Psychiatric Disorders Flashcards
What is EUPD?
A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan is minimal and outburst of intense anger may lead to violence or “behavioural explosions
What are the characteristics of the borderline type of EUPD?
- Characteristics of emotional instability present, in addition to the patients own self-image, aims and internal preferences (including sexual) are often unclear or disturbed. There are often chronic feelings of emptiness. A liability to become involved in unstable and intense relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-help (although these may occur without obvious precipitants)
What are the characteristics of the unstable type of EUPD?
- Emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others.
How do you manage EUPD?
Develop a crisis plan
- identify potential triggers
- specify self-management strategies that are likely to be effective
- psychotherapy
- mood stabilisers or second generation antipsychosis
What are the characteristics of paranoid personality disorder?
o Excessive sensitiveness to setbacks and rebuffs
o Tendency to bear grudges persistently, e.g. refusal to forgive insults and injuries or slights
o Suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous
o A combative and tenacious sense of personal rights out of keeping with the actual situation
o Recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner
o Tendency to experience excessive self-importance, manifest in a persistent self referential attitude
o Preoccupation with unsubstantiated “conspiratorial” explanations of events both immediate to the patient and in the world at large
What are the characteristics of schizoid personality disorder?
o Few, if any, activities provide pleasure
o Emotional coldness, detachment or flattened affect
o Limited capacity to express either warm, tender feelings or anger towards others
o Apparent indifference to praise or criticism
o Little interest in having sexual experiences with another person
o Almost invariable preference for solitary activities
o Excessive preoccupation with fantasy and introspection
What are the characteristics of dissocial personality disorder?
o Callous unconcern for the feelings of others
o Gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations
o Incapacity to maintain enduring relationships, though having no difficulty establishing them
o Very low tolerance to frustration and a low threshold for discharge of aggression, including violence
o Incapacity to experience guilt or to profit from experience, particularly punishment
o Marked proneness to blame others, or to offer plausible rationalisations that has brought the patient into conflict with society
What are the characteristics of histrionic personality disorder?
o Self-dramatization, theatricality, exaggerated expression of emotions
o Suggestibility, easily influenced by others or by circumstances
o Shallow and labile affectivity
o Continual seeking for excitement and activities in which the patient is the centre of attention
o Inappropriate seductiveness in appearance or behaviour
o Over-concern with physical attractiveness
Associated features may include ego-centricity, self-indulgence, continuous longing for appreciation, feelings that are easily hurt and persistent manipulative behaviour to achieve own needs.
What are the characteristics of anankastic personality disorder?
o Feelings of excessive doubt and caution
o Preoccupation with details, rules, lists, order, organisation, or schedule
o Perfectionism that interferes with task completion
o Excessive pedantry and adherence to social conventions
o Rigidity and stubbornness
o Unreasonable insistence by the patient that others submit to exactly his or her way of doing things or unreasonable reluctance to allow others to do things
o Intrusion of insistent and unwelcome thoughts or impulses
What are the characteristics of anxious avoidant personality disorder?
o Persistent and pervasive feelings of tension and apprehension
o Belief that one is socially inept, personally unappealing, or inferior to others
o Excessive preoccupation with being criticised or rejected in social situations
o Unwillingness to become involved with people unless certain of being liked
o Restrictions in lifestyle because of the need to have physical security
o Avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection
What are the characteristics of dependent personality disorder?
o Encouraging or allowing others to make most of ones important life decisions
o Subordination of one’s own needs to those of others on whom one is dependent and undue compliance with their wishes
o Unwillingness to make even reasonable demands on the people one depends on
o Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself
o Preoccupation with dears of being abandoned by a person with whom one has a close relationship and of being left to care for oneself
o Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others
What is generalised anxiety disorder?
A syndrome of ongoing anxiety and worry about many events or thoughts that the patient generally recognises as excessive and inappropriate
What are the symptoms of GAD?
A feeling of dread, restlessness/feeling on edge, being easily fatigued, irritability, muscle tension, sleep disturbance for at least 6 months
What are the autonomic symptoms of GAD?
Palpitations or pounding heart Accelerated heart rate Sweating Trembling or shaking Dry mouth (not due to medication or dehydration)
What are the chest and abdomen symptoms of GAD?
Difficulty breathing
Feeling of choking
Chest pain or discomfort
Nausea or abdo distress (churning in stomach etc.)
What are the GAD symptoms that involve 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
What are the general symptoms of GAD?
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
What is the management of GAD?
- Identify, assess, educate and monitor
- low intensity psychological support, non-facilitated or guided self help
- CBT/applied relaxation or drug treatment
- Specialist drug and/or psychological treatment, multi-agency teams, crisis intervention, outpatient or inpatient care
What is the pharmacological management for GAD?
Sedative antihistamines/benzodiazepines (RAPID RESPONSE)
SSRI/venlafaxine = first line
Switch SSRI if no response after 12 weeks
Pregabalin can be considered if SSRIs untolerated
Name SSRI’s that are suitable for GAD?
Setraline
Esciltalopram
Citalopram
Paroxetine
What medical illnesses can mimic anxiety?
Hyperthyroidism Hypoparathyroidism Arrhythmia B12 deficiency Phaeochromocytoma Hypoglcyaemia Serotonin syndrome Carcinoid tumour Alcohol/drug withdrawal
What is panic disorder?
- Attacks of severe anxiety which are not restricted to any particular situation or set of circumstances, and which are therefore unpredictable.
What are the symptoms of a panic attack?
Palpitations Chest pain Choking sensation Dizziness Feelings of unreality (depersonalisation or derealisation)
What is the criteria for a panic disorder diagnosis?
o Several severe attacks of autonomic anxiety should have occurred within a period of 1 month:
In circumstances where there is no objective danger
Without being confined to known or predictable situations;
With comparative freedom from anxiety symptoms between attacks (anticipatory anxiety is common)
What is the management of panic disorder?
Avoid caffeine, check for alcohol or drug misuse, suggest CBT
Drug Therapy
- SSRI (paroxetine, sertraline, fluoxetine, esciltalopram)
- Imipramine or clomipramine (TCAs) may be useful
- Benzodiazepines can be useful for short-term anxiety crisis management and can be an adjunct to SSRI
What is OCD?
- A condition characterised by recurrent obsessional thoughts or compulsive acts. Obsessions are ideas, images or impulses that enter the individual’s mind again and again in a stereotyped form. They are often distressing, and the sufferer tries to resist them. Compulsions are acts or rituals that are repeated again and again that are carried out to ease the anxiety caused by the obsessions.
What is the criteria for diagnosis of OCD?
- Obsessional symptoms and compulsive acts must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities.
What is the management of OCD?
Mild functional impairment
- CBT and exposure therapy
- SSRI
Moderate and Severe Impairment
- High intensity CBT or exposure therapy
- SSRI
- clomipramine
What is an acute stress reaction?
- A transient disorder of significant severity which develops in an individual without any other apparent mental disorder in response to exceptional physical and/or mental stress which usually subsides within hours or days.
What are the symptoms of an acute stress reaction?
Daze, constriction of consciousness, narrowing of attention
Palpitations, nausea, headaches, breathing difficulties, reckless behaviour, emotional numbing, low mood, irritability, mood swings, poor sleep and concentration may be present
How long does an acute stress reaction last?
Symptoms usually begin a few minutes after the traumatic event and can last up to 3 days afterwards
What is PTSD?
- A delayed and/or protracted response to a stressful event or situation or an exceptionally threatening or catastrophic nature which is likely to cause pervasive distress in almost anyone.
What are the symptoms of PTSD?
o Intrusion
Flashbacks, nightmares, intrusive distressing images or sensory impressions, distress after being reminded about the event
o Avoidance
Avoiding situations/people that remind them with the event or events associated with their trauma, memory suppression, rumination (why did this happen to me? could it have been prevented? etc)
o Hyperarousal
Hypervigilance, exaggerated startle response, irritability, difficulty concentrating, sleeping problems
o Emotional Numbing
Difficulty experiencing emotions, feelings of detachments, anhedonia
What is the management of PTSD?
EDMR therapy
CBT
paroxetine
mirtazepine
What symptoms are present in a depressive episode?
- Mild, moderate and severe depressive episodes are characterised by low mood, anhedonia and reduced energy leading to increased fatiguability and diminished activity. Other symptoms include
o Reduced concentration and attention
o Reduced self-esteem and self-confidence
o Ideas of guilt and unworthiness
o Bleak and pessimistic views of the future
o Ideas or acts of self-harm or suicide
o Disturbed sleep
o Diminished appetite - Lowered mood varies little from day to day, and is unresponsive to circumstances. Diurnal variation may occur
How long do symptoms need to be present for a diagnosis of depression?
2 weeks but shorter periods are reasonable if symptoms are unusually severe and of rapid onset
What is the management for depression?
SSRI SNRI TCAs MAOI Psychotherapy - CBT - Interpersonal Therapy - Psychotherapy ECT for severe treatment resistant depression
What is bipolar affective disorder?
- Repeated episodes in which the patients mood and activity levels are significantly disturbed – sometimes increased energy and activity (mania/hypomania) and sometimes low mood and decreased energy (depression).
What are symptoms of mania?
o Increased self esteem o Grandiosity o Decreased need for sleep o Pressured speech o Flight of ideas o Distractability o Increase in goal-directed activity o Decreased inhibition
What is the management of Bipolar Affective Disorder?
Mood stabiliser
- lithium, sodium valproate, carbamazepine
Anti-psychotic
- risperidone, olanzapine, quetiapine
Clonazepam
Lamotrigene can be added if rapid cycling
What is cyclothymia
- A persistent instability of mood, involving numerous periods of mild depression and mild elation. Instability usually develops early in adult life and pursues a chronic course.
What is Benzodiazepine Overdose?
Consuming an excessive amount of benzodiazepines
What are the signs of a benzodiazepine overdose?
sedation, impaired mental status, ataxia, impaired reflexes, resp depression, coma
What investigations should be carried out if a BZD overdose is suspected?
Pulse oximetry, FBC, serum chemistry and glucose, urine tox screen, ECG
How are BZD overdoses managed?
Supportive care - airway maintenance and IV fluids
Flumanezil can be used in first time or infrequent BZD users as it can reverse CNS depression but risks often do not outweigh the benefits as seizures are common whilst using this drug
What is serotonin syndrome?
A potentially life-threatning-drug-induced condition caused by too much serotonin in the synapses of the brain
What drugs can cause serotonin syndrome?
SSRI
SNRI
MAOI
St Johns Wort
Ondansentron
Metoclopramide
Illicit drugs - cocaine, MDMA, amphetamine, LSD
What are the autonomic symptoms of serotonin syndrome?
hypertension tachycardia hyperthermia (>41 oC) hyperactive bowel sounds mydriasis excessive sweating
What are the neuromuscular abnormalities caused by serotonin syndrome?
Tremor Clonus Ocular Clonus Hypertonicity Hyperreflexia
What are the mental state changes that are seen in serotonin syndrome?
Anxiety
Agitation
Confusion
What investigations are performed if serotonin syndrome is suspected?
Diagnosis of serotonin syndrome is based off clinical findings
UsEs and CK levels will be useful to see if there is any renal impairement and to check for rhabdomyolysis
FBC
LFTs useful too
What is the management of Serotonin syndrome?
REMOVE OFFENDING AGENT
IV Fluids and control agitation using BZDs
Mild SS = supportive measures
Moderate SS = correct CV and thermal disturbances, cyproheptadine
Severe SS = intensive care with early sedation, neuromuscular paralysis and ventilatory support
