Psych 1 Flashcards
1
Q
Acute and transient psychotic disorder: criteria
A
- Sudden onset of symptoms (within 2 weeks or less)
- Presence of syndrome which is changing and variable with schizophrenic symptoms
- Prescence of associated acute stress (job loss, psychological trauma
- Symptoms cant be described as depressive or manic
- Individual must not have been using drugs or alcohol. And no proof of a metabolic or nervous system disorder
2
Q
Acute and transient psychotic disorder
A
Tends to have sudden symptoms of psychosis that do not last more than a month. May have severe hallucinations and delirium symptoms
3
Q
Early signs of acute and transient psychotic disorder
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- Seeming out of touch or aloof
- Ignoring responsibilities
- Having inappropriate emotional responses such as going into a rage over something small
- Speaking to someone who is not there
- Coming up with conspiracy theories
- Obsession with religion or governmental involvement
- Forgetting things or remembering things that did not happen
- Lacking in emotions
- Seeming to be on edge or paranoid
4
Q
Signs and symptoms of acute and transient psychotic disorder
A
- Hallucinations, which include hearing or seeing things that are not there
- Delusions, which include believing in things that are not real.
- Disorganized speaking and thinking, which includes speaking different (fake) languages or about strange topics
- Not being able to make decisions
- Not sleeping, having a weird sleep schedule, or sleeping too much
- Being confused or disoriented
- Attention and memory problems
- Wearing strange clothes or dressing unusual in general
5
Q
Management of transient psychosis
A
- Antipsychotic medication therapy and rehabilitation
- 70-80% chance of recurrence within a year
6
Q
Acute stress reaction: definition
A
Symptoms can occur up to 4 weeks after the event and last for up to a month (later then that then PTSD)
7
Q
Summary acute stress reaction
A
- Condition following exposure to severe stress or traumatic events
- Range of symptoms including disorientation, confusion, dissociation, intrusive memories, avoidance behaviours, negative mood alterations and difficulty sleeping.
- Emotional reaction like overwhelming anxiety with physical symptoms of anxiety
- Symptoms are rapid onset after the event and last up to a month
8
Q
Acute stress reaction: management
A
- First line: trauma focused CBT
- Medication for management i.e. Benzodiazepines
9
Q
Adjustment disorder definition
A
- Significant emotional distress and disturbance which interferes with normal social functioning
- Occurs during a period of adaption due to a stressful life event like bereavement or separation
- Begins within 3 months of event and lasts up to 6 months
- In acute stress reaction, the stressor is typically severe or life-threatening. While in adjustment disorder the stressor is not severe or outside normal human experience i.e. being made redundant
10
Q
Adjustment disorder clinical features
A
- Mood disturbance: depression or anxiety
- Behaviour: impaired social or occupational functioning, irritability
- Interpersonal disruption and avoidance behaviours
- Cognitive alterations: preoccupation with the stressor, persistent negative outlook
- Intensity and persistence disproportionate to stressor severity
11
Q
Adjustment disorder: management
A
- First line is psychotherapy including CBT, group therapy or family therapy
- Meds: anti-anxiety and anti-depressants
- Self care: stress management, regular physical activity, social support
- Treatment is short term and not needed when stressor is removed
12
Q
Generalised anxiety disorder (GAD)
A
- A chronic condition caused by excessive worry across various life domains
- Must be present for at least 6 months
- Not due to another health condition or side effect of medication/substance
- Associated symptoms: Restlessness, muscle tension, fatigue
- Risk factors: female, middle age, lower socioeconomic status, unemployment, divorce
13
Q
GAD clinical features
A
- Psychological: Fears, worries, poor concentration, irritability, depersonalization, derealization, insomnia, night terrors
- Motor symptoms: Restlessness, fidgeting, palpitations, butterflies in the stomach, loose stools, tremors
- Muscle tension, difficult sleep
14
Q
Organic differentials for GAD
A
- Hyperthyroidism
- Cardiac: palpitations/arrhythmias
- Medication induced: salbutamol
- Substance misuse: amphetamines, withdrawal, alcohol
- Depression
15
Q
GAD-7
A
- Helps assess severity of anxiety disorder
- 5-9 indicates mild anxiety
- 10-14 indicates moderate anxiety
- 15-21 indicates severe anxiety
16
Q
GAD management
A
- Early or mild: advice and reassurance. Self help strategies, diet, exercise and avoiding alcohol, caffeine and drugs
- First line: low intensity psychological interventions (individual guided self help, psychoeducation)
- Second line or marked impairement: CBT and SSRI/SNRI
- Can use propranolol for palpitations
17
Q
Panic disorder
A
- A prevalent anxiety disorder with recurrent, unexpected panic attacks
- Diagnosed when panic attacks are followed by at least one month of persistent worry about having another attack
- Cause worries about future attacks and avoidant behaviour to prevent attacks
- Onset in adolescence or early adulthood, typically female
18
Q
Panic disorder criteria
A
Panic disorders criteria: they start abruptly and are discrete episodes of intense fear. They last some minutes and is a fear of catastrophic outcomes. It is random, not situational. Lasts for 20 minutes. They have the 4 symptoms of anxiety, the patient tends to think that they are going to die and lose control
It is diagnosed when it is not causes by substances/medication or another medical condition. It is not better explained by another medical disorder.
19
Q
Panic disorder clinical features
A
- Sudden episodes of intense fear which peaks within minutes
- Difficulty in breathing, chest discomfort, palpitations, hyperventilation
- Shaking, sweating, dizziness
- Depersonalization/derealization
- Development of fear of fear pattern
- Diagnostically depression takes precedence if it predates panic disorder or fulfils diagnostic criteria
20
Q
Panic disorder: management
A
- First line: CBT
- Medical: SSRI if no response after 12 weeks or contraindicated Clomipramine or Impramine (TCA)
- propanol for symptoms
21
Q
PTSD
A
- A complex psychiatric condition due to exposure to a traumatic event i.e. childbirth or car accident. Symptoms tend to arise within 6 months of event
- Clusters of Symptoms: Intrusion, avoidance, negative alterations in cognition and mood, arousal, and reactivity.
- Duration: Persists for more than 1-6 months.
- The Trauma Screening Questionnaire (TSQ) can be used as a screening tool
22
Q
PTSD symptoms
A
- Intrusion symptoms: distressing memories and nightmares, problems recalling event
- Functional impairment required
- Deliberate avoidance of trauma related nightmares
- Persistent negative emotions: distorted blame
- Heightened arousal and reactivity: hypervigilance, exaggerated startle response and concentration difficulties
23
Q
Management of PTSD
A
- Moderate/severe PTSD: refer to secondary care for psychological therapy and/or medication
- First line psychotherapy: Trauma focused CBT with EMDR (eye movement desensitisation and reprocessing therapy) in more severe cases
- Veterans with service related PTSD are referred to secondary care more quickly
- Screen for other mental health conditions
- Prevention: trauma focused CBT within month of event
24
Q
Medication for PTSD
A
- Do not offer drugs to prevent TSD from occurring: particularly avoid Bensodiazepine
- Venlafaxine or SSRI could be considered: If first time with PTSD or declining psychotherapy. Dont use routinely first line.
- Risperidone or similar anti-psychotics could be offered if: there is severe hyperarousal, there is severe psychosis, other drug treatments have failed
25
Complex PTSD
- Severe and pervasive problems in affect regulation
- Persistent negative beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the traumatic event
- Persistent difficulties in sustaining relationships and in feeling close to others.
- Causing significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
26
Social anxiety disorder
- Fear and Anxiety of social situations and negative evaluation by others
- Fear of scrutiny by others in relatively small groups (as opposed to crowds), resulting in the avoidance of social situations. I.e. groups of 5-6, usually 1-2 is tolerable
- May be specific (public speaking) or generalized (any social setting).
- Symptoms present for >6 months
- Present for several months with functional impairment
- Can progress to panic attacks.
27
Symptoms of social anxiety
- Physical symptoms include blushing, fear of vomiting.
- Symptoms include blushing (characteristic), palpitations, trembling, sweating.
- Can be precipitated by stressful or humiliating experiences, parental death, separation, chronic stress.
28
Social anxiety disorder management
- Management: individual CBT, self-help, SSRI (Escitalopram or Sertraline)
- Adults: individual CBT. If rejected can offer short term psychodynamic psychotherapy
- Children: individual or group CBT, consider involving parents or care givers
29
Phobias
- Excessive and irrational fears triggered by a specific object or situation i.e. animals heights
- Usually apparent in early adulthood and leads to avoidance behaviour
- Severity depends on effect on quality of life
30
Agoraphobia
- Anxiety around situations where escape maybe difficult or help unavailable.
- Tends to be fear of open spaces and associated factors like crowds or perceived difficulty of easy escape
- Tends to begin in 20s or mid thirties
- Gradual onset or caused by a sudden panic attack
31
Management of phobias
- First line: CBT
- Exposure techniques
- If ineffective/severe functional impairment: SSRI are first line with propanol for physical symptoms
32
OCD
- Condition characterised by intrusive thoughts and repetitive behaviours
- Onset: adolescence or early adulthood
- Risk factors: pregnancy/postnatal period, history of abuse, bullying
- Severity assessed by Y-BOCS scale
- Either obsessions or compulsions that present on most days for a period of at least two weeks.
33
OCD definition
- Obsessions: Intrusive, unwanted thoughts or images causing distress.
- Compulsions: Repetitive behaviours (washing hands) or mental acts (counting) aimed at reducing anxiety.
- Must originate in the mind of the patient and be repetitive and unpleasant
- The individual tries to resist them and carrying out the obsessive thought or act is not pleasurable
34
OCD: types of obsessions or compulsions
- Obsessions: contamination fear, harm related, unwanted sexual thoughts, religious/moral obsessions, perfectionism/symmetry
- Compulsions: cleaning/washing, checking rituals (door locked), counting/repetitive rituals, ordering/arranging behaviour, mental neutralizing strategies (prayer)
35
OCD diagnosis
- Presence of obsessions, compulsions, or both.
- Rituals consume significant time and impair daily functioning >1hr for diagnosis
- Not explained by another medical condition
36
OCD management
- Mild: Low intensity CBT including exposure and response prevention (ERP)
- Moderate: intensive CBT including ERP OR an SSRI
- Clomipramine is an alternative to SSRI
- Severe functional impairment: combined treatment with intensive CBT (including ERP) and an SSRI and refer to secondary care
- If medication effective continue for 12 months can then review
37
Bipolar affective disorder criteria
- Characterized by at least two episodes, including one hypomanic or manic episode. Depressive episodes should be prominent lasting at least 2 weeks
- BPAD Type 1: One or more manic episodes and one or more depressive episodes.
- BPAD Type 2: Recurrent major depressive episodes and hypomanic episodes.
38
Mania vs hypomania
- Both have elevated mood or intense irritability. They can have physical symptoms with increased energy or decreased sleep.
- Mania: Severe functional impairment or psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) persisting for at least seven days.
- Hypomania: Increased or decreased function for at least four days without psychotic symptoms.
39
Bipolar risk factors
genetics, stressful life event, substance misuse, a manic switch can be triggered by antidepressants
40
Bipolar clinical features
- Depressive Phase: Low mood, feelings of worthlessness, decreased energy, and suicidal ideation.
- Manic Phase: Elevated or irritable mood, inflated self-esteem, decreased need for sleep/sleep disturbance (is both a feature of, and can precipitate manic episodes), impulsivity, pressured speech, and potential psychotic symptoms.
- Additional Features: Psychotic symptoms (delusions, hallucinations) and risk-taking behaviours (sexual disinhibition, spending/gambling, violence).
41
Bipolar investigations
- Especially is first presentation important to rule out substance misuse (i.e. urine toxicology, amphetamine levels)
- Delirium also needs to be ruled out, which can be secondary to infection, thyroid dysfunction (TFTs,), vitamin deficiencies (B12/folate)
42
Bipolar management acute
- If hypomania then routine referral to community mental health team (CMHT), if mania/severe depression urgent referral
- Stop SSRI (taper down)
- Mania with agitation: IM neuroleptic or benzodiazepine, potential psychiatric admission
- Mania without agitation: Oral antipsychotic monotherapy (haloperidol, olanzapine, quetiapine, or risperidone). Addition of sedatives or mood stabilizers (lithium) if antipsychotics are unsuccessful. Electroconvulsive therapy (ECT) is a last resort.
- Acute depression: increase mood stabiliser if taking otherwise SSRI (fluoxetine) and atypical antipsychotic (olanzapine) cover
43
Bipolar management chronic
- 4 weeks after resolution of acute episode
- Maintenance therapy is with mood stabilizers such as Lithium (first line) or Valproate (second line), and psychotherapy.
- High-intensity Psychological Therapies: Cognitive-Behavioral Therapy (CBT), Interpersonal Therapy.
44
Management of bipolar disorder: Relapse of manic or hypomanic episode
- Optimise current treatment
- Check compliance
- Antipsychotic – start with what works the last time
- Mood stabilisers – choice of Lithium, Valprote, Carbamazepine
- Do not offer Lamotrigine
- ?use of alcohol/recreational substances
45
Criteria for manic episode at least 1 week off
- Euphoria, irritability, expansiveness
- Increased activity/increase energy
- Increase self-esteem/grandiosity
- Rapid/pressure of speech
- Flight of ideas
- Decrease need for sleep
- Distractibility
- Impulsive/Reckless behaviour
- Rapid changes between mood states (labile mood)
46
Lithium side effects
- Fine tremor
- Weight gain
- Chronic kidney disease
- Hypothyroidism and goitre (it inhibits the production of thyroid hormones)
- Hyperparathyroidism and hypercalcaemia
- Nephrogenic diabetes insipidus
47
Long term management of bipolar disorder: psychological
- Educate patients and carers (with patients’ consent) about nature & severity of illness.
- The aim is to empower patients to manage their illness – self-monitoring, recognition of early warning signs eg decrease need for sleep may trigger a manic relapse.
- Discuss about future management according to patients’ preferences inc advance directive
- Offer CBT/Interpersonal Therapy/Family Intervention according to patients’ needs & preferences.
48
Delirium: definition and risk factors
- An acute and fluctuating disturbance in attention and cognition often accompanied by change in consciousness, typically reversible
- Risk factors: age, severity of illness, pre-existing cognitive impairment
49
Delirium: types
- Hyperactive Delirium: Marked by increased psychomotor activity, restlessness, agitation, and hallucinations.
- Hypoactive Delirium: Characterised by lethargy, reduced responsiveness, and withdrawal.
- Mixed Delirium: Combines features of both hyperactive and hypoactive delirium.
50
Causes of Delirium (DELIRIUMS)
- D: Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational)
- E: Eyes, ears and emotional disturbances
- L: Low Output state (Myocardial Infarction, Acute Respiratory Distress Syndrome, Pulmonary Embolism, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease)
- I: Infection
- R: Retention (of urine or stool)
- I: Ictal (related to seizure activity)
- U: Under-hydration/Under-nutrition
- M: Metabolic disorders (Electrolyte imbalance, thyroid disorders, Wernicke's encephalopathy)
- (S): Subdural hematoma, Sleep deprivation
