Psychiatry Flashcards
V-Risk 10
- what is the #1 risk for violence?
- Previous or current violence
- Previous or current threats
- SUD
- Severe mental illness
- Personality disorders
- Lack of insight
- Suspiciousness
- Lack of empathy
- Unrealistic planning
- Exposure to future stress situations
Types of Aggression
- Instrumental aggression - to get what they want
- Fear-driven aggression - to avoid being hurt
- Irritable aggression - due to emotional wounds
Countertransference
- when a therapist projects their own emotions on to a client
Miller’s Law
- to understand someone, try and assume what they are saying is true
Drugs used for aggression
Benzos (especially if drug intoxication/ alcohol withdrawal)
- Ativan 1-2mg, PO or IM
- Midazolam 2-2.5mg, IV or IM
Anti-Psychotics (all PO or IM)
- Haldol 2.5-5mg
- Olanzapine 5-10mg
- Loxapine 12.5-50mg
Form 4
Form 5
Health Care Consent Act
4 –> Certification. Can only be done by an MD, initially lasts for 48h.
5 –> Consent for treatment to be given against a patient’s will.
HCCA - not an actual form, but dictates that a patient cannot leave the hospital.
Panic Disorder
A. Recurrent and unexpected panic attacks. A panic attack is an abrupt surge of fear/ discomfort that peaks in minutes with 4 or more of:
- Palpitations, increased HR
- Sweating
- Trembling/ shaking
- SOB
- Feelings of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Dizziness
- Chills/ heat
- Paresthesias
- Derealization/ depersonalization
- Fear of losing control/ going crazy
- Fear of dying
B. At least one of the attacks has been followed by 1 month of one of:
- Persistent concern about having another panic attack
- Maladaptive change in behaviour (avoidance)
- More common in women
- Adolescent onset
*20x suicide risk than the general population
Agoraphobia
A. Fear/anxiety about two of:
- Public transport
- Being in an open space
- Being in enclosed spaces
- Standing in line/ crowd
- Being outside of home Alone
B. Fear is due to thoughts of escape being difficult/ embarrassing
C. These situations almost always provoke fear
D. These situations are actively avoided, or are endured with help
E. Fear is out of proportion
F. Lasts 6 months or more
G. Significant distress/ impairment
Social Anxiety Disorder
- Specifier?
A. Fear/anxiety of at least one social situation in which scrutiny is possible (conversations, eating, public speaking)
B. They fear they will show anxious symptoms that will be negatively evaluated
C. These situations almost always cause fear
D. These situations are avoided or endured
E. Out of proportion
F. Lasts 6 months
G. Distress, impairment
- Can be specified as performance only (i.e. speaking)
*more common in females
*often under 25 - more commonly lower SES/ unmarried
Generalized Anxiety Disorder
A. Excessive worry more days than not for at least 6 months about many things
B. Difficult to control the worry
C. 3 of:
- Restlessness
- Irritability
- Easily fatigued
- Sleep disturbance
- Difficulty concentrating
- Muscle tension
- more common in women
Specific Phobias
A. Fear about a specific object or situation
B. Exposure almost always provokes fear
C. The phobia is avoided or endured
D. Out of proportion
E. Marked distress, impairment
F. 6 months
*Normally under 7 years old onset
*Most common anxiety disorder!
Underlying medical causes of anxiety
- Hypo AND hyperthyroidism
- caffeine
- anemia
Risks for developing an anxiety disorder
- Family or personal history (including mood disorders i.e. BD/ MDD)
- ACEs
- Female
- Chronic illness
- Behavioural inhibition
Anatomy of Anxiety
- Fear originates in the amygdala
- Anxiety is due to an over-excitation of the amygdala and it’s connected structures and Cortico-striatal-thalamo-cortical loops
- leads to automatic thoughts and schemas associated with danger, overestimation of risk, uncontrolability, and incapacity to cope
General class overview of treatment for anxiety
- Increasing serotonergic input: SSRIs, SNRIs, TCAs, MAOis, azapirones
- Increasing GABA (inhibitory NT): benzodiazepines
- Block Glutamate (excitatory NT): alpha-2 delta ligands i.e. pregabalin (1st line)/ gabapentin
*There is only a 50-70% response to first line treatment
Treatment for specific phobias
- Meds are not often used as CBT is so effective - especially exposure therapy
- May use benzos in the short term for acute relief
Schedule of evaluating drug efficacy for anxiety
- for GAD/SAD/PD, improvement should be seen in 6-8 weeks
- Continue meds until avoidance behaviour is overcome (NOT only if anxiety has decreased)
- Continue to use meds for at least 12 months, if not indefinitely (especially if chronic)
CBT
- As effective as medications (70%) - may be a slight advantage in mixing both
- Longer lasting than meds, but can be time consuming and costly
- 1st line for depression
- Usually 10-12 weeks of sessions
- Cognitive challenging of distortions, gradual exposure, involves homework
- Focuses on thoughts and behaviours, as they are more changeable than emotions
- Can include mindfulness, social skills, etc.
OCD
- Specifiers?
A. Presence of obsessions, compulsions, or both:
- Obsessions: recurrent and persistent thought/ impulses/ images that are intrusive and unwanted, cause distress in most individuals, and there is some attempt to suppress or ignore (i.e. harm, contamination, symmetry, somatic, religious, sexual)
- Compulsions: repetitive behaviours/ mental acts that and individual feels driven to do due to an obsession/rules. These aim to reduce distress but are unrealistic or excessive (i.e. checking, collecting, cleaning, counting, repeating)
B. Time consuming (1h+) or cause distress/ impairment
- Can specify as good/poor/absent insight or delusional beliefs
*More common in females (especially post-partum)
*90% have another illness, 30% have tic disorder
*Average onset is 19y, earlier in men
*Both O+Cs are common in the general population
Method of Assessing OCD
- Yale-Brown Obsessive Compulsive Scale
- Remission is under 8
OCPD
Preoccupation with orderliness, perfectionism, and mental control at the expense of flexibility/ openness/ efficiency.
- Preoccupation with details/ rules/ lists/ schedules to the point the activity is useless
- Perfectionism that interferes with task completion
- Excessive devotion to work and productivity, excluding leisure and friends
- Inflexible and overconscientious about morality, ethics, values
- Unable to discard old objects
- Reluctant to delegate tasks
- Miserly spending style
- Rigidity and Stubbornness
OCD vs OCPD
- in OCPD, obsessions are more egosyntonic, and they are not as distressed
Treatment for OCD
1st Line –> Paroxetine, Fluvoxamine, Fluoxetine, Sertraline, Escitalopram
Ist Line Adjuncts –> Aripiprazole, Risperidone
+CBT –> exposure/response prevention (addresses thought-action fusion (if i think it, it will happen), over-importance of thoughts, intolerance of uncertainty, emotional reasoning, inflated responsibility)
*CBT alone can be sufficient for mild/mod, severe needs medication
*dose is often higher than for depression
*8-12 weeks
*Try 2 SSRIs first, and if nothing works go to CLOMIPRAMINE (worse side effects)
3 Levels of Cognition
Core beliefs: deep cognitive structures regarded as truth (I am incompetent)
Intermediate Beliefs: attitudes/rules/assumptions for processing info (If I try, I will not succeed)
Automatic Thoughts: rapid cognitions in response to a situation that can be based on erroneous logic
- jumping to conclusions, all or nothing thinking, magnifying/minimizing, overgeneralization, etc.
Beck’s Cognitive Triad of Depression
- negative views about the self, others, and the world
Cognitive and Behavioural Techniques
Cognitive - identifying and modifying automatic thoughts, socratic dialogue, thought change records
- modifying core/intermediate beliefs is more difficult, attempt to restructure early experiences
Behavioural - hierarchy of difficulty, subjective units of distress, graded exposure, behavioural activation to reverse anhedonia/avoidance
CB Relapse Prevention Therapy in SUD
- identify triggers, maladaptive thoughts and beliefs, avoid high risk situations, cope with cravings, set attainable goals, etc.
Unique Treatments for Unique Anxiety Disorders
PD –> interoceptive exposure (exposure to physical sensations)
Phobias –> applied muscle tension to prevent fainting, virtual reality exposure
SAD –> assertiveness training
GAD –> muscle relaxation
PTSD –> imaginal and in vivo exposure, EMDR
*exposures are more effective if planned, structured, close together, prolonged, many different settings, etc.
