PSYCH Flashcards
PSYCH HX + AX
What are the components of a psychiatric history?
PC, HPC, Past psych Hx, PMH, Medications (regular, OTC, allergies), FHx (mental + physical), personal Hx (timeline from birth–adulthood, education, employment, relationships, psychosexual), SH, Forensic Hx (law involvement either perpetrator/victim)
PSYCH HX + AX
What are the components of a mental state examination?
ASEPTIC –
- Appearance + behaviour
- Speech
- Emotions (mood + affect – objectively + subjectively).
- Perceptions (hallucinations, etc).
- Thoughts (alientation, disordered)
- Insight
- Cognition
PSYCH HX + AX
What should you do after a psychiatric assesssment?
Risk assessment at the end, consider how likely the event is, when it might occur + how bad the consequences will be (e.g. self-harm, harm to others, self-neglect)
PSYCH HX + AX
What are the 5Ps in formulation and what do they mean?
- Presenting problem (what the pt presents with)
- Predisposing factors (what increases a pts risk of developing a mental illness)
- Precipitating factors (potential trigger to the onset of current problem)
- Perpetuating factors (what maintains the problem once it’s been established)
- Protective factors (strengths that reduce the severity of problems)
PSYCH HX + AX
Give examples of what might come under the 5Ps (excluding presenting).
- Predisposing = genetics, life events, temperament
- Precipitating = abuse, drug misuse, loss of family
- Perpetuating = drug abuse, lack of social support, financial difficulties
- Protective = family support, children, marriage
PHENOMENOLOGY
What is a mental disorder?
Any disorder or disability of the mind, excluding substance abuse
PHENOMENOLOGY
Define psychosis
Severe mental disturbance characterised by a loss of contact with external reality (schizophrenia)
PHENOMENOLOGY
Define neurosis
Relatively mild mental illness in which there is no loss of connection with reality (depression, anxiety)
PHENOMENOLOGY
Define phenomenology
The study of signs + symptoms describing abnormal states of mind
PHENOMENOLOGY
Define illusion
The false perception of a real external stimulus
PHENOMENOLOGY
Define hallucination
An internal perception occurring without a corresponding external stimulus. The person experiences it as they would a real perception.
PHENOMENOLOGY In terms of hallucinations, what are... i) the main senses? ii) somatic? iii) hypnogogic/hypnopompic iv) autoscopic? v) reflex? vi) extracampine?
i) Auditory, visual, olfactory, gustatory, tactile
ii) within the person
iii) when going to sleep/when waking up
iv) seeing oneself
v) production of a hallucination in one sensory modality by a stimulus in a different modality
vi) hallucinations which are experienced outside the normal sensory field (seeing something behind them)
PHENOMENOLOGY
What is Charles-Bonnet Syndrome?
What conditions may it be seen in?
- Complex visual hallucinations in a patient with partial/severe blindness (macular degeneration, diabetic retinopathy).
- Pts understand that the hallucinations are not real + so often have insight
PHENOMENOLOGY
Define pseudo-hallucination
A perception in the absence of an external stimulus, experienced in one’s subjective inner space of the mind rather than external sensory objects – often have insight
PHENOMENOLOGY
Define over-valued idea
A false or exaggerated belief held with conviction but not with delusional intensity. This idea although perhaps reasonable, dominates their life + causes distress
PHENOMENOLOGY
Define delusion
A fixed, false, unshakable belief which is out of keeping with the patient’s educational, cultural + social norms. It’s held with extraordinary conviction + certainty (even despite contradictory evidence)
PHENOMENOLOGY In terms of delusions, what are... i) persecutory? ii) grandiose? iii) nihilistic? iv) guilt?
i) the idea that someone/something is trying to inflict harm on them (being followed, poisoned, drugged, spied)
ii) idea that the person themselves are powerful/crucially important beyond truth
iii) theme involves intense feelings of emptiness, sense of everything being unreal
iv) ungrounded feeling of remorse or guilt for situations, can be due to a minor error or unrelated to them (may feel responsible for world disasters)
PHENOMENOLOGY In terms of delusions, what are... i) poverty? ii) reference? iii) inadequacy? iv) religious?
i) pt strongly believes they are financially incapacitated
ii) false belief that insignificant remarks/objects in one’s environment have personal meaning/significance (newspaper has hidden text related to them)
iii) false belief of inability to accomplish tasks + meet expectations
iv) false belief related to religious themes/subject matter.
PHENOMENOLOGY
What are the 3 delusional misidentification syndromes?
- Capgras = idea someone has been replaced by an imposter.
- Fregoli = idea various people are the same person
- Intermetamorphosis = one significant relative is replaced by another (father is son).
PHENOMENOLOGY
Define delusional perception and give an example
A primary delusion of two components – where a normal perception is subject to delusional interpretation
E.g. – traffic light changed red so that means I am the son of God
PHENOMENOLOGY
Define thought alienation. What are the 3 components of this?
Sx of psychosis in which patients feel that their own thoughts are in some way no longer in their control
Insertion = delusional belief thoughts placed into pts head from external
Withdrawal = delusional belief thoughts removed from head from external
Broadcast = delusional belief thoughts are accessible directly to others without expressing them
PHENOMENOLOGY
Define concrete thinking
Loss of ability to understand abstract concepts + metaphorical ideas leading to a strictly literal form of speech
PHENOMENOLOGY
Define thought disorder and formal thought disorder
TD = disorganised thinking as evidenced by disorganised speech/beliefs FTD = pts expressive language (form) indicates that the links between consecutive thoughts aren't meaningful (disorganised speech evident from disorganised thinking)
PHENOMENOLOGY In terms of thought disorders, what is... i) flight of ideas? ii) pressure of speech? iii) poverty of speech/alogia?
i) Abrupt leaps between topics as a result of thoughts presenting more rapidly than can be articulated. Each thought = more associations. ?Discernible links between successive ideas. Presents as pressure of speech.
ii) Rapid speech w/out pauses which is difficult to interrupt as a consequence of pressure of thought. Connection between sequential ideas may become increasingly hard to follow
iii) speech lacking in amount or content
PHENOMENOLOGY In terms of thought disorders, what is... i) tangentiality? ii) thought block? iii) clang association (± alliteration) iv) circumstantiality?
i) wandering from the topic + never returning to it or providing info asked
ii) sudden + unintentional break in chain of thought, may be explained as due to thought withdrawal
iii) severe form of flight of ideas whereby ideas are related only by similar/rhyming sounds rather than meaning
iv) irrelevant wandering in conversation (going around the point).
PHENOMENOLOGY In terms of thought disorders, what is... i) loosening of association? ii) perseveration? iii) echolalia?
i) aka derailment/Knight’s move thinking = a lack of logical association between sequential thoughts, often leading to incoherent speech, impossible to follow train of thought.
ii) persistent repetition of words/ideas that were initially appropriate but continue past this point + when the topic changes
iii) repeating other’s words/phrases
PHENOMENOLOGY In terms of thought disorders, what is... i) neologisms? ii) incoherence/word salad? iii) poverty of thought?
i) making up new words
ii) confused or unintelligible mixture of seemingly random words and phrases
iii) subjective experience of being devoid of thoughts + having a feeling of emptiness, often leads to poverty of speech
PHENOMENOLOGY
Define confabulation + state what conditions you would find this in
Giving a false account to fill in a gap in memory.
Korsakoff’s psychosis + dementia
PHENOMENOLOGY
Define passivity phenomena + somatic passivity
- Delusion that one is a passive recipient of actions from an external agency against their will
- The same but sensations are controlled by an external agency
PHENOMENOLOGY
Define psychomotor retardation + state what conditions you would find this in
- Slowing of thoughts + movements with decreased spontaneous movement, often due to subjective sense of actions being laborious
- Parkinson’s, depression
PHENOMENOLOGY
Define incongruity of affect
Emotional responses that differs markedly from the expected emotion for the situation/subject like laughing whilst discussing trauma
PHENOMENOLOGY
Define blunting of affect
A limited range of normal emotional responsiveness
PHENOMENOLOGY
Define flattening of affect
Diminution of the normal range of emotions
PHENOMENOLOGY
Define depersonalisation + derealisation
- Where a person doesn’t believe themselves to be real
- Where a person doesn’t believe the world/people around them to be real
PHENOMENOLOGY
Define obsession
Recurrent thoughts/feelings/images/impulses which are intrusive + persistent despite efforts to resist. They are recognised as the person’s own thoughts (insight preserved)
PHENOMENOLOGY
Define compulsion
Repetitive, purposeful behaviour performed in response to an obsession despite the recognition of its senselessness + anxiety if not performed
PHENOMENOLOGY
Define thought echo
Experience of an auditory hallucination in which the content is the individual’s current thoughts spoken aloud as if next to them
PHENOMENOLOGY
Define catatonia/stupor
Abnormality of movement + behaviour arising from a disturbed mental state, typically severe depression or schizophrenia
PHENOMENOLOGY
Define anhedonia
Inability to feel pleasure in normally pleasurable activities
PHENOMENOLOGY
Define belle indifference
A surprising lack of concern for, or denial of, apparently severe functional disability (not specific to psych)
PHENOMENOLOGY
Define dissociation
When a person feels disconnected from themselves or their surroundings (including emotions)
PHENOMENOLOGY
Define conversion
Development of features suggestive of physical illness but which are attributed to psych illness or emotional disturbance rather than organic pathology
PHENOMENOLOGY
Define sterotypy
Repetitive + bizarre act which is not goal-directed. Action may have delusional significance to the pt
PHENOMENOLOGY
Define mannerism
Abnormal + occasionally bizarre performance of voluntary, goal-directed activity
PHENOMENOLOGY
Define projection + give an example
What is emotionally unacceptable in the self is unconsciously rejected + projected to others (e.g. mother projects anxiety on children claiming they’re anxious)
MENTAL HEALTH ACT 1983
What does the main part of the MHA allow for?
- ‘Sectioning’ = compulsory admission to hospital for those that are mentally ill.
- Drs should persuade pts to come in voluntarily if they have capacity, but not always possible (esp if they lack insight)
MENTAL HEALTH ACT 1983
What are the main principles of the MHA?
- Respect for pts wishes + feelings (past + present)
- Minimise restrictions on liberty
- Public safety
- Pts well-being + safety
- Effectiveness of treatment
MENTAL HEALTH ACT 1983
What is does an individual have to show to be sectioned?
- Evidence of MH disorder
- Evidence they’re serious risk to self, safety or others
- Evidence there is good reason to warrant attention in hospital
- Appropriate treatment must be available for a S3
MENTAL HEALTH ACT 1983
What is a…
i) section 12 approved dr?
ii) approved mental health professional?
i) ≥ST4 Dr who has done extra training in MH to get S12 approved to section pts
ii) AMHPs are often social workers who have done extra training in MH
MENTAL HEALTH ACT 1983
Who can remove sections?
- Consultant psychiatrist
- MH review tribunal (MHT) if pt disagrees w/ section
- Nearest relative can make an order to discharge pt from hospital with 72h written notice
MENTAL HEALTH ACT 1983
If a relative requests a section removal how can the clinician respond if they disagree?
- Issue a barring report within 72h which stops discharge up to 6m from then
- Can still apply to MHT if disagrees
MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved for a Section 2?
P – admission for assessment, treatment can be given w/out consent
D – 28d, cannot be renewed, can be converted to S3
L – anywhere in community (airports, jail, A+E, etc)
Prof – 2 Drs (1x S12), 1 AMHP, or nearest relative
MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved for a Section 3?
Who is involved if a pt is medicated without consent?
P – admission for treatment
D – 6m, can be renewed
L – anywhere in community
Prof – 2 Drs (1x S12), 1 AMHP, nearest relative
Second opinion appointed doctor (SOAD) – after 3m SOAD reviews if medication w/out consent is necessary
MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved, evidence needed for a Section 4?
P – emergency order D – 72h L – anywhere in community P – 1 S12 Dr, 1 AMHP, nearest relative E – same as S2 but only in an urgent necessity when waiting for a second dr (for a S2) would lead to undesirable delay/outcome
MENTAL HEALTH ACT 1983
Where can you apply a S5?
What can the team not do?
- Voluntary pt in hospital that wants to leave (NOT A+E as not admitted)
- Coercively treat the pt
MENTAL HEALTH ACT 1983
What is the purpose, duration + professionals involved for a Section 5(2)?
P – Drs holding power, allows for S2/3 assessment
D – 72h
Prof – 1 Dr (usually in charge of their care or nominated deputy
MENTAL HEALTH ACT 1983
What is the purpose, duration + professionals involved for a Section 5(4)?
P – nurses holding power until Dr attends to assess
D – 6h
Prof – 1 registered nurse
MENTAL HEALTH ACT 1983
What are the 2 police sections and their differences? What is the duration and purpose of these?
- S135 – needs magistrates court order to access pts home + remove them
- S136 –person suspected of having mental disorder in a public place
D – 24h (extend to 36h if intoxicated but should be seen sooner)
P – taken to place of safety (local psych unit, police cell) for further assessment
ANTI-PSYCHOTICS
What are the two types of anti-psychotics?
Give examples.
- Typical/1st gen = haloperidol, zuclopenthixol (decanoate = depot), chlorpromazine
- Atypical/2nd gen = olanzapine, risperidone (depot), clozapine, aripiprazole (depot), quetiapine
ANTI-PSYCHOTICS
What is the mechanism of action of typical anti-psychotics?
What is the issues?
- Antagonism of Dopamine D2 receptors
- Reduced release of dopamine from dopaminergic neurones + so reduced electrical activity in dopaminergic pathways
- Not selective so can bind to other dopaminergic pathways causing generalised dopamine receptor blockade
ANTI-PSYCHOTICS
What pathway do typical anti-psychotics work on to…
i) have anti-psychotic effect?
ii) cause side effects?
i) Mesolimbic pathway (reduces +ve Sx)
ii) Nigrostriatal (Parkinsonism), tuberoinfundibular (prolactin)
ANTI-PSYCHOTICS
What is the mechanism of action of atypical anti-psychotics?
What is the benefit of atypical anti-psychotics?
What anti-psychotic has a reduced SE profile and why?
- Antagonists at dopamine D2 receptors but more selective in dopamine blockade + so block serotonin 5-HT2a
- More useful in treating -ve Sx of schizophrenia + less likely to cause EPSEs
- Aripiprazole as partial dopamine agonist
ANTI-PSYCHOTICS
What is the most crucial adverse effect of clozapine?
What is the most common adverse effect?
What other adverse effects may it have?
- Severe life-threatening agranulocytosis
- Constipation (big issue in elderly)
- Reduced seizure threshold, hypersalivation (Rx hyoscine hydrobromide)
ANTI-PSYCHOTICS
What are the 5 broad categories of SEs caused by anti-psychotics?
- Extra-pyramidal side effects (EPSEs)
- Hyperprolactinaemia
- Metabolic
- Anticholinergic
- Neurological
ANTI-PSYCHOTICS
What are the EPSEs?
- Acute dystonic reaction
- Parkinsonism
- Akathisia
- Tardive dyskinesia
ANTI-PSYCHOTICS
How does Parkinsonism present?
How is it managed?
- Bradykinesia, rigid, resting pill-rolling tremor + postural instability
- Reduce dose or switch to atypical anti-psychotic
ANTI-PSYCHOTICS
How does akathisia present?
What is a risk of this?
How is it managed?
- Motor restlessness, typically lower legs (can’t sit still)
- Massive RF for suicide in young men with schizophrenia
- Reduce dose, introduce beta-blocker (propranolol)
ANTI-PSYCHOTICS
How does tardive dyskinesia present?
When does it present?
How is it managed?
- Purposeless involuntary movements (chewing, lip smacking, blinking, tongue protrusion)
- After months-years of Tx
- Prevention crucial, switch to atypical anti-psychotic, tetrabenazine used if mod–severe but unlikely to completely resolve
ANTI-PSYCHOTICS
What are the SEs from hyperprolactinaemia?
- Sexual dysfunction (+ anti-adrenergic)
- Osteoporosis risk
- Amenorrhoea
- Galactorrhoea, gynaecomastia + hypogonadism in men
ANTI-PSYCHOTICS
What are the metabolic SEs?
- Weight gain (esp. olanzapine)
- Hyperlipidaemia, risk of stroke + VTE in elderly
- T2DM risk + metabolic syndrome
ANTI-PSYCHOTICS
What are the anticholinergic SEs?
Can't see, pee, spit, shit – - Blurred vision - Urinary retention - Dry mouth - Constipation \+ tachycardia
ANTI-PSYCHOTICS
What are the neurological SEs?
- Seizures
- Postural hypotension (anti-adrenergic)
- Sedation
- Headaches
ANTI-PSYCHOTICS
What baseline investigations are done for people starting on anti-psychotics?
- FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin, BP, ECG (QTc prolongation) + smoking status (can reduce effects by enhancing metabolism so issues if suddenly stop)
ANTI-PSYCHOTICS
What regular investigations are done for people on anti-psychotics?
- Lipids + BMI at 3m
- Fasting glucose + prolactin at 6m
- Frequent BP during dose titration
- FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin + CV risk yearly
ANTI-PSYCHOTICS
What specific monitoring is required for clozapine?
What happens if they miss a dose?
- FBC at baseline + weekly for 18w, fortnightly until 1y + monthly after
- If not taken for 48h needs retitrating
ANTI-DEPRESSANTS
What monitoring is needed when starting someone on an anti-depressant?
When can an anti-depressant be stopped?
- 2 weekly to ensure dose working + patient stable, may take up to 6w to start working, weekly if <30y as increased suicide risk
- Carried on 6m after Sx resolved even if patient feels better
ANTI-DEPRESSANTS
How should anti-depressants be stopped?
Why?
- Gradual dose reduction over 4w
- Sudden cessation can cause severe withdrawal effects (mostly GI) – pain, diarrhoea, vomiting, restlessness, sweating + mood change
ANTI-DEPRESSANTS
What is the mechanism of action of SSRIs?
Give some examples
- Prevents reuptake + subsequent degradation of serotonin from synaptic cleft by inhibiting its reuptake transporter on the post-synaptic membrane
- Prolonged serotonin in synaptic cleft = prolonged neuronal activity
- Citalopram, sertraline, fluoxetine
ANTI-DEPRESSANTS
What are the side effects of SSRIs?
- GI Sx most common (N+V, hyponatraemia, abdo pain, bowel issues, increased bleed risk)
- Sedation + sexual impotence
- Citalopram + QTc prolongation (dose-dependent)
ANTI-DEPRESSANTS
What are some cautions for SSRIs?
- Suicidal thoughts may increase initially, esp. younger patients
- May precipitate manic phase in bipolar
- 1st trimester risk of CHD, 3rd trimester risk of persistent pulmonary HTN
ANTI-DEPRESSANTS
What are some interactions for SSRIs?
- NSAIDs + aspirin = increased risk of bleeding, co-prescribe PPI
- Can lower seizure threshold
- Do not start until 2w after stopping MAOI + vice-versa as increased risk of serotonin syndrome
ANTI-DEPRESSANTS
What is the mechanism of action of SNRIs?
Give some examples
- Prevents reuptake + subsequent degradation of serotonin AND noradrenaline from synaptic cleft by inhibiting reuptake transporters on post-synaptic membrane
- Venlafaxine, duloxetine
ANTI-DEPRESSANTS
What are some side effects of SNRIs?
What are some interactions of SNRIs?
- GI (N+V, constipation), central/peripheral effects (SIADH, rhabdomyolysis)
- NSAIDs + warfarin (increased risk of bleeding), lower seizure threshold
ANTI-DEPRESSANTS
What is the mechanism of action of monoamine oxidase inhibitors (MAOI)?
Give some examples.
- Inhibits monoamine oxidase enzyme which reduces breakdown of adrenaline, noradrenaline + serotonin so increases level
- Selegiline is selective MAO-B inhibitor which also increases dopamine
- Isocarboxazid, phenelzine
ANTI-DEPRESSANTS
What are some side effects from MAOIs?
- Sexual dysfunction, weight gain + postural hypotension
ANTI-DEPRESSANTS
What are some cautions with MAOIs?
- Increased risk of serotonin syndrome if used with other serotonergic drugs
- Hypertensive crisis with ingestion of foods containing tyramine (aged cheeses, smoked/cured meats, pickled herring, Bovril, Marmite)
ANTI-DEPRESSANTS
What is the mechanism of action of tricyclic antidepressants (TCAs)?
Give some examples
- Prevents reuptake + subsequent degradation of serotonin + noradrenaline from synaptic cleft by inhibiting reuptake transporters on post-synaptic neuronal membrane
- Amitriptyline, dosulepin, imipramine
ANTI-DEPRESSANTS
What are the side effects of TCAs?
- Anticholinergic (can’t see, pee, spit, shit)
ANTI-DEPRESSANTS
What cautions are there for TCAs?
- Caution in CVD, avoid following MI
- Cardiotoxic in overdose so caution in suicidal patients (QTc prolongation)
ANTI-DEPRESSANTS
In terms of TCA overdose…
i) mild-moderate Sx?
ii) severe Sx?
iii) ECG signs?
iv) management?
i) Dilated pupils, dry mouth, urinary retention, increased tendon reflexes + extensor plantars
ii) Fits, coma, cardiac arrhythmias > arrest
iii) Sinus tachy, wide QRS, prolonged QT interval
iv) Sodium bicarbonate
ANTI-DEPRESSANTS
What is the mechanism of action of mirtazapine?
What are some side effects?
- Blocks alpha-2 adrenergic receptors > increased release of neurotransmitters
- Increased appetite + weight gain + sedation are big ones, also increased triglyceride levels
MOOD STABILISERS
What are some examples of mood stabilisers?
What is the mechanism of action?
Important drug information?
- Lithium (first line), AEDs such as valproate, carbamazepine, lamotrigine
- Lithium inhibits cAMP production which inhibits monoamines
- Narrow therapeutic range 0.4–1.0mmol/L
MOOD STABILISERS
What are the side effects of lithium?
LITHIUM –
- Leukocytosis
- Insipidus (diabetes, nephrogenic)
- Tremors (fine if SE, coarse if toxicity)
- Hydration (easily dehydrates, renally cleared)
- Increased GI motility (N+V, diarrhoea)
- Underactive thyroid
- Mums beware (Ebstein’s anomaly)
Can cause weight gain + derm (acne, psoriasis) long-term too
MOOD STABILISERS
What drugs does lithium interact with?
- NSAIDs, ACEi, ARBs + diuretics may increase lithium levels
- Diuretics = dehydration, NSAIDs = renal damage
MOOD STABILISERS
What baseline measurements are taken for lithium?
- FBC, U+Es, eGFR, TFTs, BMI + ECG
MOOD STABILISERS
What regular monitoring is done for lithium?
- Weekly serum lithium after initiation + dose changes until stable then every 3m for a year, then every 6m (sample taken 12h after dose)
- 6m = TFTs, U+Es, eGFR
- Annual = BMI
MOOD STABILISERS
What might carbamazepine and lamotrigine interfere with?
- Contraceptive pill
BDZs
What is the mechanism of action of anxiolytics/benzodiazepines (BDZs)?
- Enhance effect of inhibitory GABA by increasing frequency of Cl- channels + flow of Cl- ions causing hyperpolarisation of membrane + so prevention of further excitation
BDZs
Give some examples of BDZs?
What are they suitable for?
- Diazepam (longer duration), lorazepam + temazepam (shorter duration), clonazepam, chlordiazepoxide
- Short-term Tx (<4w), sedation + anxiolytic
BDZs
What are some adverse effects of BDZs?
- Amnesia, ataxia (esp elderly = falls risk), confusion, drowsiness, dizziness next day (hangover effect), tolerance
- Monitor for resp depression (caution in resp disease)
BDZs
What drugs can BDZs interact with?
How would you manage an overdose? Risk of this?
- Anti-hypertensives as enhanced hypotensive effect
- IV flumazenil (danger of inducing status epilepticus or death though)
HYPNOTICS
What is the mechanism of action of hypnotics?
Give some examples
What are the adverse effects?
- GABA agonists on alpha2-subunit of GABA(A)-BDZ receptor/Cl- channel complex
- Zopiclone, zolpidem, BDZs used for hypnotic effect (lorazepam, temazepam)
- Same as BDZs
ECT
What are the reasons why ECT can be done?
When is electroconvulsive therapy (ECT) recommended?
- Rapid improvement of severe Sx after adequate trial of other Tx proven ineffective and/or condition potentially life threatening
- Severe mania or depression, suicide risk, catatonia, Rx resistant psychosis
ECT
What are some contraindications to ECT?
- NO absolute, all relative
- General anaesthesia (reactions)
- Cerebral aneurysm
- Recent MI, arrhythmias
- Intracerebral haemorrhage
ECT
What are some adverse effects of ECT?
- Short-term retrograde amnesia
- Headache
- Confusion + clumsiness
DEPRESSION
What is depression?
How common is it?
- Persistent low mood ± loss of pleasure in activities – unipolar depression.
- 2–6% prevalence globally, F>M but men more likely to be substance misusers + commit suicide
DEPRESSION
What are 2 theories speculating the causes of depression?
- Stress vulnerability = someone with high vulnerability will withstand less stress before becoming mentally unwell
- Monoamine hypothesis = depression caused by deficiency in monoamines (serotonin, noradrenaline) hence why Tx works
DEPRESSION
What are the biological causes of depression?
- Personal/FHx + genetics
- Personality traits (dependent, anxious, avoidant)
- Physical illness (hypothyroid, anaemia, childbirth)
- Iatrogenic (beta-blockers, steroids, substance misuse)
DEPRESSION
What are the…
i) psychological
ii) social
causes of depression?
i) Disrupted relationships, child abuse, poor coping mechanisms
ii) Low socioeconomic status, poor social support, discrimination, divorce, refugee
DEPRESSION
What are some risk factors for depression?
- Physical co-morbidities, esp. chronic + painful (MS, stroke, DM)
- Genetics + FHx, female, older age, substance abuse
- Traumatic events (+ve/-ve) like divorce/marriage, (un)employment, poverty, loss
- Adverse childhood experiences like abuse, poor parent relationships
DEPRESSION
What are the 3 diagnostic criteria for depression?
- Sx present most days ≥2 weeks + change from baselines
- Sx not attributable to other organic or substance causes
- Sx impair daily function + cause significant distress
DEPRESSION
What are the three core symptoms of depression?
- Low mood
- Anhedonia
- Anergia
DEPRESSION
What are some psychological symptoms of depression?
- Guilt, worthlessness, hopelessness
- Self-harm/suicidality
- Low self-esteem
DEPRESSION
What are some cognitive symptoms of depression?
- Beck’s triad = negative views about oneself, the world + the future
- Poor concentration + impaired memory
- Avoiding social contact + performing poorly at work (social Sx too)
DEPRESSION
What are some somatic, or biological, symptoms of depression?
- Disturbed sleep (EMW, initial insomnia, frequent waking)
- Disturbed appetite + weight
- Loss of libido
- Diurnal mood variation (worse in morning)
- Psychomotor retardation
DEPRESSION
What are the 4 classifications of depression?
- Mild = ≥2 core + ≥2 other (minimal interference)
- Mod = ≥2 core + ≥3 other (variable interference)
- Severe = all core + ≥4 other (marked interference)
- Psychotic = Sx of depression + psychosis
DEPRESSION
What are some features of psychotic depression?
- Mood congruent hallucinations (auditory = derogatory or accusatory voices, olfactory = bad smells)
- Nihilistic delusions
- Delusions of poverty, guilt, hypochondriacal
- Catatonia or marked psychomotor retardation (depressive stupor)
DEPRESSION
What is Cotard’s syndrome?
- Delusional belief that they are dead, do not exist, are rotting or have lost their blood + internal organs
DEPRESSION
What are some…
i) psychiatric
ii) organic
differentials for depression?
i) Dysthymia, stress-related disorders, bipolar, schizophrenia, anxiety, substance misuse/withdrawal
ii) Dementia, Parkinson’s, anaemia, hypoglycaemia, Addison’s, Cushing’s
DEPRESSION
What are some complications of depression?
- Reduce QOL
- Increased morbidity + mortality (IHD, DM)
- Suicide (20x more likely than gen pop)
DEPRESSION
What are some investigations for depression?
- FBC, ESR, B12/folate, U+Es, LFTs, TFTs, glucose, Ca2+
- ECG, MSE + risk assessment
- Urine drug screen
- PHQ-9 + HADS to screen for depression
DEPRESSION
When would you consider hospital admission ± MHA in depression?
- Serious risk of suicide or harm to others
- Severe depressive or psychotic symptoms
- Initiation of ECT
DEPRESSION
What is the management of mild depression?
- Watchful waiting
- Low-intensity psychosocial interventions first line (computerised CBT, individual-guided CBT, structured group physical activity programme) + psychoeducation
DEPRESSION
Should biological therapy be used in mild depression?
No unless…
- Consider if PMH mod-severe depression
- Mild depression for 2y or persists after interventions
DEPRESSION
What is the management of moderate–severe depression?
- Combination of SSRI + high-intensity psychosocial interventions first line
- CBT with professional, interpersonal therapy, behavioural activation therapy
- Psychoeducation
DEPRESSION
What is the CAMHS management of depression?
- Watch + wait, lifestyle
- First-line = CBT ± family ± interpersonal therapy (may need intensive if no response)
- 1st line antidepressant = fluoxetine
- Mood + feelings questionnaire (MFQ) to follow-up monitoring in secondary care to assess progress
DEPRESSION
What is the management for resistant depression?
- Different antidepressants (SNRI, MAOI, mirtazapine) or sometimes two
- Augmentation with lithium, atypical antipsychotic or tryptophan
DEPRESSION
What is the management of psychotic depression?
- ECT first line + v effective in severe cases followed by antidepressant
- Antipsychotic initiated before antidepressant if ?primary psychotic disorder then add SSRI
DEPRESSION
What is atypical depression?
What is the management?
- Mood depressed but reactive
- Hypersomnia (>10h/day)
- Hyperphagia (excessive eating + weight gain)
- Leaden paralysis (heaviness in limbs ≥1h/day)
- Oversensitivity to perceived rejection
- Phenelzine or another MAOI, if not SSRI
DEPRESSION
What is dysthymia?
What is the management?
- Chronic, low-grade or sub-threshold depressive Sx which don’t meet diagnostic criteria over a long period of time
- Typically >2y of mildly depressed mood + diminished enjoyment, less severe but more chronic
- SSRIs + CBT first line
DEPRESSION
What is seasonal affective disorder?
What is the management?
- Episodes of depression which recur annually at same time each year (Jan-Feb) with remission in between
- Light therapy + SSRI
SELF-HARM + SUICIDE
What is self-harm?
What are some causes?
Why do people self harm?
- Act of intentionally injuring yourself
- Bullying, bereavement, homophobia, low self-esteem
- Feel in control, reduces feelings of tension or distress, if they feel guilty can be a punishment
SELF-HARM + SUICIDE
What are some methods of self-harm?
What are some risk factors?
What does previous self-harm indicate?
- Self-poisoning (paracetamol), cutting, head banging
- F, social deprivation, single or divorced, LGBTQ+, mental illness
- Greatest predictor of future self-harm + increased suicide risk
SELF-HARM + SUICIDE
What is suicide?
What are some methods?
Why is depression higher in females but suicide higher in males?
- Act of intentionally ending your life
- Overdose, violent means (jumping from height, into traffic, hanging, cutting)
- Men tend to use violent means which are irreversible
SELF-HARM + SUICIDE
What is parasuicide?
Why might this occur?
- Act that mimics suicide but does not result in death
- Someone interrupts them, not enough pills, vomited some of the substances out
SELF-HARM + SUICIDE
What are some risk factors for suicide?
SAD PERSONS – - Sex (M>F) - Age (peaks in young + old) - Depression - Previous attempt - Ethanol - Rational thinking loss (psychotic illness) - Social support lacking (unemployed, homeless) - Organised plan (avoid discovery, plan, notes, final acts) - No spouse - Sickness (physical illness) 0–4 low, 5–6 mod (?hospital), ≥7 high
SELF-HARM + SUICIDE
What are some protective factors for suicide?
- Married men
- Active religious beliefs
- Social support
- Good employment
SELF-HARM + SUICIDE
What are some indicators someone may commit suicide?
- Obsessive thoughts of death, feelings of hopeless/helplessness
- Active planning (buy equipment, manage affairs, leave notes
SELF-HARM + SUICIDE
How should a suicide assessment be conducted?
- Before (?trigger) – amount of planning, notes, final acts?
- During – method, attempt to avoid discovery, lethality?
- After – regret? Intend to re-attempt? Evidence of hopelessness?
SELF-HARM + SUICIDE
How should paracetamol overdose be managed?
- Acetylcysteine if staggered (>1h) or above treatment line
- Rarely if present <1h then activated charcoal can be used
SELF-HARM + SUICIDE
What is the general management for suicide?
- Plan for further suicidal thoughts + coping strategies
- Reduce social isolation, regular contact with services
- Manage depression (if present)
- ?Inpatient stay or ECT
BIPOLAR DISORDER
What is bipolar affective disorder?
When is the peak age of onset?
- Recurrent episodes of altered mood + activity involving both upswings or (hypo)mania + downswings or depression
- Early 20s
BIPOLAR DISORDER
What are the 4 types of bipolar?
- Bipolar 1 = mania + depression in equal proportions, M>F
- Bipolar 2 = more episodes of depression, mild hypomania (easy to miss), F>M
- Cyclothymia = chronic mood fluctuations over ≥2y (episodes of depression + hypomania, can be subclinical)
- Rapid cycling = ≥4 episodes of (hypo)mania or depression in 1 year
BIPOLAR DISORDER
What are some potential causes of bipolar?
What are some risk factors?
- Structural brain abnormalities, neurotransmitter imbalances
- FHx of depression or bipolar, genetics, traumatic life event (abuse), drugs + other meds (antidepressants, BDZs, steroids) + sleep deprivation
BIPOLAR DISORDER
What is the diagnostic criteria for bipolar?
- ≥2 episodes of mood disturbance (1 or which MUST be [hypo]manic)
BIPOLAR DISORDER
What is the clinical presentation of hypomania?
> 4d with ≥3 Sx –
- Elevated mood (euphoria)
- Increased energy
- Increased talkativeness
- Poor concentration
- Mild reckless behaviour (overspending)
- Over-familiar, increased self-esteem
- Increased libido
- Decreased need for sleep
- Appetite change
- Partial insight
BIPOLAR DISORDER
What is the clinical presentation of mania?
> 1w with ≥3 Sx –
- Extreme elation or irritability
- Overactivity + distractibility
- Pressure of speech + flight of ideas
- Impaired judgement
- Extreme risks (jump off buildings, spending spree)
- Social disinhibition + grandiosity
- Sexual disinhibition
- Decreased need for sleep, restless
- MOOD CONGRUENT PSYCHOTIC Sx
- TOTAL loss of insight
BIPOLAR DISORDER
In order to differentiate a manic and hypomanic episode, psychotic symptoms must be present.
What are some of these?
- Grandiose idea may be delusional
- Persecutory delusions sometimes
- Pressure speech may become so great that it’s incomprehensible
- Irritability > violence
- Preoccupation with thoughts > self-neglect
- Catatonia ‘manic stupor’
BIPOLAR DISORDER
What are some…
i) psychiatric
ii) organic
differentials for bipolar?
i) substance abuse (cocaine, amphetamines), schizophrenia, schizoaffective disorder, ADHD
ii) Hyperthyroidism, steroid-induced psychosis, Cushing’s
BIPOLAR DISORDER
What investigations would you perform in suspected bipolar?
- Full Hx, MSE + physical exam to exclude organic
- FBC, U+Es, LFTs, glucose, TFTs, calcium, syphilis serology, urine drug test, ?neuroimaging if SOL
BIPOLAR DISORDER
What is the acute biological management of bipolar disorder?
- Antipsychotic (olanzapine, risperidone)
- Lithium (both acutely + long-term) is first-line
- ?Stop any antidepressants as can precipitate mania
- ?ECT if severely psychotic, catatonic or suicide risk
BIPOLAR DISORDER
What is the long-term biological management of bipolar disorder?
- Lithium first-line (antipsychotics in pregnancy)
- Fluoxetine SSRI of choice if depressive episode
BIPOLAR DISORDER
What type of referral would you do in bipolar?
What is the psychological management of bipolar disorder?
- Hypomania = routine CMHT referral, mania or severe depression = urgent
- CBT for depression, bipolar support groups + psychoeducation
SCHIZOPHRENIA
What is schizophrenia?
What area of the brain is most affected?
- Splitting or dissociation of thoughts, loss of contact with reality
- Temporal lobe
SCHIZOPHRENIA
What is the neurodevelopmental hypothesis in schizophrenia?
- Hypoxic brain injury, viral infections in-utero, TLE + cannabis smoking = risk of schizophrenia indicating brain development link
- Imaging has showed enlarged ventricles (poor prognostic feature), small amounts of grey matter loss + smaller, lighter brains
SCHIZOPHRENIA
What is the neurotransmitter hypothesis in schizophrenia?
- Excess dopamine + overactivity in mesolimbic tract = +ve Sx
- Lack of dopamine + underactivity in mesocortical tracts = -ve Sx
- Overactivity of dopamine, serotonin, noradrenaline + underactivity of glutamate + GABA
SCHIZOPHRENIA
What is the epidemiology of schizophrenia?
What are some risk factors?
- 1% lifetime risk, M=F, mortality 25y before gen pop.
- Affects 1/100, 2 incidence peaks – men earlier (18–25), women (25–35)
- Strongest RF = FHx, others = Black Caribbean, migrants, urban areas, cannabis use + traumatic pregnancy (emergency c-section)
SCHIZOPHRENIA
What are the 6 different types of schizophrenia?
- Paranoid (most common)
- Hebephrenic
- Simple
- Catatonic
- Undifferentiated
- Residual (‘burnt out’)
SCHIZOPHRENIA
What are the features of…
i) paranoid
ii) hebephrenic
iii) simple
schizophrenia?
i) Persecutory delusions + auditory hallucinations
ii) Dx in adolescents with mood changes, unpredictable behaviour, shallow affect + fragmentary hallucinations, poor outlook as -ve Sx may develop rapidly
iii) Pts never really experienced +ve Sx, mostly -ve
SCHIZOPHRENIA
What are the features of…
i) catatonic
ii) undifferentiated
iii) residual
schizophrenia?
i) Psychomotor disturbance such as posturing, rigidity + stupor
ii) Sx do not fit neatly into other subtypes
iii) Previous +ve symptoms less marked, prominent -ve Sx
SCHIZOPHRENIA
What can cause schizophrenia?
- Thought to be combination of biopsychosocial factors
- Schizophrenia susceptibility + emotional life experiences may = trigger
SCHIZOPHRENIA
What are the first rank symptoms of schizophrenia?
What is the relevance?
- Delusional perceptions
- Auditory hallucinations (3 types)
- Thought alienation (insertion, withdrawal + broadcasting)
- Passivity phenomenon, incl. somatic
- ≥1 for at least 1m is strongly suggestive Dx
SCHIZOPHRENIA
What are the three types of auditory hallucinations that count as a first rank symptom?
- 3rd person = talking about the patient (he/she)
- Running commentary = often on person’s actions or thoughts
- Thought echo = thoughts spoken aloud
SCHIZOPHRENIA
What are some secondary symptoms of schizophrenia?
What is the relevance?
- 2nd person auditory or hallucinations in other modalities
- Other delusions (persecutory, reference)
- Formal thought disorder
- Lack of insight
- Negative Sx (incl. catatonia)
- ≥2 for at least 1m is strongly suggestive Dx
SCHIZOPHRENIA
What is the difference between positive and negative symptoms of schizophrenia?
- +ve = presence of change in behaviour or thought, something added (all of the first rank + secondary Sx)
- -ve = decline in normal functioning, something removed
SCHIZOPHRENIA
What are the negative symptoms of schizophrenia?
Often early prodromal, 5As –
- Affect blunting, flattening or incongruity
- Anhedonia + amotivation
- Asociality
- Alogia (poverty of speech)
- Apathy
(Delusional mood = ominous feeling of something impending)
SCHIZOPHRENIA
What are some…
i) psychiatric
ii) organic
iii) substance
differentials for schizophrenia?
i) Delusional disorder, transient psychosis, mania, psychotic depression
ii) TLE, encephalitis, delirium, syphilis/HIV, SOL
iii) Drug-induced psychosis, alcoholic hallucinosis, steroid-induced
SCHIZOPHRENIA
What are the investigations for first-episode psychosis?
- Full Hx, MSE + risk assessment
- FBC, CRP/ESR, U+Es, LFTs, TFTs, fasting glucose, Ca2+, phosphate, B12 + folate
- Urine + serum drugs screen
- ?Serological syphilis + HIV
- CT/MRI head if ?SOL
SCHIZOPHRENIA
What teams would be involved in the management of schizophrenia?
- Early intervention team = initial referral after first episode psychosis
- CMHT = provide daily support + treatment
- Crisis resolution team = pts with acute psychotic episode, often pre-existing diagnosis
SCHIZOPHRENIA
What would warrant hospital admission ± MHA in schizophrenia?
- High risk of suicide or homicide
- Severe psychotic, depressive or catatonic Sx
- Failure of OP treatment or non-compliance
SCHIZOPHRENIA
What is the biological management of schizophrenia?
- Anti-psychotic (tailor SE profile to patient)
- Aim for minimal effective dose, use depot if non-compliant to prevent relapse
SCHIZOPHRENIA
What is treatment resistant schizophrenia?
What is the management?
- ≥2 antipsychotics (1 atypical) trialled for ≥6w but ineffective
- Clozapine
- ECT is last line if resistant to therapy or catatonic
SCHIZOPHRENIA
What is the psychological management for schizophrenia?
- All patients offered CBT
- Family therapy + psychoeducation to reduce or notice relapses
SCHIZOPHRENIA
What is the social management of schizophrenia?
- Social work + housing involvement may be needed
- Drop-in community centres + support groups
- Substance misuse service if needed
- Depot non-attendance at GP/CPN appt may act as early warning system
SCHIZOPHRENIA
After a Mental Health Act detention, what approach should be taken to their care?
What does it involve?
- Care programme approach
- Assess health + social needs, create care plan, appoint key worker as point of contact + review treatment
PARAPHRENIA
What is paraphrenia?
How does it compare to schizophrenia?
- Late-onset schizophrenia >45y
- Less emotional blunting + personality decline, F>M
PARAPHRENIA
Why is it often undiagnosed?
What are some risk factors?
- Older patients tend to be socially isolated
- Social isolation, poor eyesight + hearing, reclusive + suspicious pre-morbid personality
PARAPHRENIA
What is the clinical presentation of paraphrenia?
How is it managed?
- Delusions, hallucinations + paranoia usually about neighbours
- Partition delusions where they believe people + objects can go through walls
- Less -ve Sx + formal thought disorder
- Low dose antipsychotics
TRANSIENT PSYCHOSIS
What is transient psychosis?
What may cause it?
What is it associated with?
- Brief psychotic episodes that last less than time required to diagnose schizophrenia (<1m)
- Usually resolves within that time
- Acute stressor (loss, marriage, unemployment)
- Paranoid, borderline + histrionic personality disorders
DELUSIONAL DISORDER
What is a delusional disorder?
- Pt experiences strong delusional beliefs (often non-bizarre) + perceptions but with the absence of prominent hallucinations, thought or mood disorder or significant flattened affect
- ICD 10 ≥3m (if less it’s persistent delusional disorder)
DELUSIONAL DISORDER
What is erotomania or De Clerambault’s syndrome?
- Delusion in which patient (usually single woman) believes another person (typically higher social status) is in love with them
DELUSIONAL DISORDER
What is Othello syndrome?
- Delusional jealousy
- Patients (typically men) possess fixed belief that their partner has been unfaithful + often try to collect evidence
DELUSIONAL DISORDER
How else might delusional disorder present?
- Delusions about illness, cancer or skin infestation
- Grandiose delusions
- Persecutory delusions
DELUSIONAL DISORDER
What is the management of delusional disorder?
- Antipsychotics, ?SSRIs
- Individual therapy = establish therapeutic alliance, maybe CBT
SCHIZOAFFECTIVE
What is schizoaffective disorder?
What are the two types?
How does it differ to schizophrenia?
- Features of both affective disorder + schizophrenia present in equal proportion
- Manic type or depressive type
- Psychotic Sx tend to wax + wane, unlike in schizophrenia
SCHIZOAFFECTIVE
What is the prognosis of schizoaffective disorder?
What is the management of it?
- Better than schizophrenia but worse than primary mood disorders
- Antipsychotics, mood stabilisers of antidepressants (depends on affective disorder)
GAD
What is Generalised Anxiety Disorder (GAD)?
What can it be comorbid with?
- Syndrome of excessive, persistent worry + apprehensive feelings about everyday events that the patient recognises as excessive + inappropriate
- Other anxiety disorders, depression, substance abuse, IBS
GAD
What are 3 cardinal features of GAD?
- Symptoms of muscle + psychic tension
- Causes significant distress + functional impairment
- No particular stimulus
GAD
What is the epidemiology of GAD?
- Highest prevalence 45–69y, F>M
- Early onset = childhood fears + marital or sexual disturbance
- Late onset = stressful event, single, unemployment
GAD
What model can be used to explain the causes of GAD?
Triple vulnerability –
- Generalised biological
- Generalised psychological (diminished sense of control)
- Specific psychological (stressful events)
GAD
What are some organic differentials for GAD?
- Endo = hyperthyroidism, pheochromocytoma, hypoglycaemia
- CVS = arrhythmias, cardiac failure, anti-hypertensives, MI
- Resp = asthma (excessive salbutamol), COPD, PE
GAD
What are some risk factors for GAD?
- Alcohol, BDZs or stimulants (particularly withdrawal)
- Co-existing depression, FHx, female
- Child abuse/neglect or excessively pushy parents
- Life stresses (finance, divorce)
- Physical health problems
GAD
What is the ICD criteria of GAD?
What are the groups of symptoms present in GAD?
- Difficulty controlling worry, present for more days than not for ≥6m
- ≥4 symptoms with ≥1 from autonomic arousal section
- Autonomic arousal, physical, mental, general, tension, other
GAD
What symptoms in GAD come under the following categories…
i) autonomic arousal?
ii) physical?
iii) mental?
iv) general?
v) tension?
vi) other?
i) Palpitations, tachycardia, sweating, tremor
ii) Breathing issues, choking, CP, nausea, abdo distress
iii) Dizzy, derealisation + depersonalisation, fear of losing control, impending death
iv) Numbness + tingling, hot flushes + chills, sleep issues (initial insomnia, fatigue on waking)
v) Muscle aches + pains, restless, lump in throat
vi) Exaggerated responses to minor surprises/startled
GAD
What are the investigations for GAD?
- History, MSE + risk assessment
- GAD-7 + Hospital Anxiety + Depression Scale (HADS) questionnaire
- Exclude organic (FBC, U+Es, LFTs, TFTs, fasting glucose, PTH)
GAD
What is the stepwise management for GAD?
- Education + active monitoring, exercise
- Low-intensity psychological interventions like individual self-help or groups
- High-intensity psychological interventions (CBT, applied relaxation, arts + music therapy) or biological management
GAD
What is the role of CBT in GAD?
- Cognitive = educate about bodily response to anxiety
- Behavioural = use of relaxation to overcome
GAD
What is the biological management used in GAD?
- Sertraline first line, if ineffective offer alternative SSRI or SNRI
- If SSRI/SNRI not tolerated then pregabalin
- Beta-blockers like propranolol for physical Sx sometimes
GAD
What is the CAMHS management of GAD?
- Watch + wait
- Self-help (meditation, mindfulness), diet + exercise
- CBT, counselling + SSRI like sertraline may be considered if more severe (specialists)
PANIC DISORDER
What is panic disorder?
- Recurrent panic attacks that are unpredictable + unrestricted in terms of situation, ≥4/week for ≥4w
- Usually persistent worry about having another attack
- Chronic relapsing condition > distress + social dysfunction
PANIC DISORDER
What is a panic attack?
- Period of intense fear characterised by range of physical Sx that develop rapidly, peak intensity at 10m, generally no longer than 20–30m
PANIC DISORDER
What is the epidemiology of panic disorder?
- Females 2–3x more likely
- Bimodal distribution
PANIC DISORDER
What is panic disorder associated with?
What are some risk factors?
- Meds like SSRIs, BDZs, zopiclone withdrawal
- Widowed, divorced or separated, living in city, limited education, physical or sexual abuse, FHx
PANIC DISORDER
What are the 3 key elements of panic disorder?
- Sudden onset panic attack with ≥4 characterised Sx
- Not necessarily associated with a specific stimulus
- Pt preoccupied with suffering death or severe life-threatening illness
PANIC DISORDER
What are the features of panic attacks?
Same as GAD but in discrete attacks –
- Palpitations, tachycardia, sweating, tremor
- Breathing issues, choking, CP, nausea, abdo distress
- Dizzy, derealisation + depersonalisation, fear of losing control, impending death
- Numbness + tingling, hot flushes + chills, muscle aches + pains
PANIC DISORDER
What is the stepwise management of panic disorder?
- Recognition + diagnosis with treatment in primary care
- CBT or drug therapy (SSRIs 1st line, if C/I or no response after 12w then imipramine or clomipramine)
- Psychodynamic psychotherapy + specialist MH services if severe
PANIC DISORDER
What is the social management of panic disorder?
- Healthy eating, exercise, avoid caffeine.
- Meditation, mindfulness, self-help groups
SIMPLE PHOBIAS
What is a simple or specific phobia?
- Recurring excessive + unreasonable anxiety attacks, in the (anticipated) presence of a specific feared object or situation, leading to avoidance if possible
SIMPLE PHOBIAS
What might people be phobic of?
Give some examples.
- Animals, blood, injection or injury, situational, natural environment
- Emetophobia, claustrophobia, arachnophobia, iatrophobia
SIMPLE PHOBIAS
What is the epidemiology of simple phobias?
- F>M
- Mean age is 15 (animal phobias can be as young as 7)
SIMPLE PHOBIAS
What are some potential causes of phobias?
- Psychoanalytical = phobia is symbolic representation of repressed unconscious conflict
- Learning theory = conditioned fear response to traumatic situation with learned avoidance
SIMPLE PHOBIAS
What is the clinical presentation of simple phobias?
Same features as GAD but to a specific stimulus –
- Palpitations, tachycardia, sweating, tremor
- Breathing issues, choking, CP, nausea, abdo distress
- Dizzy, derealisation + depersonalisation, fear of losing control, impending death
- Numbness + tingling, hot flushes + chills, muscle aches + pains
SIMPLE PHOBIAS
What is the management of simple phobias?
- Exposure + response prevention (ERP)
- CBT (education + anxiety management, coping strategies)
- BDZs in severe cases to reduce avoidance
