Psychiatry - General Flashcards
What does “flight of ideas”/”flight of thought” mean?
Racing thoughts which change topic rapidly
What is Bipolar affective disorder (BPAD)?
- Episodes of mania or hypomania and episodes of depressed mood
- Two or more episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression)
- When someone has experienced at least 1 manic/mixed episode (type I) or a hypomanic episode and at least 1 depressive episode (type II)
- Recovery usually complete between episodes
- Repeated episodes of hypomania or mania only are classified as bipolar
What is rapid cycling BPAD?
if the person experiences four or more episodes within 1 year
commoner in women
What is a hypomanic episode?
- Abnormally elevated mood or irritability and related symptoms with decreased or increased function for 4 days or more
- Some interference with personal functioning in daily living
- At least 3 signs must be present
What is a manic episode?
- Abnormally elevated mood or irritability and related symptoms with severe functional impairment or psychotic symptoms for 7 days or more
- Severe interference with personal functioning in daily living
- At least 3 signs must be present/4 if the mood is merely irritable
Difference between hypomania and mania?
• Degree of functional impairment (hospitalisation is a proxy of functional deterioration)
o Hypomania
Duration of symptoms for at least 4 consecutive days
Does not impair functional capacity in social or work setting
Unlikely to require hospitalisation
Does not exhibit any psychotic symptoms
o Mania
Duration of symptoms for at least 1 week
Causes severe functional impairment in social and work settings
May require hospitalisation due to risk of harm to self or others
May present with psychotic symptoms
Type I BPAD vs Type II BPAD vs Cyclothymic disorder
Type I BPAD: one or more manic/mixed episodes, often alternating with depressive episodes
Type II BPAD: one or more hypomanic episodes and at least one depressive episode without manic/mixed episodes
Cyclothymic disorder: persistent mood instability over at least 2 years.
Numerous periods of hypomanic + depressive symptoms present during more of the time than not, causing significant distress and/or functional impairment
What is secondary mania?
Mania due to a secondary cause
• Organic brain damage (esp. R hemisphere) – more common in elderly , delirium, intoxication (amphetamines, cocaine), dementia, frontal lobe damage, cerebral infection (e.g. HIV), myxoedema madness (paradoxical state of hyperactivity seen in extreme hypothyroidism)
• Medication: o L-DOPA, o corticosteroids o Bromocriptine (dopamine agonist) o Amphetamine o Cocaine o Antidepressants increase monoamines and can trigger mania Antidepressants are avoided in people with history of hypomania/mania due to the risk of switching from depression to mania o Glutamate overactivity
- Illicit drugs: stimulant or other street drugs – mania induced if mood state significantly outlasts drugged state, then a dx of bipolar disorder can be made
- Hypothyroidism – picture similar to depression, Hyperthyroidism – picture similar to hypomania or agitated depressed
- Schizoaffective disorder – psychotic + affective symptoms evolve simultaneously
- Emotionally unstable personality disorder – labile mood and impulsivity can mimic mania but will be persistent traits, not episodic symptoms
- Perinatal disorders
- ADHD – ADHD is more persistent and develops earlier (by the age of 6)
Define
Subthreshold depression Mild depression Moderate depression Severe depression Recurrent depressive disorder Complex depression Persistent depressive disorder (dysthymic disorder)
ICD 10
ICD-10 - for a dx of depression to be made at least 2/3 core symptoms (low energy, anhedonia, low mood) must be present for at least 2 weeks
• Subthreshold (minor) depression – 2-4 depressive symptoms, incl. depressed mood or anhedonia >2 weeks in duration
• Mild depression = 2 core symptoms + 2 other symptoms
Symptoms result in only minor functional impairment
ICD10 - 2 or 3
• Moderate depression = 2 core symptoms + 3+ other symptoms
Symptoms of functional impairment between mild and severe (ICD10 – 4 or more symptoms)
• Severe depression = most symptoms.
3 core symptoms + 4+ other symptoms
Symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms
- Severe depression with psychosis = severe depression (as above) and psychotic symptoms (delusions +/- hallucinations)
- Recurrent depressive disorder = when someone experiences at least 2 depressive episodes, separated by several months of wellness
- Complex depression = depression that shows an inadequate response to multiple treatments, is complicated by psychotic symptoms and/or is associated with significant psychiatric comorbidity or psychosocial factors
• Persistent depressive disorder (dysthymic disorder) – 2 years (>1 children/adolescents) of 3 or 4 dysthymic symptoms for more days than not. Dysthymic symptoms are o Depressed mood o Appetite change o Sleep disturbance o Low energy o Low self-esteem o Poor concentration o Hopelessness
How would you explain CBT to a patient?
CBT helps people think about their thoughts, feelings and behaviours + build an alternative set of more realistic beliefs
- Looks at link between thoughts, feelings and behaviours
- Evaluates thoughts to develop newer balanced alternatives
- links mood and activities
- builds in activities that bring a sense of pleasure and achievement/raise their energy levels/develop interests
- formulation - core concept in CBT
Looking for the rational for the patient’s problem - helps recognize and challenge negative automatic thoughts (NATs)
o The unhelpful ideas that pop into the patient’s head and trigger low mood and unhelpful behaviours
o common thinking errors - generalization, minimization - identify and challenge cognitive distortions
o A cognitive distortion is an exaggerated or irrational thought pattern that causes individuals to perceive reality inaccurately and is involved in the onset and perpetuation of psychopathological stated e.g. depression and anxiety - relpase prevention
o keeping away from old thinking and behavioural habits
Explain sleep hygiene to someone
o Bed only for sleep and sex o Routine is essential, even on weekends o Daytime – don’t sleep, exercise, no coffee after lunch o Evenings No alcohol/drugs Avoid heavy meals, nicotine, excess fluids Avoid screens Wind down for an hour before bed Ensure bedroom is quiet and dark
o Nights
If awake after 30 mins, get up and be bored for 20-30 minutes
Then return to bed
Repeat until sleepy
Depression - differential dx
Medications - anti-HTN, steroids, H2 blockers, sedatives, muscle relaxants, retinoids, chemo agents, sex hormones, psych medications
Substance misuse - alcohol, bzd, opiates, marijuana, cocaine, amphetamines
Psychiatric illness - bipolar, dysthmia, anxiety, schizophrenia, personality disorder
Neurological - dementia, PD, tumours, stroke
Endocrine - hyper/hypothyroidism, Addison’s disease, Cushing’s disease, menopause, hyperPTH
Metabolic - hypoglycaemia, hypercalcaemia, porphyria
Others - anaemia, infection (syphillis, lyme, HIV, encephalopathy), sleep apnoea
sadness/bereavment
postpartum depression
burnout
What is “depressive stupor”?
• Depressive stupor: severe depressive illness can deteriorate into a “depressive stupor” where a person is conscious but is non-responsive to any stimulation
RF for serotonin syndrome
o Antidepressant use (esp. higher dose) o Combination antidepressants o Overdose of antidepressants o Lithium o Opiates (tramadol, fentanyl) o Antiemetics (metoclopramide, ondansetron) o Illicit drugs (cocaine, MDMA, LSD) o ECT
What should be done
before
during
after
ECT?
• Before the procedure:
o Routine physical examination for all patients
o Investigations:
Bloods (FBC, U&Es, LFTs, Sickle cell for specific ethnic groups)
ECG – for all pts >50 years of age, <50 if medical indication
CXR – for all pts >55 yrs of age, <55 only if medical hx indicates
o Medication review:
Medications that increase seizure threshold: Benzodiazepines, Mood stabilisers (anticonvulsants)
Medications that reduce seizure threshold: antipsychotics, TCAs, Lithium
o NBM 8h prior to procedure
• During the procedure:
o Do an EEG – make sure that the patient has had a seizure, can’t always see it
o Pharmacological treatment should be used concomitantly to ECT, however its beneficial effects are unlikely to occur fast enough to be life saving.
• After the procedure asses clinical status using a formal valid outcome measure:
o Rating scales e.g. MADRS
o Cognitive tests e.g. MMSE
o Review for side effects and for improvements in their mental state
When should ECT be stopped?
• Stop treatment:
o When remission has been achieved
If a persons depression has responded to a course of ECT, antidepressant medication should be started or continued to prevent relapse
Consider lithium augmentation of antidepressants
o Sooner if side effects outweigh the potential benefits
How often should cognitive function be monitored during treatment with ECT?
• Assess cognitive function before the first ECT treatment + monitor at least ever 3-4 treatments + at the end of a course of treatment:
o Orientation and time reorientation after each treatment
o Measures of new learning, retrograde amnesia, subjective memory impairment carried out at least 24h after a treatment
Give advantages and disadvantages of unilateral vs bilateral ECT
Bilateral \+ more effective effective at threshold more efficacious quicker
-
may cause more cognitive impairment
may cause language problems or visuospatial orientation problems
unilateral - placed on the non-dominant side of the brain
+
fewer cognitive side effects
- technically difficult not as effective not effective at threshold slower action higher stimulus dose associated with greater efficacy but increased cognitive impairment compared with a lower stimulus dose
How often is ECT given and how many sessions are required?
- ECT usually given twice a week
* Number of sessions undertaken during a course of ECT ranges from 6-12
Main indications for ECT
- Used in current UK clinical practice as a treatment option for individuals with depressive illness, catatonia and mania
- Occasionally used to treat schizophrenia
• Severe depressive illness that is life-threatening
o Only if there is a life-threatening situation i.e. poor oral intake, acutely suicidal, if treatment resistant depression
o Antidepressants, psychotherapy, counselling
• Catatonia
o Syndrome associated with both schizophrenia and affective disorders
o Characterized by marked changes in muscle tone or activity that may alternate between the extremes of catatonic stupor (deficit of movement) and catatonic excitement (excessive movement)
o Benzodiazepines, psychotropic agents
• Prolonged or severe manic episodes
o Elated, euphoric or irritable mood and increased energy. The term may refer to a mental disorder or to a mood state or symptom
o Mania is associated with bipolar disorders
o In severe manic episodes individuals are psychotic require continual supervision to prevent physical harm to themselves or others
o Antipsychotics, lithium, anticonvulsants
• [[Schizophrenia (NICE: the current state of evidence does not allow the general use of ECT in the management of schizophrenia to be recommended) however it is occasionally used to treat schizophrenia but schizophrenia is not an indication for ECT]]
o Characterized by a broad range of cognitive, emotional and behavioural problems in general classified into positive and negative symptoms
o Individuals with delusions or hallucinations are described as psychotic
o Antipsychotics, clinical, emotional, social support
Contraindications to ECT
• Technically no absolute contraindications
• Caution in higher risk patients (concerns particularly about the anaesthetic)
o Heart disease/stroke
o Raised ICP
o Risk of cerebral bleeding (HTN, stroke)
o Pacemaker, pregnant woman, epilepsy
Complications of ECT
• Risks associated with anaesthetic
o MI, arrythmias, aspiration pneumonia, prolonged apnoea, malignant hyperthermia, broken teeth, death
o Mortality associated w ECT not higher than that associated with the administration of GA during a minor surgery
• Risks of ECT
o Common complaints (80%) – confusion, muscle pain, headache, nausea
o Effect on cognition (10%)– retorgrade and anterogrde memory loss (events immediately before and after ECT) – most patients will fully recover at 6 months
• Retrograde amnesia (Short-term or long-term memory impairment for past events) and anterograde amnesia (current events)
o Very rare to have long-term complications
o Short term side effects – headache, nausea, short-term memory impairment, memory loss of events prior to ECT, cardiac arrhythmia
o Long-term side-effects – impaired memory
• ECT administration affects the CNS + causes changes in cardiovascular dynamics dictates the need for special caution in those individuals who are at increased risk of cardiovascular event
• Other immediate potential complications (incidence: 1 per 1300-1400 treatments)
o Status epilepticus
o Laryngospasm
o Peripheral nerve palsy
Which classes of medications are RF for depression?
Which might be protective?
B-blockers corticosteroids oral contraceptives statins ranitidine antihypertensives
There is some evidence that inflammation is relevant to the pathogenesis of depression, therefore anti-inflammatory drugs are being trialled as depression treatments.
DSM-V definition of schizophrenia
Criterion A
• >2 or more of the following
• For a significant portion of time during a 1 month period (or less if successfully treated)
• At least one of these must be delusions, hallucinations or disorganized speech (active phase symptoms)
o Hallucinations
o Delusions
o Disorganised speech
o Negative symptoms
o Grossly disorganised or catatonic behaviour
Criterion B
• For a significant portion of the time since the onset of the disturbance, level of functioning in at last 1 major area e.g. work, interpersonal relations, selfcare is markedly below the levels achieved prior to onset
Criterion C
• Duration
o Continuous signs of the disturbance persist for at least 6 months with at least 1 month of active-phase symptoms (or less if successfully treated)
o May include periods of prodromal or residual symptoms during which;
disturbance may be manifested by only negative symptoms
or >2 active-phase symptoms present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences)
Criterion D
• schizoaffective disorder + depressive disorder or BPAD with psychotic features have been ruled out because
o No major depressive or manic episodes have occurred concurrently with the active phase symptoms or
o If mood episodes have occurred during active phase symptoms they have been present for a minority of the total duration of the active and residual periods of the illness
Criterion E
• The disturbance is not attributable to the physiological effects of a substance or another medical condition
Criterion F
• If there is a hx of ASD or communication disorder of childhood onset, the additional dx of schizophrenia is made only if prominent delusions or hallucinations in addition to the other required x of schizophrenia are also present for at least 1 month (or less if successfully treated)
ICD-10 definition of schizophrenia
- Symptoms must have persisted for at least one month and are not due to organic causes
- The course can be continuous, or episodic or there can be one or more episodes with complete or incomplete remission
How to differentiate the negative symptoms of schizophrenia from those of depression?
In schizophrenia there is lack of: weight change sleep problems guilt/hopelessness/low self-worth social withdrawal
e.g. delusion in depression “I am responsible for all the bad things”
delusion in schizophrenia “People want to harm me”
• Post-psychotic depression prolonged depressive episode that occurs on resolution of psychosis. Can be distinguished from negative symptoms of schizophrenia bc:
o Schizophrenia – negative symptoms increase/decrease in conjunction with the severity of the positive symptoms. No insight
o Post-psychotic depression – depressive type symptoms do not change in concordance with any positive symptoms. Patient has a good degree of insight. Can be a result of neuroleptic medication
Subtypes of schizophrenia (5)
• Paranoid
o Most common type
o Prominent hallucinations + delusions (usually persecutory)
• Catatonic
o Dominated by psychomotor disturbance
o Catatonia can kill – people can stop eating + drinking - this is an indication for ECT
o Stupor – immobility, mutism, unresponsiveness despite being conscious (eyes are open + can track movement)
o Excitement – periods of extreme, purposeless motor activity (may alternate with stupor)
o Posturing – assuming + holding inappropriate/bizarre positions
o Rigidity – holding a rigid posture against efforts to be moved
o Waxy flexibility – person’s limbs offer minimal resistance to being placed in seemingly uncomfortable positions, which are maintained for unusually lengthy periods
o Automatic obedience – to any instructions
o Preservation – inappropriate repetition of words or movements
• Hebephrenic
o Predominantly disorganized and chaotic mood, behaviour and speech
o Shallow or inappropriate affect
o Aimless behaviour
o Delusions and hallucinations less prominent
• Simple
o Negative features only
o Never showing positive psychotic symptoms
• Residual
o Prominent negative symptoms that remain after delusions + hallucinations subside
What is considered “treatment-resistance” in schizophrenia?
• Treatment resistance = failure to respond to 2 or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks
Schizophrenia - differential dx
Organic causes (organic schizophrenia) (6)
Organic causes (organic psychosis) • Dementia or delirium
- Cerebral pathology – stroke, SOL, encephalitis, epilepsy, MS, cerebral lupus, HIV, neurosyphilis
- Systemic illness – Wilson’s disease, porphyria, Cushing’s syndrome, hypo-/hyperthyroidism
- Medication side effects – steroids, DA agonists, levetiracetam
• Drugs causing psychosis through intoxication – amphetamines, cocaine, LSD, ecstasy, ketamine, GHB/GBL (gamma-hydroxybutrate/gamma-butyrolactone – can cause psychotic symptoms during withdrawal), phencyclidine (PCP), NPS, Cannabis, khat
o Can acutely induce paranoia + thought disorder
o Rarely produce negative symptoms but might produce neg symptoms
o Symptoms resolve with drug cessation
o Look at time frame –> how long does it last, when did symptoms start?
• Heavy use of alcohol can cause: alcoholic hallucinosis, delirium tremens (hallucinations, delusions)
Schizophrenia - differential dx
Non-organic causes (functional schizophrenia)
Non-organic causes (functional psychosis)
Can be considered once organic causes have been excluded
• Affective psychosis
o Congruous affect – depressed/elated
o Less likely to have 1st rank symptoms
o Increased volume of speech, flight of ideas, punning
o Disinhibition in BPAD not seen in schizophrenia
o BPAD - grandiose delusions
o Schizophrenia - persecutory delusions
• Schizoaffective disorder
o Picture of schizophrenia but with a mood disorder (moderate/severe depressive or mania) developing either simultaneously or within a few days of each other.
o In contrast, in primary mood disorders (e.g. BPAD) psychotic symptoms emerge only as mood becomes more extreme e.g. psychotic depression, mania with psychotic symptoms
o Prominent symptoms of schizophrenia (e.g. delusions, hallucinations, disorganisation in the form of thought, experiences of influence, passivity and control) are accompanied by typical symptoms of a moderate or severe depressive episode (e.g. depressed mood, loss of interest, reduced energy), a manic episode (e.g. an extreme mood state characterised by euphoria, irritability, or expansiveness; increased activity or a subjective experience of increased energy) or a mixed episode.
o Psychomotor disturbances, including catatonia, may be present.
o Symptoms must have persisted for at least one month.
o The symptoms are not a manifestation of another medical condition (e.g. a brain tumor) and are not due to the effect of a substance or medication on the central nervous system (e.g. corticosteroids), including withdrawal (e.g. alcohol withdrawal).
• Schizotypal disorder
o Enduring state lasting several years or more (classed under personality disorders in DSM-5)
o Eccentricity is central to the dx: people may dress, behave, think, speak oddly
o They may be suspicious, aloof and struggle to make close relationships
o They have unusual ideas, may experience fleeting delusions or hallucinations (not sufficient to diagnose another psychotic illness)
o Increased risk of developing schizophrenia
• Acute and transient psychotic disorder
o Psychotic symptoms occur suddenly + relatively briefly
o Symptoms peak within 2 weeks + usually resolve within a month – maximum duration is 3 months
o Symptoms can fluctuate rapidly, might be acutely disabling
o Not diagnosed if there is a hx of another psychotic illness e.g. schizophrenia
o Often associated with acute stress
• Delusional disorder o Delusions (either a single or a set of delusions) lasting more than 3 months without a clear mood disturbance and lacking other schizophrenia symptoms e.g. thought disorder, persistent hallucinations or negative symptoms o Usually absence of auditory hallucinations, delusions of control, blunting of affect and brain disease - There may also be auditory hallucinations, but there are usually no other schizophrenia-like symptoms o Level of functionality – low in schizophrenia, well kempt, good functionality in delusional disorder (no thought disorder, no chaoticness in delusional disorder) The delusions are usually either persecutory or grandiose. Three particularly common delusions are: o Dysmorphophobia – a delusion that their body is particularly deformed (e.g. they think they have a massive nose when they clearly don’t), to that it is always giving off a particularly foul smell o Morbid Jealousy – a delusion that the patient’s partner is cheating on them, despite very little evidence – e.g. they were late home one night o Erotomania – this is where the patient loves another individual, and believes the other individual also loves them – but that they are unable to show it
• Puerperal (postpartum) psychosis
o Psychosis triggered by childbirth
o Usually occurs within a few weeks of delivery
• Personality disorder
o Should be considered when there is lifelong pattern of interpersonal difficulties
o Fleeting psychotic like symptoms
o Insight preserved
Paranoid PD – prominent detachment + negative affectivity traits – suspiciousness + paranoia
Schizoid PD – prominent detachment traits – lack of interest in others or social norms (can resemble ARMS or negative symptoms)
Borderline personality pattern – brief psychotic or psychotic-like symptoms can occur at times of stress e.g. hearing voices, paranoia
• Delirium
o Visual hallucinations
o Disorientated in time, place and person – pt with schizophrenia are not disorientated in time, place and person
o “Clouding of consciousness”
What is the difference between organic and functional psychosis?
Organic psychoses were believed to result from a physical defect of or damage to the brain.
Functional psychoses were believed to have no physical brain disease evident upon clinical examination
How to distinguish schizophrenia vs BPAD?
Disinhibition in BPAD not seen in schizophrenia
BPAD - grandiose delusions
Schizophrenia - persecutory delusions
BPAD less likely to have first rank symptoms of schizophrenia
How to distinguish hallucinations from trauma vs psychosis?
o Trauma/head injury - In trauma and head injury, the patient may hear voices that they can ‘talk to’. In psychiatric disease, this does usually not occur (or if the patient claims it does occur, it is often fictitious)
What is the neuroleptic malignant syndrome? (NMS)
- Rare idiosyncratic life-threatening medical emergency that can happen in response to any antipsychotics
- Classically develops insidiously around 4-11 days after initiation or increased dose of an antipsychotic
- Caused by lack of dopamine
RF for neuroleptic malignant syndrome? (NMS)
o Typical antipsychotics (in particular haloperidol) o High dose o Rapid increase in dose o Withdrawing anticholinergics o Depot o Males (2:1) o Past history NMS o Dehydrated
Similarities and differences of neuroleptic malignant syndrome NMS and serotonin syndrome SS
distinguishing factors
Similarities
Rare and potentially lethal
Sx: altered consciousness, neuromuscular status and autonomic dysfunction
Require ABCDE approach and supportive measures
Differences
NMS
Caused by lack of DA
Treatment: Raise DA (bromocriptine, ECT)
SS
Caused by excessive serotonin
Treatment: Serotonin antagonist e.g. cyproheptadine
Distinguishing factors
NMS - lead pipe rigidity
SS - myoclonus, tremor, hyperreflexia (less rigidity)
NMS - develops over time
SS - acute timeframe
What is considered “treatment-resistance” in depression?
failure to respond to 2 adequate trials of different classes of antidepressants at adequate doses and for a period of 6-8 weeks
Define
Subthreshold depression Mild depression Moderate depression Severe depression Persistent subthreshold depressive symptoms
DSM V
- Subthreshold depressive symptoms = at least 2 symptoms but <5 symptoms, able to cope with everyday life
- Mild depression = few, if any, symptoms in excess of the 5 required to make the dx. Symptoms result in only minor functional impairment (2-3 symptoms)
- Moderate depression = symptoms of functional impairment between mild and severe
- Severe depression = most symptoms. Symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms
- Persistent subthreshold depressive symptoms = persistence of subthreshold depressive symptoms for more than 2 years. Cannot be a consequence of a partially resolved depression. At least 2 but less than 5 symptoms required for dx.
DSM - V criteria for diagnosis of depression
• DSM-V = The individual must be experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.
2 core symptoms, present most of the time for at least 2 weeks
• Low mood
• Anhedonia
Other symptoms
• Fatigue/loss of energy
• Worthlessness/excessive or inappropriate guilt
• Recurrent thoughts of death, suicidal thoughts, or actual suicide attempts
• Diminished ability to think/concentrate or indecisiveness
• Psychomotor agitation or retardation
• Insomnia/hypersomnia
• Significant appetite and/or weight loss
Diagnosis – at least 1 core symptom + at least 5/9 symptoms
ICD-10 criteria for diagnosis of depression
Must last at least 2 weeks + represent a change from normal
2/3 core symptoms must be present for a dx of depression to be made (ICD-10)
DSM - V criteria for diagnosis of GAD
o Criterion A – excessive anxiety + worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)
o Criterion B – individual finds it difficult to control the worry
o Criterion C – anxiety + worry are associated with at least 3/6 key features
Only 1 key feature required in children
BESKIM - Blank mind, Easily fatigued, Sleep disturbance, Keyed Up/Restless/On Edge, Irritability, Muscle tension
o Criterion D – the anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
o Criterion E – the disturbance is not attributable to the physiological effects of a substance or another medical condition
o Criterion F – the disturbance is not explained by another mental disorder
ICD-10 criteria for diagnosis of GAD
o Anxiety that is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is “free-floating”).
o The dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort.
o Fears that the patient or a relative will shortly become ill or have an accident are often expressed.
GAD ddx
• Organic
o Hyperthyroidism – continuous anxiety symptoms
o Dementia – anxiety may be an early presentation
o Intoxication – amphetamines, coffee – determine if onset of anxiety is related to when the drug is used
o Withdrawal – BZD, alcohol, opioids
o Episodes of hypoglycaemia – diet related, diabetes treatment related
o Tachyarrhythmias e.g. SVT
o B12 deficiency
o Heavy metal toxicity
o Phaeochromocytoma – tumour of the adrenal medulla resulting in secretion of excessive amounts of catecholamines e.g. adrenaline, NA
• Other mental disorders: o Panic disorder o Social anxiety disorder o Separation anxiety disorder o PTSD o Anorexia nervosa o Somatic symptom disorder o Body dysmorphic disorder o Illness anxiety disorder o Schizophrenia or delusional disorder
o Psychosis
Free floating anxiety may precede delusions and hallucinations, in the “at risk mental state”
o Depression
Often co-morbid
Generally diagnose the disorder which came first + is more prominent, but don’t be afraid to diagnose both if criteria are met
Mixed depressive + anxiety disorder low level anxiety + depressive symptoms present equally together, neither justifying diagnosis alone
o Personality disorder
o OCD
o Adjustment disorder – the anxiety occurs in response to an identifiable stressor within 3 months of onset + does not persist for more than 6 months after the termination of the stressor
GAD complications
• Hyperventilation syndrome o Secondary to anxiety o Can occur with prolonged hyperventilation Dizziness +/or syncope Palpitations Sweating Dry mouth Agitation Fatigue Carpopedal spasm – involuntary muscle contractions in the hands + feet [low CO2 alkalosis neutralised by H+ from plasma proteins excess protein anions take up calcium low calcium hypocalcaemic tetany o Management – slow, regular breathing
• Increased risk for medical disorders (pain syndromes, HTN, CV disorders, GI disorders)
How does CBT help in GAD?
o Changes behaviours and thoughts that maintain anxiety (the thoughts, feelings and behaviours as if the person is in imminent danger when they are not)
o Aims to reduce patient’s expectation of threat, and the behaviours that maintain threat-related beliefs
o Psychoeducation about the physiology of anxiety + techniques for managing arousal e.g. controlled breathing, relaxation exercises
o Arms patient with techniques + thought processes to address negative thought patterns and behaviour
o Addresses automatic assumptions
Explore the actual likelihood and impact of the anticipated catastrophe
Test the feared situation and their belief in a catastrophic outcome using behavioural experiments
The outcome helps disprove the worry and informs more realistic thoughts
This gradually increases the patient’s confidence in their capacity to cope with the feared situation
o Addresses thinking errors e.g. catastrophizing
Therapist challenges a way of thinking
Helps the person look for evidence that proves or disproves it
o CBT helps people reassess the level of threat notice when their anxiety is making them think illogically relax their SSBs develop more adaptive coping strategies over time replace avoidance, escape, SSB (all of these reinforce anxiety)
o Discussion of fears + triggers rational explanation replacement of these negative fearful thoughts with positive ones
o Uses exposure therapy when avoidance + escape are central to the presentation
o Can be carried out by an appropriately trained practitioner, can be self-directed online/app
Describe the principles of exposure therapy
o Used as part of the CBT approach when there are strong elements of avoidance and escape
o People escape things they fear through SSBs or substance use disorders
o In the absence of actual harm, the body can only remain extremely anxious for a short time (usually < 45 mins) before habituation occurs and anxiety levels drop
o Habituation is characterised by a decrease in anxiety until fear dies out (extinction)
o Exposure is usually through a gradual (or graded) approach called desensitisation
o The patient identifies a goal (e.g. being able to hold a slug) and constructs a hierarchy of feared situations
o The patient tackles it from least frightening to most frightening
o Repeated exposure to the same stimulus produces lower + lower anxiety levels + faster habituation until there is no response at all extinction
o The aim is to stay in the situation until the anxiety has subsided to induce learning and challenge existing thoughts
o Agoraphobia can be treated using this strategy
PTSD DSV-V criteria
• The following criteria below apply to anyone >6 years old.
• Criterion A – Exposure
o Exposure to actual or threatened death, serious injury or sexual violence
Directly experiencing
Witnessing in person
Learning that the traumatic event occurred to a close family member or close friend.
• In cases of actual or threatened death of a family member or friend, the events must have been violent or accidental
Experiencing repeated or extreme exposure to aversive details of the traumatic event
• Does not apply to exposure through electronic media, TV, movies or pictures unless that exposure is work related
In children, learning that the traumatic event occurred to a parent or caregiving figure
• Criterion B – Intrusion Symptoms
o Presence of at least 1 of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
Recurrent, involuntary, and intrusive distressing MEMORIES of the traumatic event(s)
Recurrent distressing DREAMS in which the content and/or affect of the dream are related to the traumatic event(s).
DISSOCIATIVE reactions (flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
Intense or prolonged psychological DISTRESS at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Marked physiological REACTIONS to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
Children
>6 –> repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed
Spontaneous and intrusive memories may not necessarily appear distressing and my be expressed as play reenactment
Frightening dreams without recognizable content
• Criterion C – Avoidance
o Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
• Criterion D – Negative cognition and mood
o Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by at least 2 of the following:
Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
Persistent and exaggerated negative beliefs/expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” ‘The world is completely dangerous,” “My whole nervous system is permanently ruined”).
Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest or participation in significant activities.
Feelings of detachment or estrangement from others.
Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings)
• Criterion E – changes in arousal
o Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by at least 2 of the following:
Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
Reckless or self-destructive behavior
Hypervigilance
Exaggerated startle response
Problems with concentration
Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep)
• In children, this includes extreme temper tantrums
• Criterion F – duration o Duration (Criteria B, C, D, E) is more than 1 month
• Criterion G
o The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning
• Criterion H
o The disturbance is not attributable to the physiological effects of a substance (e.g. medication, alcohol) or another medical condition
PTSD ICD-10 criteria
- Delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone
- Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence
• Typical features include
o Episodes of repeated reliving of the trauma in intrusive memories (“flashbacks”)
o Dreams or nightmares
o Sense of “numbness” and emotional blunting
o Detachment from other people
o Unresponsiveness to surroundings
o Anhedonia
o Avoidance of activities and situations reminiscent of the trauma
o Autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia
- Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent
- The onset follows the trauma with a latency period that may range from a few weeks to months
- Fluctuating course
- Recovery can be expected in the majority of cases
- Small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change
PTSD ddx
• Adjustment disorder
o The stressor can be of any severity and type and not just a traumatic event
o Should be diagnosed when there is trauma but the individual does not meet all other PTSD criteria
o the anxiety occurs in response to an identifiable stressor within 3 months of onset + does not persist for more than 6 months after the termination of the stressor
• Acute stress disorder
o Symptoms last between 3 days to 1 month following the exposure to the traumatic event
o Requires the presence of 9 or more symptoms from any of the 5 categories: a) intrusion, b) negative mood, c) dissociation, d) avoidance, e) arousal
o If symptoms >1 month –> PTSD
• Anxiety disorders – symptoms not linked to a specific traumatic event
• OCD
o Intrusive thoughts are obsessions and are not related to an experienced traumatic event
o Compulsions are absent in PTSD
• Major depressive disorder
o Does not include any intrusion or avoidance symptoms
• Personality disorders – interpersonal difficulties that develop after a trauma would suggest PTSD rather than a personality disorder which is more long standing
• Dissociative disorders (dissociative amnesia, dissociative identity disorder, depersonalization-derealization disorder)
o An experience of trauma with temporal association is not needed
o If PTSD criteria are met, add a specifier –> PTSD with dissociative symptoms
• Conversion disorder (functional neurological symptom disorder)
o New onset of somatic symptoms within the context of a traumatic event would suggest PTSD over conversion disorder
• Psychotic disorders
• TBI
o PTSD and TBI are not mutually exclusive diagnoses and may occur concurrently
o PTSD – reexperiencing + avoidance
o TBI – executive dysfunction, disorientation, confusion
OCD DSM-V criteria
• Criterion A – presence of obsessions, compulsions or both.
Obsessions defined by 1 and 2:
o Recurrent and persistent thoughts, urges or images – experienced at some time during the disturbance as intrusive + unwanted. In most individuals they are caused by marked anxiety or distress
o The individual attempts to ignore or suppress such thoughts, urges or images or to neutralize them with some other thought or action – i.e. by performing a compulsion
Compulsions are defined by 1 and 2:
o Repetitive behaviours (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly
o The behaviours or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation. However, these behaviours or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or clearly excessive
- Criterion B – the obsessions or compulsions are time-consuming (e.g. take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational or other important areas of functioning
- Criterion C – the obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition
- Criterion D – the disturbance is not explained by the symptoms of another medical disorder
OCD what are obsessions?
• Obsessions = intrusive, unwanted and repetitive thoughts, urges or images that don’t go away and are generally unwanted or ego-dystonic
o Can be violent, sexual or religious in nature
o Can be thoughts, images, impulses, doubts
o Obsessions are ego-dystonic – conflict uncomfortable with the person’s self-image
o Although the sufferer recognizes that obsessions are irrational or untrue they cause deep discomfort or anxiety, often because they bring a terrible feeling that something bad might happen
o This anxiety is neutralised by a compulsion
OCD what are compulsions?
• Compulsions = repetitive physical behaviours or mental acts performed, meant to reduce the anxiety caused by the obsessions. Individual feels driven to perform these in response to an obsession, according to rigid rules, or to achieve a sense of “completeness”.
o Neither pleasant nor useful
o May be overt (observable by others) or covert (mentally counting or repeating a phrase)
o Usually done in a very particular way – if done “incorrectly” person may have to start all over again, taking hours, causing obsessional slowness and severely affecting QOL
link between obsessions and compulsions in OCD
The link between obsessions and compulsions may seem vaguely logical or completely unrelated
When do obsessions and compulsions become OCD?
Obsessions + compulsions lasts >2 weeks
obsessions and compulsions must be time consuming (e.g. taking >1h per day) or result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. (ICD-11)
OCD prognosis
- Poor prognostic factors: early onset, poor insight, schizotypal features, thought/action compulsions
- 60-90% of individuals with OCD also have a comorbid mental disorder
o Lifetime prevalence for any comorbid anxiety disorder – 76%, mood disorder 63%, personality disorder 23-32%
- Tends to run a chronic course, with symptoms worsening at times of stress
- Without treatment it’s often disabling and commonly comorbid with depression
• Children
o Children with OCD have a 5-7% incidence of Tourette’s and up to 30% life-time history of tics
o OCD+ADHD are highly comorbid
OCD ddx
• Organic – movement disorders with repetitive, stereotyped movements resembling compulsions
o Tourette syndrome
o Sydenham’s chorea
o Huntington disease
o PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection)
• Autism spectrum disorder
o Repetitive patterns of behaviours – these are lifelong with social and communication difficulties
o ASD increases the risk of OCD
• Anxiety disorders
o GAD – focus of the worry is upcoming problems. Involves real-life concerns.
o OCD – obsessions are intrusive and unwanted thoughts, urges or images. Does not involve real-life concerns. Presence of both obsessions and compulsions
• BDD
o Obsessions + compulsions are limited to concerns about physical appearance
o Behaviours (e.g. looking in the mirror) will further increase distress whereas in OCD checking behaviours usually decrease distress
• Hoarding disorder
o Individual holds a strong sentimental value and attachment towards the hoarded objects
o If an individual has obsessions that are typical of OCD (e.g. about incompleteness or harm) and these obsessions lead to compulsive hoarding behaviours (to prevent harm) person has OCD and not a hoarding disorder
- Complex tics
- Eating disorders – obsessions and compulsions only concern wright, body image, food
• Psychosis
o Absence of other symptoms of schizophrenia/schizoaffective disorder e.g. hallucinations or thought disorder
o In psychosis delusions are believed absolutely +/- thoughts may feel alien (thought insertion)
o OCD – people recognize their obsessions as being irrational on some level (even if only when calm) + they also know that the thoughts come from their own mind
• Substance/medication induced OCS – atypical antipsychotics
• Anankastic personality disorder
o Rigidity, inflexibility, liking of order
o Shouldn’t include obsessions and compulsions
Adjustment disorder DSMV-5 criteria
• Criterion A – the development of emotional or behavioural symptoms in response to an identifiable stressor occurs within 3 months of the onset of the stressor
• Criterion B – the symptoms or behaviours are clinically significant, as evidenced by 1 of the following
o Marked distress that is out of proportion to the severity or intensity of the stressor (taking into account the external context and the cultural factors that might influence symptom severity and presentation)
o Significant impairment in social, occupational or other important areas of functioning
- Criterion C – the stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a pre-existing mental disorder
- Criterion D – the symptoms do not represent normal bereavement
- Criterion E – once the stress or its consequences have terminated, the symptoms do not persist for more than an additional 6 months
Adjustment disorder ICD-10 criteria
- States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event
- The stressor may
- have affected the integrity of an individual’s social network (bereavement, separation experiences) or
- have affected the wider system of social supports and values (migration, refugee status) or
- represented a major developmental transition or crisis (going to school, becoming a parent, failure to attain a cherished personal goal, retirement)
• Individual predisposition or vulnerability plays an important role in the risk of occurrence and the shaping of the manifestations of adjustment disorders, but it is nevertheless assumed that the condition would not have arisen without the stressor
• The manifestations vary and include
depressed mood
anxiety or worry (or mixture of these)
a feeling of inability to cope, plan ahead, or continue in the present situation,
as well as some degree of disability in the performance of daily routine
- Conduct disorders may be an associated feature, particularly in adolescents
- The predominant feature may be a brief or Prolonged depressive reaction, or a disturbance of other emotions and conduct
Difference between adjustment disorder and acute stress reaction
o Acute stress reaction – timing for symptoms to go away hours-days
o Adjustment disorder – timing for symptoms to go away months
Biopsychosocial aetiology for adjustment disorder + prolonged/atypical grief reaction
Bio
serious physical illness
Psycho Response to loss bereavement problem with close relationship unwanted move disappointment, job failure, loss parental separation, divorce, new birth in family, loss of attachment figure or object
social
migration or refuge status
stressor may involve individual or the whole group/community
