Psychiatry Flashcards
What are the different categories of disorders within psychiatry?
- Mood Disorders
- Anxiety Disorders
- Thought Disorders
- Neurodevelopmental Disorders
- Personality Disorders
- Trauma and Stressor Disorders
- Obsessive-Compulsive Disorders
- Somatic Symptom Disorders
- Eating Disorders
- Substance related and Addictive Disorders
- Dissociative Disorders
- Sleep-Wake Disorders
What are Mood Disorders and give some examples of them
Mood disorders are characterized by disturbances in a person’s emotional state, which can range from depression to mania.
Examples:
- Major Depressive Disorder
- Bipolar Disorder (Type I and II)
- Dysthymic (Persistent Depressive Disorder) Disorder
- Cyclothymic Disorder
What are Anxiety Disorders and give some examples of them
Anxiety disorders involve excessive fear or anxiety and related behavioural disturbances.
Examples:
- Generalised Anxiety Disorder
- Panic Disorder
- Social Anxiety Disorder
- Specific Phobias
- Agoraphobia
What are Thought Disorders and give some examples of them
Thought disorders are characterized by abnormalities in thinking, perception, and behaviour, typically involving psychosis (delusions, hallucinations, disorganized thinking).
Examples:
- Schizophrenia
- Schizoaffective
- Brief Psychotic Disorder
- Delusional Disorder
- Depression with Psychosis
What are Neurodevelopmental Disorders and give some examples of them
These disorders typically present early in development and are characterized by developmental deficits that affect personal, social, and academic functioning.
Examples:
- Autism Spectrum Disorder
- ADHD
- Intellectual Disability
- Specific Learning Disorders
What are Personality Disorders and give some examples of them
Personality disorders involve enduring patterns of behaviour, cognition, and inner experience that deviate markedly from the expectations of the individual’s culture.
Examples:
- Emotionally Unstable Personality Disorder (Borderline)
- Antisocial Personality Disorder
- Narcissistic Personality Disorder
- Obsessive Compulsive Personality Disorder
- Avoidant Personality Disorder
What are Trauma/Stressor Related Disorders and give some examples of them
These disorders develop after exposure to a traumatic or stressful event and include both psychological and physiological symptoms.
Examples:
- Post-Traumatic Stress Disorder
- Acute Stress Reaction
- Adjustment Disorder
What are Obsessive-Compulsive Disorders and give some examples of them
These conditions involve obsessive thoughts and compulsive behaviours or other repetitive, ritualistic behaviours.
Examples:
- Obsessive-Compulsive Disorder
- Body Dysmorphia Disorder
- Hoarding Disorder
What are Somatic Symptom related Disorders and give some examples of them
These disorders are characterized by the presence of physical symptoms that are not explained by medical conditions and are often associated with significant psychological distress.
Examples:
- Somatic Symptom Disorder
- Illness Anxiety Disorder (hypochondriasis)
- Functional Neurological Disorder
- Factitious Disorder
- Malingering Disorder
What are Eating Disorders and give some examples of them
Eating disorders are characterized by abnormal eating habits that negatively affect health.
Examples:
- Anorexia Nervosa
- Avoidant/Restrictive Food Intake Disorder (ARFID)
- Bulimia Nervosa
- Binge Eating Disorder
What are Substance Related/Addictive Disorders and give some examples of them
These disorders involve the excessive use of substances (e.g., alcohol, drugs) or behaviours that lead to significant impairment or distress.
Examples:
- Alcohol Use Disorder
- Opioid Use Disorder
- Gambling Disorder
What are Dissociative Disorders and give some examples of them
These disorders involve disruptions in consciousness, memory, identity, or perception.
Examples:
- Dissociative Identity Disorder (DID)
- Dissociative Amnesia
- Depersonalisation/Derealisation Disorder
What are Sleep-Wake Disorders and give some examples of them
Sleep disorders involve problems with the quality, timing, and amount of sleep, leading to daytime distress and impairment.
Examples:
- Insomnia Disorder
- Narcolepsy
- Sleep Apnoea
What is the definition of ADHD?
Attention Deficit Hyperactivity Disorder
Is a neuro-developmental disorder characterised by features relating to inattention and/or hyperactivity/impulsivity that are persistent.
What is the epidemiology of ADHD?
- More common in Boys (M:F 4:1)
- Persists to adult hood in 30-50% of cases.
What is the Pathophysiology of ADHD?
- Executive Dysfunction resulting in disruption in regulation and control of thought processes in the brain
- Reduced levels of dopamine and noradrenaline
- Issues in the Mesolimbic (Dopamine) and Locus Coeruleus System (Noradrenaline) which regulate executive and stress responses
What are the causes/risk factors for ADHD?
Multifactorial
- Genetics 74% heritability
- 3-4x risk if siblings suffer
- Environment
- Pregnancy issues: Alcohol, Smoking, Prematurity, Infections, Low birth weight
What are the Subsets of ADHD?
What are the Signs and Symptoms of ADHD?
Inattentive: 31%
- Easily distracted and difficult to sustain tasks
- Difficult to organise tasks and activities
- Forgetful in daily activities
- Loses things often
- Doesn’t listen when spoken to directly
- Doesn’t follow through on instructions
Hyperactive/Impulsive: 7%
- Talks Excessively
- Cannot wait their turn
- “on the go”
- Interruptive or intrusive to others
- answer prematurely before questions are finished
- Spontaneously leave their seat when expected to sit.
Combined: 62% Mix of both features
- Emotional Dysregulation - Emotional response that doesn’t fit within traditionally accepted range.
What are some other disorders that ADHD patients also commonly suffer with?
- Anxiety and Depression
- Sleep disorders
- Autism Spectrum Disorder
- Learning Disabilities
What are some complications of ADHD?
- Persists to adulthood in 30-50% of cases
- Higher prevalence of Substance Abuse
- Increased suicide rates
- 25% incidence in prison.
What is the criteria used to make a diagnosis of ADHD?
International Classification of Diseases (ICD-11)
What are the criteria on the ICD-11 for a diagnosis of ADHD?
- Symptoms of Inattention, Hyperactivity or impulsivity (DSM says 6/9 Sx)
- Present for at least 6 months
- Onset should occur during Childhood (typically before 12 years)
- Significant Functional impairment in personal, social, academic or occupational functioning
- Impairment present in 2 or more settings
- Not better explained by an alternative mental health or neurodevelopmental disorder
What are some differentials for ADHD?
Learning Disabilities:
Characterised by difficulties in reading, writing, mathematics or other learning skills, often with normal attention span.
Conduct Disorder:
Presents with persistent pattern of antisocial behaviour, such as aggression or destructiveness.
Autism Spectrum Disorder:
Mood Disorders:
E.g. depression and bipolar disorder, can cause concentration problems and impulsivity
What screening tools may be used to aid a diagnosis of ADHD?
Children:
- Strengths and Difficulties questionnaire
- Conner’s rating Scale
Adults
- Adult ADHD Self-Report Scale (ASRS)
- Diagnostic Interview for ADHD in Adults (DIVA) Questionnaire
What investigations are done for ADHD?
Diagnosis is done primarily done using the ICD-11/DSM-5 criteria. But the following can also help:
- Comprehensive history and physical examination (Clinical Interview)
- 10 week watch and wait Observation of the individual’s behaviour and see if Sx resolve
- Teacher and parent reports or rating scales
- Nurse observation in classrooms
- Neuropsychological testing
What is the management of ADHD?
What is first line
What referral may be made?
What medications can be used?
What monitoring is required for the medications?
Non-Pharmacological
- Watchful waiting for up to 10 weeks
- Healthy diet and exercise.
- Behaviour management - including reward charts, positive redirection.
- Behavioural Therapies - CBT, Psychoeducation, interpersonal therapy is first line for management
If symptoms persist
- Referral to CAMHS
Pharmacological: Stimulant Medications (Amphetamines/Methylphenidate)
- First Line in children in Severe/uncontrolled Sx: Methylphenidate on 6 week trial basis
- Second line in children: Dexamfetamine or Atomoxetine
- Cannot be given to children <5 years
- Children should have weight and height monitored every 6 months
- First Line in Adults: Either Methylphenidate/Lisdexamfetamine
- Second line: Lisdexamfetamine
What is the Mechanism of Action of Amphetamines and Methylphenidate?
CNS Stimulants:
Dopamine and Noradrenaline re-uptake inhibitors
What monitoring is required when patients are started on Methyphenidate?
Methylphenidate has appetite suppressing effects and so can lead to impacts in growth and weight
- Weight and Height should be monitored every 6 months.
A baseline ECG should also be performed as these drugs are potentially cardiotoxic.
What are the side effects of Amphetamines and Methylphenidate?
- Cardiotoxic: perform Baseline ECG before starting treatment
- Insomnia
- Nausea and Vomiting
- Decreased Appetite
- Increased Blood pressure.
What is the definition of Major Depressive Disorder?
Major Depressive Disorder
It’s a common mental health disorder typified by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable
What is the epidemiology of depression?
- Lifetime risk is around 1 in 8 (12%)
- Increased prevalence in Females (F:M 2:1)
- Mean age of onset is 40 years (but becoming more present in younger people)
What causes/risk factors depression?
Genetics
- Family history of depression
- High concordance in twins
- Personal history of depression
Environmental:
- Stressful life events
- Childhood abuse
- Substance abuse
- Medical conditions
What are some key psychosocial contributors to developing depression?
Potential triggers (e.g. loss of a family member)
Home environment
Family relationships
Relationship with friends
Sexual relationships
School situations and pressures
Bullying
Drugs and alcohol
History of self harm
Thoughts of self harm or suicide
Family history
Parental depression
Parental drug and alcohol use
History of abuse or neglect
What is the Diasthesis-Stress Model?
A Stressful event in a person with pre-existing vulnerability has a greater likelihood of developing depression.
Therefore 2 people experiencing the same stressful event: one without pre-existing vulnerability may not develop depression whilst the other individual does.
What is the Pathophysiology of Major Depressive Disorder?
Monoamine Theory:
- Lack of monoamine neurotransmitters: Serotonin, Dopamine, Noradrenaline
- However low serotonin in healthy people doesn’t cause depression.
Hypothalamic Pituitary Axis Disturbance:
- Increase cortisol, Low dexamethasone suppression.
Immune System:
- Excessive cytokine release
What is the criteria used to Diagnose Major Depressive Disorder and what are the clinical features of the criteria?
DSM-5
Must have 5 or more /9 features Including at least 1 or more core features for 2 weeks and have clinical distress/functional impairment where the symptoms are not due to substances/other conditions
Core Features:
- Low Mood
- Anhedonia
Other Features:
- Weight gain/loss
- Sleep disturbance
- Fatigue/low energy
- Psychomotor retardation
- Inappropriate guilt/worthlessness
- Reduced concentration
- Recurrent thoughts of death
What are the symptoms of Depression?
- Core symptoms
- Emotional Symptoms
- Cognitive Symptoms
- Physical Symptoms
Core Symptoms
- Low mood
- Anhedonia (a lack of pleasure or interest in activities)
Emotional symptoms include:
- Anxiety
- Irritability
- Low self-esteem
- Guilt
- Hopelessness about the future
Cognitive symptoms include:
- Poor concentration
- Slow thoughts
- Poor memory
Physical symptoms include:
- Low energy (tired all the time)
- Abnormal sleep (particularly early morning waking)
- Poor appetite or overeating
- Slow movements
What are 2 scales that can assess the severity of Major Depressive Disorder?
Patient Health Questionnaire 9 (PHQ9)
- PHQ-9 < 16 = Less severe depression
- PHQ-9 >16 = More severe depression
Severity
- 5-9 indicates mild depression
- 10-14 indicates moderate depression
- 15-19 indicates moderately severe depression
- 20-27 indicates severe depression
Hospital Anxiety and Depression (HAD) Scale:
- 14 questions - 7 for anxiety and 7 for depression
- Each question scored from 0-3 to produce a score out of 21.
- 0-7 normal, 8-10 borderline, 11 case
What are the main differentials for depression?
Bipolar Disorder
Anxiety Disorders
Substance/Medication-Induced Mood Disorder
Mood disturbance associated with intoxication or withdrawal from substances or side effects of medications.
Adjustment Disorders
Development of emotional or behavioural symptoms in response to identifiable stressors.
Various organic causes also need to be considered:
Neurological disorders
E.g. Parkinson’s disease, dementia, and multiple sclerosis.
Endocrine disorders especially thyroid dysfunction and hypo/hyperadrenalism (e.g., Cushing’s and Addison’s disease).
Substance use or medication side effects
e.g. steroids, isotretinoin, alcohol, beta-blockers, benzodiazepines, and methyldopa.
Chronic conditions
like diabetes and obstructive sleep apnea.
Long-standing infections
Neoplasms and cancers
low mood can theoretically be a presenting complaint in any cancer, with pancreatic cancer being a notable example.
What investigations are done for Depression?
Depression is primarily a clinical diagnosis using DSM-5 or ICD-11, with patients fulfilling the diagnostic criteria outlined above. Other investigations that are done can be:
- Patient Health Questionaire - 9 (PHQ-9)
- Hospital Anxiety and Depression Scale (HAD)
- FBC
- TFTs
- U+Es
- LFTs
- Blood glucose
- B12/Folate Levels
- Cortisol levels
- Toxicology Screen
- CNS Imaging
What is the Management Algorithm for Major Depressive Disorder?
Lifestyle Advice
First Line: Psychotherapy
- Favoured in Under 18s
- Should be trialled first line in less severe depression
Second Line: Mediation in combination with CBT
- For more severe depression
- For mild depression that hasn’t responded to psychotherapy.
What is the Non-Pharmacological Management of Depression?
Lifestyle Changes:
- Exercise and Diet changes
- Reduce alcohol and stop smoking
- Stop drug use
- Regular Schedule
Psychotherapies:
Less severe depression:
- Guided self-help
- Group Cognitive Behavioural Therapy (CBT)
- Interpersonal Therapy
More severe depression:
- Individual CBT (with medication)
- individual behavioural activation
What is the Pharmacological management of depression?
First-line pharmacological treatment:
- Selective Serotonin Reuptake Inhibitor (SSRI): Sertraline, Citalopram, Fluoxetine
- Fluoxetine is first line in children
- Selective Noradrenaline Reuptake Inhibitors (SNRI): Duloxetine, Venlafaxine (Work well in patients with associated pain disorders)
2nd line pharmacological treatment
- Atypical Anti-depressants: Mirtazapine
- Tricyclic Antidepressants (TCAs): Amitriptyline
- Monoamine Oxidase Inhibitors: Selegiline
What should be considered/informed when starting anti-depressant medications?
- Tend to take a few months to work where symptoms may get worse before they get better
- Continuation of antidepressants for at least six months post-remission is recommended to mitigate relapse risk.
- Tapering should be done gradually over a four-week period when discontinuing antidepressants.
What is the definition of Refractory Depression?
Its defined as a failure to demonstrate an adequate response to an adequate treatment trial
How is Refractory Depression Managed?
- Antipsychotics: Olanzepine, Quetiapine
- Lithium
Electroconvulsive Therapy (ECT) (After all other approaches have been tried). is safe and effected for Severe medication resistant and psychotic depression
- Requires a GA
- Electrodes trigger a short generalised seizure
- Side effects include: Headache, Muscle Ache, Memory loss (short term)
What is Depression with Psychosis?
Involves Depression with Psychotic features:
- Delusions
- Hallucinations
- Thought Disorder
What is the management of Depression with Psychosis?
Combination of:
- Antipsychotics (Olanzapine, Quetiapine)
- Antidepressants (Sertraline, Citalopram)
- ECT is an option
What is the definition of Austistic Spectrum Disorders (ASDs)?
ASDs are a set of complex neuro-developmental disorders, characterised by a spectrum of impaired social, communication, and behavioural deficits. and restrictive or repetitive patterns or interests
What is the epidemiology of Autistic Spectrum Disorders?
- Higher prevalence in Males (M:F 3/4:1)
- Prevalence of 1-2%
- Features normally present by age 3
- Around 50% of children with ASD have intellectual disability
What are some risk factors for developing an ASD?
Genetics:
- Male sex
- Advanced parental age at the time of conception
- Certain genetic mutations
- Maternal exposure to specific drugs or infections during pregnancy
Environment:
- No current clear risk factors
What deficits in social interaction might someone with Autism show?
- Lack of eye contact
- Delay in smiling
- Avoids physical contact
- Unable to read non-verbal cues
- Difficulty establishing friendships
- Not displaying a desire to share attention (i.e. not playing with others)
What deficits in communication might someone with Autism show?
- Delay, absence or regression in language development
- Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest
- Difficulty with imaginative or imitative behaviour
- Repetitive use of words or phrases
What behavioural traits may someone with Autism show?
- Greater interest in objects, numbers or patterns than people
- Stereotypical repetitive movements. There may be self-stimulating movements that are used to comfort
themselves, such as hand-flapping or rocking. - Intensive and deep interests that are persistent and rigid
- Repetitive behaviour and fixed routines
- Anxiety and distress with experiences outside their normal routine
- Extremely restricted food preferences
What criteria is used to diagnose Autism Spectrum Disorder?
DSM-5 criteria based on 2 major areas: Impairments in
- Social communication and Interaction
- Restricted or Repetitive behaviour/interests/activities
With
- Sx present in early developmental period
- Sx cause significant impairment
- Not better explained by intellectual disability
Diagnosis is made by an Autism Specialist
What other conditions are typically seen in people with ASD?
- ADHD (35%)
- Epilepsy (18%)
What are some differentials for ASDs?
Intellectual Disability
Characterised by generalised deficits in intellectual functioning and adaptive behaviour, typically lacking the social deficits seen in ASD.
Attention Deficit Hyperactivity Disorder (ADHD)
Exhibits symptoms of inattention, hyperactivity, and impulsivity, but does not exhibit significant social or language communication deficits as seen in ASD.
Specific Language Impairment
Characterised by difficulties in language acquisition in the absence of cognitive impairment. Unlike ASD, social interaction is not typically affected.
Childhood Schizophrenia
Characterised by hallucinations, delusions, and disorganised speech or behaviour, which are not typical in ASD.
How is an ASD diagnosed?
Diagnosis should be made through a multidisciplinary assessment completed by a specialist in autism.
This can involve:
- Psychological evaluation
- Speech and language assessment
- Cognitive assessment
- Thorough review of the child’s behaviour in different settings (home, school, etc.).
Who may be involved in the MDT for a patient with ASD?
Child and adolescent mental health services (CAMHS)
Psychologists
Speech and language specialists
Dieticians
Paediatricians
Social workers
Specially trained educators and special school environments
Charity organisations (e.g., National Autistic Society
What is the Management for Autism Spectrum Disorder?
MDT approach: focussing on Behavioural interventions and Family support
- Applied Behavioural Analysis (ABA)
- ASD Preschool program
- Family support and Counselling
- Family education on interaction and acceptance of child’s behaviour
- Medications: like SSRIs may be helpful for some symptoms
What is Bipolar Disorder?
Bipolar disorder is a chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression
What is the Epidemiology of Bipolar Disorder?
- Develops in the late teen years
- Lifetime prevalence of 2%
- Male:Female ration of 1:1
What are the risk factors for developing Bipolar Disorder?
Genetics:
- First degree family member = 10x risk
- 1 parent affected = 15-30% risk
- 2 parents affected = 50-75% risk
Environment:
- Stressors such as death, illness, relationships or financial problems
What are the types of Bipolar Disorder?
what is the condition ccalled if they dont meet criteria?
Type I: At least 1 episode of Mania with depression that follows (most common)
Type II: At least 1 episode of Major depression and an episode of Hypomania
Cyclothymic Disorder depressive and hypomania like episodes that do not meet the DSM-5 criteria
What is the DSM-5 criteria for mania/hypomania?
Mania: 3 or more features for >7 days AND impaired function or threat to others
Hypomania: 3 or more features for >4 days that do not cause impairment but may be observable to others
Features:
- Diminished need for sleep
- Sense of Grandiosity
- Pressured Speech
- Racing thoughts/ideas/Flight of ideas
- Distractibility
- Goal oriented behaviour
- Excessive pleasures
Psychosis features (delusions and hallucinations) suggest mania rather than hypomania
What is Mania/Hypomania?
Mania: Excessively elevated mood and energy that significantly impacts normal functions (caring and work responsibilities)
Hypomania: milder symptoms of mania without a significant impact on their function.
What is the clinical presentation of Bipolar Disorder?
It depends on the phase of the disorder:
Depressive Phase
- Withdrawal
- Tearfulness
- Low mood
- Poor sleep
- Anhedonia
- Potential suicidal ideation or attempts.
Manic Phase
- Elevated mood
- Irritability
- Disinhibition and sexual inappropriateness
- Impulsivity
- Reduced need for sleep
- Mood congruent delusions
- Pressured speech
- Flight of ideas.
What are some differentials for Bipolar Disorder?
Major Depressive Disorder
Characterised by low mood, loss of interest or pleasure, feelings of worthlessness, impaired concentration, and possible suicidality.
Schizoaffective Disorder
Presents with hallucinations, delusions, disorganised speech, disorganised behaviour, and symptoms of depression or mania.
Generalised Anxiety Disorder
Chronic and excessive worry, restlessness, fatigue, impaired concentration, and sleep disturbance.
Substance-Induced Mood Disorder
Mood disturbances caused by substance misuse or withdrawal.
How is Bipolar Disorder diagnosed?
ICD 10/11
- At least 2 episodes of significant mood disturbance
ICD10
- Where there is at least one or more episode of mania/hypomania
- and one or more depressive episodes
ICD 11
- Where each of the two episodes includes both Mania/hypomania and Depressive episodes
AND
- Significant impairment in social, occupational or other important areas of functioning
What is the acute management for Bipolar Disorder?
Acute manic episode (what else must be remembered)
Acute Depressive Episode
Acute Manic Episode:
- First Line: Antipsychotic medications: Olanzapine, Haloperidol, Risperidone
- Existing antidepressants are Tapered and stopped
- Other options: lithium, Sodium Valproate
Acute Depressive Episode:
- First Line: Olanzapine PLUS Fluoxetine
- Lamotrigine
- Psychotherapy: CBT
What is the chronic management for Bipolar Disorder?
Long-term maintenance therapy is crucial due to high relapse risk:
Mood stabilisers
- First line: Lithium
- Alternatives: Anti-epileptics (Sodium Valproate, Lamotrigine, Carbamazepine), Olanzapine
High-intensity Psychotherapies
- CBT, interpersonal therapy, or couples/family therapy better for managing depressive features
Resistant cases/very severe Bipolar disorder:
- Electroconvulsive therapy
- Transcranial Magnetic Stimulation
When should referrals be made by Primary care for Bipolar disorder?
Symptoms of hypomania then NICE recommend routine referral to Community Mental Health Team (CMHT)
Symptoms of Mania or Severe depression then NICE recommend urgent referral to CMHT
What are the side effects of Lithium?
LITHIUM:
Level - 0.4-1 mmol/l - Leukocytosis
Insipidus - Nephrogenic DI increasing ADH
Tremors (fine)
(de)Hydration - Dry mouth, Diarrhoea, Thirsty
Increased weight, calcium, PTH hormone and memory problems
Underactive thyroid (Decreased TSH) can also cause acute thyrotoxicosis
Mums aware - Epstein’s anomaly, Metallic Taste
What needs to be monitored when using Lithium?
What should be considered to avoid problems?
Renal and thyroid function
- Sodium restricted diet
- Diuretics and NSAIDs should be used with caution
Why are antidepressants rarely used as a monotherapy in the management of Bipolar disorder?
They can precipitate episodes of Mania
Fluoxetine is commonly used in combination with Olanzapine
Why does monitoring need to be done when taking lithium?
Monitoring for renal or thyroid dysfunction
- Serum lithium levels taken 12 hours after the most recent dose.
Monitoring for Lithium Toxicity
What are some features of lithium Toxicity?
What are some precipitants to Lithium Toxicity?
What is the management of Lithium Toxicity?
Features of Toxicity (TOXIC):
- Tremor (coarse)
- Oliguric renal failure
- ataXia (affects coordination, balance and speech)
- Increased reflexes
- Convulsions / Coma / loss of Consciousness
Precipitants: (4 D’s):
- Dehydration
- Drugs (NSAIDS,ACEis)
- Diuretics
- Depletion of Sodium
Management:
- Stop and withdraw Lithium
- Rehydrate with normal IV Saline Fluids
What considerations are made in regards to using Valproate as a mood stabiliser?
Valproate Pregnancy Prevention Programme
Define the term anxiety?
When may an individual be termed to have anxiety disorder?
A state of apprehension, uncertainty or uneasiness in anticipation of a real or perceived threat.
When these feelings are persistent and impact an individuals ability to function, they may be termed Anxiety disorder
What are some specific disorders that come under the umbrella term anxiety disorder?
- Generalised Anxiety Disorder
- Specific Phobias
- Panic Disorder
- Agoraphobia
- Social Anxiety Disorder
- PTSD
- Separation anxiety
- OCD
- Selective Mutism
What is the definition of a Generalised Anxiety Disorder (GAD)?
Generalised anxiety disorder (GAD) is defined as at least 6 months of excessive worry about everyday issues that is disproportionate to any inherent risk, causing distress or impairment.
What is the epidemiology of GAD?
Higher prevalence in Females
Higher prevalence in younger age groups (age of onset after 35 is more indicative of depressive disorder or organic disease).
What are some risk factors for GAD?
Comorbid anxiety disorders
Females (F:M 2:1)
Genetics: first degree relative
Childhood adversity
- Maltreatment (e.g. sexual or physical abuse), neglect.
- Maternal depression, family disruption (e.g. divorce).
- Domestic violence, parental alcoholism, or drug use.
Physical, sexual, or emotional trauma
- Physical or sexual abuse or assault.
- Motor vehicle accident.
- Sudden bereavement.
Sociodemographic factors
- Separated, widowed, divorced.
- Unemployment.
- Low socioeconomic status.
- Low education levels.
- Substance dependence or exposure to organic solvents
Chronic physical condition
How can you distinguish between different anxiety disorders?
Symptoms of Anxiety
- autonomic - palpitations, sweating, nausea, dizziness
- Motor Tension - headaches, fidgety
- Apprehension
Present for about a month
Panic Disorder come on acutely, in extreme bursts, no anxiety in between
Phobias come on in a particular situation/avoidance of that
GAD pervasive features present majority of the time
What is the criteria to diagnose GAD?
DSM-5 Criteria where symptoms last for 6 months with the anxiety being disproportionate to threat which has an impact on the individuals ability to function and these symptoms are not due to another medical condition or substance use
3 of the following 6 key symptoms are required for a diagnosis (only 1 in kids)
- Restlessness or nervousness
- Being easily fatigued
- Poor concentration
- Irritability
- Muscle tension
- Sleep disturbance
in combination with an inability to manage their worry
How is GAD severity assessed?
what are the results?
Generalised Anxiety Disorder Questionnaire (GAD-7)
- 5-9 indicates mild anxiety
- 10-14 indicates moderate anxiety
- 15-21 indicates severe anxiety
What are some differentials for GAD?
- Hyperthyroidism
- Substance abuse/withdrawal
- Panic disorder
- Depression
- Medications - Salbutamol, theophylline, corticosteroids, antidepressants and caffeine
- Avoidant personality disorder
How is GAD managed?
NICE suggest Step-wise approach:
- Step 1 (Mild GAD): Psychoeducation about Lifestyle (sleep, diet, exercise, smoking, alcohol, drugs) .Psychoeducation about GAD + active monitoring
- Step 2 (Mild GAD): low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
- Step 3 (Moderate-severe GAD): high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.
- Step 4 (Severe GAD): highly specialist input e.g. Multi agency teams
What is the Medication management of Generalised Anxiety Disorder?
First Line: Sertraline
Second Line: Alternative SSRI or an SNRI
Third Line: Pregabalin
Propranolol may be used to treat physical symptoms but doesn’t control underlying anxiety
Patients under 30 years should be warned of increased risk of suicidal thinking and self-half when starting medication
Define Panic Disorder
Recurrent panic attacks that may be due to a specific situation or without a trigger occurring for at least 1 month that leads to impact beyond the attacks (such as worry of having panic attacks)
What is the epidemiology of Panic Disorder?
- 1/3 people will suffer a panic attack
- 10% of these may have Panic Disorder
- Onset commonly in 20s
- More common in females
What are panic attacks?
Sudden onset intense physical and emotional symptoms of anxiety that come on within minutes and last for 10-20 minutes before the symptoms gradually fade.
What is the Criteria for Diagnosing Panic Disorder?
Recurrent panic attacks for at least 1 month where there is a sudden surge of fear/anxiety/physical discomfort which leads to the fear of having panic attacks and thus avoiding situations plus at least 4 of:
- Palpitations
- Sweating
- Trembling
- Sensation of breathlessness
- Sensation of chocking
- Chest pain/discomfort
- Nausea/abdominal discomfort
- Light-headedness
- Chills
- Paraesthesia
- Derealisation
- Fear of losing control
- Fear of dying
What is the management for Panic Disorder?
Stepwise approach:
- Step 1: recognition and diagnosis
- Step 2: treatment in primary care: CBT or SSRI (sertraline)
- Step 3: review and consideration of alternative treatments (No response after 12 weeks then try imipramine)
- Step 4: review and referral to specialist mental health services
- Step 5: care in specialist mental health services
What are the 3 common CAMHS anxiety disorders?
Separation anxiety
School Phobia
Selective Mutism
What are the features of Separation Anxiety?
4 week period
Most common anxiety disorder under 10
- Developmentally inappropriate
- Excessive worry about harm coming to primary care giver
- Causing pronounced stress and agitation
- Leading to inability to be separated (eg. school, bedtime)
What are the features of Selective Mutism?
Period of at least 6 months occurring most days
- Selective mutism is related to social anxiety disorder
- Fear of speaking in social contexts or situations
What are the features of School Phobia?
Significant anxiety symptoms
Fear of a specific part of school
Avoidance of School
What is the definition of Obsessive Compulsive Disorder (OCD)?
Obsessive-compulsive disorder (OCD) is a mental health disorder characterised by the presence of persistent obsessions and/or compulsions
These are time consuming (i.e. take more than 1 hour per day) and/or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
What are Obsessions?
Obsessions are unwanted and uncontrolled thoughts and intrusive images that the person finds it very difficult to ignore.
E.g. an overwhelming fear of contamination with dirt or germs; or violent or explicit images that keep appearing in their mind.
What are the 3 most common obsessions in OCD?
Contamination/Hygiene
Harm
Order/Symmetry and exactness (perfectionism)
What are Compulsions?
Compulsions are repetitive actions the person feels they must do, generating anxiety if they are not done. Often these compulsions are a way for the person to handle the obsessions.
E.g. checking that all electrical equipment is turned off to settle the anxiety of obsessing about the house burning down.
Describe the cycle of anxiety seen in OCD?
Obsessions lead to anxiety, which leads to the compulsive behaviour, which leads to a temporary relief in the anxiety.
Shortly after the temporary improvement in anxiety the obsession reappears, leading to further anxiety, further compulsive behaviour with a temporary relief.
This cycle continues and each time gets more engrained in the person’s behaviour. Without doing the compulsions, the person feels they cannot get relief from their anxiety.
What is the epidemiology of OCD?
It affects Males and Females equally (although presents earlier and more severely in males)
Affects around 3% of population
More common in pregnant and post-partum women
Bimodal age of onset, peaking at 10 and 21 years
What are the risk factors for developing OCD?
- Family history
- Age: peak onset is between 10-20 years
- Pregnancy/postnatal period
- History of abuse, bullying, neglect
- History of anxiety disorders
What is the diagnostic criteria for OCD?
OCD is a clinical diagnosis and according to the DSM-5 or ICD-11:
- Presence of obsessions, compulsions or both
- Time consuming (>1 hour a day) which causes clinically significant distress or functional impairment
- Cannot be attributed to substance use or medical condition
- Not better explained by another mental disorder
What scale is used to assess the severity of OCD symptoms?
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
What is the management for OCD?
Always give education and self help resources
Mild OCD
- First Line: CBT with exposure and response prevention ERP)
- Second Line: Offer SSRI or more intensive CBT
Moderate OCD
- Referral to CAMHS in children
- First line: Offer either SSRI (Sertraline, Fluoxetine, Paroxetine) or intensive CBT including ERP
- Second line: consider Clomipramine (if patient has previously had good response to it or SSRI is contraindicated
Severe OCD:
- Referral to Secondary Care Mental Health Team for assessment
- Offer combined treatment with SSRI and CBT (including ERP)
What is Exposure Response Prevention?
Used for OCD
Psychological method involving exposing a patient to anxiety provoking situations and stopping them engaging in their compulsion.
This helps to confront their anxiety and reduces the habituation of the response
What is the definition of Postpartum depression?
It’s a significant mood disorder that can develop at any time up to one year after the birth of a baby.
This condition represents a considerable aspect of maternal mental health and extends beyond the common “baby blues”.
Typically presenting with persistent depressive symptoms that may interfere with daily functioning and parenting.
What causes Postpartum depression?
Development of postpartum depression is multifactorial with a combination of Biological, Psychological, and Social factors all contributing.
What biological factors contribute to the development of postpartum Depression?
- Hormonal fluctuations post-delivery, including sudden drops in progesterone, estrogen, and thyroid hormones.
- Alterations in melatonin and cortisol rhythms and immune-inflammatory processes
- Genetic predispositions
What Psychological factors contribute to the development of postpartum Depression?
- A history of mood or anxiety disorders
- Previous episodes of postpartum depression
- Certain personality traits such as neuroticism
- Psychological stress from the transition to parenthood
- Unrealistic expectations of motherhood
What Social Factors contribute to the development of postpartum depression?
- Lack of social support
- Relationship issues,
- Life stressors
- Low socioeconomic status
What are the signs and symptoms of postpartum depression?
- Persistent lowering of mood and reduced enjoyment or interest in activities.
- Lowering of energy levels.
- Biological symptoms of depression like poor appetite and disturbed sleep patterns (not associated with normal disturbed sleep patterns with a baby)
- Concerns related to bonding with the baby, caring for the baby, and in extreme circumstances, thoughts about harming oneself or the baby.
What are some differentials for postpartum depression?
Baby blues
Characterised by mild mood swings, irritability, anxiety, and tearfulness. However, these symptoms usually present within the first two weeks after birth and resolve spontaneously.
Postpartum Psychosis
Adjustment disorders
These disorders may develop in response to a major life change or stressor, such as having a baby, but the emotional or behavioural symptoms are less severe than in depression.
Generalized Anxiety Disorder (GAD)
What is the main screening tool for Postpartum depression?
Edinburgh Postnatal Depression Scale (EPDS)
A cutoff score of over 10 is used as a positive result.
What is the management of postpartum depression?
First-line treatments:
- Self-help strategies and psychological therapies e.g. Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT).
Pharmacological treatments
- Antidepressants considered in high risk cases
In severe cases admission to a mother and baby inpatient mental health unit might also be necessary.
What is the definition of Postpartum Psychosis?
It’s a serious psychiatric disorder that typically develops within the first two weeks following childbirth.
It is characterised by a range of psychological symptoms, including paranoia, delusions, hallucinations, mania, depression, and confusion.
What are the risk factors for Postpartum Psychosis?
- Prior history of severe mental illnesses such as schizophrenia or bipolar affective disorder
- Family history of postpartum psychosis
- Previous episode of postpartum psychosis
What is the clinical presentation of Postpartum Psychosis?
Paranoia
Delusions
Hallucinations
Manic episodes
Depressive episodes
Confusion
What is the main differential for Postpartum Psychosis?
Postpartum depression with psychotic features
How is Postpartum depression diagnosed?
Diagnosis is predominantly clinical, based on the presenting signs and symptoms.
It requires a thorough psychiatric evaluation.
Consideration should be given to other medical conditions that may cause similar symptoms, such as thyroid disorders or sepsis.
How is Postpartum psychosis managed?
Pharmacotherapy with:
- Antipsychotic medications
- Mood stabilisers in some instances
Potential referral to a specialist mother and baby inpatient mental health unit in very severe cases (when the mother experiences command hallucinations, thoughts of self-harm or suicide, or delusional beliefs regarding the baby’s role or identity).
What needs to be considered when prescribing medications for Postpartum Psychosis?
The mother’s breastfeeding status and the potential for the transfer of drugs to the nursing infant.
What is the definition of Post Traumatic Stress Disorder (PTSD)?
A relatively common mental health condition resulting from traumatic experiences, with ongoing distressing symptoms and impaired function.
What is Direct Vs Indirect PTSD?
Direct: An individual experiences the trauma themselves
Indirect: An individual learns about the trauma from another source, witnesses the trauma happening to someone else or a loved one is affected
Give examples of traumatic events that may lead to PTSD?
- Violence (e.g., sexual assault, domestic violence, abuse or physical attacks)
- Major car accidents
- Major health events (e.g., traumatic childbirth, serious illness or death of a loved one)
- Natural disasters
- Military, combat and war zone events
Any event the individual finds traumatic has the potential to cause PTSD
What is the criteria for PTSD?
ICD-11 Criteria:
- Exposure to a traumatic event
- Development of 3 core symptom clusters for at least 2 weeks
- Re-experiencing
- Avoidance
- Persistent heightened current threat (hypervigilance)
- Causing Functional Impairment
- Not explained by another disorder or substance.
What are some symptoms of intrusion associated with PTSD?
- Recurrent/intrusive thoughts relating to the evvent
- Nightmares
- Flashbacks
- Physiological distress to reminders such as tachycardia, hypertension
What are some symptoms of avoidance associated with PTSD?
- Avoiding stimuli such as people, events or places
- This is to prevent reminders of the event
What are some Negative alterations in Mood associated with PTSD?
- Unable to recall certain aspects
- Distorted sense of self
- Fragmented recollection
- Fear, anger and Guilt
- Anhedonia
What are some symptoms of Arousal/reactivity associated with PTSD?
- Aggressive behaviour
- Feeling on edge, irritable, easily startled
- Hypervigilance
- Poor sleep/concentration
- Recklessness
What are some variants of PTSD?
Acute Stress Disorder
- Symptoms last less than 1 month
Complex PTSD
- Exposure to prolonged trauma
- Have PTSD symptoms PLUS: Emotional dysregulation, significant negative identity disturbance
What are some Risk Factors for PTSD?
- Type of Trauma: Assault based > Natural disaster base trauma
- Females > Males
- Pre-existing mental health conditions
- Childhood adversity
- Lack of social support
HARD
What is the clinical features of PTSD?
Hyperarousal/Hypervigilance: Poor sleep, irritability, poor concentration
Avoidance behaviours: avoiding people, places, events
Re-experiencing: Flashbacks, Nightmares, Repetitive and distressing intrusive images
Dull/emotional numbing: Feeling detached.
When is usually the time of onset for PTSD?
PTSD tends to develop soon after the event. It may be delayed, but delayed onset greater than a year post-trauma is very rare.
What are some differentials for PTSD?
Acute Stress reaction
Prolonged grief disorder
Depression
Adjustment disorders
Enduring personality change after catastrophic experience
What screening questionnaires are there for PTSD (1st line investigations)
Trauma Screening Questionnaire (TSQ)
A set of 10 items covering re-experiencing and arousal symptoms.
DSM-5 PTSD Checklist
A 20 item checklist assessing the symptoms of PTSD according to DSM-5.
What are the Non-Pharmacological managements of PTSD?
- watchful waiting for 4 weeks if traumatic event happened within the last month
- Psychotherapies:
- Trauma Focused Cognitive Behavioural therapy (TF-CBT)
- Narrative/Prolonged exposure therapy
- Eye Movement Desensitisation and Reprocessing (EMDR) Therapy
First Line for PTSD is TF-CBT
EMDR offered to patients presenting >3 months after non-combat related trauma
What is the Pharmacological management of PTSD?
First line:
- SSRI (e.g. sertraline/paroxetine)
- Venlafaxine
In serious cases that haven’t responded to previous drug or psychological therapies:
- Antipsychotics (like risperidone) in addition to psychological therapies
Define the term Learning Disability
Give some examples of LDs
It’s a general umbrella term encompassing a range of different conditions that affect the ability of the child to develop new skills.
Examples include:
- Dyslexia
- Dysgraphia refers to a specific difficulty in writing.
- Dyspraxia
- Auditory processing disorder
- Non-verbal learning disability
- Profound and multiple learning disability
They can vary from very mild to severe
What is the definition of Dyslexia?
It refers to a specific difficulty in reading, writing and spelling.
What is the definition of Dysgraphia?
It refers to a specific difficulty in writing.
What is the definition of Dyspraxia?
Also known as developmental co-ordination disorder.
It refers to a specific type of difficulty in physical co-ordination.
More common in boys.
It presents with delayed gross and fine motor skills and a child that appears clumsy.
What is the definition of Auditory processing disorder?
It refers to a specific difficulty in processing auditory information.
What is the definition of a Non-verbal learning disability?
It refers to a specific difficulty in processing non-verbal information, such as body language and facial expressions.
What is the definition of a Profound and multiple learning disability?
It refers to severe difficulties across multiple areas, often requiring help with all aspects of daily life.
How are Learning disabilities classified?
The severity of the learning disability is based on the IQ (intelligence quotient): < 70
55 – 70: Mild
40 – 55: Moderate
25 – 40: Severe
Under 25: Profound
What are the risk factors for Learning Disabilities?
- Family history of learning disability
- Abuse
- Neglect
- Psychological trauma
- Toxins
- Certain conditions
What conditions are associated with learning disabilities?
- Genetic disorders such as Downs syndrome
- Antenatal problems, such as foetal alcohol syndrome and maternal chickenpox
- Problems at birth, such as prematurity and hypoxic
- ischaemic encephalopathy
- Problems in early childhood, such as meningitis
- Autism
- Epilepsy
What does the management of learning disabilities involve?
The key is a multidisciplinary approach to support the parents and child:
Health visitors
Social workers
Schools
Educational psychologists
Paediatricians, GPs and nurses
Occupational therapists
Speech and language therapists
What are the features required to assess if someone has capacity to make a decision?
- Understand the decision that needs to be made
- Retain the information long enough to make the decision
- Weight up the options and the implications of choosing each option
- Communicate their decision
Define Psychosis
Psychosis is a term used to describe a person experiencing things differently from those around them as they have lost contact with reality
What are the 2 main causes of Phychosis?
Psychosis can be due to:
- Primary (“non-organic”) psychiatric disorders
- Secondary to substance use or specific medical (“organic”) aetiologies
Give some examples of primary psychotic disorders
Schizophrenia (most common)
Delusional disorder
Schizoaffective disorder
Schizophreniform disorder
Brief psychotic disorder
Bipolar disorder
Puerperal Psychosis
What are some secondary causes of psychosis?
- Brain tumours or cysts
- epilepsy
- Dementia
- Parkinsons
- MS
- Thyroid dysfunction
- Cushings
- Addisons
- CNS infections
- Liver disease (korsakoff psychosis)
- Substance induced
- Alcohol
What are the clinical psychotic features?
- Hallucinations (e.g. auditory)
- Delusions
- Thought disorganisation
- Alogia: little information conveyed by speech
- Tangentiality: answers diverge from topic
- Clanging
- Word salad: linking real words incoherently → nonsensical content
What are some common associated features of psychosis?
- Agitation/aggression
- Neurocognitive impairment (e.g. in memory, attention or executive function)
- Depression
- Thoughts of self-harm
How is Psychosis investigated?
- Physical examination
(detailed neurological examination and a complete mental status examination) - Complete psychiatric and medical history
(review of head injury, seizures, cerebrovascular disease, sexually transmitted infections, and new or worsening headaches) - Laboratory work-up
What lab work should be done for a Psychosis investigation?
FBC
Comprehensive metabolic profile
TFTs
Urine toxicology
Parathyroid hormone
calcium
vitamin B12
folate
niacin
Based on clinical suspicion, testing for HIV infection and hepatitis C,
What is the management of psychosis?
It depends on the underlying cause.
If Schizophrenia:
1st line is (2nd gen) atypical antipsychotics e.g. Risperidone or Olanzapine
Haloperidol is also still used
What is the definition of Schizophrenia?
It’s a severe mental disorder characterised by chronic or relapsing episodes of psychosis.
It involves altered perceptions of reality, disordered thinking, and social dysfunction.
Explain Schizophrenia in simple terms
Schizophrenia is a condition that affects how the brain processes information.
Normally, the brain is very good at understanding reality, deciding what is important and what is not, and organising thoughts in a structured way.
With schizophrenia, the brain struggles to understand the world, makes mistakes in deciding what information is important and organises thoughts in a confused way.
This can lead to strong beliefs that do not fit with reality, called delusions. They may also experience voices that are not there, called hallucinations.
The disorganised thoughts can lead to unusual speech and behaviours, which is called thought disorder.
When these symptoms occur, it is called psychosis.”
What are the risk factors for Schizophrenia?
-
Family History
- 10% if either a parent or sibling is affected
- 50% if both parents or a monozygotic twin
- Childhood trauma, like poor maternal bonding, poverty, or exposure to natural disasters
- Heavy cannabis use in childhood
- Maternal health issues, including malnutrition and infections like rubella and cytomegalovirus
- Birth trauma, particularly hypoxia and blood loss
- Urban living and immigration to more developed countries
What are Schneider’s First Rank Symptoms?
- Auditory hallucinations
- Thought disorders
- Passivity phenomena
- Delusional perceptions
What are the specific features of Schneiders first rank symptoms?
Auditory Hallucinations:
- Thought Echo: Hearing one’s own thoughts spoken aloud, as if they are echoing back.
- Voices Commenting: Hearing voices that provide a running commentary on the person’s actions or thoughts.
- Voices Conversing: Hearing multiple voices talking to each other, usually discussing the person in the third person.
Thought Disorder
- Thought Insertion: The belief that thoughts are being inserted into one’s mind by an outside force.
- Thought Withdrawal: The belief that one’s thoughts are being taken out or removed by an external force.
- Thought Broadcasting: The belief that one’s thoughts are not private but are being broadcasted or accessible to others.
Delusional Perception:
- The person has a normal perception (like seeing a particular object or event) but interprets it with delusional significance, such as thinking the perception has a unique or personal meaning (e.g., seeing a red car and concluding that it means they are being watched).
Passivity Phenomena (or Delusions of Control):
- Made Actions: Belief that one’s actions are controlled by an external force, as though someone else is “making” them move.
- Made Impulses: Belief that impulses to act are not one’s own but are imposed by an external force.
- Made Feelings and Emotions: Belief that one’s emotions or sensations are being controlled or influenced by someone else.
What is the typical presentation of Schizophrenia?
Prodrome Phase
- Precedes full symptoms of psychosis
- May experience Sx such as poor memory, reduced concentration, mood swings, suspicion of others, sleep issues, social withdrawal
Psychosis and positive symptoms: (ABCD)
- Auditory hallucinations
- Broadcasting/insertion/blocking of thoughts
- Control issues ie. passivity phenomena
- Delusional perceptions
- Ideas of reference
Negative Symptoms ‘4 A’s’
- Alogia (Poverty of Speech)
- Avolution (Lack of motivation)
- Affect blunting or incongruity (Minimal emotional reaction)
- Anhedonia (Lack of interest)
Miscellanous Symptoms ‘2 C’s’
- Catatonia
- Cognitive: impaired memory + attention deficit + reduced executive function
What is Catatonia?
- Catatonia involves abnormal movement, communication and behaviour. It can present in a variety of ways.
- Patients are awake but not behaving normally.
- They may hold unusual postures, perform odd actions, repeat sounds or words, or remain blank and unresponsive.
- The symptoms can vary in severity over time.
What are the positive symptoms of Schizophrenia?
- Auditory hallucinations (hearing voices, particularly a voice narrating the patient’s actions)
- Somatic passivity (believing that an external entity is controlling their sensations and actions)
- Thought insertion or thought withdrawal (believing that an external entity is inserting or removing their thoughts)
- Thought broadcasting (believing that others are overhearing their thoughts)
- Persecutory delusions (a false belief that a person or group is going to harm them)
- Ideas of reference (a false belief that unconnected events or details in the world directly relate to them)
- Delusional perceptions
What are the negative symptoms of Schizophrenia?
- Affective flattening (minimal emotional reaction to emotive subjects or events)
- Alogia (“poverty of speech” – reduced speech)
- Anhedonia (lack of interest in activities)
- Avolition (lack of motivation in working towards goals or completing tasks)
What are the different pattern types observed in Schizophrenia?
- Continuous
- Episodic (relapsing and remitting)
- Single Episode Only
What are some differentials for Schizophrenia?
- Schizoaffective Disorder
- schizophreniform Disorder
Others:
- Mania
- Psychotic depression
- Drugs (e.g., hallucinogens and cannabis)
- Stroke
- Brain tumours
- Cushing’s syndrome (e.g., patients taking systemic steroids)
- Hyperthyroidism
- Huntington’s disease
How long do you need to have symptoms of Schizophrenia for to be diagnosed?
- Symptoms including the prodrome phase must have been present for at least 6 months
- Symptoms of the active phase (delusions, hallucinations and thought disorder) must have been present for at least 1 month
What is the DSM-5 Criteria for a diagnosis of Schizophrenia?
- 2 or more symptoms of:
- Delusions
- Hallucinations
- Disorganised Speech
- Disorganised/Catatonic Behaviour
- Negative Symptoms
- Of which at least one of of either:
- Delusions
- Hallucinations
- Disorganised Speech
- Symptoms must have been actively present (most of the time) for 1 or more months
- Symptoms (including Prodrome) must have had significant impact for at least 6 months
- Symptoms cannot be due to substances or other medical conditions
What investigations may be done to rule out other potential differentials in Schizophrenia?
- Brain imaging (CT/MRI) to rule out structural abnormalities
- Blood tests to exclude infectious (e.g.,HIV, syphilis) or metabolic causes (e.g., thyroid function tests)
- Drug screening to identify substance misuse
What is the management of Schizophrenia?
1st line
acute episodes
resistant to therapy
Other
1st Line:
- Second-generation (atypical) antipsychotics e.g. Risperidone
In acute episodes:
- Sedatives (e.g. lorazepam, promethazine, or haloperidol) to manage dangerous behaviour.
when schizophrenia is resistant to other antipsychotics (2 have been tried)
- Clozapine is considered (Due to its potential lethal side effects, it requires intensive monitoring.)
Psychotherapy, such as cognitive-behavioural therapy offered to all patients
Give some examples of some Oral Antipsychotics for Schizophrenia?
What can be done if adherence is poor?
- Quetiapine
- Aripiprazole
- Olanzapine
- Risperidone
Depo IM injections
- Aripiprazole
- Flupentixol
- Paliperidone
- Risperidone
What is the definition of Schizoaffective disorder?
Schizoaffective disorder combines the symptoms of schizophrenia with bipolar disorder. Patients have psychosis and symptoms of depression and mania.
Define Schizophreniform Disorder
Features of Schizophrenia lasting between 1 day and 1 month
Define Somatisation Disorder
Somatic symptom disorder or Briquet’s Syndrome
- A psychiatric condition characterized by the presence of multiple, recurrent and clinically significant somatic complaints that cannot be fully explained by any underlying medical conditions
- Present for at least 2 years
What are the risk factors for Somatisation Disorders?
- History of IBS
- History of PTSD
- History of sexual or physical abuse
What is the typical presentation of Somatic Syndrome?
Symptoms that are generally severe enough to affect work and relationships and lead the person to consult a doctor and take medication.
A lifelong history of ‘sickliness’ is often present:
Stress often worsens the symptoms.
Examples include:
- Cardiac (SOB, Palpitations, Chest Pain)
- GI (Vomiting, Abdominal pain, nausea, diarrhoea)
- MSK ( Back pain, Joint pain)
- Neurological (Headaches, dizziness, amnesia, vision changes, paralysis or muscle weakness)
- Urogenital (Pain during urination, low libido, dyspareunia, impotence).
How is Somatic Syndrome Diagnosed?
Somatisation is often a diagnosis of exclusion but it’s much more effective to pursue a positive diagnosis when the patient presents with typical features:
- multiple symptoms, often occurring in different organ systems.
- Symptoms are vague or that exceed objective findings.
At least 6 months
cause significant distress and impairment
not attributed to specific medical or other psychiatric conditions
What is the management of Somatic Syndrome?
1st Line treatment is Psychotherapy, and Cognitive behavioural therapy shows the best outcomes
Pharmacological interventions show little effect on the disease although psychiatric disorders associated with somatisation like anxiety and depression can be treated with antidepressants which will often improve somatic symptoms.
