Psych Flashcards
differentiate between suicide and deliberate self harm
suicide = intentional self-inflicted death DSH = intention, non-fatal self-inflicted harm
what factors make someone more likely to attempt suicide?
mental illness, in particular: depression bipolar disorder schizophrenia alcohol/substance misuse emotionally unstable personality disorder anorexia nervosa
also:
chronic pain/disease
availability of means (ligature points, firearms, paracetamol pack size reductions)
family history of suicide
lack of social support or recent adverse event (bereavement, loss of job/relationship)
give some suicide prevention strategies
- detect and treat mental illness
- be alert to risk and respond to it - lots of people see GP in the weeks preceding suicide
- safer prescribing - avoid prescribing drugs with high overdose toxicity to patients with suicide risk
- urgent hospitalisation/detention for people with suicide intent
- careful management of DSH - high risk of future completed suicide
- tackle population factors like unemployment, access to means
describe epidemiological differences between who self harms and who completes suicide (e.g. by age, sex etc)
also give some of the common methods for each
suicide - M > F, older single men big risk. hanging most common method in UK, others incl jumping in front of train/car, poisoning
DSH - F > M, more common in women, under 35s, lower social classes and single/divorced
means - mostly drug overdose or physical self-injury e.g. cutting or stabbing
give four different categories that motives behind DSH can broadly be categorised into
- desire to interrupt a sequence of events seen as inevitable or undesirable
- need for attention
- attempt to communicate
- true wish to die
what are indicators of high risk in a suicide/DSH history
leaving a note, making a will, continued determination to die, marked feelings of hopelessness, precautions taken against discovery, high lethality risk (either objective, or patient believes! i.e. 3 paracetamol is high risk if patient believed that’s lethal dose)
also if older, male, unemployed, socially isolated
hx of previous attempts/DSH - biggest indicator of future completed suicide
list the different options for management of DSH
MEDIATE Medically stabilise Establish rapport Diagnose and treat mental illness Iatrogenic risk - prescribe safely (e.g. SSRIs rather than tricyclics) Assess likelihood of recurrence: Thoughts might return? = make a plan Evaluate social problems
basically want to reduce risk of them doing it again, ensure treatment of underlying mental illness is either started or continued, address any social problems and make sure they know what to do if they feel like they might do it again - e.g. come to A&E, contact crisis team - do they need admission?
DBT good for repeated DSH in EUPD
what are the main areas to consider in a psychiatric risk assessment?
risk to self
risk to others
risk of self neglect/accidental harm
vulnerability to abuse
risk should be regularly reviewed as it fluctuates
remember past behaviour biggest predictor of future risk!!
what would you document when assessing risk to self?
- current suicidal thoughts, plans and intent
- anything that prevents patient acting on these thoughts eg. family, religion (protective factors)
- prev eps of DSH - circumstances, methods, management
- factors predisposing to DSH/suicide (FHx, social isolation, substance misuse etc)
- hx of disengagement from support services, whether they’re currently willing to engage
in MSE look for thoughts of hopelessness/worthlessness, command hallucinations inciting self-harm
what would you document when assessing risk to other?
- acts or threats of violence - to whom, frequency, severity, methods used, any serious harm resulting
- deliberate arson
- sexually inappropriate behaviour
- episodes of containment (compulsory detention, treatment in hospital, secure unit, locked ward, prison, police station)
- compliance with prev and current treatment - note past disengagement
Factors increasing risk:
- recent stopping prescribed drugs
- change in use of recreational drugs
- alcohol/substance misuse
- impulsive or unpredictable behaviour
- recent stressful life events, change in personal circumstances, lack/loss of social support
in MSE:
- expressed violent intention or threats
- irritability, disinhibition, suspiciousness
- persecutory delusions
- delusions of control/passivity phenomena
- command hallucinations
give examples of self-neglect/accidental injury someone with mental illness could be at risk of
- malnutrition - forgetting to eat, eating out of date foods
- failure to access healthcare
- living in squalid conditions
- falls - physical frailty, drug/alcohol intoxication
- failure to take safeguards against fire/explosion e.g. cigarette burned bed sheets, leaving gas on)
- wandering, poor road safety
- accidental overdose/not taking meds
- vulnerability to crime due to leaving door open, persistently losing key or inviting strangers in
give examples of abuse someone with mental illness could be at risk of
abuse = single or repeated lack of appropriate action occurring within any relationship where there is an expectation of trust and which causes harm or distress to a vulnerable person
may be verbal, physical, financial or sexual, or neglect
- people in institutions are at risk
- also occurs in private homes
make sure carers aren’t having to deal with verbal/physical abuse from patient
what acronym can you use to remember factors affection risks to vulnerable adults?
HOW SAFE?
HOme safety e.g. leaving gas on
Wandering
Self neglect e.g. poor self care
Abuse, neglect, crime vulnerability
Falls
Eating - malnutrition
describe steps that should be taken in immediate management of a violent patient
- consider if admission necessary, need for MHA assessment - PICU, secure ward?
- staff will be trained in breakaway techniques (to exit situation) and also in respectful restraint (talking down always first)
- medication e.g. benzodiazepines and/or antipsychotics e.g. midazolam (short acting), lorazepam (intermediate acting)
- seclusion if needed
what acronym can you use to remember immediate management of violence?
BE CAREFUL
Breakaway
Evaluate and talk down
Control and restraint
Assess need for medication to sedate and/or treat disorder
RE-evaluate setting - higher security?
FULly review care plan
what steps can be taken to prevent future violence after a violent incident?
WARN Write risk incidents in notes Assess in safe environment Read documentation before assessing Notifying professionals involved of risks
communication between agencies, good use of care plans, monitoring level specific to that patient’s needs
in the context of a risky patient, when is it appropriate to break confidentiality?
- if aware of specific threat to named individual - must inform that person (and probably also the police)
- rarely, can justify breaking in name of public interest e.g. to assist in prevention, detection or prosecution of serious crime
- also must report significant abuse causing harm to children and vulnerable adults - to social services or police if severe
explain the mechanism of action of ECT
induction of a modified cerebral seizure - patient undergoes a series of these (e.g. twice a week for 4-12 sessions)
effects include (nobody really knows):
neurotransmitter release - serotonin, noradrenaline, dopamine
transient increase in blood-brain-barrier permeability
modulation of neurotransmitter receptors
synaptogenesis and neurogenesis
hypothalamic and pituitary hormone secretion
explain the legal aspects of ECT
if a patient with capacity refuses it, it cannot be given - not even if under section.
patient must give informed consent before each session
or can be given if:
pt lacks capacity and it doesn’t conflict with advanced decision
AND it’s an emergency and independent consultant has not yet assessed
OR
independent consulted appointed by mental health act commission agrees
what are some indications for use of ECT?
- severe depression (this is the main one)
- prolonged or severe episode of mania that doesn’t respond to treatment
- catatonia
- moderate depression not responsive to multiple drug and psychological therapies
must only be used to induce fast and short-term improvements of severe symps after all other options failed
patients usually need subsequent treatment to prevent relapse
what are some relative contra-indications to ECT?
raised ICP
recent stroke
recent MI
unstable angina
how is ECT given?
patient fasts for 4 hours
anaesthetist gives short-acting anaesthetic + muscle relaxant + preoxygenation
psychiatrist then runs electric current through electrodes on head
induces seizure - lasts 20-60s, monitor EEG and movement
monitor during recovery
typically twice a week for 4-12 sessions depending on response
give some side effects of ECT
- cognitive impairment is the biggie - cognition should be assessed before, during and after a course of treatment
- if significant impairment - consider switching electrode placement, reducing stimulant dose or stopping treatment
also: - anaesthetic complications
- dysrhythmias due to vagal stimulation
- post-ictal headache
- confusion
- retrograde and anterograde amnesia - difficulties in registration and recall may persist for several weeks
explain a bit about the newer methods of brain stimulation
transcranial magnetic stimulation (TMS) - prefrontal cortex stimulation by application of strong magnetic field - shows promise for depression
vagal nerve stimulation - used in epilepsy and refractory depression - generator implanted under skin used to electrically stimulate the nerve
deep brain stimulation - thin electrode inserted directly into brain - used in Parkinsons, research into its role in OCD
what are the first and second rank symptoms for schizophrenia? (ICD 10)
ICD 10 says need these for >1 month
first rank (any one = schizophrenia):
- Thought echo/insertion/withdrawal/broadcast
- Delusions of control, influence, ot passivity or phenomenon
- third person auditory hallucinations (discussing them/running commentary)
- Bizarre persistent delusions
second rank (any two)
- any persistent hallucination
- neologisms (made-up words) or other forms of disorganised speech/thought disorder
- ‘negative’ symptoms e.g. apathy, poverty of speech, blunted affect & catatonic Sx
what is ‘psychosis’? give some examples of psychotic disorders
losing touch with reality - misperception of thoughts/ perceptions arising in the patient’s own mind as reality - includes delusions and hallucinations - symptom rather than a diagnosis
e.g. schizophrenia, delusional disorder, schizoaffective disorder, psychotic depression and bipolar affective disorder
what are the positive symptoms of schizophrenia?
delusions - persecutory, or delusions of reference
hallucinations
formal thought disorder (disorganised sepech) e.g. neologisms
what are the negative symptoms of schizophrenia?
poverty of speech flat affect poor motivation social withdrawal lack of concern for social conventions poor attention and memory (cognitive symptoms)
what are the DSM 5 criteria for schizophrenia?
at least two of following, including 1 positive symp (1-3), for at least 6 months (incl 1 month of symptoms):
1) delusions
2) hallucinations
3) disorganised speech
4) disorganised or catatonic behaviour
5) negative symptoms
what are the different subtypes of schizophrenia according to ICD 10 (DSM 5 doesn’t have subtypes)?
- paranoid schizophrenia - most common, delusional and auditory hallucinations
- catatonic - psychomotor disturbances e.g. rigidity, posturing, echolalia, echopraxia
- hebephrenic aka disorganised - early onset, poor prognosis, irresponsible behaviour, mood inappropriate, affect incongruous e.g. lots of giggling etc, fleeting delusions and hallucinatiosn
- residual - history of one of the ones above, but currently it’s mostly just negative symptoms
- simple schizophrenia - negative symps without preceding overt psychotic symptoms - rare
what features might suggest someone is at risk of an acute psychotic illness?
- prodromal period - symptoms of anxiety, depression, ideas of reference (feelings of being watched)
- person that’s distressed, with declining social functioning and transient psychosis - at risk
- consider CBT and treatment of comorbid conditions, but antipsychotics not appropriate
aetiology/risk factors of schizophrenia?
- genetics - definite familial element
- advancing paternal age - to do with germ line mutation in dad
- neurodevelopmental hypothesis - factors interfering with early brain development increase risk e.g. obstetric complications
- social factors - SE deprivation, urbanity, excess of life events in 3 weeks before symptoms (e.g. bereavement, loss of job etc)
- early cannabis use
- ethnicity - afro-caribbean/black african at higher risk
- those in families with high expressed emotion
- neurochemical changes- possible final pathway involving dopamine excess
what are the key components of management of acute schizophrenia?
early intervention is key
antipsychotics - normally kick in within 2-3 weeks, gradually becoming more effective - benzodiazepine used to sedate/keep calm in mean time.
psychology - self-help, psychoeducation (education of family helps!)
social - support, focus on engagement, hope, reduce stigma.
early intervention team support people in first few years of illness. aim for community treatment but may require admission/detention - for assessment and treatment.
describe management options for schizophrenia in terms of reducing risk of relapse and promote long-term recovery after controlling an acute psychotic episode
maintenance treatment on antipsychotics
psychology - family therapy to reduce expressed emotion if present, also CBT for schizophrenia. art therapy.
support to reduce substance misuse, gain employment/study and find accommodation
describe the role of medication in treatment of schizophrenia
after single acute episode - antipsychotics started and should be continued for 12-24 months before tailing off if they remain well - don’t stop earlier as massive risk of relapse, but if well don’t keep on forever either due to risk of tardive dyskinesia etc.
typical and atypical effective but different side effects.
trial a drug for 4-6 weeks before deciding whether to up it or switch. IM/depot used if non-compliance or patient preference.
clozapine is saved for if failed to respond to 2 other drugs - requires regular bloods.
antipsychotic/benzodiazepine sedation if agitated/violent.
negative symptoms not improved by clozapine or other antipsychotics!
describe the role of psychological treatment for schizophrenia
should all be offered individual CBT for schizophrenia - alleviates distress and disability, doesn’t focus on eliminating voices etc, more on strategies to cope with them e.g. playing music, how to respond to them.
family therapy to reduced excessive expressed emotion.
art therapy - particularly for negative symptoms.
self-help groups e.g. Hearing Voices group.
describe the role of social support/interventions in treatment of schizophrenia
schizophrenic patients often struggle with day to day life so social support/rehab really important.
- need to help them get back to work/study and appropriate accommodation to give them a good QoL.
- if work not poss - volunteering or day centres to provide structure
- often require supported living requirement and/or extensive rehab focussed on maximising independence
list some good prognostic factors for a person with schizophrenia
FINDING PLANS: Female In relationship, good social support No negative symptoms aDheres to medication Intelligence (more educated) No stress Good premorbid personality
Paranoid subtype Late onset Acute onset No substance misuse Scan (CT/MRI brain) normal
give some differential diagnoses for a patient presenting with schizophrenia vibes
delusional disorders psychotic depression manic episode schizoaffective disorder schizotypal disorder puerperal psychosis
organic disorders - substance misuse, drug-induced psychosis, iatrogenic (levodopa, methyldopa, steroids, antimalarials), complex partial epilepsy, delirium, dementia, Huntington’s disease, SLE, syphilis
what drugs can cause a patient to become psychotic?
steroids, levodopa, methyldopa, antimalarials, isoniazid
what is “high expressed emotion” and what does it mean in relation to schizophrenia?
families with high expressed emotion = more at risk of schizophrenia, much more at risk of relapsing as well.
expressed emotion is intensity and amount of emotional involvement of the family with the patient - e.g. overbearing, lots of critical comments etc.
theory is that family therapy focussed on reducing this can reduce relapses.
note that if expressed emotion too low, this exacerbates negative symptoms of apathy and withdrawal.
list some factors associated with poor prognosis of schizophrenia
demographics:
- young age at onset (<25 yrs)
- male
- isolated, unmarried
- poor work record
- premorbid personality disorder
- substance misuse
illness characteristics:
- insidious onset
- prolonged untreated psychosis (early intervention is key!!!)
- disorganized subtype
- no mood disturbance
- early negative symptoms
- non-compliance with medication
list some biological vs psychological risk factors for schizophrenia
biological:
- FHx
- obstetric complications
- season of birth
- advancing paternal age
- early cannabis - may be precipitating, also psychoactive substance use in general is a maintaining factor
psychological:
- life stressors (precipitating and/or maintaining)
- high expressed emotion in family (maintaining)
- social
- poverty
- urban birth/upbringing
- migration
briefly outline the dopamine hypothesis of schizophrenia
excess of dopamine transmission (hyperdopaminergia) in schizophrenia (unclear if due to excess dopamine, excess receptors or what)
they think this cos:
- antipsychotic drugs are all dopamine D2 receptor antagonists
- dopamine agonists (e.g. levodopa, amphetamines) can produce paranoid psychosis
- some CSF and brain studies have shown abnormal levels of dopamine/metabolites/enzymes/receptors
what is schizoaffective disorder?
affective and schizophrenic symptoms occur together with equal prominence
used for patients who satisfy criteria for schizophrenia AND mood disorder during the same episode - otherwise diagnosis predominant syndrome (or neither!)
i.e. one first-rank symptom in mania doesn’t mean schizoaffective disorder, neither does a bit of a labile mood in schizophrenia
what is the management and prognosis of schizoaffective disorder?
use a combo of mood stabilisers (e.g. lithium) and antipsychotics to treat the mood and psychosis problems.
prognosis - somewhere between those for schizophrenia and mood disorder - better in those whose mood problem is mania rather than depression
what are delusional disorders? what kind of delusions is it normally?
fixed delusion or delusional system (associated delusions) with other areas of thinking and functioning well preserved.
so basically have delusions but not hitting criteria for schizophrenia and also don’t have organic cause.
usually persecutory delusions - hallucinations rare.
what is acute delusional disorder? what are the clinical features?
acute onset of delusions, not schizophrenia though, usually rapidly resolving.
features - multiple, transient, persecutory delusions, suspicious, labile mood.
can be caused by drugs (in which case not actually delusional disorder!) or follow extreme stresses.
what is persistent delusional disorder? what are the features of this?
lasting 3+ months - systematised delusions (stable and combined into a complex system) often focussed on alleged injustices.
but rest of mental state is normal.
onset usually middle age - social isolation, deafness, paranoid personality traits are risk factors.
what are the specific (mostly eponymous) types of delusional disorder?
Othello's syndrome aka morbid jealousy somatic delusional disorder de Clerambault's syndrome aka erotomania folie a deux Capgras delusion Fregoli's delusion
what is Othello’s syndrome?
type of delusional disorder where patient (normally male) has delusional belief of partner being unfaithful.
can be dangerous - they often threaten/attack partner or supposed lover.
usually symptom of psychotic depression of schizophrenia but can be isolated delusional disorder.
considered risky enough to overrule confidentiality - must do full risk assessment.
what is somatic delusional disorder?
delusional belief that the personal has an illness/deformity - aka monosymptomatic hypochondriacal psychosis - generally fixed on one specific illness - distinguishes from hypochondriasis.
what is de Clerambault’s syndrome?
aka erotomania - patient, usually female, has delusion that man of high standing (e.g. pop star, or their doctor) is in love with her.
seen in some stalkers.
what is folie a deux?
when two people, often isolate sisters, share a delusion - one is truly psychotic while other is ‘induced’ to become so and will normally recover spontaneously when they’re separated.
what is Capgras’ delusion?
aka illusion des soisies
belief that someone close by has been replaced by imposter/double
what is Fregoli’s delusion?
belief that someone close to them is impersonating other people.
what is schizotypal disorder? what are the key features?
like a chronic, attenuated schizophrenia - beliefs stop short of being delusion, sensory experiences not quite hallucinatory. features: - aloof and suspicious manner - eccentric behaviour - avoidance of social contact - odd beliefs, magical thinking - vague, rambling or metaphorical speech - tendency to odd ideas and sensory experiences - 3+ of the above for >2 years
what are the core symptoms of depression?
ICD-10 states should have at least two of these, every day for at least two weeks:
1) low mood
2) anhedonia - loss of enjoyment in formerly pleasurable activities
3) decreased energy (or increased fatiguability)
list some of the non “core” symptoms of depression
- reduced concentration and attention - cognitive features
- reduced self-esteem and self-confidence
- ideas of guilt and worthlessness
- feelings of hopelessness for the future
- thoughts of self-harm
- decreased sleep and/or appetite
severity of depression (mild/moderate/severe) depends on:
- no. symptoms present
- severity of symptoms
- degree of associated distress
- interference w/ daily activities
any psychotic features = severe.
what is Beck’s cognitive triad?
the three main areas focussed on by negative/pessimistic thoughts in depression:
1) the self (low self esteem)
2) the world
3) the future
other areas incl. guilt/worthlessness, death/suicide
give some biological symptoms of depression
reduced sleep - classically early waking >2hrs earlier than normal - mood is lowest in morning as well (diurnal variation)
reduced appetite - leading to weight loss (some people experience overeating and weight gain)
reduced libido
psychomotor agitation/retardation/both - of speech and/or movement
what kinds of delusions/hallucinations are typically experienced in severe depression?
usually nihilistic - believe that they/a body part is dead/rotting
also hypocondriacal - concerning illness or death
hallucinations - usually auditory, in second person and derogatory or urging suicide.
give some differentials for depression
- normal sadness, esp in context of bereavement or severe physical illness
- if psychotic symps - differentiate from schizophrenia
- alcohol or drug withdrawal
- if recurrent depressive episodes = unipolar depressive disorder (consider bipolar dx even when no mania if really strong FHx, v early onset and marked agitation)
describe the aetiology of depression
- genetic contribution, particularly if bipolar.
- current theory is genetic predisposition that will be triggered if exposed to adverse life events
- monoamine neurotransmitter availability in synaptic cleft reduced (noradrenaline and serotonin) - this is where antidepressants act
- psychosocial factors - adverse life events, unemployment, lack of confiding relationship, parental loss, major childhood stress/abuse
- physical illnesses (most endocrine things, cancers) and medications (incl steroids, isotretinoin)
- structural features - limbic system and prefrontal cortex play a role
when would you refer a depressed patient for management beyond GP land
if:
- pt not responding to treatment
- substantial risk of harm to self or others
- second opinion on diagnosis/treatment needed
- combo of drugs or rarely used drugs being considered
- to access specialised psychology, OT etc
- pt is severely unwell and admission or ECT needed
describe management of depression
mild = self-help groups, structured physical activity, guided self-help, computerised CBT
next step = individual CBT or IPT
moderate/severe = combine CBT and antidepressants - technically shouldn’t just be on meds!
always keep on antidepressants for at least 6 months after episode to reduce relapse - if recurrent depression, keep on for at least a couple of years
if treatment resistant - consider augmenting with antipsychotic or lithium or another antidepressant (E.g. mirtazipine)
still not working - consider ECT
what psychological treatment options are recommended by NICE for moderate-severe depression / persistent mild depression?
individual CBT/IPT/behavioural activation - 16-20 sessions over 3-4 months
behavioural couples therapy (where relevant) - 15-20 sessions over 5-6 months
what is ‘somatic syndrome’ in relation to depression?
physical/biological manifestations of depression - psychomotor retardation (slow movements and thinking), agitation, loss of libido, constipation, amenorrhoea
what is dysthmia?
long standing mild/subthreshold depressive symptoms
what is Cotard’s syndrome?
nihilistic delusions where patient believes they, or a part of them, is dead - common in psychotic depression.
what are the symptoms of psychotic depression?
Cotard’s syndrome/nihilistic delusions
auditory hallucinations - derogatory or encouraging DSH/suicide
severe psychomotor retardation - to point of ‘depressive stupor’ - sitting mute and still (?indication for ECT)
list some factors that might affect choice of management options in depression, and what each one implies
- serious suicide risk = consider admission, drug rx w/SSRI not TCA as less toxic in overdose
- psychotic symps? = add antipsychotic, consider ECT
- what are the main symptoms? = can affect drug choice e.g. sedative antidepressant (mitrtazapine) if insomnia
- past hx of response? = use what worked last time
- past hx of mania? = caution with antidepressants, consider mood stabiliser
- any comorbid medical problems? = avoid TCAs after recent MI
- what does patient want? = might have preference for drug vs psychology
give some options for managing someone with depression that has not responded to first line drug treatment
- switch class e.g. from SSRI to SNRI, or try another drug within the same class
- add psychological therapies if haven’t already
- trial mirtazapine
- augment - add mirtazapine to an SSRI - useful for insomnia/agitation; add lithium; add second-gen antipsychotic e.g. olanzapine or quetiapine esp. if psychotic symptoms, agitation or insomnia
- switch to an MAOI, esp if atypical depression
- psychiatric referral
- consider ECT for severe and intractable
what is bipolar affective disorder?
characterised by recurrent episodes of altered mood and activity - episodes of depression and mania
episodes are either - depressive, manic, hypomanic, mixed
define hypomania
less severe than mania and without psychotic symptoms.
lasts >4 days (mania tends to be >7 days)
core features are mild or moderate
dysfunction only mild or moderate
partial insight preserved
no psychotic features
they basically have excess ‘zest for life’ and energy, but are just about holding it together
people who’s mood never exceeds hypomania are said to have bipolar II disorder (DSM)
define mania
mood that is predominantly elevated, expansive or irritable and definitely abnormal for the individual.
plus 3 of the following:
- increased activity or physical restlessness
- pressure of speech
- flight of ideas
- socially disinhibited/inappropriate behaviour
- decreased need for sleep
- inflated self-esteem/grandiosity
- distractibility/constant changes in activity or plans
- risky/reckless behaviour
- marked sexual energy/inappropriate sexual behaviour
can have psychotic features - mood congruent, grandiose e.g. blessed with special powers, might hear voices supporting this
what is cyclothymia?
mild, chronic bipolar variation of mood - cycle between the two states, but only mildly
give some organic causes of depressive mood disorders
Cushing's Addison's hypothyroidism hypercalcaemia DM beta blockers carcinomas digoxin chronic amphetamine use
give some organic causes of manic mood disorders
hyperthyroidism steroids acute amphetamine use levodopa antidepressants bromocriptine isoniazid
give some organic causes of either manic or depressive mood disorders
MS cerebrovascular disease SLE epilepsy brain tumours
explain aetiology of bipolar affective disorder
- genetic link really strong
- no childhood risk factors known
- some structural abnormalities implicated e.g. in limbic system
- always consider drug-induced mania
how do you manage a manic patient?
if severe, can require admission (usually compulsory)
antipsychotics (risperidone, olanzapine) or valproate and lithium are all effective anti-manics.
benzodiazepines for sedation
if on antidepressant already - MUST stop
if on lithium already - check levels to assess adherence
ECT if intractable
how do you manage a bipolar patient in a depressive episode?
quetiapine (atypical antipsychotic) can be highly effective - sedation and weight gain limits long term acceptability
antidepressants typically less effective - must be used with mood stabiliser/antimanic agent or else they can destablise and precipitate mania
lamotrigine can help
if severe - antipsychotics, ECT and admission could all be needed
what longer-term drug management options are there for bipolar affective disorder?
mood stabilisers - lithium first-line
valproate second-line
what needs to be done when starting someone on lithium?
- advise the person that poor adherence or rapid discontinuation may increase the risk of relapse
- measure BMI and do for U&Es incl calcium, eGFR, TFTs, FBC
- ECG for people with CVD or risk factors for it
- give leaflets etc on taking lithium safely
- establish a shared-care arrangement with GP for prescribing lithium and monitoring adverse effects
- measure plasma lithium 1 week after starting, and 1 week after every dose change until they stabilise
tell patient to:
- seek medical attention if they develop D&V or become acutely ill for any reason
- ensure they maintain their fluid intake, particularly after sweating (for example, after exercise, in hot climates or if they have a fever), if they are immobile for long periods or if they develop a chest infection or pneumonia
- talk to their doctor ASAP if they become pregnant or are planning a pregnancy.
- don’t take OTC NSAIDs - avoid prescribing them too
what monitoring is required for a patient on lithium (after stable levels)?
measure plasma levels every 3 months for first year
after first year measure every 6 months, or every 3 months for people in the following groups:
- older people
- people taking drugs that interact with lithium
- people who are at risk of impaired renal or thyroid
- function, raised calcium levels or other complications
- people who have poor symptom control
- people with poor adherence
- people whose last plasma lithium level was 0.8 mmol per litre or higher
monitor BMI, U&Es (specifically calcium), eGFR, TFTs every 6 months
at each appt, ask about symptoms of neurotoxicity, including paraesthesia, ataxia, tremor and cognitive impairment, which can occur at therapeutic levels of lithium
what is puerperal psychosis? treatment? risk factors?
occurs in 1-2 in 1000 births - psychosis in postpartum period.
usually onset in second postnatal week.
baby at risk either of direct harm due to mum’s delusions, or of neglect due to mum’s preoccupation with her own symptoms.
almost always requires admission - MBUs!
Rx = antipsychotics, antidepressants, low threshold for ECT
usually full recovery, big increase in risk after next delivery/in lifetime.
RFs - past or family Hx of puerperal psychosis, diagnosis of bipolar affective disorder, being primigravida
what are baby blues?
tearful, labile, irritable mood typically on 3rd/4th postnatal day
symps resolve within days without treatment - explanation and reassurance helpful though.
no association with other mood disorders.
thought to be due to fall in sex steroids after delivery.
what is PND? tool to screen for it? treatment?
starts within a month of delivery - negative thoughts focussed on perceived failings of mother or baby’s wellbeing.
use edinburgh PND score.
Rx - explain and reassure. consider interventions for mother-baby relationship. mother’s groups, midwife, health visitor.
consider antidepressants or psychology if moderate/severe - otherwise should resolve on its own within a few weeks.
if admission - MBU.
it’s more common in women with hx of psychiatric disorder - change in sensitivity of dopaminergic system implicated.
what are the characteristic features of ‘normal’ grief?
5 classic stages:
Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
Anger: this is commonly directed against other family members and medical professionals
Bargaining
Depression
Acceptance
how do you manage the normal grief reaction? when is it an ‘abnormal’ grief reaction?
bereavement counselling and support - often voluntary sector has a role here.
abnormal grief:
1) absent/delayed - either no outward signs of grief, or grieving doesn’t begin for a few weeks
2) prolonged - if prominent symptoms after 6-12 months - begin to consider whether this is depression
3) excessive - more intense than would be expected - although who are we to define this? - be vigilant for depression
all of this is a bit of a grey area!!
when is a substance regarding as being ‘misused’?
if it produces physical, psychological or social harm
what are the different categories of substance misuse?
“at-risk consumption” - (alcohol) intake at a level associated with increased risk of harm
“harmful use” - misuse associated with health and social consequences but without dependence
“dependence” - prolonged, regular use of substances e.g. alcohol, opioids, amphetamines can lead to dependence (addiction) and withdrawal syndromes
“intoxication” - acute effect of the substance e.g. being drunk or high
list commonly misused substances by ‘type’
alcohol
legal/prescribed drugs - benzodiazepines, nicotine, caffeine, cannabis
opioids - heroin, morphine, methadone
stimulants - amphetamines, cocaine, ecstasy
hallucinogens - LSD, phencyclidine (PCP), solvents
what are the main principles of managing substance misuse?
- identify at-risk consumption and harmful use early and give accurate info and advice
- in dependency, facilitate withdrawal (detox) and abstinence
- help maintain abstinence
- if abstinence not possible, minimise harm with continuing use
- treat complications e.g. drug induced psychosis
- prevention - population-level interventions e.g. pricing policies
- advise on risks and legalities of driving under influence
give some aetiological/risk factors for substance abuse
- genetic - inherited vulnerability/predisposition
- neurobiological - abnormalities in dopamine, GABA, endogenous opioid systems, trait EEG patterns
- psychological - personality factors, learned behaviours, positive reinforcement (drugs lead to behaviours that increase their use)
- socioeconomic - price and availability, cultural norms/acceptability
- legal - restrictions on sale, penalties for possession/dealing
what are the definitions of different levels of drinking in UK?
hazardous = above recommended limits (14 units per week)
harmful = >50 units p/w men, >35 units p/w women
dependent drinking = people with features of dependence/addiction
what are the clinical features of alcohol dependence/alcoholism?
- feeling compelled to drink
- primacy of drinking over other activities e.g. work, family
- increased tolerance
- relief drinking - drinking to stop/prevent withdrawal symptoms
- stereotyped pattern of drinking
- reinstatement after abstinence aka unable to give up alcohol for long
- drinking despite awareness of harmful consequences
- withdrawal symptoms
what are the clinical features of alcohol withdrawal?
onset 6-12 hours after stop drinking
- tremors (the shakes)
- agitation
- nausea and retching
- sweating
- overwhelming desire to drink (craving)
- withdrawal symps relieved by alcohol
- might experience withdrawal symptoms on waking
if severe, can progress to delirium tremens and/or seizures
seizures peak onset = 36 hours
DT at 48-72 hours
what are the clinical features of delirium tremens?
onset at 48-72 hours
- delirium
- visual hallucinations (classically lilliputian aka little animals in corners etc)
- delusions - usually persecutory and transient
- fear and agitation, sometimes aggression
- coarse tremor
- seizures
- autonomic disturbance (sweating, fever, tachycardia, hypertension)
- insomnia
- dehydration and electrolyte disturbance
- lasts 3-4 days, then exhaustion and patchy amnesia
POTENTIALLY FATAL
what is Wernicke’s encephalopathy?
triad of ophthalmoplegia/nystagmus, ataxia and confusion is classic.
caused by thiamine deficiency - petechial haemorrhages occur in a variety of structures in the brain including the mamillary bodies and ventricle walls
Features: nystagmus (the most common ocular sign) ophthalmoplegia ataxia confusion, altered GCS peripheral sensory neuropathy
urgently treat with thiamine replacement
what is Korsakoff’s syndrome?
occurs if Wernicke’s encephalopathy goes untreated. called Wernicke-Korsakoff syndrome - characterised by the addition of antero- and retrograde amnesia and confabulation in addition to Wernicke’s encephalopathy symptoms.
how can GPs screen for hazardous alcohol consumption?
- ask about alcohol intake during all consultations
- use any of FAST, CAGE or AUDIT questionnaires
- follow up on any comments suggesting patient thinks they drink too much
- brief motivational interviewing has a role
describe the use of screening tools/questionnaires in alcohol misuse
CAGE - 4 screening qus (cut down, annoyed, guilty, eye opener)
FAST - 4 qus, if above certain threshold it’s an indication for doing AUDIT
AUDIT - 10 qu questionnaire
SADQ - assesses severity of dependence
list some harmful medical effects of alcohol
liver damage - fatty liver, hepatitis, cirrhosis
cardio - cardiomyopathy, HTN
GI - peptic ulcer, oesophageal varices, pancreatitis
neoplasms - liver, oesophagus
blood - anaemia, haemochromatosis
list some harmful neurological/organic psychiatric effects of alcohol
blackouts epilepsy neuropathy DT Wernicke's syndrome Korsakoff's syndrome cerebellar degeneration central pontine myelinosis head injury (from falls)
list some harmful psychiatric effects of alcohol
alcoholic hallucinations morbid jealousy alcoholic dementia depressive disorders anxiety disorders sexual dysfunction suicide
list some harmful social effects of alcohol
accidents problems with relationships domestic violence employment difficulties crime
what management should be done for someone with hazardous/harmful drinking?
usually brief interventions in primary care e.g. FRAMES advice
- structured Feedback on risk/harm
- emphasis patient’s Responsibility for change
- clear Advice on changing drinking
- discuss Menu of options for making change
- express Empathy and be non-judgement
- reinforce patient’s Self-efficacy
principles - accurately assess consumption, nature/extent of harm (e.g. do LFTs), give brief advice on hazards of excess, book in to review
what is involved in managing an alcohol dependent patient through detox?
initial step = detox - controlled withdrawal, using reducing course of benzodiazepine (often chlordiazepioxide)
if mild - withdraw at home ± chlordiazepoxide
if moderate - at home, chlordiazepoxide over 5 days, thiamine supplementation (oral, IV if high Wernicke’s risk)
if severe/hx of DTs/seizures - higher doses of chlordiazepoxide and probs want them in hospital so you can manage seizures. IV thiamine.
how do you manage a patient to maintain abstinence from alcohol after detox period?
- complete abstinence needed really - controlled drinking rarely works
- regular LFTs and breath alcohol tests to monitor progress
- encourage attending AA or other local groups
- medications - disulfram (antabuse), acamprosate or opioid antagonists
- disulfram = negative reinforcement - basically massively exaggerates hangover after hardly any alcohol
- acamprosate = reduces craving for alcohol
- opioid antagonists act on autonomic nervous system
- psychology - offer CBT, social skills training, problem solving and motivational interviewing
how does cannabis act on the brain?
derived from hemp plant
THC = main psychoactive ingredient (tetrahydrocannabinol)
acts on endogenous cannabinoid receptors in brain
cannabis also contains cannabidiol - slightly antagonises effects of THC
THC content varies - increasing in UK over time
list the effects of cannabis
dose-related impairment in reaction time, info processing, coordination, motor performance, attention
exaggeration of pre-existing mood
mellowness and increased enjoyment of aesthetic experience
distortion of sense of space and time
reddening of eyes
give some adverse health effects of cannabis
- anxiety and panic, esp in first time users
- paranoid ideation, occasionally delirium - also in first time users typically
- increased risk of road traffic accidents
- risk of using other, more harmful drugs
- possible increased risk of respiratory disease
- can provoke angina in people with CVD
- mild long-term cognitive impairment if heavy/regular use
- doesn’t cause dependence/withdrawal - some tolerance can occur, also ‘psychological dependence’
- early and heavy use = risk of schizophrenia
what options are there to treat cannabis use?
CBT can reduce use but high rates of reuse within 6-12 months
don’t think anybody really gets treated for cannabis use unless it’s insanely bad/they get drug-induced psychosis
explain the pharmacology of opioids / what ones are used recreationally and how?
mimic endogenous endorphins and enkephalins - activate opioid receptors
e.g. morphine, codeine, heroin, methadone
highly addictive
heroin causes intense euphoria - most commonly misused
modes of use:
- IV injection - risk of infections, thrombosis and phlebitis, also hep B and C, HIV
- inhalation
- snorting
list the effects of opioids
euphoria analgesia drowsiness respiratory depression cough reflex suppression N&V bradycardia and hypotension lowering of body temp pupillary constriction constipation
list some adverse of opioid misuse
- high levels of morbidity/mortality
- IV injecting = infections, VTE, phlebitis, hep B/C, HIV
- different routes have big influence on bioavailability, speed of onset, severity of dependence etc - makes it easy to accidentally OD!
- suicide rate increased x14
- psych comorbidity, incl misuse of other substances
- major negative social effects
what features indicate dependence on opioids?
tolerance! develops rapidly - means OD is common, often fatal due to respiratory depression
- makes pain management in opioid user difficult
- high risk of OD after detox e.g. released prisoners
list features of opioid withdrawal
onset within 8-12 hours of last dose, peaking 24-48h later and subsiding over 10 days (process longer for methadone) features (severe, but rarely life threatening): - craving - restlessness, insomnia - myalgia - sweating - abdo pain, D&V - dilated pupils, running nose and eyes - tachycardia - yawning - 'goose bumps'
list some features suggesting opioid misuse
rhinorrhoea needle track marks pinpoint pupils drowsiness watering eyes yawning
list some complications of opioid misuse
viral infection secondary to sharing needles: HIV, hepatitis B & C
bacterial infection secondary to injection: infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis
venous thromboembolism
overdose may lead to respiratory depression and death
psychological problems: craving
social problems: crime, prostitution, homelessness
what is the emergency management of opioid overdose?
ABCDEs
IV or IM naloxone: has a rapid onset and relatively short duration of action
what are some harm reduction interventions for opioid misuse?
needle exchange
offering testing for HIV, hepatitis B & C
give a general overview of management of opioid misuse
usually managed by specialist drug dependence clinics although some GPwSIs offer similar services
offered maintenance therapy or detoxification
NICE recommend methadone or buprenorphine as first-line in opioid detoxification
compliance is monitored using urinalysis
detoxification should normally last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in the community
how should detoxification and abstinence be managed for opioid misuse?
inpatient detox more effective than outpatients - avoids the chaotic environment that’s usual in opioid misusers
substitute drug e.g. methadone linctus, clonidine, naltrexone prescribed in reducing doses.
ideally then discharge into an abstinence programme e.g. residential houses of recovered addicts etc
relapse rate very high sadly
describe harm reduction/maintenance or substitution treatment as used for opioid dependence?
abstinence is so unrealistic for a lot of opioid dependent people - focus on harm reduction (e.g. reduce injecting, needle exchanges, screening for BBVs) ± substitute prescribing
substitute prescribing = oral methadone (or sometimes buprenorphine) used as alternative to injected street opiates.
usually ends up being long term use, rather than using this to detox.
how do you manage suspected opioid overdose?
recognising opioid OD - unconscious, pinpoint pupils, bradycardia, hypotension, shallow breathing/snoring, even respiratory arrest
naloxone (opioid antagonist) used to restore adequate spontaneous ventilation
what stimulant drugs are commonly misused?
amphetamines - speed, methamphetamine
cocaine
MDMA
give some info on amphetamine misuse/dependence/withdrawal
- taken orally, snorted or injected
- produce symps like hypomania - elevated mood, over-talking, increased energy, insomnia
- pulse and BP raised, pupils dilate, mucous membranes dry
- dependence - leads to depression and mood swings
- withdrawal = ‘crash’ - depression, agitation, lethargy, suicidal thoughts, cravings
- intoxication/psychosis - treat w/benzodiazepines and antipsychotics
- prolonged use –> paranoid psychosis
- potent dopamine enhances - inhibit its reuptake and stimulate its release - also enhances noradrenaline and serotonin
give some info on cocaine misuse
- similar effects to amphetamines, but more dramatic
- snorted or smoked as crack/freebase
- cocaine misuse is often accompanied by alcohol/opioid misuse
- intoxication can mimic psychosis/mania
give some info on MDMA misuse
- tolerance really common
- adverse reactions - hyperpyrexia, acute renal failure due to dehydration - also water intoxication in users who overcompensate
- can cause acute psychosis
- neurotoxic to serotonin fibres so chronic users can have low central serotonin levels and some cognitive deficits
what are hallucinogens? what’s the main one used widely? give some info
drugs altering perception, producing psychadelic experiences
LSD most common, also magic mushrooms
LSD - ‘trip’ starts 2 hours after consumption, lasts 8-12 hours - distorted sensory perception, alteration of sense of time and scale, changes in body image (E.g. out of body experience)
- rarely cause dependence or withdrawal
- might get acutely referred to psych due to panic/anxiety of ‘bad trip’ - sedate with benzodiazepines
define ‘personality’
characteristic behavioural, emotional and cognitive attributes of an individual - we all have particular traits that emerge mid-adolescence and once established remain stable - but when these are extreme this can be a personality disorder
define personality disorder
“severe disturbance in characterological constitution and behavioural tendencies of the individual, usually involving several areas of the personality and nearly always associated with considerable personal and social disruption”
“an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has onset in adolescence/early adulthood, and leads to distress or impairment”
what core features required for diagnosis of a personality disorder?
- personality attributes cause distress of dysfunction for individual or those around them
- dysfunction occurs across a range of situations
- characteristics are pervasive, stable and recognisable since late adolescence
specific PDs are then diagnosed according to domains of personality that are most affected
what are the three clusters of personality disorder?
cluster A (eccentric) - 'mad' - paranoid/schizoid cluster B (dramatic) - 'bad' - antisocial, emotionally unstable, histrionic, narcissistic cluster C (anxious) - 'sad' - anankastic (obsessive), anxious (avoidant), dependent
what are the characteristics of paranoid PD?
suspicion and distrust of others
sensitivity to criticism
bears grudges
self-importance
what are the characteristics of schizoid PD?
emotionally cold and detached
introspective
social isolation
lack of joie de vivre
what are the characteristics of antisocial PD?
callous unstable, transient relationships low frustration threshold irritable and impulsive failure to learn from experience failure to accept responsibility lack of guilt tend to be young men
what are the characteristics of emotionally unstable PD?
multiple, turbulent relationships impulsivity recurrent emotional crises variable, intense mood stress-related psychotic-like symptoms tend to be young women history of frequent DSH classically got a history of childhood sexual abuse
what are the characteristics of histrionic PD?
exaggerated, theatrical displays of emotion attention seeking vain suggestible (easily swayed) shallow, labile mood crushes and fads
what are the characteristics of narcissistic PD?
gradiose self-importance exaggerates achievements and abilities exploits others arrogant expects special praise and restraint
what are the characteristics of anankastic/obsessive PD?
excessive orderliness
preoccupation with detail
inflexible and dogmatic
humourless
what are the characteristics of anxious/avoidant PD?
persistent tens and apprehensive feelings
avoid personal contact
fear of criticism and rejection
what are the characteristics of dependent PD?
encourage others to make decisions for them
excessive need to be taken care of
what is known about aetiology of personality disorders?
not loads!
evidence that early childhood experiences, plus general upbringing and childhood traumas etc have a role
some genetic element
how do eccentric (paranoid or schizoid) PDs tend to present?
they avoid services and usually present when suspiciousness or persecutory beliefs lead them to start accusing people or promising retribution.
challenging to distinguish from delusions, and to establish the level of risk.
difficult to treat - low dose antipsychotics are an option, but compliance poor. social interventions offered but they don’t view their isolation as a problem. psychotherapy can actually be harmful so is CI’ed.
how do patients with emotionally unstable personality disorder tend to present?
frequent A&E attendance with repeated OD or DSH.
they have turbulent relationships - e.g. threaten OD every time boyf tries to leave.
may present with dramatic plea/demand for help (‘section me’).
often a history of childhood sexual abuse.
some association with eating disorders (more bulimia than anorexia)
how do patients with antisocial PD tend to present?
rarely treated because there’s no interventions that are effective.
admission often avoided - disruptive to other patients.
forensic psych deal with them usually, and they’re often detained in secure units from court or prison.
basically presents with loads of crime! rates high in prisoners.
problems worsened by drugs/alcohol.
how do anxious personality disorders tend to present?
doesn’t normally present clinically, sometimes diagnosed in people with depression/anxiety (and is a risk factor for both)
what are the broad principles of managing personality disorders?
difficult to treat - apart from ‘dramatic’ cluster B types.
- help them to avoid situations that cause problems (e.g. confrontation, intoxication)
- have a clear and consistent crisis management plan
- carefully differentiating any mood disorders/psychosis and treating them
- written care plans, good CMHT
- for EUPD - dialectical behavioural therapy helps decrease self-harm, cognitive analytical therapy may be helpful, as may therapeutic communities
explain what is meant by ‘phobic anxiety’
situational anxiety - restricted to a specific experience or anticipation of particular situation
can be very specific e.g. spiders or more general e.g. agoraphobia.
person tends to avoid the situations - this gives them relief but ultimately reinforces the fear so is BAD - overcoming this avoidance is key.
give some general symptoms of anxiety
- anxious/irritable mood
- exaggerated worries and fears
- avoidance of feared situations
- checking
- seeking reassurance
- somatic symptoms - chest tightness, shortness of breath, palpitations, ‘butterflies’, tremor, tingling of fingers (hyperventilation), aches and pains, poor sleep
how are phobic anxiety disorders treated?
key is exposure therapy - either in reality or in imagination.
CBT can help with this.
antidepressants and anxiolytics have a role.
what is agoraphobia?
most common fear - intense anxiety provoked by open/large spaces that are crowded and difficult to escape from e.g. supermarket queues
often associated with panic attacks - “panic disorder with agoraphobia”
- cognitions focus on fainting/dying or other catastrophe rather than on the actual shop/space
- can end up housebound if severe
- more common in young women, on average takes 2 yrs before help sought
list some symptoms of agoraphobia
- situational anxiety - in shops, crowded large places
- cognitions = thoughts of collapsing and being left helpless in public
- avoidance of panic-provoking situations
- panic attack symptoms
what is social phobia?
fear of other people - anticipation of a negative evaluation by them - distinguish from normal shyness, or social withdrawal due to depression/other condition.
what are the symptoms of social phobia? how is it managed?
- situational anxiety in social gatherings
- cognitions = being judged negatively by others
- avoidance of social occasions
- blushing/trembling classic
- associated with secondary alcohol misuse (self medicating)
Rx - CBT, SSRIs can be helpful.
what are the symptoms of a panic attack?
- severe incapacitating anxiety
- cognitions = of dying, going mad, losing control
- sense of impending doom
- chest tightness
- palpitations
- tremor
- tingling fingers (hyperventilation)
- nausea
- shortness of breath
attacks must be recurrent over at least 1 month for panic disorder diagnosis - differentiate from physical causes and from panic as part of phobia etc
how is panic disorder managed?
CBT usually very effective - helps pt understand symptoms as result of anxiety.
antidepressants might help, but initial increase in anxiety often puts patients off.
what is generalised anxiety disorder?
persistent anxiety associated with chronic uncontrollable and excessive worry - occurring more days than not for >6 months.
associated with 3+ of following on more days than not for >6 months: restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; sleep disturbance.
PLUS at least 4 of:
Autonomic arousal symptoms:
- Palpitations or pounding heart.
- Accelerated heart rate.
- Sweating.
- Trembling or shaking.
- Dry mouth (not due to medication or dehydration).
Symptoms involving chest and abdomen:
- Difficulty breathing.
- Feeling of choking.
- Chest pain or discomfort.
- Nausea or abdominal distress (such as churning in stomach).
Symptoms involving mental state:
- Feeling dizzy, unsteady, faint, or light-headed.
- Feeling that objects are unreal (derealisation) or that the self is ‘not really here’ (depersonalisation).
- Feeling of losing control, ‘going crazy’, or passing out.
- Fear of dying.
General symptoms:
- Hot flushes or cold chills.
- Numbness or tingling sensations.
- Muscle tension or aches and pains.
- Restlessness and inability to relax.
- Feeling keyed up, on edge, or mentally tense.
- A sensation of a lump in the throat or difficulty in swallowing.
Other nonspecific symptoms:
- Exaggerated response to minor surprises or to being startled.
- Difficulty in concentrating or mind ‘going blank’ because -of worrying or anxiety.
- Persistent irritability.
- Difficulty in getting to sleep because of worrying.
often associated with depression.
it’s NOT - paroxysmal (panic disorder), situational (phobic), or lifelong (PD)
what are some risk/protective factors for GAD?
Risk factors
Being aged between 35 and 54.
Being divorced or separated.
Living alone or as a lone parent.
Protective factors
Being aged between 16 and 24.
Being married or cohabiting.
describe NICE stepped care for GAD
Step 1 (for all new GAD) - assessment, education, monitoring
Step 2 (no change on education and lifestyle changes) - IAPT/low intensity psychology, guided self-help, psychoeducational groups
Step 3 - CBT/applied relaxation or drug treatment (SSRI or venfalaxine)
Step 4 - psych referral if still refractory
what tool can be used to screen for GAD?
GAD 7 - like PHQ 9 but for GAD
what is OCD?
anxiety disorder in which obsessions and compulsions are prominent and persistent (can be either/or)
what are the diagnostic criteria for OCD?
- obsessions or compulsions (or both) must be present on most days for > 2 weeks.
- acknowledged as originating in the mind of the patient and imposed by outside persons or influences.
- they’re repetitive and unpleasant and at least one obsession or compulsion must be present that is acknowledged as excessive or unreasonable.
- subject tries to resist them (but if very long-standing, resistance to some obsessions or compulsions may be minimal). At least one obsession or compulsion must be present which is unsuccessfully resisted.
- carrying out the obsessive thought or compulsive act is not in itself pleasurable.
- the obsessions or compulsions cause distress or interfere with the subject’s social or individual functioning, usually by wasting time.
what aetiological factors are there for OCD?
Genetic predisposition
Developmental factors - abuse or neglect, social isolation, teasing or bullying may predispose.
Psychological factors - Personality characteristics maintain OCD (e.g. anankastic PD predisposes)
Stressors/triggers - common stressor is pregnancy or the postnatal period.
