Psychiatry Flashcards
Define depression?
Causes of depression?
Depression is a disorder that causes persistent feelings of low mood, low energy and reduced enjoyment of activities. It affects people of all ages and from all backgrounds.
Depression may be triggered by life events (e.g., the loss of a loved one). However, it can occur without any apparent triggers. It is thought to be caused by genetic, psychological, biological and environmental factors. Having an affected relative is a significant risk factor.
Physical health conditions can trigger or exacerbate depression, and it commonly occurs with conditions such as stroke, myocardial infarction, multiple sclerosis and Parkinson’s disease.
Presentation of Depression?
Environmental and Essential factors to explore when taking a history
Came up - what should every encounter for depression include?
The core symptoms of depression are:
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
Environmental factors may contribute to the condition, such as:
Potential triggers (e.g. stress, grief or relationship breakdown)
Home environment (e.g., housing situation, who they live with and their neighbourhood)
Relationships with family, friends, partners, colleagues and others
Work (e.g., work-related stress or unemployment)
Financial difficulties (e.g., poverty and debt)
Safeguarding issues (e.g., abuse)
Essential factors to explore when taking a history include:
Caring responsibilities (e.g., children or vulnerable adults)
Social support
Drug use
Alcohol use
Forensic history (e.g., violence or abuse)
Every encounter should include a risk assessment for:
Self-neglect
Self-harm
Harm to others (including neglect)
Suicide
What should be considered in a psychiatric risk assessment?
when are they performed?
Every encounter for depression should include a risk assessment for:
Self-neglect
Self-harm
Harm to others (including neglect)
Suicide
Also in Self harm, acute mental health crisis, pyschosis….
My summary: Depression history in primary care…
I made this based on nice cks
- effect on daily function
- current lifestyle - diet, sleep, alcohol and substance use
- past history of self harm or suicde
- co-exsisting mental health problems - including psychotic symptoms
- supportive relationships
- Forensic history
- Risk assessmenet: Risk of harm to self, others
Pathophysiology of depression
Mechanism is poorly understood but appears to involve a disturbance in neurotransmitter activity in the CNS, partiuclarly serotonin (5-HT).
This makes sense, considering that medications that boost serotonin are effective treatments.
The cause is often described as “a chemical imbalance” or “low levels of serotonin”, which may be helpful as a simple explanation but is probably overly simplistic.
Investigations for depression?
The key investigation used to screen for and assess the severity of depression is PHQ-9 (patient health questionnaire). There are nine questions about how often the patient is experiencing symptoms in the past two weeks. The higher the score, the more severe the depression:
<9 indicates mild depression
10-19 indicates moderately severe depression
>20 indicates severe depression
Textbook - Run routine bloods to look for an organic cause - hypothyroidsim, anaemia, diabetes
Management options for depression - 4 key points
2 Key Support options for a mental health crisis? - 2
Management of Unresponsive or severe depression? - 3
Management options for depression include:
- Active monitoring and self-help
- Address lifestyle factors (exercise, diet, stress and alcohol) - see below - exercise efficacy is comparable to antidepressants or therapy
- Therapy (e.g., cognitive behavioural therapy, counselling or psychotherapy)
- Antidepressants (selective serotonin reuptake inhibitors are first-line). NICE - do not recommend offering antidepressants first-line to patients with less severe depression (defined as less than 16 on the PHQ-9) unless they have a preference for taking antidepressants
Basically one point for Bio, pyscho, social
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Mental Health crisis management:
The crisis resolution and home treatment team offer intensive support and treatment for patients having a mental health crisis without them being admitted to hospital (usually for a short period only).
Admission may be required where there is a high risk of self-harm, suicide or self-neglect or where there may be an immediate safeguarding issue.
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Additional specialist treatments for unresponsive or severe depression include:
Antipsychotic medications (e.g., olanzapine or quetiapine)
Lithium
Electroconvulsive therapy
What is psychotic depression?
Management
Psychotic depression involves the symptoms of psychosis. Psychosis involves:
Delusions (beliefs that are strongly held and clearly untrue)
Hallucinations (hearing or seeing things that are not real)
Thought disorder (disorganised thoughts causing abnormal communication and behaviour)
When psychosis accompanies depression, it generally indicates severe depression, although psychosis can occur with mild or moderate depression.
Treatment involves a combination of:
- antipsychotic drugs (e.g., olanzapine or quetiapine)
- antidepressants.
- Electroconvulsive therapy (ECT) is also an option.
What is ECT?
Anaesthesia used?
Indications?
Side effects?
Electroconvulsive therapy is the passage of a small electrical current through the brain with the aim of inducing a generalised bilateral clonic seizure for at least 30 seconds which is therapeutic.
The electical dose whould be sufficiently above the individual seizsure threshold to be clinically effective but not so high that it contributes the cognitive adverse effects of treatment.
The mechanism of action is not fully understood but it is thought to alter the neuroanl membrane permiability and therefore reduce activty in reverberating circuits between the limbic system and pre-frontal cortex. DONT MEMORISE THIS.
The procedure occours under general anaethetic and a muscle relacant (suxamethonium) is given to limit the motor effects of the seizure.
Can be bilateral (one electrode on each side of the head) or unilateral (both of the non-dominant cerebral hemisphere). Bilateral is more effective but with more cognitive side effects.
The patient usually required 6-12 treatment sessions, delivered twice a week.
Indications - ECT - Euphoric, catatonic, tearful
- E - treatment reistant mania
- C- catatonia in schizoprenia
- T - tearful - severe life threatening/ treatment-resistant depression/psychotic depression
SEVERE DEPRESSION IS THE MOST COMMON INDICATION
Side Effects:
- headache and post treatment confusion
- muscle aches
- short term memory loss
- prolongued seizure and status epilcticus
- dental trauma
Post Natal depression:
What is the spectrum of postnatal mental health issues?
When does each occur?
There is a spectrum of postnatal mental health issues:
- Baby blues is seen in the majority of women in the first week or so after birth
- Postnatal depression is seen in about one in ten women, with a peak around three months after birth
- Puerperal psychosis is seen in about one in a thousand women, starting a few weeks after birth
What are baby blues?
Management?
Baby blues affect more than 50% of women in the first week or so after birth, particularly first-time mothers.
It presents with symptoms such as mood swings, low mood, anxiety, irritability and tearfulness.
Baby blues may be the result of a combination of significant hormonal changes, recovery from birth, sleep deprivation, increased responsibility and difficulty with feeding.
Symptoms are usually mild, last only a few days and resolve within two weeks of delivery. No treatment is required.
What is post-natal depression?
Management?
Postnatal depression is similar to depression that occurs outside of pregnancy, with the classic triad of low mood, anhedonia (lack of pleasure in activities) and low energy.
Typically, women are affected around three months after birth. Symptoms should last at least two weeks before postnatal depression is diagnosed (me - usually lasts a few months).
Treatment is similar to depression at other times, depending on the severity:
Mild cases may be managed with additional support, self-help and follow up with their GP
Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy
Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit
Screening test for post natal depression?
Interpretation of results?
The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week as a screening tool for postnatal depression. There are ten questions, with a score out of 30 points.
A score of 10 or more suggests postnatal depression.
What is puerperal psychosis?
4 Management?
Puerperal psychosis is a rare (0.2% women) but severe illness that typically has an onset between two to three weeks after delivery. Women experience full psychotic symptoms, such as:
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
Women with puerperal psychosis need urgent assessment and input from specialist mental health services.
Treatment is directed by specialist services, and may involve:
- Admission to the mother and baby unit
- Cognitive behavioural therapy
- Medications (antidepressants, antipsychotics or mood stabilisers)
- Electroconvulsive therapy (ECT)
What is Mirtazapine?
Key side effects
An anti-depressant medication.
Mirtazapine has key side effects of sedation, increased appetite and weight gain. It is taken at night due to the sedative effect. The sedative effect appears to be greatest at low doses (e.g., 15mg) and less present at higher doses (e.g., 45mg).
Mirtazapine is less likely to cause sexual dysfunction compared with SSRIs - LECTURE - MIRTAZIPINE IS USED WHEN THIS IS A SIDE EFFECT!
TOM TIP: The side effects of sedation and increased appetite may be beneficial, depending on the patient. In someone with a loss of appetite, weight loss, and poor sleep due to depression, these side effects can be very helpful. For this reason, it is commonly used in older patients. However, in someone else who is overweight and oversleeping already, these side effects would be a big problem.
What are the main types of Antidepressant medication? 3 + 1
What is the mechanism of action of the main 3?
The main types of antidepressants are:
Selective serotonin reuptake inhibitors (SSRIs): Sertraline, Citalopram and Fluoxitine
Serotonin and norepinephrine reuptake inhibitors (SNRIs): venalafaxine and Duloxetine
Tricyclic antidepressants (TCAs): Amitryptaline and Nortryptaline
Others (e.g., mirtazapine and vortioxetine)
Mechanism of Action
Neurones (nerve cells) communicate with each other at connections called synapses. Each neurone is connected to many other neurones via synapses. The synapse is found at the end of one neurone (the axon terminal) and the start of another (the dendrite). The axon terminal releases chemicals called neurotransmitters, such as dopamine, serotonin, noradrenaline and gamma-aminobutyric acid (GABA). The neurotransmitter crosses the synapse and stimulates receptors on the post-synaptic membrane, creating a response in the neurone. Once this stimulation occurs, the neurotransmitter is returned to the axon terminal of the original neurone (reuptake).
Selective serotonin reuptake inhibitors (SSRIs) work by blocking the reuptake of serotonin by the presynaptic membrane on the axon terminal. This results in more serotonin in the synapses throughout the central nervous system, boosting the communication between neurones.
Serotonin and norepinephrine reuptake inhibitors (SNRIs) work by blocking the reuptake of serotonin and noradrenaline by the presynaptic membrane. This results in more serotonin and noradrenaline in the synapses throughout the central nervous system.
Tricyclic antidepressants have a more complex mechanism. They block the reuptake of serotonin and noradrenaline by the presynaptic membrane. They also have additional actions, including blocking acetylcholine and histamine receptors, which give them anticholinergic and sedative side effects.
SSRIs - Which drugs:
- can cause cardiac arrhythmia?
- has a long half life and is first line in children and adolescents?
- Is safest in patients with heart disease and useful in anxiety disorders as well?
Key side effects of SSRIs? -7 get as many as you can x
Sertraline:
- helpful anti-anxiety effects
- one of the safest in patients with heart disease (MI or heart failure)
- SE - higher rate of diarrhoea
Citalopram and Escitalopram:
- can prolong the QT interval, although this effect is dose-dependent (a higher dose is more likely to cause a prolonged QT). QT prolongation can lead to torsades de pointes. They are considered to be the least safe SSRI in patients with heart disease and arrhythmia (although still a lot safer than TCAs).
Fluoxetine:
- long half life of 4-7 days - remains active in the body long after stopping
- first line in children and adolescents.
Key side effects of SSRIs include:
- Gastrointestinal symptoms (e.g., nausea and diarrhoea)
- Headaches
- Sexual dysfunction - Significant in the young (concordance)
- Hyponatraemia (due to SIADH)
- Anxiety or agitation, typically in the first few weeks of use
- Increased suicidal thoughts, suicide risk and self-harm (this applies to all antidepressants)
SNRIs?
2 Examples and When are they used?
Contraindicated when?
2 key Indications?
Examples of SNRIs include duloxetine and venlafaxine.
They have similar side effects to SSRIs.
They can increase the blood pressure and are contraindicated in uncontrolled hypertension.
Indications:
Venlafaxine is often used when there is an inadequate response to other antidepressants.
Duloxetine is also used to treat neuropathic pain, particularly diabetic neuropathy.
TCAs
- common indication?
- key side effect? - 2 main categories
Examples of tricyclic antidepressants (TCAs) include amitriptyline and nortriptyline. They are commonly used at a low dose to treat neuropathic pain. The neuropathic pain dose is too low to treat depression.
Tricyclic antidepressants are particularly known to cause arrhythmias, including tachycardia, prolonged QT interval and bundle branch block. The effects are dose-dependent. Their effect on the heart makes them very dangerous in overdose, with a high risk of death. For these reasons, they are not generally used to treat depression, especially in patients with heart disease or risk factors for suicide.
They have anticholinergic side effects, such as dry mouth, constipation, urinary retention, blurred vision and cognitive impairment. They also cause sedation and are typically taken at night.
Aaron you know this hun!
What is Serotonin Syndrome?
3 key categories of symptoms?
management?
Serotonin syndrome can range from mild symptoms to severe and potentially life-threatening. It is caused by excessive serotonin activity. It usually occurs with higher doses of antidepressants and when multiple antidepressants are used together.
There is a long list of possible symptoms, which fall into three categories:
Altered mental state (e.g., anxiety and agitation)
Autonomic nervous system hyperactivity (e.g., tachycardia, hypertension and hyperthermia)
Neuromuscular hyperactivity (e.g., hyperreflexia, tremor and rigidity)
Severe serotonin syndrome is a medical emergency. Severe cases can cause confusion, seizures, severe hyperthermia (over 40°C) and respiratory failure.
Diagnosis is based on the clinical presentation and excluding other causes of the symptoms. Management involves supportive care (e.g., sedation with benzodiazepines) and withdrawal of the causative medications.
Key Points for starting and stopping antidepressants:
- inital side effect
- how long do they take to work
- how long should people stay on them
- how are antidepressants withdrawn
Starting Antidepressants:
- Can be inital period of worsened agitation, anxiety and suicidal ideation (2 week review)
- If there isnt a noticible response at 2-4 weeks, swap to an alternative treatment (SSRIs can often be swapped, mirtizapine needs titrating- complex)
Stopping Antidepressants:
- Antidepressants should be continued for at least 6 months before stopping
- Dose needs to be slowly reduced to minimise discontinuation symptoms: flu-like symptoms, irritability, insomonia, electric shock like sensation, vivid dreams
Self Harm vs suicide:
- definitions
- demographics
- most common forms of DSH
Self-harm involves intentional self-injury without suicidal intent.
DSH can take the form of:
Self-poisoning in the form of overdose - 90%
Self-injury in the form of cutting, burning, slashing - 10%
DSH is more common in females and those aged under 25. It is often a response to emotional distress and acts as a way for the person to cope with their emotions. Self-harm is not always associated with depression, anxiety or suicide, although it does increase the risk of these conditions.
Suicide involves a person causing their own death. Death by suicide is around three times more common in men and most common around the age of 50 years. It also increases in older age.
What is the cycle of self harm
The cycle of self-harm involves the following six repeating steps:
Emotional suffering
Emotional overload
Panic
Self-harming
Temporary relief
Shame and guilt -> emotional suffering.
Suicide risk assessment - 3 parts to assessing someone’s suicide risk
Suicidal thoughts range from a passing idea that is quickly dismissed and involves no intention to robust and persistent thoughts with intentions and a plan. They need to be explored in detail to determine the risk and suitable management strategy. They can change over time, so a safety plan and reassessment when required are necessary.
Presenting features that increase the risk of suicide include:
Previous suicidal attempts
Escalating self-harm
Impulsiveness
Hopelessness
Feelings of being a burden
Making plans
Writing a suicide note
Background factors that increase the risk of suicide include:
Mental health conditions
Physical health conditions
History of abuse or trauma
Family history of suicide
Financial difficulties or unemployment
Criminal problems (prisoners have a high rate of suicide)
Lack of social support (e.g., living alone)
Alcohol and drug use
Access to means (e.g., firearms)
Protective factors that may help reduce the risk of suicide include:
Social support and community
Sense of responsibility to others (e.g., children or family)
Resilience, coping and problem-solving skills
Access to mental health support
Me this is different to a general psychiatric risk assessment with risk to self, risk from others, risk to others, neglect
Management of DSH or suicide attempts
Management considerations for self-harm include:
Treatment of any physical injuries (separate card) - drug detox and suturing wounds.
Identifying triggers for episodes
Separating the means of self-harm (e.g., removing blades or medications from the environment)
Discussing strategies for avoiding further episodes (e.g., distractions, alternative coping strategies and getting help)
Providing details for support services in a crisis (e.g., mental health services, Samaritans and Shout)
Treating underlying mental health conditions (e.g., depression and anxiety)
Cognitive behavioural therapy
raising any safeguarding concerns
Treatment of an Overdose
Paracetamol
Opioids
Benzodiazepines
Beta Blockers
Cocaine
Carbon Monoxide
others…
Generally, the first step when a patient presents with an overdose is to check TOXBASE for recommendations about treating an overdose of almost any substance. They also have a contact number for advice.
Activated charcoal may be given within one hour of overdose of various substances to reduce the absorption (e.g., aspirin, SSRIs, tricyclic antidepressants, antipsychotic drugs, benzodiazepines and quinine).
Paracetamol - N-Acetylcysteine - TESTED
Opioids - Naloxone
Benzodiazepines- Flumazenil
Beta blockers- Glucagon for heart failure or cardiogenic shock, Atropine for symptomatic bradycardia
Calcium channel blockers - Calcium chloride or calcium gluconate
Cocaine- Diazepam
Cyanide- Dicobalt edetate
Methanol (e.g., solvents or fuels); Ethylene glycol (e.g., antifreeze) - Fomepizole or ethanol (alcohol)
Carbon monoxide - 100% oxygen
What is Bipolar Affective disorder?
What is Mania vs Hypomania
Bipolar disorder is characterised by recurrent episodes of depression and mania or hypomania. The symptoms often start at a younger age (under 25 years). It has a particularly high rate of suicide.
Depressive episodes feature low mood, anhedonia and low energy and can be severe.
Manic episodes involve excessively elevated mood and energy, significantly impacting their normal functions (e.g., caring and work responsibilities). Me - I think manic episodes last for several weeks, if just a manic day then could be EUPD.
Hypomanic episodes involve milder symptoms of mania without having a significant impact on their function.
Mixed episodes can involve a mix of symptoms or rapid cycling between mania and depression.
KEY Features of Mania
Potential features of mania include:
Abnormally elevated mood
Significant irritability
Increased energy
Decreased sleep (sometimes going days without sleeping) - TESTED IN THE MOCK
Grandiosity, ambitious plans, excessive spending and risk-taking behaviours
Disinhibition and sexually inappropriate behaviour
Flight of ideas (rapidly generating and jumping between ideas)
Pressured speech (rapid and unrelenting speech)
Psychosis (delusions and hallucinations)
Types of Bipolar Disorder? 4
Bipolar I disorder involves at least one episode of mania.
Bipolar II disorder involves at least one episode of major depression and at least one episode of hypomania.
Cyclothymia involves milder symptoms of hypomania and milder low mood. The symptoms are not severe enough to significantly impair their function.
Unipolar depression refers to when the person only has episodes of depression, without hypomania or mania.
ME - Note Unipolar depression includes Major Depressive Disorder (MDD): A clinical condition marked by episodes of major depression; and Persistent Depressive Disorder (Dysthymia): A chronic form of depression with less severe symptoms but lasting for two years or longer.
Management of an Acute Bipolar Episode - Manic vs Depressive
Secondary care specialists should manage acute episodes of bipolar disorder. Patients require a referral for an urgent mental health assessment or hospital admission.
Treatment of an acute manic episode:
- Antipsychotic medications (e.g., olanzapine, quetiapine, risperidone or haloperidol) are first-line
- Other options are lithium and sodium valproate
- Existing antidepressants are tapered and stopped
Treatment of an acute depressive episode:
- Olanzapine plus fluoxetine
- Antipsychotic medications (e.g., olanzapine or quetiapine)
- Lamotrigine
KEY CARD
Longterm management of bipolar affective disorder?
What monitoring is required? Normal drug level?
What are the adverse effects? (key) - short term and long term
management of toxicity?
Lithium is the usual long-term treatment.
Serum lithium levels (taken 12 hours after the most recent dose) are closely monitored to ensure the dose is correct. The usual initial target range is 0.6–0.8 mmol/L. They are taken weekly until they are stable and then every three months.
Lithium toxicity can occur if the dose and levels are too high (usually >1.5):
NICE CKS Signs of lithium toxicity include:
- fine tremour
- weight gain
- diarrhoea and vomiting
- muscle weakness
- dizziness and ataxia (lack of coordination)
- tinnitus and blurred vision
NICE CKS longterm adverse of lithium include:
- Chronic kidney disease
- Hypothyroidism and goitre (it inhibits the production of thyroid hormones)
- Hyperparathyroidism and hypercalcaemia
- Nephrogenic diabetes insipidus
**^ just remeber toxic to renal, thryoid/parathyroid and tremor
**
Management is supportive and monitoring lithium levels until they return back down to normal range.
Alternatives to lithium for long-term treatment include sodium valproate and olanzapine. Remeber the issues with prescribing valproate though!
Lasting power of attorney and advanced decisions can be helpful, particularly for future episodes of mania where the person’s judgement and decision-making may be impaired, resulting in harmful outcomes (e.g., excessive spending or gambling).
Define Generalised Anxiety disorder?
GAD vs Panic disorder
Secondary causes of anxiety
Generalised anxiety disorder (GAD) is a mental health condition that causes excessive and disproportional anxiety and worry that negatively impacts the person’s everyday activity. Symptoms should be persistent, occurring most days for at least six months, and not caused by substance use or another condition.
Panic disorder involves recurrent panic attacks. The panic attacks are unexpected (they appear randomly, often without a trigger) and result in worry about further attacks and maladaptive behaviour changes relating to the attacks (e.g., avoiding activities).
Me - The other form of episodic anxiety disorder is phobia disorder, where episodes are caused by specific triggers
Secondary Causes of anxiety:
Substance use (e.g., caffeine, stimulants, bronchodilators and cocaine)
Substance withdrawal (e.g., alcohol or benzodiazepine withdrawal)
Hyperthyroidism
Phaeochromocytoma
Cushing’s disease - cortisol = stress hormone
Presentation of GAD
Emotional and cognitive symptoms of GAD include:
Excessive worrying
Unable to control the worrying
Restlessness
Difficulty relaxing
Easily tired
Difficulty concentrating
Physical symptoms (caused by overactivity of the sympathetic nervous system) include:
Muscle tension
Palpitations (e.g., a feeling of their heart racing)
Sweating
Tremor
Gastrointestinal symptoms (e.g., abdominal pain and diarrhoea)
Headaches
Sleep disturbance
What are panic attacks, Sx?
Panic attacks involve a sudden onset of intense physical and emotional symptoms of anxiety. They come on quickly (within minutes) and last a short time (e.g., 10 minutes) before the symptoms gradually fade. The duration and frequency vary between individuals. Panic attacks are relatively common and do not always indicate a panic disorder.
Physical symptoms include tension, palpitations, tremors, sweating, dry mouth, chest pain, shortness of breath, dizziness and nausea.
Emotional symptoms include feelings of panic, fear, danger, depersonalisation (feeling separated or detached) and loss of control.
What is a phobia?
Phobia involves an extreme fear of certain situations or things, causing symptoms of anxiety and panic. There are many types, including fear of animals, heights, pathogens, flying, injections or environments.
Examples of common specific phobias include:
Claustrophobia (fear of closed spaces)
Acrophobia (fear of heights)
Arachnophobia (fear of spiders)
Glossophobia (fear of public speaking)
Trypanophobia (fear of needles)
Agoraphobia is a fear of situations in which they may be unable to escape if something goes wrong. For example, this could be a fear of busy places, public transport, or anywhere outside their home.
Social phobia involves a fear of social situations (also called social anxiety disorder).
Investigations for GAD
The Generalised Anxiety Disorder Questionnaire (GAD-7) can help assess the severity. It involves seven questions, each scored depending on how often the symptoms are experienced. The total score indicates the severity:
5-9 indicates mild anxiety
10-14 indicates moderate anxiety
15-21 indicates severe anxiety
Me - also do TFTs for hyperthyroidism, FBC
Management of Generalised Anxiety disorder?
phobia disorder and panic disorder
Mild anxiety:
active monitoring and advice about self-help strategies (e.g., meditation), sleep, diet, exercise and avoiding alcohol, caffeine and drugs.
Moderate to severe anxiety may require more intervention. Options include:
Cognitive behavioural therapy
Medication
Medication:
SSRIs (particularly sertraline) are the first-line medication for generalised anxiety disorder and panic disorder.
Other options for generalised anxiety disorder mentioned in the NICE guidelines (2020) are:
SNRIs (e.g., venlafaxine)
Pregabalin
Propranolol is a non-selective beta-blocker often used to treat physical symptoms of anxiety. It helps reduce sympathetic nervous system overactivity, improving symptoms such as palpitations, tremors, and sweating. However, it does not treat the underlying anxiety and only has a short-term effect. The main contraindication is asthma (it can cause bronchoconstriction in asthmatic patients).
Benzodiazepines (e.g., diazepam) work by stimulating GABA receptors (similar to the effects of alcohol). GABA receptors have a relaxing effect on the rest of the brain, giving relief from anxiety. However, prolonged use quickly results in down-regulate GABA receptors, leading to tolerance (reduced effects at the same dose) and dependence (significant withdrawal symptoms on stopping). The NICE guidelines (2020) recommend not offering benzodiazepines for GAD. The exception is using them for a short duration during a crisis, stopping them as soon as possible.
**Panic and Phobia Disorder management - also CBT and Sertraline
**
What is PTSD?
A stress disorder with ongoing distressing Sx and impaired functioning following a traumatic exprience.
It is relatively common, affecting adults and children. It increases the risk of other mental health conditions, including depression, anxiety, substance misuse and suicide.
Traumatic Events
PTSD can result from any event that the individual finds traumatic. Examples include witnessing or experiencing:
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
PTSD Symptoms
he history will contain exposure to one or repeated traumatic events.
Key symptoms include:
Intrusive thoughts relating to the event
Re-experiencing (experiencing flashbacks, images, sensations and nightmares of the event)
Hyperarousal (feeling on edge, irritable and easily startled)
Avoidance of triggers that remind them of the event (e.g., people, places or talking about the event)
Negative emotions (e.g., fear, anger, guilt or worthlessness)
Negative beliefs (e.g., the world is dangerous)
Difficulty with sleep
Depersonalisation (feeling separated or detached) - PHENOMONOLOGY
Derealisation (feeling the world around them is not real) - PHENOMONOLOGY
Emotional numbing (unable to experience feelings)
Screening tool for PTSD
The Trauma Screening Questionnaire (TSQ) can be used as a screening tool, prompting a referral for further assessment.
Like most anxiety and depressive disorders, the Ix is a questionnaire.
Management of PTSD
Management is tailored to the individual. Options include:
Psychological therapy (e.g., trauma-focused CBT)
Eye movement desensitisation and reprocessing (EMDR)
Medication (e.g., SSRIs, venlafaxine or antipsychotics)
Eye movement desensitisation and reprocessing (EMDR) involves processing traumatic memories while performing specific eye movements. The theory is that the improperly stored traumatic memories are reprocessed and stored again in a more normal way so that they no longer cause as much negative emotion and distress.
Define Obsessions and compulsions
Obsessive compulsive disorder (OCD) is characterised by obsessions and compulsions.
Obsessions are unwanted and uncontrolled thoughts and intrusive images that the person finds very difficult to ignore. Examples of this are an overwhelming fear of contamination with dirt or germs or violent or explicit images that keep appearing in their mind.
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 their obsessions. For example, they check that all electrical equipment is turned off to settle the anxiety of obsessing about the house burning down. Although this behaviour can be normal and appropriate, a person with OCD may check every plug in the house ten times before being reassured.
The obsessions and compulsions are present daily and are not something the person will enjoy or do willingly. They impact other areas of life, such as their social life or other interests.
There is a cycle in OCD involving:
Obsessions
Anxiety
Compulsion
Temporary relief
The obsessions lead to anxiety, which leads to compulsive behaviours, which leads to a temporary improvement in the anxiety. Shortly after the temporary improvement in anxiety, the obsession reappears, and the cycle reoccurs. Each time, the cycle gets more ingrained in the person’s behaviour. Without completing the compulsions, the person feels no relief from their anxiety about the obsessions.
How can the severity of OCD symptoms be scored
The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) can be used to assess the severity of symptoms
Management of OCD
Mild OCD may be managed with education and self-help resources.
More significant OCD may require:
Cognitive behavioural therapy (CBT) with exposure and response prevention (ERP)
SSRIs
Clomipramine (a tricyclic antidepressant)
Exposure and response prevention involves gradually facing the obsessive thoughts and anxiety without completing the compulsions.
What are Personality disorders
Personality disorder covers a variety of maladaptive personality traits that cause significant psychosocial **distress **and interfere with functioning. These traits remain relatively persistent in the person over time and impact their life and relationships.
Personality disorders are characterised by patterns of thought, behaviour and emotion that differ from what is normally expected. It leads to difficult relationships, reduced quality of life and poor physical health.
Personality disorders are thought to result from a combination of genetic and environmental factors. Patients often have a history of early childhood trauma and difficult circumstances. Me - Attachement theory have a poor foundation for healthy relationships and are not taught how to regulate their emotions.
A wide range of symptoms and behaviours occur with personality disorders. The symptoms typically emerge during the teenage or early adult years. Symptoms vary depending on the type and individual.
Sx of Boderline Personality disorder
possible symptoms in someone with borderline personality disorder include:
Strong and intense emotions (e.g., anger)
Emotional instability (rapidly changing emotions)
Difficulty managing emotions
Difficulty maintaining relationships
Poor sense of identity
Feelings of emptiness
Fear of abandonment
Impulsive and risky behaviour
Recurrent self-harm
Recurrent suicidal behaviours
In the DSM-5, personality disoderds fall into what three categories based on their domminant features?
There are many different types of personality disorders based on the dominant features. In the DSM-5, they fall into three categories:
Cluster A – Suspicious
Cluster B – Emotional or impulsive
Cluster C – Anxious
ABC SEA - mnemonic
types of personality disorder - Define
Paranoid PD
Shizoid PD
Schizotypal PD
Antisocial PD
Boderline PD/EUPD
Histirionic PD
Narcistic PD
Avoidant PD
Dependent PD
OCPD
Suspicious Personality Disorders:
Paranoid personality disorder features difficulty in trusting or revealing personal information to others.
Schizoid personality disorder features a lack of interest or desire to form relationships with others and feelings that this is of no benefit to them.
Schizotypal personality disorder features unusual beliefs, thoughts and behaviours, as well as social anxiety that makes forming relationships difficult.
Emotional and Impulsive Personality Disorders
Antisocial personality disorder features reckless and harmful behaviour, with a lack of concern for the consequences or the impact of their behaviour on other people. It often involves criminal misconduct. Includes psychopath (calculated) and sociopath (impulsive)
Borderline personality disorder features fluctuating strong emotions and difficulties with identity and maintaining healthy relationships.
Histrionic personality disorder involves the need to be the centre of attention and performing for others to maintain that attention.
Narcissistic personality disorder features feelings that they are special and need others to recognise this, or else they get upset. They put themselves first. Believe they are better than others
Anxious Personality Disorders
Avoidant personality disorder features severe anxiety about rejection or disapproval and avoidance of social situations or relationships.
Dependent personality disorder features a heavy reliance on others to make decisions and take responsibility for their lives, taking a very passive approach.
Obsessive-compulsive personality disorder features unrealistic expectations of how things should be done by themselves and others and catastrophising about what will happen if these expectations are not met.
If confused the mind page is really useful.
Management of personality disorders
Management of personality disorder can be challenging. The patterns of thinking and behaviours are deeply ingrained and are difficult to change.
Pyschoeducation - Patient and carer education is very important to help them understand the condition.
Risk management is important, considering short and long-term risks (e.g., ongoing self-harm, suicide and harm to others). Risks are reviewed regularly and managed across the multidisciplinary team. Supportive care is provided during crises to help keep the patient safe.
Psychological treatment is the main treatment:
- CBT
- dialectical behaviour therapy - EUPD developing strategies for managing distress other than self harm
Medications are not recommended for the long-term treatment of personality disorders. Sedative medications (e.g., sedative antihistamines) are sometimes used short-term (e.g., for less than one week) in a crisis. Personality disorders can co-exist with other psychiatric problems (e.g., depression), where medications may be beneficial.
