Psychiatry Flashcards
DEPRESSION Dx
2 core symptoms (depressed mood, low energy, anhedonia)
+
2 or more of the other symptoms
(<2 = mild; >2 + <5 moderate; >5 severe)
+
for at least 2 weeks
Mood - Definition
mood reflects person’s INTERNAL emotional experience (e.g. good, ok, frustrated, angry)
Affect - definition
affect reflects the person’s EXTERNAL emotional expression - which can be evaluated by the interviewer. It can be described as:
- EUTHYMIC (normal, well-balanced mood)
- DYSTHYMIC (sullen, flat)
- EUPHORIC (intensely elated mood)
DEPRESSION Sx
Depressed mood (CORE) + SIGECAPS
– S = Sleep (decreased overall pattern and architecture)
– I = Interest/Enjoyment/
Anhedonia (low) (CORE)
– G = Guilt/Hopelessness/Pessimist/Self-blaming/Nihilistic
– E = Energy (low) (CORE)
– C = Concentration (decreased)
– A = Appetite (usually low, but can be increased)
– P = Psychomotor retardation
– S = Suicidal thoughts
typically, in depression, mood is worse in the morning and betters as the day progressed (this is called “diurnal variation”)
DEPRESSION
major depression with ATYPICAL features
- mood remains reactive (lifting of depressive symptoms during happy life events)
- reversed diurnal variation (i.e. evening are the most difficult time of the day for the mood)
- feeling rejected and unloved (interpersonal rejection sensitivity)
- leaden paralysis (dull/heavy limbs to lift)
- hyperphagia/weight gain
- hypersomnia
Rx: MAOi
Dysthymic Disorder (Persistent Depressive Disorder)
Chronic condition characterised by depressive symptoms that:
- occur for most of the day
- more days than not
- for > 2 years
common features:
- H: Hopelessness (despondency)
- E: Energy (decreased)
- S: Self-esteem (decreased)
- S: Sleep (decreased)
- A: Appetite (decreased)
- D: decision making (impaired)
DEPRESSION: Sleep disturbances types
MOST COMMON - waking up during the night and having trouble going back to sleep (also referred as middle insomnia). if successful [in going back to sleep], broken sleep thereafter
- early morning wakening and being unable to get back to sleep at all (also referred as terminal insomnia)
- increased REM stage
- Decreased stage 3 non-REM stage (less stage 3 means less restorative periods => day light tiredness)
LESS COMMON/UNCOMMON
- increased sleep latency (i.e. difficulty falling asleep) = MORE COMMON IN ANXIETY or associated with the use of nocturnal stimulants (e.g. caffeine)
- Hypersomnia and oversleeping are much
- Dramatic dreams (including dreams about death) ARE NOT TYPICAL OF DEPRESSION
DEPRESSION
Risk Factors
- perfectionism
- obsessionality
- intellectual developmental delay
- Family history of depression.
- Family history of Autism
– Substance Misuse.
– Unemployment
– Low socioeconomic status.
– Elderly person with cognitive decline or bereavement.
– All family members who have experienced family violence.
– Experience of child abuse
DEPRESSION
groups are at higher risk than of depression
- Women
- Postpartum women
- Young rural males
- Adolescents
DEPRESSION
Features in children/adolescents
- Anhedonia/Apathy may be as severe or more apparent than mood abnormalities (often expressed as severe boredom)
- sadness(sad appearance)
- despondency (hopelessness)
- excessive irritability
- feeling rejected and unloved (interpersonal rejection sensitivity)
- somatic complaints (eg, headaches, abdominal pain, insomnia), and persistent self-blame.
- anorexia, weight loss (or failure to achieve expected weight gain)
- sleep disruption (including nightmares)
- suicidal ideation
DEPRESSION vs SCHIZOPHRENIA
***PATTERN
- episodic
vs
- progressive
DEPRESSION
If a patient, who has successfully been stable on prophylactic dose of a particular mood stabiliser, develops acute depression, what is the next best step in management?
- Adding an antidepressant to the prophylactic mood stabilizer: the choices of the drug would be the same as for major depression. SSRls first line.
- Increasing the dose of prophylactic mood stabilizer (ONLY if the patient’s psychosis is indicated in coming back, otherwise continue same dose)
DEPRESSION
Antidepressants alone are ________ effective in patients with severe depression
50% to 60%
DEPRESSION
Effect size of most treatments of depression
ECT (0.8) > CBT (0.5) > Anti-depressants (0.4)
At least ______% of patients with major depression will respond to AT LEAST one antidepressant medication
80%
SSRI
Fluoxetine
Paroxetine
Sertraline
Citalopram/escitalopram
Which SSRI is contraindicated in pregnancy
Paroxetine
Which SSRI is safe for MI
Fluoxetine
SNRI
Venaflaxine
Desvenaflexine
Duloxetine
Indications for SNRI
For treating depression AS WELL AS anxiety (75% depression 25% anxiety)
Venlafaxine contraindication
- Diastolic Hypertension
- Breast feeding
Bupropion in contraindicated in patients suffering from seizures
it reduces seizure threshold
In patients with severe depression or suicidal ideation taking HCV treatment (interferon). Management should be
Stop interferon, start SSRI. deal with depression and once the depression is managed, start interferon again
Examples of Overvalued Ideas
Body dysmorphic disorder
Anorexia Nervosa
Hypochondriasis
BIPOLAR DISORDER
Dx
Elevated Mood + 3 of DIG FAST
or
Irritability + 4 of DIG FAST
FOR 1 week or more
BIPOLAR DISORDER
Sx
1- D – DISTRACTIBILITY
2- I – IMPULSIVITY (please seeking behaviours)
3- G – GRANDIOSITY (can border on the psychotic delusions and hallucinations.
4- F – FLIGHT OF IDEAS
5- A – ACTIVITY (psychomotor agitation/goal direct activity)
6- S – SLEEP = decreased need
7- T – TALKATIVINESS
BIPOLAR DISORDER
MANIA ≠ HYPOMANIA by following features
- Minimum 7 days of symptoms
(4 days for hypomania) - Marked functional impairment
(no functional impairment in hypomania) - Delusions and hallucinations
(absent in hypomania) - Patient often requires hospitalisation
(less commonly required in hypomania)
“ELEVATED MOOD IS SEEN BOTH”
BIPOLAR DISORDER
Features more commonly seen in Bipolar Depression than in Unipolar Depression
- Psychomotor retardation.
- Increased appetite (hyperphagia)
- Increased sleep (hypersomnia)
- Positive family history of bipolar disorder
- Early onset of first depression before 25 years of age.
- Delusions and hallucinations (psychotic features)
BIPOLAR DISORDER
Suicidal Risk
- 15 x more likely to commit suicide
- 25% of BD patients will attempt suicide
- history of drug taking is an important finding as it can be considered as suicide attempt
Hypomania vs HISTRIONIC PERSONALITY DISORDER
Some symptoms of hypomania overlap with histrionic personality disorder. These include:
- shallow emotions
- flirty nature
However:
- flirting in hypomania = increased sexuality
- flirting in histrionic personality disorder = attention seeking behaviour
BIPOLAR DISORDER
MANIA vs PSYCHOTIC DISORDERS
***NATURE of delusions
- grandiose
- reward-oriented
vs - conspiratorial thinking
- paranoia
- thought manipulation/control by outside force
***DISTINGUISHING SYMPTOMS
- flight of ideas, distraction
vs
- thought disorganisation + negative sx
***PATTERN
- episodic
vs
- progressive
Drug of choice for Bipolar disorder
Lithium
Haloperidol (Emergency, if uncooperative)
Schizophrenia
DX
2 Sx for at least 6 months
(at least ONE POSITIVE sx)
symptoms rarely have an acute onset. Instead, there is often a prodromal state followed by a progressive worsening of the symptoms
SCHIZOPHRENIA - Psychosis definition
- Psychosis is a loss of contact with reality - loss of insight into the fact that one is mentally ill
- Some people with psychosis have false beliefs that can best be described as fearfulness and suspiciousness (paranoia);
- They may have vague fears or complaints about others controlling their lives, but many describe consistent suspicions of very specific, elaborate, and persistent plots against THEM. Very often, these beliefs are directed at family members or friends.
SCHIZOPHRENIA - Delusions definition
false beliefs that are inconsistent with patient’s background and cannot be corrected by reasoning (result of an illness or illness process)
SCHIZOPHRENIA - Hallucinations definition
false perceptions in the absence of any external stimuli (e.g. auditory, visual) - no one else feels them
SCHIZOPHRENIA - Illusions definition
misperceptions of genuine stimuli, a specific form of sensory distortion because:
- individuals have been deliberately misled (e.g. by a magician);
- if their attention is diminished (e.g. delirium, fatigue, boredom or laziness)
- there is a lack of visual clarity (e.g. dim lighting, semi-darkness, fog)
- if they are intensely aroused by fear, passion or depression.
Some people have vivid imaginations and may see faces or figures in ordinary environmental features such as clouds, tree trunks, rock formations etc. This is quite common in children and is not considered
Schizophrenia - POSITIVE Sx
(should not be present, but are)
‘HD BS’
- Hallucinations (auditory most common)
- Delusions (paranoid or persecutory)
- Thought Disorganisation = Behaviour (disorganised) + Speech (disorganised)
Schizophrenia - features of the auditory hallucination
- comes OUTSIDE of the head (as opposed to inside)
- RIGHT side
- commentary between speakers (as opposed to one voice)
- mix of male and female voices
- intermittent (rather than continuous)
Person will find specific REDUCING BEHAVIOURS (e.g. listening to radio/watching TV/talk to others very loud, wear headphones)
Person may seen reacting to what the voices are telling them (“RESPONDING TO INTERNAL STIMULI”)
SCHIZOPHRENIA
examples of Disorganised Behaviour
- Motor perseveration (repeating same motions over and over)
- echopraxia (copying someone’s movements)
- Catatonia
SCHIZOPHRENIA
examples of Disorganised Speech
- clang association ( words based on its sound/
phonetics, like rhyming, rather than the actual meaning) - neologism
- echolalia
- perseveration (say the same word repeatedly w/o a purpose)
- word salad (non-sense words)
- concrete thinking (inability to think in abstract terms)
- loosening association (Rapidly shifting from topic to topic, with no connection
between one thought and the next) - Circumstantiality - an inability to answer a question without unnecessary and excessive detail
Schizophrenia - NEGATIVE Sx
(should be present but aren’t)
The 5 A’s
- Affect (flat/blunted)
- Ambivalence/Avolition (difficulty making decisions/executing commands/poverty of thoughts)
- Alogia (decreased or even absent speech)
- Anhedonia
- Asociality (social withdrawal)
Schizophrenia - EPIDEMIOLOGY/PROGNOSIS
- incidence general population 1/100 (1%)
- men more affected than women 3/2 (1.5x)
- earlier in men (18-25) than for in women (25-35)
- men tend to exhibit more severe form and worse outcome
- earlier onset
- chances of recurrence after first episode (90% - similar to bipolar disorder)
- SUICIDE: when it occurs, tends to happen in early stages when the insight is still preserved
- negative symptoms are least likely to respond to medication.
Schizophrenia - RISK FACTORS
- Monozygotic twin 50% chance of developing
- Dizygotic twin has a 15% chance.
- There is 48% chance if both parents are affected
- There is 12 -13% chance if one birth parent is affected
- There is increased risk with advanced paternal age, where the parent was aged over 55
- Winter birth
- Foetal hypoxia (Pre-eclampsia and emergency c-section)
- use of illicit drugs (cannabis, amphetamines, cocaine, LSD)
- Urban areas
- stressful life experiences/migrants
- physical/sexual abuse in childhood
Schizophrenia - Symptoms and different age groups
YOUNG PATIENTS (15-35 yo)
- spontaneous remission more common
- requires higher doses
- more likely to have “negative symptoms”
LATE ONSET (> 40-45 yo)
- less likely to remit spontaneously
- respond to lower doses
- persecutory delusions is most common symptom, along with accusative or abusive auditory hallucinations
- less likely to have thought disorder and negative symptoms
> 60 yo
- less likely to remit spontaneously
- visual hallucinations
- less likely to have thought disorder and negative symptoms
Early sings of Schizophrenia in teenagers
- Withdrawal from friends and family
- A drop in performance at school
- Trouble sleeping
- Irritability or depressed mood
- Lack of motivation
- Strange behavior
- Sudden and bizarre changes in emotions
- Severe problems in making and keeping friends
- Difficulty speaking, writing, focusing or managing simple tasks.
???
symptoms seen in early pre-psychotic Prodrome of schizophrenia/psychosis
Symptoms seen in late stage prodrome period of psychosis
2nd earliest symptoms seen in pre-psychotic prodrome of schizophrenia/psychosis
Recurrent depressive symptoms over the course of 3-5 years
Paranoid ideation
odd beliefs
Loss of motivation and social disability developing within 12 to 18 months of first recurrent depressive symptoms
SCHIZOPHRENIA timeline DDx
- Brief Psychotic disorder: > 1 day & < 1 month
- Schizophreniform Disorder: > 1m & < 6 m
- Schizoaffective Disorder
SCHIZOPHRENIA vs Schizoaffective Disorder
HATS:
- H: HALF or more of the time ill must be spent with mood sx
- A: psychotic sx must occur ALONE (i.e. w/o mood sx)
- T: psychotic sx must occur TOGETHER (i.e during an episode of mood disorder)
- S: exclude effect of SUBSTANCES or other medical conditions
SCHIZOPHRENIA vs BPD
- stable or improving level of disfunction after early adulthood (as opposed to progressive decline over time seen in Schizophrenia)
- affect instability of BPD involves rapidly emotional shifting (as opposed to weeks to months changes)
- psychotic sx tend to be an sign of distress (experienced during times os stress)
- Auditory hallucinations- if present - are described as inside (as opposed to outside) and vague/unclear (as opposed to clear/vivid)
SCHIZOPHRENIA vs Dementia
- late onset
- lack of prior psychiatric sx or signs
- match average population in social milestones (school, work, marriage)
- visual hallucinations
- loss of recall of learnt information and visuospatial ability (schizophrenic patients have these intact)
Charles-Bonnet Syndrome (CBS):
Intact cognition/preserved insight
Ocular Pathology (BLIND or, commonly, macular degeneration) or occipital disease - NOT psychiatric
Visual Hallucination
- vivid, colourful, and well-organised hallucinations
- experience may last for seconds or hours at a time
- patient has good insight
- hallucinations are not distressing, but may be quite engaging
Capgras syndrome
- Also called delusional misidentification syndrome
- Disorder in which a person believes that an identical-looking has replaced a friend, spouse, parent, or other close family member impostor
- commonly occurs in patients with paranoid schizophrenia,
dementia and brain injury
Cotard Syndrome
patient believes they have lost important body parts, blood, internal organs, or even their soul
- prevalent in schizophrenia, bipolar disorder, non-dominant temporo-parietal lesions and migraine.
Ekbom syndrome
Delusional infestation with parasites or worms in schizophrenic patients
≠
Willis-Ekbom disease (WED); Witmaack-Ekbom syndrome or Restless leg syndrome (RLS) is characterised by a ‘compulsive’ restlessness or need to move the legs, often associated with paraesthesiae or dysaesthesiae. Symptoms at rest or disturbing sleep, quickly but temporarily relieved by standing and walking, with nocturnal worsening of symptoms.
FOLIE a DEUX
Shared psychotic disorder
Delusion developing in a person in close relationship with another person who has an established delusion (more common in mother-daughter or sister-sister relationships)
Dominant person and submissive or
dependent person in the relationship is clearly established.
Delusion similar in content.
HAPPENS IN FAMILIES – GROUPS OF PEOPLE
– example is a cult.
Treatment:
biggest challenge is getting the pair (or system) to accept the need for treatment.
FIRST STEP IS to separate the person or people with the secondary disorder from the person with the primary disorder, as the secondary’s delusions often don’t persist following separation.
Atypical antipsychotics aripiprazole and quetiapine most effective
Antipsychotics
Order from lowest to highest potency
Aripiprazole
Quetiapine
Olanzapine
Risperidone
Clozapine
Amisulpride??
How long to wait before reevaluating if prescribed medication is working in a schizophrenic patient?
*** 3 weeks
- Increase dose of the initial medication first,
- wait until 4-6 weeks
*** after 4-6 weeks
- change to another antipsychotic of the same generation (depending on positive/negative symptoms)
Common adverse effect of Antipsychotics
Hyperprolactinemia (>2000 mIU/L)
galactorrhea
gynaecomastia
sexual dysfunction
infertility
amenorrhoea
Hyperactive Delirium
Patients with hyperactive delirium demonstrate features of restlessness, agitation and hyper-vigilance. They often experience hallucinations and delusions but have no insight.
Lewy Body Dementia
Dementia with Lewy Bodies is characterised: -impaired cognition
- fluctuating levels of
awareness and attention
- Parkinsonism (ataxic gait)
- visual hallucinations
- sleep disorders. They
- tend to lack insight into the visual hallucinations
ANXIETY DISORDERS
Generalised Anxiety Disorder (GAD) Dx
Excessive anxiety/worry occurring on most days for at least 6 months (“chronic”)
Associated with 3 or more of the 6 symptoms.
ANXIETY DISORDERS
Generalised Anxiety Disorder (GAD) Sx
“MISERA-ble”
M - Muscle tension
I - Irritability
S - Sleep (decreased)
E - Energy (easy fatigue)
R - Restlessness, feeling keyed up, on the edge
A - Attention (Mind going blank or difficulty concentrating)
Not due to medical/ substance abuse/other
psychiatric disorders.
ANXIETY DISORDERS
Generalised Anxiety Disorder (GAD) Mx
Therapy CBT/SPS (structured problem solving) - should always be first-line treatment
If severe or CBT ineffective after 3 months,
then SSRI can be introduced.
(SSRIs are decreased and ceased if patient is
symptom free for 6 months)
Other options
- Buspirone - anxiolytic
- Benzodiazepines (short term of 2 weeks
and tapered over next 2 weeks; although it
has a more rapid effect it can easily lead to
physical dependence and should not be
used as long-term treatment)
- SNRI
- Beta blockers - if associated palpitation,
tremors.
ANXIETY DISORDERS
Panic Attack Dx
- Intense ACUTE fear or discomfort
- in which 4 or more symptoms develop abruptly
- reaches a peak in 5-10 minutes (crescendo-decrescendo pattern)
ANXIETY DISORDERS
Panic Attack Sx
STUDENTS Fear C’s
S - Sweating
T - Trembling - shaking
U - Unsteadiness or Dizziness/Faintness
D - Derealisation/depersonalisation/
dissociation
E - Elevated HR (Tachycardia/Palpitations)
N - Nausea
T - Tingling (Paresthesia)
S - Shortness of breath/ smothering sensation
FEAR - Fear of dying, Fear of loosing control or going crazy
C’S
= Choking feeling
= Chills - hot flushes
= Chest pain/tightness
ANXIETY DISORDERS
Panic Disorder Dx
1/6 people with panic attacks will develop panic disorder
Panic Disorder results from anxiety about having future panic attacks that impact one’s ability to lead a normal life
“SURP-rise”
S - Sudden (without a trigger)
U - Unexpected
R - Recurrent
P - Panic attacks
Rise anxiety
Not associated with substance abuse
ANXIETY DISORDERS
Panic Attack/Disorder Mx
FIRST: exclude medical condition. (acute
MI, asthma, thyrotoxicosis).
At the time of attack:
- slow breathing technique (if
hyperventilating)
- distraction methods
- benzodiazepines
Treatment to prevent further attack
- CBT (stress management, exposure and
desensitisation)
- avoid caffeine
if Psychotherapy is not working - SSRI or
buspirone.
- should be used in conjunction with CBT
ANXIETY DISORDERS
Agoraphobia
It is generally a specific coping mechanism that arises in response to having panic attacks/disorder where one begins to avoid going out at all preferring to stay in the safety of their own home (become housebound) where they feel less vulnerable to panic attacks - however, it can occur alone
it develops in about 1/4 of people with Panic Disorder (it is a marker of severe Panic Disorder
ANXIETY DISORDERS
Social Phobia/ Social Anxiety Disorder
Persistent fear of interpersonal rejection
Affected individuals avoid social or performance situations in fear they’ll embarrass themselves or be judged as anxious or stupid
ANXIETY DISORDERS
Diseases that often present with anxiety as chief complaint and their differences
- OCD (obsessional thoughts)
- Somatisation ( anxiety to physical sx)
- PTSD (re-experiencing trauma)
Medical conditions that often present as anxiety
Pheochromocytoma
Diabetes Mellitus
Temporal epilepsy
Hyperthyroidism
Carcinoid
Alcohol withdrawal
Arrhythmias
OCD
Definition of Compulsion
Compulsive behaviours are:
- repetitive actions driven by anxiety or distress;
- They often serve as a coping mechanism to alleviate stress or prevent a feared event or situation through a repeated behaviour
- Associated with negative reinforcer (taking something - ie anxiety - away)
≠
Impulsive behaviour are:
- spontaneous actions performed without forethought or consideration of the consequences
- These behaviours are driven by immediate desires
- Associated with positive reinforcer ( often meaning is pleasurable)
OCD
patients are egosyntonic or ego-dystonic with how they view their disorder?
Ego-dystonic = recognise one’s intrusive thoughts are not reflective (discordant) of their true desires (insight is preserved)
OCD Obsessive thoughts characteristics
“I MURDER”
I - Intrusive
M - Mind-based (not thought insertion)
U - Unwanted
R - Resistant
D - Distressing
E - Ego-dystonic
R - Recurrent
OCD
Clinical features
- obsessive thoughts and compulsive rituals
- Compulsions are “repetitive purposeful”, “intentional” behaviours conducted to prevent an adverse outcome
- While OBSESSIONS are REQUIRED for the diagnosis, COMPULSIONS are OPTIONAL (not everyone with obsessions will develop compulsions; however, everyone with compulsions will have obsessions)
OCD
Epidemiology
- Men and women are “EQUALY” affected
- once of symptoms often during childhood or young adulthood (< age of 20-30)
OCD Mx
optimal management always include a combination of both>
CBT (ERP = exposure & response prevention)
\+
SSRI
NOTE: Alcohol makes OCD symptoms feel better for a while, however, it is not recommended as a therapy due to the risk of alcohol abuse
NOTE: “CLOMIPRAMINE” is a TCA and can be used as a second-line alternative if CBT+SSRI have failed or in more severe cases of OCD
NOTE Neurosurgery (i.e cynguloctomy) is reserver for severe/refractory cases
Risks of developing Obsessive Compulsive Disorder
- Anxiety
- Depression
- Alcohol or substance misuse
- Eating disorders
- Body dysmorphic disorders
- Chronic physical health problems (skin problems due to excessive hand washing)
BODY DYSMORPHIC DISORDER
Key features
“FIX ME DOC”
FIX - Fixation on perceived flaw
M - Medical care-seeking
E - Ego-Syntonic
D - Disabling
O - Obsessive thoughts
C - Compulsive behaviours
BODY DYSMORPHIC DISORDER
patients are ego-syntonic or ego-dystonic with how they view their disorder?
Ego-syntonic
Patient does not admit that their fears and preoccupations are extreme or excessive
BODY DYSMORPHIC DISORDER Mx
CBT ± SSRI
Comorbid conditions found with BDD
- Anxiety
- Social Phobia
- OCD
- Delusional disorder
- Alcohol or substance misuse
HYPOCHONDRIASIS Dx
Illness Anxiety Disorder
fears and symptoms persist for ≥ 6 months
HYPOCHONDRIASIS
features
- Preoccupation with or fear of having (as opposed to getting) a serious disease, despite medical reassurance, leading to significant distress/impairment.
- Ego-syntonic (involuntary/non-volitional & unconsciously)
- Often involves history of prior physical disease.
HYPOCHONDRIASIS Mx
- group therapy ± SSRI
- schedule regular appointments with the patient’s primary caregiver (if existing)
Difference between Hypochondriasis & Somatisation
Hypochondriasis:
patient presents with a diagnosis
focus on the disease, not a particular symptom
failure to respond to reassurance
Somatisation: - presents with a variety of unexplained sx - primary focus of preoccupation/concern with the symptoms themselves
PTSD Signs & Symptoms
“TRAUMA”
T - Trauma core
R - Re-experiencing core
A - Arousal core
U - Unable to function
M - Month ( present > 4 weeks)
A - Avoidance core
PTSD
Trauma features
Must be:
- life-threatening
- actual or threatened physical and/or sexual violence
- secondary exposure to a traumatic event (such as about a spouse or family member) also qualifies
NOTE: other non-life-threatening events such as harassment and non-violent bullying do not “qualify” as trauma per DSM-5 (despite these being distressing and resulting in S/S indistinguishable from PTSD) and ADJUSTMENT DISORDER with ANXIOUS MOOD should be considered
PTSD
Arousal phenomenon
Persistent (chronic) and generalised
- Hyper-arousal State:
increased anxiety and awareness - hyper-vigilance:
constant scanning of their environment for
clues to the presence of danger - MISERA-ble = MUSCLE tension, IRRITABILITY, trouble with SLEEP, low ENERGY, RESTLESSNESS, inability to pay ATTENTION (poor concentration and memory) to non-trauma related stimuli
PTSD Timing
Symptoms must be present for at least 1 month
NOTE: it does not necessarily mean that symptoms have to present in the first month after the trauma occurs (delayed onset is more characteristic)
ACUTE: symptoms last < 3 months
CHRONIC: symptoms last > 3 months
DELAYED ONSET: Sx appear at least 6 months
after traumatic event
PTSD vs ACUTE STRESS DISORDER
When the core trauma-related symptoms have not yet reached ONE month in length
NOTE: the presence of ASD immediately following a traumatic event does not rule in later development of PTSD, nor does its absence rule it out
PTSD Avoidance features
– physical avoidance (people, places, things)
– Psychological avoidance (emotionalnumbing)
an attempt to protect against strong negative
emotions; however, interferes with ability to
experience positive emotions such as joy
(flattening affect), satisfaction, love
(detachment from others)
PTSD Risk factors
- alcohol and drug abuse
- previous history of depression
- previous history of sexual abuse.
- Victims of domestic violence
PTSD
Features that predict a higher chance of having PTSD one year from the incident
- the intentional nature of the trauma
(eg sexual abuse/rape/assassination attempt) - Experiencing the trauma alone
- lack of social support network
- presence of at least one pre-trauma psychiatric diagnosis
NOTE: Onset of symptoms soon after the traumatic event (ie ACUTE DISTRESS DISORDER)
PTSD Mx
- CBT (FIRST-LINE TREATMENT)
- trauma-based psychotherapy, crisis
intervention therapy, - EMDR (eye movement desensitisation and
reprocessing therapy)
- trauma-based psychotherapy, crisis
- Life-style modifications (sleep hygiene,
relaxation techniques) - If not responding, then SSRI (it does not help specifically with either sleep or nightmares)
ADJUSTMENT DISORDER
with ANXIOUS MOOD or DEPRESSIVE MOOD
features:
Diagnostic criteria:
onset of anxiety/depression symptoms within 3 months of identifiable psychosocial stressor(s)
which:
- are time-limited (Once the stressor or its consequences have terminated, the symptoms do not persist for more than 6 months)
- Aren’t severe enough to meet criteria for MDD or GAD and incurs in response to as stress that isn’t life-threatening or violent enough to be trauma
- are in excess of normal expectations of reaction to the stressor(s)
- are not due to another identifiable mental disorder
- are not part of a continuing pattern of overreaction to stress impair social or occupational functioning.
- Significant impairment in social,
occupational, or other important areas of
functioning
ADJUSTMENT DISORDERS
Mx
- primary interventions = psychological supportive therapy including counselling, relaxation, problem solving, stress management, and cognitive behavioural therapy (CBT)
- short-term pharmacotherapy (usually less than 2 wks) with BZP = if the symptoms are severe, if significant impairment of functioning and there is inadequate response to psychological interventions.
NOTE: Intermittent use, on occasional days when there is a severe exacerbation of anxiety, may suffice and is preferable to continuous treatment.
NOTE: Most drugs used to treat anxiety (ie [SSRIs]) take a number of weeks to produce an
effect, thus in this situation the use of a BZP may be appropriate
ADDICTION/SUBSTANCE ABUSE vs OCD
Compulsive vs. Impulsive:
The primary difference between compulsive and impulsive behaviours lies in their motivation and execution.
- Compulsive behaviours stem from an internal drive to alleviate the fear and anxiety triggered by obsessive thoughts
- Impulsive behaviours are spontaneous and often driven by desires.
ADDICTION/SUBSTANCE ABUSE
overall pattern
- Repeated use
- Reinforcers (Positive)
- Repercussions (Njuegative)
ADDICTION/SUBSTANCE ABUSE
Stimulants intoxication/overdose Sx:
— cardiovascular effects
- tachycardia
- hypertension
- arrhythmias
— central nervous system (CNS) excitation
- euphoria, agitation
- delirium
- seizures
— neuromuscular features
- hyperreflexia
- tremor
— autonomic effects
- hyperthermia
- diaphoresis
- flushing
- pallor
- mydriasis
— gastrointestinal effects
- nausea, vomiting, diarrhoea.
ADDICTION/SUBSTANCE ABUSE
Stimulants withdrawal Sx:
- hypersomnia
- hyperphagia
- irritability and aggression
- depression (low energy, low mood, apathy)
- craving
ADDICTION/SUBSTANCE ABUSE
Stimulants
overdose Mx
- There is almost no role for decontamination in stimulant drug toxicity and there is significant risk and difficulty inadministering it.
- In rare cases, when patients present early (within 1 hour after ingestion) and their clinical status
allows them to protect their airway, activated charcoal may be considered -
Agitation: benzodiazepines
diazepam VO if patient cooperative
lorazepam IV if not cooperative -
Hypertension:
nitrates (nitroprusside)
NOTE: Beta-blockers are contraindicated in
treatment of stimulant drug induced
hypertension
Hyperthermia: If temperature > 39 °C = be cooled
using active measures
Seizures: 1st line - IV benzodiazepines (Diazepam,
Midazolam, Lorazepam
- If not IV line –» IM midazolam
2nd line - Phenobarbital
Do not give diazepam by intramuscular injection as absorption is poor and erratic - Onset of action is not much faster than with VO and there is a greater likelihood of causing severe adverse effects - such as respiratory depression.
If an injection necessary:
- it must not be diluted
- must be given slowly over several minutes (to minimise the risk of respiratory depression or arrest.
ADDICTION/SUBSTANCE ABUSE
Stimulants dependence Mx:
- little conclusive evidence on the effectiveness of pharmacotherapeutic interventions
- psychological interventions, such as CBT
ADDICTION/SUBSTANCE ABUSE
Benzodiazepines Overdose/Poisoning Sx
— CNS effects
* drowsiness
* sedation
* coma
* respiratory depression
— cardiac effects
* bradycardia and hypotension (with very
large overdoses)
— other effects
* hypothermia (with very large overdoses)
ADDICTION/SUBSTANCE ABUSE
Benzodiazepines Overdose/Poisoning Mx
NOTE I:
When taken alone in overdose full recovery is expected with good supportive care. Elderly patients and those with significant respiratory disease are more at risk of complications.
NOTE II:
Flumazenil has little role in managing benzodiazepine overdose ( it has a duration of action of approximately 45 to 60 minutes, after which time re-sedation may occur because most benzodiazepines have a much longer duration of action)
NOTE II:
There is no indication for activated charcoal in benzodiazepine overdose due to the rapid onset of sedation and good outcome with supportive care.
- Respiratory support is the primary treatment, but the majority of benzodiazepine overdoses do not require Intubation and ventilation.
(evidenced by decreased respiratory rate and raised partial pressure of carbon dioxide [PaCO2] on blood gas results). - Patients who have poor respiratory effort should not be administered oxygen in the absence of respiratory support
- Hypotension is initially treated with intravenous fluids
ADDICTION/SUBSTANCE ABUSE
Benzodiazepines Overdose/Poisoning: FLUMAZENIL USE
There are a few exceptions where use of flumazenil in management of benzodiazepine overdose is warranted, namely:
— ELDERLY or other patients with respiratory disease (eg chronic obstructive pulmonary disease)
where intubation should be avoided, as CNS depression with poor respiratory effort and poor cough may result in atelectasis and respiratory infection
— in the TREATMENT of CNS DEPRESSION due to iatrogenic over-treatment with benzodiazepines (eg in procedural sedation), where short-term use of flumazenil may be beneficial
— unintentional lone paediatric benzodiazepine ingestion with compromised airway and breathing
