Psychiatry Flashcards
Mental state examination history - guidelines
Presenting complaint Risk assessment Past Psychiatric Past medical history Drugs history Family history Social History Personal history - birth development and childhood - education - occupation - psychosexual - relationships - traumatic events - premorbid personality - forensic history
Mental state exam guide
- Appearance and Behaviour
- Speech
- Mood and affect
- Thoughts: control & content
- Perception
- Cognitive function
- Insight
MSE: Behaviours
- General: relaxed, agitated, fidgety, restless, anxious, guarded, suspicious, hostile.
- Eye contact: able to make and maintain it.
- Posture: open and responsive or closed off.
- Excessive (psychomotor agitation) or inadequate (psychomotor retardation) amount of movements.
- Disinhibition/overfamiliarity
- Comment on how these behaviours impacted on ability to build rapport.
MSE: Speech
• Level of articulation. • Rate: slow, normal, rapid (pressure of speech). • Volume: quiet, adequate or loud. • Quantity: o Increased pressured o Decreased monosyllabic mute • Clear abnormalities: stammer, dysarthria. • Variation in tone (prosody) • Speech delay
MSE: Mood and Affect
Mood: Subjective: it what the patient tells you
Affect: Objective assessment: your observation
- reactive
- blunted
- flattened
- labile
Thoughts flow and form
Flow
o Amount and speed of thoughts.
o Pressure: rapid, abundant, wide ranging.
o Poverty: slow, limited range of thoughts.
o Blocking: abrupt end to chain of though.
Form
o Flight of ideas: jumps from idea to idea via very loose links between the subjects.
o Loosening of associations (Knights move): jumps from idea to idea, with their being no apparent connection between them.
o Circumstantiality: questions answered in very round about way.
o Tangential: wanders off topic and never returns to it.
o Preservation: involuntary repetition of ideas and thoughts when subject has been changed.
o Neogolisms: new words invented for objects, with only the patient understanding these.
Thought content
o Nature: guilt, suicidal, worthlessness, homicidal.
o Preoccupations: thoughts that are in an individuals mind but not fixed, false or intrusive.
o Overvalued ideas: nature of thought is unreasonable but patient able to stop thinking about them.
o Obsessions: thoughts are undesired, unpleasant, irrational, intrusive and cannot be suppressed.
o Delusions: fixed, firm belief that is inappropriate to background, firmly held in the face of logical argument or contrary evidence and of great significance to the patient. not modified by experience or reason and usually very individualised / of great personal significance
delusion: themes, content
o Themes of delusions
e.g. disease, nihilism, poverty, sin, guilt typical in depression
e.g. control, persecution, reference, religion, love typical in schizophrenia
e.g. grandiosity, persecution, religion typical in mania
Reference: innocuous events hold high significance. Two red cars sat at the traffic light which means the FBI are following me.
o Content of delusions
the specific content is culturally defined
a persecutor is often recognisable to society/culture as a danger/threat
• e.g. IRA, mafia, MI5, KGB, CIA, devil, evil spirits
control is by ghosts / spirits in the past, but also now by XRay / radio transmitters
feared disease: plague syphilis cancer AIDS
o Delusions - Origin
Are often attempts to explain anomalous experiences e.g. hallucinations, passivity experiences, depression i.e. secondary delusions
”My thoughts do not see to be my own. They feel like they are coming from outside of me” is description of inner (abnormal) experience NOT a delusion.
“they are being transmitted by the Mafia” is an explanatory delusion
Intensity of certain thoughts can be challenged by asking “what would you say to someone if they were to say this wasn’t true”
Perceptions
• Depersonalisation: feeling that the body is strange or unreal.
• Derealization: feeling that object in the external world are strange or unreal.
• Illusions: normal sensory stimuli are misinterpreted.
• Hallucinations: perception in the absence of a sensory external stimulus and not conscious manipulation
o Visual.
o Auditory
second person voices which directly address the patient
third person voices which discuss the patient or provide a running commentary on his actions
thought echo: the patient experiences his own thoughts spoken or repeated out loud
o Olfactory.
o Tactile.
o Gustatory.
Depression aetiology
Social: significant life events e.g. birth, unemployment
• Psychological: childhood environment, personality traits.
Biological
Genetic predisposition
Depression is associated with changes in brain regions e.g. Hippocampus, Amygdala, Alteration in HPA Axis & Reduced function of serotonin and noradrenergic systems
Depression general criteria
should last 2 weeks and present more or less everyday without significant changes throughout the day
no hypomanic or manic symptoms
At least 2/3 symptoms must be present:
o depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and almost every day, largely uninfluenced by circumstances, and sustained for at least 2 weeks
o Anhedonia: loss of interest or pleasure in activities that are normally pleasurable
o Fatigue/lack of energy: decreased energy or increased fatiguability
An additional symptom or symptoms from the following list should be present, to give a total of at least four
o loss of confidence or self esteem
o unreasonable feelings of self-reproach or excessive and unreasonable guilt
o recurrent thoughts of death or suicide, or any suicidal behaviour
o decreased libido
o Poor concentration
o change in psychomotor activity, with agitation or retardation (either subjective or objective)
o sleep disturbance of any type (oversleeping or not sleeping enough)
o change in appetite (decrease or increase) with corresponding weight change
Classification ICD-10 depression
• Mild depressive episode: The majority of ‘depression’ found in primary care
o 2 core + 2 others
• Moderate depressive episode
o Two core symptoms + four others, to give a total of at least six
• Severe depressive episode without psychotic symptoms
o All 3 core symptoms + 5 others, to give a total of at least eight
• Severe depressive episode with psychotic symptoms
• Other depressive episodes
• Depressive episode, unspecified
depression ddx
Bipolar: I know you are currently experiencing a low mood but have you ever had periods of the opposite, where your mood has been very high?
Schizophrenia: Have you ever experienced anything, like seeing or hearing something that others haven’t or had thoughts that seemed unusual but you weren’t able to shake from your mind?
Anxiety: do you feel yourself anxious, physical symptoms of anxiety?
Dysthymia: chronic mild/moderate depression for a minimum of 2 years in which episodes are either not long enough or severe enough to meet criteria for depression.
depression Mx
Mild:
• Low intensity psychological interventions focussed on sleep hygiene, anxiety management (mindfulness) and problem solving
• Supportive measures
o Self-help: books, mood juice.
o Confiding in friends and family.
o Taking up exercise, trying to get involved in activities you used to enjoy.
• Psychological: CBT and IPT
Moderate:
• Combination of anti-depressant and high intensity psychological intervention (CBT or interpersonal therapy)
• 1st episode: SSRI is recommended e.g. fluoxetine (under 18s), citalopram (or escitalopram: best all-round SSRI) or sertraline (better cardiac safety profile and easy dose titration: IHD)
o Low dose and titrated up (full effect can take up to 6 weeks)
• 2nd line: another SSRI
• 3rd line:
o Noradrenergic and specific serotonergic antidepressant e.g. mirtazapine
o SNRI: Venlafaxine: can help anxiety
Severe
Lithium: adjunctive therapy
Consider older Ads: TCA (nortriptyline & clomipramine), MAOIs (moclobemide & phenelzine), SARI (trazodone)
ECT
ECT
o MRI evidence that it interrupts the hyperconnectivity between various areas of the brain that maintain depression
o Used for: Severe depression, severe maniac episode and catatonia (immobility) and psychotic episodes. People refusing to eat or drink or post-partum psychotic illness
o Performed under GA with muscle relaxant and involves electric current across 2 electrodes applied to the anterior temporal areas of the scalp to induce a seizure lasting 15-30 seconds.
o Seizure is monitored visually and with EEG can be stopped with benzodiazepine if prolonged
o Twice per week for 3-6 weeks
o Post ictal confusion and headache
o Transient retrograde short term amnesia (autobiographical) and temp defect in new learning
Recurrent depression
First episode – continue anti-depressant for at least 6 months after full recovery without reducing dose
Second episode - continue anti-depressant for at least 1-2 years after full recovery without reducing dose
Prescribing for older people
• SSRI and SNRIs are prone to reducing your sodium level (hyponatremia)
o Mirtazapine is safer
• Polypharmacy: drug interactions
Somatic syndrome: depression
Somatic symptom disorder is characterized by an extreme focus on physical symptoms — such as pain or fatigue — that causes major emotional distress and problems functioning
Four of the following symptoms should be present :
o marked loss of interest or pleasure in activities that are normally pleasurable
o lack of emotional reactions to events or activities that normally produce an emotional response
o waking in the morning 2 hours or more before the usual time
o depression worse in the morning
o objective evidence of marked psychomotor retardation or agitation (remarked on or reported by other people)
o marked loss of appetite
o weight loss (5 % or more of body weight in the past month)
o marked loss of libido
Atypical Depression
• Mood reactivity (mood brightens in response to actual or potential positive events)
• Two (or more) of the following:
o significant weight gain or increase in appetite
o hypersomnia: excessive sleepiness
o leaden paralysis (that is, heavy, leaden feelings in arms or legs)
o long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment
Cotard’s syndrome:
o More common in the elderly
o Often nihilistic delusions – “I can’t eat because my bowels have turned to dust”
o May be as extreme as “I’m dead…the world doesn’t exist anymore”
SSRI examples and mechanism
- Examples: Escitalopram, Sertraline, Fluoxetine, Paroxetine & Citalopram
- Mechanism: Block specifically serotonin re-uptake from the synapatic cleft. The actual anti depressant effects are thought to be mediated by neuro – adaptive processes that reduce the amount of inhibitory controls of serotonin release.
SSRI side effects
o GI upset: abdominal pain, constipation, nausea, which usually settles within a couple of weeks.
o General: increased anxiety, insomnia, agitation, sexual dysfunction.
o Younger patients: increased suicidality in first few weeks.
o Older patients: hyponatremia and falls.
o Serotonin syndrome: toxic hypersertonergic state: ingestion of two or more drugs that increase 5-HT levels
Agitation, confusion, tremor, diarrhoea, tachycardia and hypertension: medical emergency
o Long QT syndrome: citalopram and escitalopram (high doses)
Tricyclics (TCA) examples and mechanism
- Examples: Amitryptiline, Imipramine, Dosulepin, Norytrptiline, Lofepramine, Clomipramine.
- Mechanism: Primarily block the reuptake of noradrenaline and serotonin from the synapse by blocking their transporters.
- Also antagonize dopamine, histamine and muscarinic acetylcholine receptors, which is responsible for their side effect profile.
Tricyclics (TCA) side effects
o General: sedation, weight gain.
o Cardiac: arrhythmia (QT prolongation), posture, hypotension & tachycardia
o Anti cholinergic: dry mouth, constipation, blurred vision, urinary retention, sexual dysfunction.
o Cardiotoxic in overdose
Serotonin and Noradrenaline re-uptake inhibitors (SNRI) examples and mechanism
- Examples: Venlafaxine, Duloxetine.
- Mechanism: Similar to TCA but selectively block noradrenaline and serotonin reuptake into pre-snyaptic terminals. Also week antagonists of dopamine reuptake.
Atypical anti-depressant drugs: Noradrenaline and serotonin specific antidepressant (NASSA) example and mechanism and side effects
- Example: Mirtazapine.
- Mechanism (mixed receptor effects): It is a noradrenergic and specific serotonergic antidepressant (NaSSA) that acts by antagonizing the adrenergic alpha2-autoreceptors and alpha2-heteroreceptors as well as by blocking 5-HT2 and 5-HT3 receptors.
Sedation and weight gain
Monoamine oxidase inhibitors (MAOI) examples and mechanism and S/E
Examples:
o Reversible: Moclobemide.
o Non reversible: Phenelzine.
• Mechanism: block monoamine oxidase (MA0-A and B) which prevents the breakdown of serotonin and noradrenaline amongst other neurotransmitters. Additionally helps increase neurotransmitter levels
o Interacts with TCA and SSRI, so patient needs to be off of them for several weeks before starting as risk of hypertensive crisis.
o Requires dietary restriction if non reversible antagonist is used as dietary tyramine breakdown is prevented. Need to avoid foods like cheese, red wine and soy.
Bipolar affective disorder
• A disorder characterized by two or more episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of hypomania or mania, and on others, depression.
Bipolar aetiology
- Multifactorial: 80% of cases thought to have genetic component, with onset thought to be triggered by stressful life events, sleep deprivation or physical illness.
- Strong associated with DiGeorge syndrome (Velocardiofacial).
- Medication: steroids, illicit substances (cocaine and amphetamines) and anti-depressants
- Physical: infection, stroke, neoplasm, epilepsy, MS and metabolic disturbances
Hypomania criteria
• The mood is elevated or irritable to a degree that is definitely abnormal for the individual concerned and sustained for at least 4 consecutive days
• At least three of the following signs must be present, leading to some interference with personal functioning in daily living:
o increased activity or physical restlessness
o increased talkativeness
o difficulty in concentration or distractibility
o decreased need for sleep
o increased sexual energy
o mild spending sprees, or other types of reckless or irresponsible behaviour; (this depends on how much money you have in the first place)
• they can still do some of the daily activities and duration/severity is less
Mania criteria
Mood must be predominantly elevated, expansive or irritable, and definitely abnormal for the individual concerned. The mood change must be prominent and sustained for at least 1 week
• At least three of the following signs must be present (four if the mood is merely irritable), leading to severe interference with personal functioning in daily living:
o Increased activity or physical restlessness;
o Increased talkativeness (‘pressure of speech’);
o Flight of ideas or the subjective experience of thoughts racing;
o Loss of normal social inhibitions resulting in behaviour which is inappropriate to the circumstances;
o Decreased need for sleep;
o Inflated self-esteem or grandiosity;
o Distractibility or constant changes in activity or plans;
o Behaviour which is foolhardy or reckless and whose risks the subject does not recognize e.g. spending sprees, foolish enterprises, reckless driving;
o Marked sexual energy or sexual indiscretions.
o +/- psychosis
• Grandiosity: special powers or knowing people
Bipolar classification
• Cyclothymia
o Chronic mood disturbance associated with numerous episodes of mild hypomania and depression. Episodes are either not long enough or severe enough to meet criteria for bipolar diagnosis.
• Bipolar I
o Has to have met criteria for mania, although previous episodes may have been hypomanic and/or depressive
o Represents the ‘classic’ form of manic-depressive psychosis in the last century
•Bipolar II (most common form)
o Current or past hypomanic episode and current or past depressive episode
o Has never met criteria for manic episode
• Rapid cycling
o Four or more episodes of mood disturbance within a year.
• Bipolar III A.k.a. ‘pseudo-unipolar’
o Hypomanic episodes only occur following use of antidepressants for depression
• Bipolar IV
o Depressions arising from a hyperthymic temperament
ICD-10 classification of mania and psychotic
• F30.1 Mania without psychotic symptoms
o The absence of hallucinations or delusions, although perceptual disorders may occur (e.g. subjective hyperacusis, appreciation of colours as specially vivid)
• F30.2 Mania with psychotic symptoms
o Delusions or hallucinations are present, other than those listed as typical schizophrenic (i.e. delusions other than those that are completely impossible or culturally inappropriate and hallucinations, that are not in the third person or giving a running commentary)
o The commonest examples are those with grandiose, self-referential, erotic or persecutory content
Bipolar Mx
- Maximise antimanic dose if patient already on maintenance treatment
- Anti-depressants should be discontinued
- Combination therapy maybe required (mood stabilisers)
Acute mania Mx
1st line Olanzapine. Quetiapine or risperidone
2nd line Lamotrigine, Valproate.
Lithium, carbamazepine
3rd line ECT.
- Antipsychotic is first line treatment and should be oral if possible – IM medication may be need (risk to themselves and won’t take oral medication themselves)
- Benzodiazepines or Z-drugs can be used for symptom control e.g. agitation and insomnia
Acute bipolar depression Mx
1st line Quetiapine, olanzapine or lurasidone (not currently licensed). Anti-depressants such as fluoxetine combined with olanzapine
2nd line Lithium, Lamotrigine (takes time to titrate), valproate.
Anti-depressants such as fluoxetine combined with olanzapine.
3rd line ECT.
• Antidepressants (not without antimanic drug) can be used alongside antipsychotic, lithium or valproate (to prevent mania)
Bipolar maintenance/prophlaxis
1) Lithium: may block phosphatidylinositol pathway (second messenger system) or inhibit Glycogen Synthase Kinase 3β or modulate NO signalling
- 12 hour
- therapeutic levels (0.4-1mmol/l)
- Toxic (>1.5 mmol/l)
CBT and psychoeducation
2nd line:
•Anti convulsants: Lamotragine (primarily depressed), Valporate (hypomanic/manic), Carbamazepine
o Mode of action: very unclear, perhaps potentiate GABA transmission and therefore block overactive pathways (kindling model of bipolar disorder)
o Side effects:
Valproate & carbamazepine: drowsiness, ataxia, cardiovascular effects, induces liver enzymes
Valproate: teratogenicity (neural tube defects)
Lamotrigine: very small risk of Stevens-Johnson syndrome
• Anti-psychotics: usually atypical e.g. Quetiapine, Aripiprazole, Olanzapine, Lurasidone
o Mode of action: Dopamine antagonism + 5-HT antagonism
o Side effects:
sedation, weight gain, metabolic syndrome
extra-pyramidal side-effects (Aripiprazole)
Lithium side effects and toxic side effects
Toxic: reduced vision, D&V, hypokalaemia, ataxia, tremor, dysarthria, convulsions, reduced LOC and coma
Side effects Fine tremor. Dry mouth and Metallic taste. Polydipsia & polyuria Weight gain. Hypothyroidism. QT prolongation. Decline in renal function: monitor U&E Teratogenic: epseins cardiac anomaly
Anorexia Nervosa signs/symptoms
refusal to maintain body weight at or above 85 % of the expected range for weight and height (BMI 17.5 or below versus 20-25)
• Self-induced weight loss: strict dieting, vomiting, excessive exercise and medication e.g. laxatives to help them loose weight
• Intense fear of weight gain in spite of being underweight; disturbance of body image with abnormal perception of body size/shape; denial of the seriousness of the low weight; amenorrhoea; self-evaluation overly reliant on weight.
• However, some patients do not experience amenorrhoea even at very low body weights.
• Shopping and food preparation can become very time consuming with prolonged studying of the calorie content of food and weighing and measuring portion sizes.
• There may be an obsession with weighing themselves several times a day or a complete avoidance of knowing their weight.
Fitness apps used to calculate calorie requirements
Physical Complications: signs/symptoms of AN
- Electrolyte disturbances: hypokalaemia or hyponatraemia secondary to behaviours such as self-induced vomiting, excess fluid intake, laxative or diuretic misuse or severe malnutrition
- Cardiac disturbances: low heart rate, low blood pressure, prolonged Qtc interval, arrhythmias, cardiac arrest.
- Dental problems: dental caries can be severe in patients who induce vomiting and who consume large amounts of acidic or sugary foods; enlarged parotid glands.
- Gastro-intestinal: abdominal discomfort, indigestion and bloating are common; oesophageal or gastric tears or rupture secondary to bingeing and vomiting, may be life threatening; constipation due to poor intake or stopping laxatives; diarrhoea and incontinence with laxative abuse; delayed gastric emptying in starvation.
- Oedema and Dehydration: vomiting/laxatives/diuretics can cause dehydration then rebound water retention; oedema can greatly increase weight causing alarm and increased efforts to restrict; poor protein intake can also contribute to oedema.
- Neurological: vitamin/mineral/potassium deficiencies can contribute to peripheral paraesthesia, tetany or seizures; brains scans show reduced grey matter and enlarged ventricular spaces.
- Renal: renal damage secondary to chronic hypokalaemia; organ breakdown as body “eats” itself to obtain calories.
- Endocrine: loss of body fat causes amenorrhoea as ovaries shut down to reduce fertility in absence of reliable food supply; not a reliable contraceptive; hypothalamus impaired; reduced body temperature; abnormal thyroid function tests.
- Hepatic: raised LFTs as liver is broken down in starvation to provide energy; can lead to liver failure.
- Dermatological: dry skin; hypercarotenaemia (too much carrots), lanugo hair; poor peripheral circulation (cold and blue); hair loss
- Musculoskeletal: muscle wasting; weakness; osteopenia or osteoporosis; calluses on back of hand (Russell’s sign) from induced vomiting.
- Haematological: low WBC common; reduced ability to fight infection; anaemia (iron, B12 deficiency); bone marrow suppression; thrombocytopaenia.
Psychological Complications of AN
- Mood: low mood and anxiety are common; irritability and angry outbursts; mood may become more labile when re-feeding; episodes of elation can occur; obsessions and compulsions.
- Personality: narrowed range of interests; rigid thinking; social withdrawal
- Cognition: may be poor concentration; impaired decision making; drowsiness; but may still achieve highly academically
Risk assessment: High risk AN
• BMI < 13,0, wt loss >1kg/week o 16 – 17.5: low – moderate risk. o 15 – 16: moderate risk. o 13 – 14.9: high risk. o <13: very high risk
- Prolonged QT, HR <40, systolic BP <80
- Core temp <34 C
- Unable to rise from squat without using arms for leverage
- Cognitive impairment
AN Ix
- Haematology: Low WCC and FBC/B12
- Biochemistry: LFTs (raised GGT, ALT, Protein and albumin)
- ECG
- DEXA bone scan if they have not menstruated in a year: if there is high risk bone thinning stop them from doing high risk
AN Mx
FBT: 1st choice in children and adolescents
CBT
IPT
SSCM
Dietitian: aim to restore weight by 0.5-1.0kg per week (3500-7000 extra calories)
• Medication: there is no specific drug treatment for anorexia nervosa;
o multivitamin supplements recommended;
o calcium and vitamin D supplements in bone thinning;
o oestrogen patches may be indicated in adolescent females with amenorrhoea;
o antidepressants for low mood;
o olanzapine/quetiapine/aripiprazole used in severe cases off licence to manage anxiety/ rigid thinking/ obsessions around re-feeding.
• Inpatient treatment for high risk (MHA)
Refeeding syndrome
• potentially fatal shifts in fluids and electrolytes in malnourished patients undergoing rapid re-feeding. These shifts result from hormonal and metabolic changes, and may cause serious complications.
• Re-feeding syndrome can cause cardiac abnormalities, delirium, respiratory failure, status epilepticus, and suppression of the haematological system.
• The hallmark feature of re-feeding syndrome is hypophosphataemia. However, the syndrome is complex and may also feature hypokalaemia, hypomagnesaemia, abnormal fluid and sodium balance, changes in fat, glucose and protein, and thiamine deficiency.
Re-feeding oedema can be marked, occasionally leading to weight gain of up to 1kg per day
• Diuretics should be used with extreme caution, as they may precipitate further loss of potassium and cardiac arrest.
• Acute gastric dilation is a rare, but potentially lethal, complication of re-feeding. It presents with vomiting, and abdominal pain and distension. If recognised early, it responds to nasogastric aspiration and intravenous feeding.
• prevent by frequent blood monitoring and slow pace of initial refeeding
Bulimia Nervosa
• The symptoms of bulimia nervosa are recurrent binges associated with compensatory behaviours including vomiting, excessive exercising or fasting.
• Binges occur at a frequency of at least once a week for 3 months and there is excessive pre-occupation with body shape and weight.
• A binge is defined as the consumption of an unusually large amount of food within a short time interval associated with loss of control.
• Attempts to counter affects of binges (starvation, vomiting, laxatives, drug misuse, morbid fear of fatness)
• Russell’s sign refers to the calluses that may develop on the back of the hand through self-induced vomiting.
• Parotid hypertrophy
co-morbid depression
Dental caries are common
• Medical complications
o Oesophageal reflux, tears and rupture
o Hypokalaemia
o Subconjunctival haemorrhage
o Dehydration
o Seizures metabolic abnormalities
BN Mx
- Individual or group CBT.
* High dose fluoxetine has been shown to reduce cravings for food.
Binge eating disorder
recurrent bingeing at least once a week for 3 months without the use of compensatory behaviours that causes significant distress.
- 3 or more of the following symptoms have to be present:
- eating more rapidly than normal
- eating until uncomfortably full
- eating large amounts of food when not physically hungry
- eating alone because of being embarrassed by how much one is eating
- feeling disgusted, depressed or guilty about over eating.
Avoidant Restrictive Food Intake Disorder (ARFID)
- An eating disturbance manifested by a restrictive eating pattern with persistent failure to meet appropriate nutritional needs.
- This can be related to sensory issues such as being unable to tolerate certain food textures rather than due to body image concerns.
- The individual may or may not be underweight.
- There may be a co-existing autistic spectrum disorder.
Diabulimia
eating disorder in a person with diabetes, typically type I diabetes, where the person deliberately restricts insulin in order to lose weight.
• The person has chronically very raised blood sugar levels and may have repeated episodes of ketoacidosis.
Bigorexia/Megarexia
• Muscle dysmorphia seen in some male body builders.
Personality disorders
• A personality disorder is an individual characteristic and enduring patterns of inner experience and behaviour that deviate markedly as a whole from culture expectations
o It is pervasive behaviour that is inflexible, maladaptive or dysfunctional across all social settings
o Personal distress and or adverse impact on the person
o Stable, long duration, onset in late childhood/adolescence
Manifested in more than one of: o Cognition: thinking o Affectivity: emotional response o Impulse control o Interpersonal functioning: functioning relationships with others
Cluster A: …
odd and eccentric
Paranoid personality Disorder
Cluster A: Distrust and suspicious of others
Personality disorder characterized by 4 of:
• excessive sensitiveness to setbacks and rebuffs;
• tendency to bear grudges persistently e.g. refusal to forgive insults and injuries or slights
• suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous;
• a combative and tenacious sense of personal rights out of keeping with the actual situation;
• recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner;
• tendency to experience excessive self-importance, manifest in a persistent self-referential attitude;
• preoccupation with unsubstantiated “conspiratorial” explanations of events both immediate to the patient and in the world at large.
• Reluctant to confide in others, hold grudges, doubts loyalty of friends
Paranoid personality Disorder Mx
Low dose anti-psychotics (quetiapine, olanzapine and haloperidol) can reduce the suspiciousness of the three cluster A personality disorders (paranoid, schizoid and schizotypal)
Schizoid Personality Disorder:
Cluster A: socially withdrawn with poor emotions
4:
• few, if any, activities, provide pleasure;
• emotional coldness, detachment or flattened affectivity;
• limited capacity to express either warm, tender feelings or anger towards others (restricted expression of emotion: emotional coldness)
• apparent indifference to either praise or criticism
• little interest in having sexual experiences with another person (taking into account age);
• almost invariable preference for solitary activities
• excessive preoccupation with fantasy and introspection;
• lack of close friends or confiding relationships (or having only one) and of desire for such relationships;
• marked insensitivity to prevailing social norms and conventions
• a lot of overlap between this and autism
Schizoid Personality Disorder Mx
Low dose anti-psychotics (quetiapine, olanzapine and haloperidol)
Psychodynamic and group therapy
Schizotypal PD
Cluster A: Eccentric with distorted reality
5 or more of:
• Ideas of reference (excluding delusions of reference)
• Odd beliefs or magical thinking, inconsistent with subcultural norms e.g. superstitious, belief in clairvoyance, telepathy or 6th sense)
• Unusual perceptual experiences including bodily illusions
• Odd thinking and odd speech e.g. vague circumstantial metaphorical elaborate or stereotyped
• Suspiciousness or paranoid ideation
• Inappropriate or constricted defect
• Behaviour or appearance that is odd, eccentric or peculiar
• Lack of close friends or confidants other than first degree relatives
• Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self
• Poor rapport due to interpersonal deficits. Leads to social withdrawal.
Management
Schizotypal PD Mx
• Low dose anti-psychotics (quetiapine, olanzapine and haloperidol)
Cluster B personality disorders
Dramatic and emotional
Dissocial (Anti-social) Personality Disorder
Cluster B: Disregard and violation of the right of others
3 of:
• callous unconcern for the feelings of others
• gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations (lack of concern for others feelings or safety)
• incapacity to maintain enduring relationships, though having no difficulty in establishing them
• very low tolerance to frustration/irritable and a low threshold for discharge of aggression, including violence (impulsivity)
• incapacity to experience guilt or to profit from experience, particularly punishment
• marked proneness to blame others, or to offer plausible rationalizations, for the behaviour that has brought the patient into conflict with society
• usually young men
Dissocial (Anti-social) Personality Disorder Mx
Psychological interventions: group based cognitive and behavioural interventions
anti-depressants can help with the mood and emotional difficulties
• SSRIs can help people to be less impulsive and aggressive in borderline and anti-social personality disorders
Emotionally unstable personality disorder
Cluster B: Impulse and borderline
3 of:
• A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability (emotion)
• The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or “behavioural explosions”; these are easily precipitated when impulsive acts are criticized or thwarted by others.
• The predominant characteristics are emotional instability and lack of impulse control.
• Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others.
• Difficulty in maintaining any course of action that offers no immediate reward
• Unstable mood (transient stress induced psychosis?)
Emotionally unstable personality disorder Mx
Anti-depressants
• Mood stabilers/anti-psychotic such as lamotrigine can help with unstable mood and impulsivity
• dialectical behavioural therapy: 6 months-1 year
Skills training in a group
Telephone crisis coaching
Emotionally unstable personality disorder Borderline sub type
2 of:
• Several of the characteristics of emotional instability are present;
• Disturbances in and uncertainty about patient’s own self-image, aims, and internal preferences (including sexual) are often unclear or disturbed.
• A liability to become involved in intense and unstable relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment
• Recurrent series of suicidal threats or acts of self-harm (although these may occur without obvious precipitants).
• There are usually chronic feelings of emptiness.
Emotionally unstable personality disorder Borderline sub type Mx
Anti-depressants
• Mood stabilers/anti-psychotic such as lamotrigine can help with unstable mood and impulsivity
• dialectical behavioural therapy: 6 months-1 year
Skills training in a group
Telephone crisis coaching
Histrionic PD:
Cluster B: excessively emotional and attention seeking
least 3 of the following:
• self-dramatization, theatricality, exaggerated expression of emotions;
• suggestibility, easily influenced by others or by circumstances;
• shallow and labile affectivity;
• continual seeking for excitement, appreciation by others, and activities in which the patient is the centre of attention;
• inappropriate seductiveness in appearance or behaviour;
• over-concern with physical attractiveness.
Histrionic PD Mx
- Anti-depressants can help with the mood and emotional difficulties with cluster B personality disorders (dissocial, emotionally unstable, histrionic and narcissistic)
- Psychodynamic and dialectal behavioural therapy.
Narcissistic PD (DSM V)
Cluster B: Pre-occupied with power prestige and vanity
- has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
- is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
- Credence he or she is “extraordinary” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
- Desire for unwarranted admiration
- has a sense of entitlement, i.e. unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations
- is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
- lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
- is often envious of others or believes that others are envious of him or her
- display of egotistical and conceited behaviours or attitudes
Narcissistic PD Mx
Anti-depressants
Anakastic perosnality disorder: obsessive compulsive
Cluster C: order, control, perfectionist and inflexible
- feelings of excessive doubt and caution
- preoccupation with details, rules, lists, order, organization or schedule
- perfectionism that interferes with task completion
- excessive conscientiousness, scrupulousness, and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships
- excessive pedantry and adherence to social conventions
- rigidity and stubbornness
- 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
Anakastic perosnality disorder: obsessive compulsive Mx
- Anti-depressants can reduce anxiety in cluster C personality disorders (anankastic, avoidant and dependent)
- Psychotherapy and CBT
Anxious/Avoidant PD
Cluster C: social inhibition and inadequacy
4 of the following:
• persistent and pervasive feelings of tension and apprehension;
• belief that one is socially inept, personally unappealing, or inferior to others;
• excessive preoccupation with being criticized or rejected in social situations;
• unwillingness to become involved with people unless certain of being liked;
• restrictions in lifestyle because of need to have physical security;
• avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.
