Psych Flashcards
what is parasuicide
an act that looks like suicide but does note result in death.
Parasuicide can be tantamount to attempted suicide but not necessarily – may just be a cry for help
how would you carry out a suicide assessment?
first thing is to ensure medical safety and fitness
history
- event leading up to the suicide
- planned?
- did they leave a note?
- precaution against discovery?
self-harm incident
- what method? violent vs non-violent
- intoxicated?
- alone?
- what was going through their head?
- who found them? found by chance?
after the incident - how did the patient feel? - did they seek help after the event? - how did they get to A&E? - how do they feel about the event now? regret?
perform a full risk assessment
- current suicidal ideations and mental state
- screen fore depression/psychosis/alochol dependency/anorexia
- previous attemtps?
- outlook for futures? what will they do when thy get home
- any protetct factors?
management for suicide attempt
• Acute management
o Ensure patient is medically safe and stable
o Complete a full assessment
• Long term management will depend upon:
o Level of risk
o Comorbidities
Anxiety and depression need appropriate management
o Was it an impulsive act?
Acts that are genuinely regretted in adults often do not need long term follow up
o Part of a pattern of repeated self-harm?
• In most cases patient can be discharged back into the community
o Especially if strong social support network and no current suicidal thoughts
o Safety plan (see prevention below):
o Crisis Team information
o Refer to GP for follow up – in some cases also the CMHT
If already under the care of CMHT contact their care co-ordinator as soon as possible
what is dementia
a syndrome due to disease of the brain that is chronic or progressive in nature. Involves disturbances of higher cortical function
• Should be present for at least 6 months
what are the main types of dementia?
- Alzheimer’s – most common
- Atrophy of the cerebral cortex, ↓ Ach, senile (β amyloid) plaques, ↑ neurofibrillary Tau protein tangles
- Lewy Body
- Lewy bodies = intracellular eosinophilic inclusions – consist of abnormally phosphorylated neurofilament proteins, aggregated with ubiquitin and alpha synuclein → neuronal loss → ↓ Ach. Senile plaques may also be seen
- Fronto-temporal (Pick’s disease)
- Selective, asymmetrical knife blade atrophy in the frontal and temporal areas. Pick cells = ballooned neurons. Pick bodies = Tau +ve neuronal inclusions.
- Vascular
- Thrombotic event = deterioration. Stepwise progression
clinical features of dementia
- Diagnosis based upon cognition is impaired & activities of daily living are affected
- No clouding of consciousness
- Memory Loss - short term memory affected more than long term. I.e. difficult to learn new things & commonly disorientated
- Impaired Thinking - concrete thinking, poor judgement, reduced fluency, struggles to make plans, may have delusions, sundowning (confusion worse in the evening)
- Agnosia - inability to recognise things: visual, auditory, prosopagnosia (inability to recognise faces)
- Language - expressive (Broca’s - frontal) / receptive dysphasia (Wernicke’s - parietal)
- Lexical anomia - word finding difficulty (i.e forgetting that a phone is called a phone)
- Personal Functioning - severe senile self neglect (Diogennes Syndrome); tendency to hoard rubbish
- Personality & Behaviour - euphoria, emotional lability (rapid changes); apathy, irritable, frustrated, disinhibition in social setting - can lead to aggression
- Hallucinations – mostly visual
- Motor impairment – apraxia, spastic paresis, urinary incontinence
what are the 5 As of alzheimer’s
Amneis aphasia agnosia apraxia associated behvaiours. psychological, delusions
psychological - delusions, hallucinations, depression, anxiety
behavioural - aggression, wandering, agitation
clinical features of Lewy body dementia
- Marked fluctuations in cognitive impairment and alertness
- Vivid visual hallucinations (70%) – occurs earlier than any other dementia
- Early parkinsonism (70%)
- Frequent faints and falls
clinical features of fronto-temporal dementia
- Insidious onset and gradual progression
- Early decline in social interpersonal conduct
- Early impairment in regulation of personal conduct
- Early emotional blunting
- Early loss of insight
what are some risk assessment of confused older adults are there?
to self
- wandering
- leaving the gas on
- leaving keys in the door
- abuse
- neglect by self or others
- falls
to others
- driving - have to inform DVLA and unable to drive
- aggression
- risk behaviors
what are some investigations for dementia
MMSE/Addenbrook’s
bloods = FBC, U&Es, TFT< LFT, b12, folate, ca, mg, serum cholesterol, serum glucose
cxr
ct head
mri - 1st chocie for suspected fronto-temporal disease
SPECT (Dat) - Lewst body
differentials for dementia
- Drugs, delirium
- Emotions/depression
- Metabolic disorders
- Eye and ear impairment
- Nutritional disorders
- Tumours, toxins, traumas
- Infections
- Alcohol, arteriosclerosis
management of dementia
- Memory aids e.g. clocks, calendars, photographs
- Try and keep at home for as long as possible
- Psychological:
- Emotional support
- CBT
- Social
- Carer support
- Occupational therapy
- Biological
- Alzheimers
- AchEI e.g. donepezil, rivastigmine. SE: stomach ulcers, N+V
- Diazepam/lorazepam for anxiety
- SSRI’s for depression
- Mementine (NMDA receptor) – 2nd line
- Risperidone (antipsychotic) for agitation
- Lewy body – AchIn e.g. rivastigine. AVOID antipsychotics
- Diazepam/lorazepam for anxiety
- SSRI’s for depression
- Mementine (NMDA receptor) – 2nd line
- Vascular – Stop smoking, healthy eating, exercise, anticoagulants
- Fronto-temporal – AVOID AchEI’s
what is an adjustment disorder?
A protracted (lasting longer than usual) response to a significant life change or event (within the last 3 months)
how long does acute adjustment disorder need to be?
< 6 months
how long does chronic adjustment disorder need to be?
> 6 months and causes disruption to a person’s life
what is acute stress reaction?
o Acute response to highly threatening or catastrophic experience
o Anxiety dies down within hours/days
clinical features of acute stress reaction?
traumatic event
dazed
amnesia or denial to the events
overactivity or withdrawal
somatic symptoms eg tachycardia, sweating, flushed, “dazed”
clinical features of adjustment disorder
significant life changes longer period of time, symptoms fluctuates depression, anxiety preoccupation with events angry outburst, disturbed
some somatic symptoms
management of acute stress reaction
remove stress, reassurance, support, short course benzodiazepine
management of adjustment disorder
- Usually self resolving
- Psychological interventions may be useful: problem solving psychotherapy, crisis intervention
- Biological: antidepressants/Anxiolytics rarely required
what is bereavement
objective state of having experienced a loss
what is grief
the subjective state of experiencing the psychological and physiological reaction to loss
what is complicated/pathological grief
failure to return to a pre-loss level of performance or state of emotional wellbeing
often > 6 months
what are the stages of normal bereavement?
< 12 months
DAB DA
Denial - may include auditory/visual psuedohallucinations
Angry
Bargaining
Depression
Acceptance
what is considered normal bereavement
< 12 months
sadness,anxiety, apathy, hallucinations
no functional impairment
wants to be with the deceased - inc wanting to die specifically to be with them
what is abnormal bereavement
> 12 months
sadness, anxiety, apathy, hallucinations
functional impairment
suicidal ideations with no intentions of it being just to be with the loved one
management of normal bereavement
- 3C’s – Comfort, Consultation, Coping (restitution)
- CBT
- Medications e.g. depressive, anxiety symptoms
- Individual counseling
- Group therapy
what is the management of abnormal bereavement
- 3C’s – Comfort, Consultation, Coping (restitution)
- CBT
- Medications e.g. depressive, anxiety symptoms
- Individual counselling
- Group therapy
- Complicated grief treatment
- Residential inpatient management/ outpatient grief rehabilitation programmes
what is somatisation
Physical symptoms that cannot fully be explained by other medical, neurological or psychiatric disorders
aetiology of somatisation
- Female
- Hx of life stressors
- Recent life stressors
- Anxiety
- Depression
clinical features of somatisation
- Multiple physical SYMPTOMS present for a long time (>2 years) that cannot be accounted for with a physical disorder
- Symptoms that are distressing or result in significant disruption of daily life eg abdo pain, headahce, aching muscles, fatigue, neuro symptoms
- Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
- Disproportionate and persistent thoughts about the seriousness of one’s symptoms
- Persistently high levels of anxiety about health or symptoms; excessive time or energy devoted to these symptoms or health concerns
- Even if any one somatic symptom is not continuously present, the state of being symptomatic is persistent (typically more than 6 months)
what other conditons are included in somatization?
somatoform disorder
hypochondriacal disorder - – worrying that you are going to DEVELOP a serious medical condition despite medical reassurance to the contrary
conversion disorder - conversion anxiety into more tolerable symptoms that attack benefits of the sick role
what is anxiety?
A state consisting of psychological & physical symptoms brought out by a sense of apprehension by a perceived threat
what are some neurochemical theory of anxiety?
inc noradrenergic and seratonergic neurons & GABA may contribute to symptoms of anxiety disorders
what are the different types of anxiety disorder
phobia
- agoraphobia -Fear of places that are difficult or embarrassing to escape from
- social phobia - fear of being judged by pthers & being embarrased or humiliated. can be in spefici social situations
- specific phobia
GAD
PTSD
Panic Disorder
aetiology of anxiety disorder
- Young adulthood
- Women
- Endocrine: hyperthyroid, Cushing’s pheochromocytoma, hypoglycaemia
- Genetic: neurotic personality traits
- Environmental: can be triggered by stressful events, particularly those involving threat. Also results from stressful/traumatic events in childhood e.g. parental indifference/ physical abuse
- Drug/alcohol intoxication/withdrawal
what are some clinical features of anxiety disorder
biological
- palpitations, tachycardia, chest pain
- dry mouth, globus hsytericus, abdo discomfort, frequent/loose motions
- hyperventilation, difficulty catching breath, chest tightness
- urinary frequency, failure of erection, amenorrhoea
- hot flushes,cold chils, tremour, sweating, headhcales, muscle pains, numbness
psychological
- the feeling of impending doom, restlessness, startle response, poor concentration, insomnia, night terrors, depersonalisation, derealisation
what are some GAD specific symptoms
long-standing anxiety that may fluctuate but is neither situational or episodic, free-floating
> 6 months of worry without prominet tension
worry about everyday events
autonomic arousal irritability poor concentration muscle tension tiredness sleep disturbance depressive symptoms
what are the clinical features of panic disorder?
rapid onset of severe anxiety lasting 20-30 minutes
can occur unexpectedly
panic disorder = panic attack occurs recurrently
ICD criteria - 4 of the following - palpitations - dizziness - feeling of choking - chest pain \+ 1 autonomic arousal symptoms \+ 4 panic attacj in 4 weeks --> each lasting > 10 minutes
investigations for anxiety disorder
mainly clinical and make sure no other organic causes
GAD-7
identify social anxiety - mini SPIN
what is the management for GAD?
GAD – work in a stepwise fashion:
1) Education on the condition, self help resources for both patient and family, active monitoring of the person’s symptoms and functioning
2) Individual non facilitated self help (self help + minimal therapist contact), Individual guided self help (CBT in written form, facilitated by a trained practitioner and face to face/telephone consultations), psychoeducational groups
3) CBT/applied relaxation + SSRI/SNRI
4) Specialist care
management of phobias
Phobia: • Avoid TCA/benzos • Do not routinely offer mindfulness-based interventions 1) CBT with graded exposure 2) SSRI/SNRI 3) Short term psychodynamic therapy
management of panic disorder
Mild to moderate: Individual non facilitated self help (self help + minimal therapist contact), Individual guided self help (CBT in written form, facilitated by a trained practitioner
2) Moderate to severe: CBT AND/OR SSRIs/TCAs
3) 2 interventions tried together and not successful = specialist referral
• Benzodiazepines can be used short term
clinical features of PTSD
re-experiencing of the event (flashbacks)
avoidance
hyperarousal - hypervigilance, anger, irritability
emotional numbing/dysregulation
dissociation
-ve self perception
management of PTSD?
• Avoid benzodiazepines due to high risk of dependence
1) Peer support groups
1) Within 1 month of the event with subthreshold symptoms: active monitoring
1) Within 1 month of the event and symptomatic:
• Trauma focused CBT
• Eye movement desensitisation and reprocessing
• Supported trauma focused computerised CBT
2) Venlafaxine/SSRI
3) Risperidone – consider in addition to psychological therapies if severe hyperarousal/psychotic symptoms
how long does the symptoms of PTSD must be present in order for a diagnosis to be made?
> 1 month
what is obsessional compulsive disorder
• Can be classified as predominantly obsessional thoughts, compulsive acts or mixed obsessional compulsive
pathophsiology of OCD
• Pathology in the caudate nucleus fails to suppress signals from the orbitofrontal cortex → hypothalamus becomes overexcited & sends strong signals back to orbitofrontal cortex
what are some aetiology of OCD
Fhx of OCD
PANDAS - paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection
male
clinical features of OCD
obsessional thought
- recurrent idea, image or impulse that is perceived as being sensless
- intrusive thought doesn’t leave quickly
- unsuccessfully resisted & that results in marked anxiety/distress
- common obsessional thoughts - contamination, safety, orderliness, physical symptoms, sex, aggression
compulsive act
- a recurrent stereotyped behaviour that is not enjoyable or useful, however, reduced anxiety & distress temporarily
- usually perceived as being senseless. however is unsuccessfully resisted
- behaviour is repeated again and agina
- time-consuming> 1 hour per day
- common compulsive actions - washing & cleaning, counting, arranging & ordering, repeating a phrase, checking
what are some investigation for obsessional compulsive disorder
Yale Brown Obessive Compulsive scale
differentials for OCD
obsessive compulsive personality disorder delusional disorder Austim/ Asperger's Tourette's other anxiety disorder psychotic disorder depressive disorder
