Psychogenic symptoms Flashcards
Delirium
- most common
- Acute; hours, days, waxing-waning, DAY-NIGHT reversal
- Look for the trigger: new med or stop med, lyte abnormality or infections
- Change from baseline, disorganized though processing, inattention
- Presentation - HYPO-ACTIVE: Sleepy, Lethargy, obtunded.
- Hyperactive: common: restless, hallucinate, myoclonus.
- Indicate DAYS to WEEKS prognosis: Terminal delirium
Depression
- Chronic: More than 2weeks
- Anhedonia, guilt/worthless, hopelessness/self defacing, escalating pain, weight change, sleep change
Anxiety
- Chronic: Days to weeks
- ON EDGE, Loss of control, HIGH energy, Restless, Jittery, fearful, SOB, Tachycardia
- +ve history of anxiety
Delirium Triggers
Drugs, Dehydration
Electrolyte abnormalities
Low Oxygen states
Infections
Retention
Ictal state
Under-medications/withdrawal
Metastasis, Metabolic changes
First-treatment for delirium
- Haldol, Risperidol or olanzapine
- Chlorpromazine
- Keep Ativan for withdrawal, seizure or h/o EtOH
Treatment plans for delirium
- Symptomatic: anti-psychotic
- Treat the underlying cause if possible
- ENSURE adequate pain control
- Wean off Benzo, anti-cholinergic medications
Anticipatory grief VS Depression
Temporary/ Periodically vs Persistent
- Fleeting mood VS Persistent sadness
- Hope for CURE or life-prolongation VS HOPELESS
- Pleasure in life VS Persistent anhedonia
- Better with activities, socialization VS Helplessness
- Temporary desire for Death vs Persistent
Adjustment disorder
- IDENTIFIABLE stressors
- Within 3months onset
- Excessive and OUT of proportion leading to impairment in social, occupational, or educational functioning.
- NO anhedonia, Self-defacing, Sadness
Demoralization
- Self perception or understanding of the stress and assigns meanings and place of the future.
- Specific distress that occurs when individuals feel their intactness or integrity as persons is threatened
- Associated with chronic illness, disability, social ISOLATION
- SUICIDAL ideation is HIGH
- Promoted by poor symptom control, poor communication, dismissive attitudes, and avoidance behavior
- NO anhedonia, Self-defacing, Sadness
- Anhedonia separates depression from demoralization.
- Management: make a connection to the patient by touch and by assuring the patient that you are there for them and will not abandon them.
SUICIDE in terminal illness
- Threats of self-harm -> STAT psychiatry
- Once attempt,pt will go on to committed suicide
Management Depression
- Treat unrecognized untreated pain
- Psychotropic/ stimulantSSRI: 1st line, 3-6weeks,TCA: consider when sedation is desired, or neuropathic pain; nightly, ANTICHOLINERGIC
-Psychotherapy
When to refer the patient?
- Suicidal
- history of major psychiatic disorder
- Psychotic or confused
- Unresponsive to first-line antidepressants
- Dysfunctional family
Psycho-stimulant: Methylphenidate, pemoline
Psycho-stimulant only for patient with limited prognosis.
- Effective in 24-48hr;
- Small dose and titrate to effectiveness
- SEs: arrhythmia, anorexia, confusion.
- Hepatotoxin: Pemoline
SSRI: citalopram, setraline, escitalopram, paroxitine
- PTSD, depression - once daily
- Effect sees after 3-6 weeks
- Serotonin syndrome, libido, drug-INTERACTION
Antidepression side-effects
Serotonin syndrome
- Confusion, restlessness, agitation, fever, hyperthermia, diaphoresis, hypertonia/clonus (usually symmetrical), tremor, shivering, hyper-reflexia
- Tylenol: hyperthermia
- Benzodiazepines for seizures or muscle hyperactivity
- Serotonin antagonists: cyproheptadine 4-8 mg up to four times a day
Key Feature of Anxiety and anxiety-liked
Anxiety: Restlessness, irritability, excessive fear/ dread, poor sleep and concentration, Intrusive thoughts, Muscle tension, tremor, sweating, tachycardia,hyperventilation, POOR control symptoms (COPD, CHF), WITHDRAWALs,
GAD: Excessive worry >6MONTHS, NO control over, DISRUPTs day life, NOT due to substance
PTSD: VIVID, Re-experiencing, detachment, avoidance/ ISOLATION, NIGHTMARE, HYPER-arousal.
Panic disorder: 1attack following by 1month; AFRAID of the ATTACK
Anxiety Screening tools
Palliative Care Outcome Scale
Edmonton Symptom Assessment Schedule (ESAS)
Nervous? Fearful? Persistent feeling fo dread
Anxiety treatment
- Psychotherapy: relaxation therapy
- CBT: PTSD
- Stress managment: CBT, relaxations, positive self talk
Medications
Long acting: Diazepam
Moderate: Ativan
Short:Xanax
Delirium evaluation tools
- Memorial Delirium Assessment scale (MDAS): delirium from those with other cognitive or non-cognitive psychiatric disorders.
- The Confusion Assessment Method (CAM):
CONFUSION ASSESSMENT METHOD (CAM)
THE DIAGNOSIS OF DELIRIUM REQUIRES A PRESENT/ABNORMAL RATING FOR CRITERIA: (1)
AND (2) AND EITHER (3 or 4)
- ACUTE ONSET AND FLUCTUATING COURSE: Is there evidence of an acute change in mental status from the patient’s baseline? Did this behavior fluctuate during the past day, that is, tend to come and go or increase and decrease in severity?
- INATTENTION: Does the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
- DISORGANIZED THINKING: Is the patient’s speech disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
- ALTERED LEVEL OF CONSCIOUSNESS;how would you rate this patient’s level of consciousnesss?
- Alert (normal)
- Vigilant (hyperalert)
- Lethargic (drowsy, easily aroused)
- Stupor (difficult to arouse)
- Coma (unarousable)
