer 14

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

Question 15

How is OCD investigated?

Answer 15

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

Question 16

How is OCD managed?

Answer 16

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

Question 17

What is PTSD?

Answer 17

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

Question 18

What are the diagnostic factors of PTSD?

Answer 18

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

Question 19

How is PTSD investigated?

Answer 19

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

Question 20

How is PTSD managed?

Answer 20

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

Question 21

Define neuroleptic malignant syndrome

Answer 21

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

Question 22

What is the pathophysiology of NMS?

Answer 22

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.

Question 23

What medications can cause NMS?

Answer 23

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

Question 24

What are the signs of NMS?

Answer 24

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.

Question 25

How is NMS investigated?

Answer 25

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

Question 26

How is NMS managed?

Answer 26

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)

Question 27

What is tardive dyskinesia?

Answer 27

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

Question 28

What is the pathophysiology of tardive dyskinesia?

Answer 28

Dopamine receptor supersensitivity as a result of chronic receptor blockade

Question 29

What serious condition can be misdiagnosed as tardive dyskinesia?

Answer 29

Huntington’s

Question 30

How is tardive dyskinesia managed?

Answer 30

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

Question 31

What is the prognosis for tardive dyskinesia?

Answer 31

1/3 achieve resolution but can take months-years

May be indefinite

Question 32

What are the signs & symptoms of GAD?

Answer 32

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

Question 33

What is an acute stress reaction?

Answer 33

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

Question 34

What are the predisposing factors & risk factors for PTSD?

Answer 34

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

Question 35

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

Answer 35

> 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

Question 36

How is GAD diagnosed?

Answer 36

• > 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)

Question 37

How is NMS diagnosed?

Answer 37

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

Question 38

What are the complications of NMS?

Answer 38

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

Question 39

What are the signs & symptoms of tardive dyskinesia?

Answer 39

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

Question 40

What is an adjustment disorder?

Answer 40

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