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Year 3- placement > Personality disorder, psychosis and learning disability > Flashcards

Personality disorder, psychosis and learning disability Flashcards

1
Q

Transference and counter-transference

A
  • Transference: projections of attitudes/feelings from the past onto people in the present
  • Counter-transference: unconscious attitudes that a clinician develops/acts out in response to a patients behaviour
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2
Q

Biological and social management of personality disorder

A
  • Biological: no medication is licensed for treatment of personality disorder. Treat co-morbidities: depression, anxiety, substance misuse, psychosis
  • Support around practical issues: benefits, housing, substance misuse
  • Finding a purpose: employment, voluntary work, social groups/hobbies
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3
Q

Psychological management of personality disorders

A
  • Dialectical behavioural therapy: skills based and mindfulness. Over 3 domains (emotional regulation, distress tolerance and interpersonal effectiveness)
  • Individual therapy to reinforce skills and look at behavioural changes
  • Best Evidence for EUPD but overlap of symptoms with other personality disorders and therefore used more widely
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4
Q

Different clusters of personality disorder

A
  • Cluster A ‘Odd or Eccentric’: Paranoid, Schizoid, Schizotypical
  • Cluster B ‘Dramatic, Emotional or Erratic’: Antisocial, Borderline (Emotional unstable), Histrionic, Narcissistic
  • Cluster C ‘Anxious and Fearful’: Obsessive-compulsive, Avoidant, Dependent
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5
Q

Cluster A: Paranoid

A
  • Hypersensitivity and an unforgiving attitude when insulted
  • Unwarranted tendency to questions the loyalty of friends
  • Reluctance to confide in others
  • Preoccupation with conspirational beliefs and hidden meaning
  • Unwarranted tendency to perceive attacks on their character
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6
Q

Cluster A: schizoid

A
  • Indifference to praise and criticism
  • Preference for solitary activities
  • Lack of interest in sexual interactions
  • Lack of desire for companionship
  • Emotional coldness
  • Few interests
  • Few friends or confidants other than family
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7
Q

Cluster A: schizotypical

A
  • Ideas of reference (differ from delusions in that some insight is retained)
  • Odd beliefs and magical thinking
  • Unusual perceptual disturbances
  • Paranoid ideation and suspiciousness
  • Odd, eccentric behaviour
  • Lack of close friends other than family members
  • Inappropriate affect
  • Odd speech without being incoherent
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8
Q

Cluster B: Antisocial

A
  • Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;
  • More common in men;
  • Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
  • Impulsiveness or failure to plan ahead;
  • Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
  • Reckless disregard for the safety of self or others;
  • Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;
  • Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
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9
Q

Cluster B: Borderline aka emotionally unstable

A
  • Efforts to avoid real or imagined abandonment
  • Unstable interpersonal relationships which alternate between idealization and devaluation
  • Unstable self image
  • Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
  • Recurrent suicidal behaviour
  • Affective instability
  • Chronic feelings of emptiness
  • Difficulty controlling temper
  • Quasi psychotic thoughts
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10
Q

Cluster B= Histrionic

A
  • Inappropriate sexual seductiveness
  • Need to be the centre of attention
  • Rapidly shifting and shallow expression of emotions
  • Suggestibility
  • Physical appearance used for attention seeking purposes
  • Impressionistic speech lacking detail
  • Self dramatization
  • Relationships considered to be more intimate than they are
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11
Q

Cluster B: Narcissistic

A
  • Grandiose sense of self importance
  • Preoccupation with fantasies of unlimited success, power, or beauty
  • Sense of entitlement
  • Taking advantage of others to achieve own needs
  • Lack of empathy
  • Excessive need for admiration
  • Chronic envy
  • Arrogant and haughty attitude
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12
Q

Cluster C: Obsessive compulsive

A
  • Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
  • Demonstrates perfectionism that hampers with completing tasks
  • Is extremely dedicated to work and efficiency to the elimination of spare time activities
  • Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
  • Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
  • Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
  • Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
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13
Q

Class C: avoidant

A
  • Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
  • Unwillingness to be involved unless certain of being liked
  • Preoccupied with ideas that they are being criticised or rejected in social situations
  • Restraint in intimate relationships due to the fear of being ridiculed
  • Reluctance to take personal risks due to fears of embarrassment
  • Views self as inept and inferior to others
  • Social isolation accompanied by a craving for social contact
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14
Q

Class C: dependent

A
  • Difficulty making everyday decisions without excessive reassurance from others
  • Need for others to assume responsibility for major areas of their life
  • Difficulty in expressing disagreement with others due to fears of losing support
  • Lack of initiative
  • Unrealistic fears of being left to care for themselves
  • Urgent search for another relationship as a source of care and support when a close relationship ends
  • Extensive efforts to obtain support from others
  • Unrealistic feelings that they cannot care for themselves
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15
Q

Psychosis

A

Condition which affects the mind, where there has been loss of contact with reality. More likely to occur in young people.

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16
Q

Effects of psychosis

A
  • Confused thinking: flow of thought, concentration, perplexed
  • False beliefs
  • Perceptual abnormalities
  • Changed feelings: sudden changes in feeling, reduced emotions, incongruous affect
  • Changed behaviour
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17
Q

Causes of psychosis

A
  • Psychological severe stress
  • Physical illness
  • Drunk intoxication
  • Mental illness: schizophrenia, affective disorder, dementia
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18
Q

Psychosis: assessment

A
  • History
  • Physical examination, including neurological
  • MSE
  • Bloods: FBC, U&E, LFT, TFT, PTH, calcium, B12, CRP, lipids, glucose, prolactin, ECG, EEG
  • Urine drug screen
  • Brain imaging: CT/MRI
  • HIV and syphilis
  • Consider antibodies (NMDS, VGKC)
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19
Q

ICD 11: schizophrenia A-C

A

At least two of the following most of the time for a period of 1 month or more. At least one of the qualifying symptoms should be from item a) through d)
A. Persistent delusions (e.g., grandiose delusions, delusions of reference, persecutory delusions)
B. Persistent hallucinations (most commonly auditory, although they may be in any sensory modality)
C. Disorganised thinking (formal thought disorder) (e.g., tangentiality and loose associations, irrelevant speech, neologisms). When severe, the person’s speech may be so incoherent as to be incomprehensible (‘word salad’)

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19
Q

ICD 11: schizophrenia A-C

A

At least two of the following most of the time for a period of 1 month or more. At least one of the qualifying symptoms should be from item a) through d). Symptoms have to be present for at least one month
A. Persistent delusions (e.g., grandiose delusions, delusions of reference, persecutory delusions)
B. Persistent hallucinations (most commonly auditory, although they may be in any sensory modality)
C. Disorganised thinking (formal thought disorder) (e.g., tangentiality and loose associations, irrelevant speech, neologisms). When severe, the person’s speech may be so incoherent as to be incomprehensible (‘word salad’)

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20
Q

ICD-11 schizophrenia: D-G

A

D. Experiences of influence, passivity or control (i.e., the experience that one’s feelings, impulses, actions or thoughts are not generated by oneself, are being placed in one’s mind or withdrawn from one’s mind by others, or that one’s thoughts are being broadcast to others).
E. Negative symptoms such as affective flattening, alogia or paucity of speech, avolition, asociality and anhedonia.
F. Grossly disorganized behaviour that impedes goal-directed activity (e.g., behaviour that appears bizarre or purposeless, unpredictable or inappropriate emotional responses that interferes with the ability to organise behaviour.)
G. Psychomotor disturbances such as catatonic restlessness or agitation, posturing, waxy flexibility, negativism, mutism, or stupor.

21
Q

Schizophrenia symptom group

A
  • Positive= Disorganised thought, Delusions, Hallucinations, Unusual behaviour
  • Negative= Poverty of thought, Poverty of affect. Leading to: social withdrawal, emotional withdrawal, anhedonia, avolition
  • Cognitive= Attention, Memory (episodic and working), Executive function, Decision making
  • Affective= Dysphoria, Depression
22
Q

Schneiders first rank symptoms

A

May be divided into auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions:
* Auditory hallucinations of a specific type:two or more voices discussing the patient in the third person, thought echo, voices commenting on the patient’s behaviour
* Thought disorders= thought insertion, thought withdrawal, thought broadcasting
* Passivity phenomena: bodily sensations being controlled by external influence. Actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
* Delusional perceptions= a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.

23
Q

Schizophrenia: factors associated with poor prognosis

A
  • Strong family history
  • Gradual onset
  • Low IQ
  • Prodromal phase of social withdrawal
  • Lack of obvious precipitant
24
Q

Differential diagnosis of schizophrenia

A
  • Delusional disorder= Narrower range of symptoms than schizophrenia, none of the negative symptoms
  • Acute and transient psychotic disorder= Time course usually shorter than schizophrenia (usually symptom duration less than one month, but can still be diagnosed if less than three months) and always more fluctuant in symptom type/intensity
  • Schizoaffective disorder= Mood symptoms equally prominent (either pole) and come on simultaneously with psychotic symptoms
  • Induced/secondary psychotic disorder= Medical condition – including antibody mediated encephalitis and SOL. Substance misuse
25
Q

Schizophrenia: risk factors

A
  • Genetics
  • Pre-term: <32 weeks, low birth weight, lack of oxygen during birth
  • Early risk factors: urban upbringing, migration, head injury, childhood adversity
  • Drug abuse: Amphetamine, cannabis, LSD, ectasy
  • Psychosocial stress: significant life event, chronic stress
26
Q

Scizoprehrenia illness pattern

A
  • Group 1: one episode only, no improvement
  • Group 2: several episodes with no or minimal impairment
  • Group 3: impairment after the first episode with subsequent exacerbation and no return to normality
  • Group 4: impairment increasing with each of several episodes and no return to normality
27
Q

Biological management of schizophrenia

A
  • Antipsychotics protect against relapse in the short, medium and long term
  • First generation/ second generation: oral or depot
  • Typical: Chlorpromazine, flupenthixol, haloperidol
  • Atypical: Clozapine, amisulpride, olanzapine, risperidone, quetiapine
  • Distinction between atypical and typical based on: incidence of extrapyramidal side effects, efficacy in treatment resistant patients, efficacy against negative symptoms
27
Q

Biological management of schizophrenia

A
  • Antipsychotics protect against relapse in the short, medium and long term
  • First generation/ second generation: oral or depot
  • Typical: Chlorpromazine, flupenthixol, haloperidol
  • Atypical: Clozapine, amisulpride, olanzapine, risperidone, quetiapine
  • Distinction between atypical and typical based on: incidence of extrapyramidal side effects, efficacy in treatment resistant patients, efficacy against negative symptoms
28
Q

Treatment resistant schizophrenia

A
  • Use Clozapine to treat
  • Additional risks: Agranulocytosis which needs monitoring, Paralytic ileus and Myocarditis/cardiomyopathy
29
Q

Schizophrenia- psychological and social

A
  • Psychological: support and reduction of stress, directed at individual or family, CBT
  • Social: rehabilitation, living skills training. May include day care, housing and occupation to balance stress and under stimulation
30
Q

Intellectual disability: aetiology

A
  • 2 or 3 standard deviation below the mean - mild
  • 3 - 4 standard deviation below the mean - moderate
  • 4 or more standard deviation below the mean - severe/profound
31
Q

Intellectual disability: concept

A
  • A neurodevelopement disorder
  • Does not infer a particular aetiology
  • Adaptive functioning is an integral part of diagnosis
  • Not a mental illness- however people with learning disabilities are at higher risk of developing a mental illness
  • Different from learning difficulties i.e. dyslexia
32
Q

IQ

A
  • IQ was previously used to classify level of intellectual disability to relate the mental development of a child to the child’s chronological age
  • Formula to calculate IQ =mental age (MA ) /chronological age (CA) x100
33
Q

IQ values and learning disability

A
  • Mild intellectual disability: 50-70
  • Moderate intellectual disability: 35 to 50
  • Severe intellectual disability: 25 to 35
  • Profound intellectual disability: <20
34
Q

Mild disorder of intellectual development

A
  • Part of the lower end of the normal distribution curve for IQ
  • Can generally communicate with spoken language
  • Role of multifactorial genetic & environmental influences
  • Higher rates in social class IV & V
  • Increasing evidence for organic involvement: Many have definite organic factors, Subtle genetic differences, Perinatal factors such as influence of alcohol, drugs, medications, maternal infections etc.
35
Q

Moderate to severe disorder of intellectual development

A
  • Need greater degree of care, often including physical care to assist with feeding, continence
  • Can nearly always assume organic pathology for severe and profound intellectual: chromosomal, other genetic, pre and peri-natal, post natal
36
Q

Profound disorders of intellectual development

A
  • Excess numbers at more severe levels (‘bump’ on IQ curve)
  • Due to organic or pathological group with cluster of disorders of definable aetiology: Genetic, Environmental – hypoxia, trauma, infections
  • Some will have syndromes like cerebral malformation syndromes or cerebral palsy, without yet defined cause
37
Q

Learning disorder= examples of specific aetiologies

A
  • Chromosomal abnormalities, e.g. Down’s Syndrome (trisomy 21), Prader-Willi Syndrome (microdeletion on chromosome 15)
  • Genetic disorders, e.g. Fragile X Syndrome (X-linked dominant), PKU (autosomal recessive), tuberous sclerosis (autosomal dominant)
  • Intrauterine & neonatal damage, e.g. infections (rubella), foetal alcohol syndrome, prematurity, labour complications
  • Developmental & anatomical abnormalities of CNS, e.g. neural tube defects (Intellectual disability usually secondary to hydrocephalus or infection), cerebral palsies
  • Other later post-natal causes, e.g. encephalitis, meningitis, trauma, hypoxia (for example, due to severe epilepsy)
  • Disorders of complex biological origin, e.g. Rett’s syndrome
38
Q

Down syndrome (trisomy)

A
  • Commonest chromosomal abnormality in people with disorder of intellectual development
  • Commonest identifiable cause of intellectual disability
  • Usually moderate to severe intellectual disability
  • Typical facial appearance: Small ears and eyes, small head, protruding tongue, Short stature
39
Q

Down syndrome: common physical signs

A
  • Decreased muscle tone at birth
  • Excess skin at the nape of the neck
  • Flattened nose
  • Upward slanting eyes
  • Small ears, small mouth
  • Wide, short hands with short fingers
  • Separated joints between the bones of the skull
  • Single crease in the palm of the hand
  • White spots on the coloured part of their eye
40
Q

Down syndrome: common health conditions

A
  • Congenital heart disease
  • Hypothyroidism
  • Visual disorders (cataracts)
  • Hearing impairment (middle ear infections, conductive hearing loss, early onset presbucysis)
  • Obesity
  • Epilepsy
  • Atlanto-axial joint subluxation
  • Diabetes mellitus
41
Q

Fragile X

A
  • Commonest inherited cause of disorder of intellectual development
  • Usually mild to moderate intellectual disability
  • Typical facial appearance: large head circumference, long and prominent ears
  • Physical features include: mitral valve prolapse, lax joints, scoliosis, flat feet, testicular enlargement
  • Behavioural features: poor concentration, hyperkinetic behaviour, avoidance of eye contact and significant social anxiety
42
Q

Clinical features of fragile X

A

Most common cardiac deficit: mitral valve prolapse
* The most common form of inherited intellectual disability
* How to confirm the diagnosis- molecular genetic test for CGG allele repeat size
* Mode of inheritance: X-linked dominant inheritance, >200 CGG repeats in FMR1 gene

43
Q

Prader-willi syndrome

A
  • Genetically determined neurodevelopmental disorder: microdeletions on chromosome 15
  • Prevalence 1:50,000
  • Infants: extremely hypotonic, failure to thrive, feeding difficulties
  • From age 2: mild developmental delay, tendency to skin pick, obesity
  • Difficulty controlling eating behaviour
  • Short stature, failure of normal secondary sexual development
  • Most individuals have mild ID (IQ around 60)
  • Complications: diabetes mellitus, sleep and respiratory disorders
44
Q

Management of Learning disability

A
  • Young people with a LD are entitled to education until age 25
  • Psychiatric co-morbidities: ASD, ADHD, Attachment difficulties, Depression/Anxiety, Psychosis and dementia
  • Diagnostic overshadowing: when a persons presenting symptoms are put down to their intellectual disability
45
Q

Learning disability: Examples of communication support

A
  • Easy read documents
  • Makaton
  • PECS, Pictorial aids, Now and next boards
  • Communication passport
46
Q

Presentation of psychiatric problems in learning diability

A
  • Level of disability: presentation in people with mild Disorders of Intellectual Disability is often similar to general population whilst more severe to profound often present with more complexity
  • Communication difficulties: result in the need to have a high index of suspicion to diagnose illnesses due to reduced reports of symptoms
  • Challenging behaviour: is often reflective of anxiety rather than being “naughty” or oppositional
  • Emotional regulation difficulties: irritability and angry outbursts could be underpinned by sleep difficulties/insomnia
47
Q

Why are mental disorders under diagnosed in learning disability and most common one?

A

What mental disorders are more common in people with learning disability: psychosis, dementia, autism, adhd

Why are mental disorders under diagnosed in learning disability?
- inability to describe their distress
- symptoms attributed to learning disability or medication
- unusual presentation

48
Q

Delusion and hallucinations

A

Delusion- A fixed firmly held belief held despite rational evidence to the contrary not explained by cultural, educational or religious background.

Hallucination- perception in the absence of stimuli

Year 3- placement (34 decks)

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