Psych disorders Flashcards
Brief overview of general anxiety disorder as described in the DSM-V
Excessive anxiety and worry occurring on more days than not over 6 months about a NUMBER of events or activities. The worry is difficult to control and also experience physical symptoms of the anxiety
Brief overview of panic disorder as described in the DSM-V
Recurrent, unexpected panic attacks followed by at least one month of persistent concern about having another panic attack.
What is a panic attack
An abrupt surge of intense fear or discomfort in which 4+ symptoms develop within a few minutes to reach peak intensity (palpitations, sweating, SOB, autonomic symptoms)
Brief overview of agoraphobia as described in the DSM-V
Anxiety about being in particular places or situations from which escape may be difficult or help may not be available in the event of a panic attack or other embarrassing/incapacitating symptom (falling, incontinence, vomiting)
Brief overview of specific phobia as described in the DSM-V
Marked, persistent fear of clearly discernible objects or situations which invoke an immediate anxiety response when exposed to it
Brief overview of social phobia/ social anxiety disorder as described in the DSM-V
Marked or persistent fear of one or more social or performance situations in which person is exposed to possible scrutiny by others - fear behaving in an embarrassing way leading to total (physical absence) or partial (minimal eye contact) avoidance
Brief overview of obsessive compulsive disorder as described in the DSM-V
Unwanted, intrusive and recurrent obsessions which the client attempts to suppress or ignore but usually end up performing compulsions to neutralise and reduce the anxiety associated. Usually obsessions about contamination, orderliness etc.
Brief overview of post-traumatic stress syndrome as described in the DSM-V
Following threat that is perceived to be potentially life threatening or cause physical harm (direct experience, witnessing, learning of event occurring to close family member, repeated or extreme exposure to aversive details) - relive traumatic event with intrusive memories, avoidance of stimuli, persistent hyper-arousal symptoms (insomnia, irritability, exaggerated startle response etc.)
Acute stress disorder: 2d-1 month post trauma lasting 3d-1m
Post-traumatic stress disorder: symptoms persist more than 1m
DSM for generalised anxiety disorder
Excessive anxiety and worry more days than not for more than 6 months about a number of different events/activities
Difficulty controlling worry
3+ physical symptoms (restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance)
Stressful life events occurring or have had since childhood/adolescence
Symptoms of post traumatic stress disorder
Reliving of event: intrusive memories, flashbacks, nightmares
Avoidance of stimuli associated with trauma
Emotional numbing
Persistent hyper-arousal: insomnia, irritability, impaired concentration, hypervigilance
Negative alterations in cognition and mood: inability to recall key features, persistent -ve beliefs and expectations about self
- marked diminished interest
- feeling alienated from others
- constricted affect
Symptoms persisting for more than 1 month
Onset of symptoms within 2 days to 1 month after traumatic event
Clinical features of a panic attack
Abrupt surge of intense feat plus 4+ of the following:
- palpitations
- sweating
- trembling and shaking
- SOB
- feeling of choking
- chest pain/discomfort
- nausea/abdominal distress
- dizzy, unsteady, faint, light-headed
- chills or heat sensations
- paraesthesia
- de-realisation or de-personalisation
- fear of losing control or going crazy
- fear of dying
Differential diagnoses of panic attack
IHD Cardiac arrhythmias Cardiac valve pathologies Pulmonary embolus Asthma Hyperthyroidism Hypoglycaemia Phaeochromocytoma Hypoparathyroidism TIA Seizure
Assessment and management of panic attacks
CVS and resp exams ECG etc. rule out IHD, arrhythmias Immediate management: - slow-breathing exercises - muscle tension-relaxation exercise - benzodiazepines Short-long term manageemnt - CBT - Cognitive therapy - interoceptive and in vivo exposure - antidepressants (SSRIs, TCAs)
Brief overview of anorexia nervosa as described in the DSM-V
Self-induced starvation due to relentless drive for thinness or fear of fatness with presence of medical signs and symptoms resulting from starvation, body weight less than 85% expected
Can be restricting type or binging/purging type
Brief overview of bulimia nervosa as described in the DSM-V
Client has a goal to reduce weight but cannot tolerate prolonged periods of starvation, leading to binge eating - panic about amount eaten and secondary attempts to prevent weight gain (e.g. purging)
Brief overview of binge-eating disorder as described in the DSM-V
Recurrent episodes of binge eating, sense of lack of control over eating at least once a week for 3 months
Subtypes of anorexia nervosa
Restrictive type:
- reduced food intake +/- increased exercise
- not engaged in binge eating or purging behaviour
Binge-eating/purging type:
- have periods of binge eating followed by panic and secondary attempts to lose weight (vomiting, misuse of laxatives, diuretics or enemas)
Physical complications of anorexia nervosa
Endocrine/metabolic: - hypoglycaemia - hypoK - arrhythmias - hypoCl alkalosis - hypoMg - hypoNa - Delayed puberty - amenorrhoea - anovulation - increase GH - reduced ADH - hypercortisolism - arrested growth - osteoporosis CVS: - ECG changes - cardiomyopathy - MV prolapse - arrhythmias (due to hypoK) - hypotension - bradycardia Renal: - Reduced GFR - increased urea - dependent oedema - renal calculi GI: - constipation Other: - lanugo - hair loss - dry skin - hypothermia - anaemia - leukopenia - thrombocytopenia
What are the complications of bulimia nervosa
Mallory-Weiss tears (rare)
Dry skin
Menstrual irregularity
Infertility
Secondary to laxative abuse:
- chronic constipation
- cathartic colon
Risk factors associated with anorexia nervosa
Teenage female Developed country Certain professions (ballet, gymnastics) Gay orientation Close and trouble relationships with parents Isolation Low levels of nurturance
Risk factors associated with bulimia nervosa
Early adulthood Females Sometimes past history of obesity Industrialised countries More conflictual families, parents neglectful and rejecting Angry, outgoing, impulsive clients Alcohol dependence
What is meant by the term somatic symptom and related disorders
A group of diseases where bodily signs and symptoms are a major focus, which are medically unexplained, and patients are convinced suffering comes from some undetected bodily condition
Types of somatic symptom and related disorders
Somatic symptom disorders: - somatisation disorders - hypochondriasis - body dysmorphic disorder - pain disorder Conversion disorder
DSM-V of somatisation disorder
Many physical symptoms before age of 30y
Occurring over a period of years
Multiple medical consultations, significant impairment in functioning
Pain, GI, sexual/reproductive, pseudoneurological symptoms
DSM-V summary of hypochondriasis
Generalised and non-delusional (not fixed) preoccupation with fears of having a SPECIFIC illness
Based on misinterpretation of bodily symptoms
Persists despite appropriated evaluation and reassurance
Brief overview of Body dysmorphic disorder as described in the DSM-V
Preoccupation with an imagined defect in appearance causing significant distress or impairment due to ideas or delusions of reference
Excessive mirror checking or avoidance
If anomaly is present, person’s concern is excessive and bothersome
Hair, nose, skin, head/face
Present to dermatologists, plastic surgeons, internists
Brief overview of pain disorder as described in the DSM-V
A psychological disorder where pain is the main focus, and of sufficient severity to warrant clinical attention. It is not intentionally produced or better accounted for by another medical conditions - may have begun in response to real condition but persists chronically
Brief overview of conversion disorder as described in the DSM-V
Conversion of emotional pain or energy into physical, NEUROLOGICAL symptoms:
- motor symptom deficit
- sensory symptom deficit
- seizure or convulsions
- mixed presentations
initiation or exacerbation of the symptom is preceded by conflicts or stressors
How would you explain the diagnosis of conversion disorder to a patient that may in your opinion have the condition?
would explain as the mind being unable to express strong emotions AS emotions, and as such, converts into a physical symptom which cannot be explained by stressors
Approach to managing conversion disorder
95% remit spontaneously within 2w of hospital admission
Therapeutic relationships with a caring and confident psychotherapist
insight-oriented supportive or behaviour therapy
ACKNOWLEDGE THAT PATIENTS SYMPTOMS ARE REAL
Hypnosis, anxiolytics, behavioural relaxation exercises
Psychodynamic psychotherapy
What are the common causes of acute agitation
FIND ME Functional - i.e. psychiatric Infectious - encephalitis, delirium etc. Neurologic - ICH, SOL etc. Drugs - substance intoxication or withdrawal, issues related to psychotropic medications
Metabolic
Endocrine
Risk factors for suicide
SAD PERSONS
Sex: male
Age: under 19 or over 45
Depression/psychiatric illness
Previous attempt Excess alcohol or substance abuse Rational thinking loss Social supports lacking Organised plan No spouse Sickness (chronic physical illness)
Indigenous Rural location Family history of suicide Sexual identity issues Custody issues Childhood sexual abuse Unemployment
Factors which may determine suicidal intent
Plan
Access to lethal means
Alcohol or drug intoxication (or withdrawal)
Impulsive, aggressive or antisocial behaviour
Tidying up personal affairs
Writing notes etc.
Expressed intent to die
Risks that clinician may need to consider in the clinical setting
Risks to self: - suicide - self-inflicted injury - self-neglect Risk to others: - homicidal intent - harmful intent - unintentional (e.g. reckless driving) - neglect of dependents (e.g. children, elderly) Vulnerability: - risk to personal finances - risk of marriage etc. - risk of STDs/pregnancy etc. Reputation Crime/violence Homelessness
Typical format for a psychiatric risk assessment
Static (historical, unmodifiable) - age - sex (M more than F) - marital status (divorced) - past history of self harm/suicide attempts - family history of suicide attempts - diagnosis of mental illness - childhood adversity (e.g. abuse) Stable (long-term but CAN be altered) - substance dependence - personality disorders/traits DYNAMIC: (present for uncertain amount of time, fluctuating) - suicidal ideation - neurovegetative features of depression - agitation - active psychological symptoms - substance intoxication/withdrawal - psychosocial stressors - impulsivity/problem-solving deficits FUTURE (can be anticipated and will result from changing circumstances) - access to preferred method of suicide - future stress (e.g. anniversary of deaths) - discharge from inpatient treatment - future response to drug treatment PROTECTIVE - resilience, personality style - good relationships with support system - children/partner
De-escalation techniques
Offer patient a choice:
- would you like something to eat or drink
- would you like some medication to reduced that stress
- would you like a room which is more quiet and private
Give personal space (+safer for you)
Soothing, caring tone of voice
Calm, open, respectful approach
Give undivided attention
Non-judgemental
Clarify messages
Ensure safe practice (room set up, chaperones etc.)
When should you consider the use of physical restraint in the clinical setting
When de-escalation is not fully effective and it is otherwise unsafe to administer medication
AND there is substantial risk of patient harming themselves, others or hospital equipment
When would you consider using medications in the acute management of agitation? Which agents would you use
De-escalation not fully effective or patient has made choice to have voluntary medication
+ it is safe to administer
Offer voluntarily first (oral or parenteral)
Patient must be detained for forced medication administration
Aiming for a calm, alert patient + some sedation
Oral (20-30m onset)
- diazepam, lorazepam or olanzapine wafer
Parenteral (IV immediate, Im 10-20m onset)
- midazolam IM or IV
Olanzapine IM
Potential adverse effects of using medications in acute management of agitation
Respiratory depression Airway compromise Sedation Paradoxical effects (midazolam only) Hypotension and tachycardia (olanzapine, diaz and loraz)
What are the main clinical symptom domains of depressive disorders
Mood:
- depressed mood
- anhedonia
- loss of interest
- apathy
- numbness
Psychomotor retardation:
- latent response
- downcast gaze
- slumped posture
- few spontaneous movements
- poor concentration
- indecisiveness
- slow, quiet speech
Cognitive:
- related to self, world and future (beck’s triad)
- themes of guilt, worthlessness, hopelessness, death, suicide
- ruminating
- may become psychotic
Vegetative:
- terminal insomnia
- fatigue
- reduced appetite (+/- weight loss)
- reduced libido
What are the main clinical symptom domains for manic episodes
Mood:
- elevated
- euphoric
- elation
- jubilation
Psychomotor AGITATION:
- fidgeting, restlessness
- energetic
- disinhibitied
- impulsive
- rapid, pressured speech
- flight of ideas
- inattention
- distractibility
Cognitive:
- around self world and future (Becks)
- self: gradiosity, inflated slef-esteem
- world: expansive
- future: optimistic
- mood congruent delusions if psychotic mania
Vegetative symptoms
- reduced need for sleep
- hypersexuality
What is the difference between biploar I and II
I: presence of mania, currently in manic or depressed episode with history of at least one depressed, manic or mixed episode
II: presence of one or more major depressive episodes, presence of at least one HYPOmanic episode - no history of manic or mixed episodes
What are the clinical features for a mixed episode
Presence of manic OR depressive episode + at least 3 symptoms from the other
(both manic and major depressive episode criteria are met nearly every day during at least one week)
How is mania different to hypomania
Shorter period: 4d for hypomania
No psychotic symptoms in hypomania
Hypomania causes unequivocal change in functioning BUT not to the extent that there is significant impairment of socio-occupational functioning or requiring hospitalisation to prevent harm to self/others
how is adjustment disorder different from a depressive disorder
There is a clearly identifiable stressor precipitating the symptoms (within 3 months of onset of symptoms)
- causes clinically significant emotional or behavioural symptoms
- disturbance does not meet criteria for depressive disorder
- once stressor is terminated, symptoms do not persist for more than an additional 6m
What is meant by the term dysthymic disorder
AKA persistent depressive disorder
Depressed mood + at least 2 other symptoms of depression
Occurring most days over last 2 years, with no asymptomatic period longer than 2 months
Does not meet criteria for major depressive disorder
What is meant by the term mood-congruent delusion?
General TONE of the delusion matches the mood
e.g. mania - grandiose delusion OR if persecutory, is so because so good everyone jealous
OR
depression - guilt, nihilistic or persecutory
What medical conditions are typically associated with depression or present with depression as a major clinical features
Post viral (flu, EBV, HEP, encephalitis)
Cancer
Cardiopulmonary disease with chronic hypoxia
Sleep apnoea
Endocrine (hypothyroid, adrenal hypofucntion, post-partum, post-menopause, premenstrual)
Collagen (vascular disease, SLE)
CNS: MS, brain tumours, strokes, complex partial seizures
Brain structures which have been associated with aetiopathogenesis of mood disorders
Psychomotor activity;
- NAd in prefrontal cortex and cerebellum
- Serotonin in prefrontal cortex, nucleus accumbens and cerebellum
- DA in prefrontal cortex, nucleus accumbens and striatum
VEGETATIVE SYMPTOMS
- change in serotonin, NAd and DA in the midbrain
COGNITIVE AND MOOD SYMPTOMS:
- changes in serotonin in VMPFC, amygdala and orbitofrontal cortex
Risk factors for developing depression
- Separation/divorce
- lower socioeconomic status
- less physical activity
- cumulative/chronic life stressors
- early life adversities
- early parental death
- social isolation
Family history
Anxious, impulsive, obsessional personality
Risk factors for developing bipolar
- Separation/divorce
- lower SES
- seasonal influence (summer)
- disruption of circadian rhythm
- negative and positive stress
- family history
Definition of delirium
Acute, reversible, fluctuating impairment of cognitino that often has an identifiable underlying medical cause
What are the core clinical features of delirium
3Cs
Conscious state (hypervigilance v drowsiness)
Cognitive impairment (inattention, disorientation, global cognitive impairment)
Course is fluctuating, with acute onset in setting of medical morbidity
What are the most common causes of delirium
Infections - UTI - pneumonia - sepsis Medications: - polypharmacy - sedatives - anticholinergics Organ failure - severe lung or liver failure - hypoxia or metabolic/endocrine disturbance Other: - urinary retention - constipation - pain - post anaesthetic
Different forms of dementia
Alzheimer's (70-80%) Dementia with Lewy bodies (15-30%) Vascular (5-20%) Frontotemporal lobar degeneration (5%) Others: - parkinson's, Huntington's, neurological (e.g. MS) - Endocrine (hypothyroid) - nutritional (thiamine) - infectious (HIV, neurosyphilis) - metabolic - traumatic - poisoning
What are defining clinical features of ALZHEIMERS type dementia
Insidious onset
Early memory loss (short-term)
Long term memory remains intact early on
Motor and behavioural changes are a late sign
