Psychological medicine week 3 Flashcards

Question

Stress response can be broken down into 4 domains :

Answer 1

- Emotion response: feeling on edge, feeling sad, irritability, tearful, over-reacting - Cognitive Response: difficulty concentrating, difficulty switching off, sensitive to criticism, self critical, difficulty making decisions - Behavioral Response: comfort eating, loss of appetite, drink or smoke more, over activity and underactivity and disturbed sleep - Psychological Response- increased heart rate, increased rate of breathing, increased perspiration and muscle tension

Answer 2

- Thoughts - Emotions - Behavior - Physical sensations

Answer 3

- can increase relapse - can increase morbidity - you may have poorer control of the chronic disease

Answer 4

- poorer compliance with medication - increase alcohol intake - epilepsy/ Liver disease - increase smoking- heart/respiratory disease - Reduced exercise – heart disease - Poor diet - diabetes

Answer 5

Why is cortisol bad? It is a stress horome. Its like a performance enhancing drug, great for short term bursts, but meant for long term use. Cortisol – high blood pressure, heart disease, type 2 diabetes, osteoporosis, acne, moon face, and other chronic diseases. It causes Weight gain. anxiety and depression, lowers your libido shrinks your brain, thins your skin, and hampers your immunity system. How does it do all that, because cortisol receptors are responsible for blood sugar regulation inflammation process regulation metabolism regulation memory formulation

Answer 6

Significant association between stressful life events and mental illness In the 3-6 months preceding the onset of a depressive illness 50-80% patients will have experienced a significant life event compared to 20-30% of non depressed patients Increased mortality rates – patients with chronic heart failure 8x more likely to die within 30 months if depression untreated. Patients with Type 2 diabetes and depression 2-3 x more likely to die over 5 years compared to patients not depressed Increased morbidity associated with the physical health problem – treating the mental illness aids self management and rehabilitation

Answer 7

Individual factors: - Premorbid personality - worrier, obsessional - Prior experience of illnesses - Mental state e.g. depression. Chronic medical illness associated with increased levels of depression. Those who are depressed report more physical symptoms, are more disabled and are less likely to adhere to treatment and lifestyle recommendations - Childhood difficulties e.g. early trauma/chaotic backgrounds, cope less well with difficult treatment regimes, difficult interactions with health professionals -Appraisal and coping styles

Answer 8

The actual illness: - Is the illness immediately life threatening - Uncontrollability - excess pain - Ambiguity - regarding outcome/treatment - Undesirability - unpleasant treatment regimes or disfiguring treatments

Answer 9

- Problem solving and Emotion focused coping Problem solving: -Seeking information -Seeking support -Learning new procedures and behaviours e.g. appropriate participation in treatment /lifestyle changes -Identifying alternative rewards/new activities -Developing a realistic action plan Emotion focused coping: -involves managing emotions and maintaining emotional equilibrium. Generally works well but only transiently. Best reserved for brief stresses or where nothing realistically can be done to modify the stress -Emotional discharge – talking about the problem (fears, anger, despair) -Making and maintaining supportive friendships -Gaining emotional support from e.g religion -Resigned acceptance – coming to terms with the inevitable

Answer 10

Medically unexplained symptoms: Physical symptoms not explained by organic disease causing distress and impairing function And for which there is positive evidence or a strong assumption that the symptoms are linked to psychological factors (stress/distress)

Answer 11

- A role assigned to the patient by society and it has certain connotations. One is that their exempt from their usual or certain responsibilities. It gives the patient the right to expect help and seek care. Sick role: (1) exempts them from certain responsibilities (2) gives them the right to expect help and seek care (3) obligation to seek and co-operate with treatment (4) the expectation of a desire to recover

Answer 12

Illness behaviour on the other hand, is how the patient internalises the meaning of being ill, and adjust their own behaviour The ways in which given symptoms may be differentially perceived, evaluated and acted (or not acted) upon by the individual Behaviours associated with the adjustment to physical or mental illness The changes in behaviours may be appropriate or not

Answer 13

- Illness denial: Behaviours to avoid the ‘stigma’/inability to accept physical/mental disease - Illness affirmation: Behaviours which inappropriately affirm illness Disproportionate disability in relation to symptoms / signs

Answer 14

Some MUS may arise from ‘normal’ bodily sensations (physiological processes) with misinterpretation. Eg: if you have an increased heart rate you might think you have a heart attack. Some MUS may arise from minor pathology and are exaggerated at times of stress

Answer 15

-Reduces stigmatization of mental illness especially in certain cultures -Allows people to assume the sick role (but it can become maladaptive) -Physical expression of distress, thus reduces internal emotional conflict. Often patients become depressed when treatment begins and they ‘face’ their emotional conflicts Eg: a partner who does not want to engage in sexual activity may get a headache Eg: a child who is getting bullied in school, sometimes develop stomach pains. The symptoms the patients have are GENUINE symptoms as genuine as other symptoms with an organic basis. The mechanism of the production of these symptoms are subconscious ie: the patient has no awareness this is going on. They haven't joined the dots between psychological distress and the production of physical symptoms.

Answer 16

Genetic – small Cognitive process’ – over interpreting symptoms, symptom catastrophizing Familial Transmission – reinforcement and modelling. ‘Emotional currency’. If you are raised in a family who does not talk about mental health and their is an expectation to solider on, then it is expected you will communicate in a similar fashion. Attachment – pathological care seeking behavior's (frequent attendances) linked to early insecure attachment

Answer 17

Imagine a child in their early years, if the child was avoiding school for example they were being bullied. In the process of being anxious about school they have a tummy ache and headache. The child would get extra support from social workers, school staff and parents. The child would learn being ill with getting more attention. And thus illness become a portal to support- as an adult it is not uncommon for these individual to unconsciously manifest with physical ailments as a means of attaining support. Its important to stress these people are not consciously pretending to be sick, but always a the body’s programme response in ascertaining health.

Answer 18

General population – 20% Primary care – 10 – 33% presenting complaint diagnosed as MUS Secondary care – 30 – 50% of new patients present with MUS

Answer 19

- Acknowledge symptoms genuine. -Avoid comments ‘there’s nothing wrong with you’ or implying the symptoms ‘are all in the mind’ - Provide clear explanations about investigations, results and conditions which are excluded or found, even if the latter don’t explain all of the symptoms -Avoid more investigations or referral on unless

Answer 20

Explanatory Models 1: Biological model - Help them to see the positive Use of analogy is helpful to help them wrap their head round a concept. Funnily enough, often a lot of idioms we use captures these presentations Explanatory Model 2: Psychosocial model

Answer 21

Explanation is the key Symptom management – analgesics (non-opioid), laxatives, antispasmodics, exercise, acupuncture, physiotherapy Promote self efficacy (web sites/self help literature) Initiate treatment for depression/anxiety if present Psychotherapies - attention is directed away from the symptoms to the problems that have provoked the MUS Aim is not for symptom cure but to help patient cope, which in turn minimises impact

Answer 22

-MUS – umbrella term. Physical expression of distress -Heterogeneous group – wide variation in severity and presentation. Lots of labels -Given the heterogeneity – likely that different mechanisms play a role in their development and manifestation -This translates into problematic management at the diagnostic level, relationally and with treatment (lack of knowledge about the nature translates into lack of appropriate treatment esp. in primary care)

Answer 23

Chronic primary pain is pain in 1 or more anatomic regions that persists or recurs for longer than 3 months and is associated with significant emotional distress or significant functional disability (interference with activities of daily life and participation in social roles) and that cannot be better explained by another chronic pain condition -Pain that comes and goes is called Recurrent or Intermittent Pain e.g. tooth ache -Short-term pain is called Acute Pain e.g. a sprained ankle -Long-term pain is called Persistent or Chronic Pain e.g. back pain

Answer 24

Nociception refers to the central nervous system and peripheral nervous system processing noxious stimuli, such as tissue damage or temperature which activates nociceptors and their pathways. Pain is understood as the subjective experience somebody feels as a result of the activation of these pathways. Pain is subjective and a mental and physical component.

Answer 25

-Genetic mutation – no sodium channels 1.7 – no pain/ too many - too much pain (if too many such receptors). -No pain – a lot of damage, premature death due to accidents - Pain/ how much pain we are sensitive to is crucial to our survival and has an adaptative role -Pain is a protective response to potential danger but also psychological stimuli -Pain sensation can be activated by physical (that nail!) or non-physical elements e.g. memories

Answer 26

the ability of the brain to form and reorganize synaptic connections, especially in response to learning or experience or following injury. Neuroplasticity, also known as neural plasticity, or brain plasticity, is the ability of neural networks in the brain to change through growth and reorganization. It is when the brain is rewired to function in some way that differs from how it previously functioned. Concept central to chronic pain management. Our senses and movements are competing for representation in the brain Injury management needs to respect constant competition for brain representation. By protecting injured area (e.g. limping) one creates runaway plasticity that will make it very difficult to recover motor/sensory ability, hence do not rely on where you are still strong.

Answer 27

- Stress and Tension: . All sorts of emotional states can worsen pain. These can include being anxious, worried, angry or depressed. - Psychological factors: : one of the most effective ways of increasing the pain is focussing your attention on it. Boredom has a similar effect. ‘Psychological pain’ and trauma known to be linked with chronic pain conditions - Lack of movement: not moving around, having stiff joints and reduced fitness, increase pain perception.

Answer 28

Central sensitisation is defined as an increased responsiveness of nociceptors in the central nervous system to either normal or sub-threshold afferent input resulting in: Hypersensitivity to stimuli.

Answer 29

Allodynia: occurs when an individual experiences pain with things that are not normally painful (touch or massage) nerves in the area are sending messages to a brain which is in a state of heightened reactivity – producing a sensation of pain & discomfort Hyperalgesia: occurs when a stimulus that is typically painful is perceived as more painful than it should (a small bump sends a CP patient through the roof) heightened reactivity produces pain that is amplified.

Answer 30

Physical: - Medication such as NSAIDS, Tricyclic Antidepressants and opiods. - A multimodal approach is recommended - TENS - Nerve blocks - Graded Excercise Physiological: - Acceptance - CBT - Fear - avoidance - Psycoeducation Behaviour/Social: - pacing - goal setting - relaxation - communication - return to work

Answer 31

Patients appraisals (assessment) of the impact of their pain on their lives and their sense of control over their pain determines the pain-depression relationship. Those patient’s who believed they could still function despite their pain and those who believed they could maintain some control did not become depressed The presence of pain is not sufficient condition for the subsequent development of depression

Answer 32

Cognitive Behavioral Therapy (CBT) Third wave cognitive therapies: -Mindfulness -Acceptance and Commitment Therapy (ACT) -Compassion-Focused Therapy (CFT) Understanding and working with psychological trauma and the physical expression of psychological pain

Answer 33

When compared to the general population, people with chronic pain tend to have at least double the rates of trauma in their past. Trauma triggers prolonged anxiety, hyper vigilance, and fearfulness and can make the nervous system persistently reactive and can lead to pain behaviour. These reactions to trauma are all indicators of a persistently aroused or reactive nervous system. As such, when patients with a history of trauma get injured or become ill, their nervous system is already in a state of persistent reactivity (i.e. central sensitisation) and are more prone to develop chronic pain due to central sensitisation . The common denominator between chronic pain and trauma is thus the nervous system.

Answer 34

Any condition that actually or potentially poses a challenge to the body’s ability to maintain homeostasis. Any change has the potential to cause stress.

Answer 35

Eustress (good type of stress): Mild stress that is useful. Prepares us to meet challenges, is helpful and improves performance, e.g. revising for year 1 exams, giving a speech, birth of baby, meeting deadlines, going on holiday etc. Distress (bad type of stress): Unpleasant or disease producing stress, e.g. death of family member, chronic pain etc. Severe stress is harmful and impairs performance

Answer 36

- Any stimulus that produces a stress response - External stressors, Internal stressors, psychosocial events and physiological events

Answer 37

Physiological response to stressors in an attempt to regain homeostasis (Hans Selye)

Answer 38

Stress response occurs in three main stages: 1. Alarm phase (short-term stress response): Initial ‘fight-or-flight’ response 2. Resistance or adaptation phase (long-term stress response): Body attempts to cope with prolonged stress 3. Exhaustion phase: Resources are depleted - body unable to maintain function

Answer 39

- The cerebral cortex processes stress and sends information to the hypothalamus. Short term: the hypothalamus immediately activates the sympathetic nervous system, which in turn activates the medulla of the adrenal glands, the adrenal medulla releases catecholamines. So if the stressor doesn't resolve and you have a sort of chronic stressor, over time you can activate the long term stress response. Long term: This activates the pituitary gland which activates the adrenal cortex, another part of the adrenal gland . And theses cells release glucorticoids such as cortisol.

Answer 40

- The release of catecholamines causes a number of responses. So the first is that it mobilizes glucose reserves so that glucose is ready to provide energy to the muscles and the rest of your body to prepare for the fight or flight response. It involves increasing the heart rate and respiratory rate to provide blood and oxygen to the tissues. There is a general increase in energy use by all the cells.

Answer 41

Long term stress response is also known as the HPA axis. Stress activates the HPA axis (hypothalamic-pituitary-adrenal) axis: 1.Neurosecretory cells in hypothalamus to release CRH (corticotropin releasing hormone) 2.CRH activates anterior pituitary gland 3.Anterior pituitary secretes ACTH (adrenocorticotropic hormone) 4.ACTH travels through blood to adrenal glands (above kidneys) 5.ACTH stimulates cells in adrenal cortex to release cortisol (a glucocorticoid)

Answer 42

Psychoneuroimmunology: Interactions between the nervous system, behaviour and the immune system

Answer 43

- Acute stressors can upregulate the immune system. Eg if you cut you knee which is a acute stressor immune cells will flow to the area of the wound to help fight infection so that the wound can heal. - Chronic stress inhibits the immune system (immunosuppression) – mediated by glucocorticoids. Cortisol (release controlled by brain) decreases B-cells and T-cells numbers Example: Bereavement – e.g. husbands whose wives died of breast cancer have dampened immune systems. Medical students in their finals are more likely to contract acute infections. Suppression of the immune system Glucocorticoids have potent anti-inflammatory and immunosuppressive properties and are used to treat arthritis – e.g. prednisolone (derived from cortisol)

Answer 44

Abnormal excessive levels of stress are thought to be involved in: -Anxiety disorders -Depression -HIGH BLOOD PRESSURE -Ulcers and other gastrointestinal diseases -Immune dysfunction -Aging -Cancer Stress also seems to increase the frequency and severity of migraine headache, asthma attacks, and blood sugar fluctuations in diabetics Suppression of sex steroid secretion – one study found a drop in testosterone levels in junior doctors

Answer 45

Prolonged exposure to high levels of cortisol causes: -Muscle breakdown -Suppression of immune response -Ulceration of gastrointestinal tract -Depression / psychosis -Failure of pancreatic beta cells -Aging

Answer 46

There is also a couple of brain areas that also are affected by the stress response. They are the amygdala and hippocampus. - The amygdala is activated when you are exposed to a fearful stimulus. The central nucleus of the amygdala is activated and this is what sends signals to the hypothalamus causing activation of the sympathetic nervous system, the short term stress response aswell as the long term stress response ( HPA activation system). - The central nucleus also activates the peri aqueduct grey matter, which leads to avoidance behavior's so the person tends to avoid or close their eyes or run away from that stressful or fearful stimulus. - It also activates the diffuse modulatory systems which causes increased vigilance. The body is alert and ready to react to that fearful stimulus, maybe by running away or fighting it.

Answer 47

- The amygdala works in conjunction in a feedback loop with the hippocampus. So the hippocampus, they form this feedback loop where the amygdala will activate the HPA axis and that stimulates the release of cortisol in the body. And this maintenance of this long term stress response. -But eventually this activates the hippocampus, which in turn inhibits the HPA axis. So it's a way of regulating that stress response. So it's a feedback mechanism. -So if you have too much cortisol, the hippocampus says. Oh wait, that's way too much cortisol, we need to down regulate that. So it does some inhibition. And this is so the body doesn't go crazy continuously releasing more and more cortisol. -So that's that feedback loop between the amygdala and the hippocampus. So they're very involved, especially in the long term stress response.

Answer 48

Inappropriate expression of fear, i.e., unrealistic and unfounded fear. Fear response occurs in an anticipatory manner. Interferes with normal daily activities.

Answer 49

A psychological disorder characterised by unrealistic, unfounded fear.

Answer 50

- Generalized anxiety disorder - Panic disorder - Phobias - Obsessive Compulsive Disorder (OCD) - Post traumatic stress disorder (PTSD)

Answer 51

First response: CBT Second response: Benzodiazepines

Answer 52

Habituation describes a decreased response to a stimulus over time. Operant conditioning: involves voluntary changes in behavior due to punishment and reinforcement. Classical conditioning: involves unconditioned (natural) responses to learned stimuli. Sensitization: heightened response to a stimulus

Answer 53

First line treatments are aphetamines Increase dopamine release by the presynaptic neuron, leading to increased dopaminergic activity on the synaptic cleft. Secondary effects of amphetamines include reducing dopamine reuptake by the presynaptic neuron.

Answer 54

Much of the circadian rhythm is controlled by light input. Light is detected by the retina, which in turn signals to the suprachiasmatic nucleus (SCN) of the hypothalamus. The suprachiasmatic nucleus is the master regulator of the circadian rhythm. "SupraChiasmatic makes you Super Cozy".

Answer 55

Depression is associated with increased REM sleep and decreased REM latency. This can be remembered by understanding that many patients with depression can suffer from chronic nightmares (nightmares occur during REM). Depression is also associated with decreased N3 sleep and earlier wake times.

Answer 56

Orexin is the opposite of melatonin and causes awakeness. It us secreted from the lateral hypothalamus. - People with narcolepsy have decreased orexin so feel more sleepy, less awake.

Answer 57

- Type of amnesia you get after drinking too much alcohol. Most commonly presents with anterograde amnesia. - irreversible damage - The initial treatment for Korsakoff syndrome (and Wernicke's encephalopathy) is to administer IV thiamine. This is done prior to the administration of glucose-based fluids.

Answer 58

Alcohol use affects thiamine absorption in the intestine, which eventually leads to thiamine deficiency. As a result, erythrocyte transketolase activity decreases, leading to atrophy of the mammillary bodies. Mammillary bodies are important for memory formation and retrieval.

Answer 59

- Buspirone is used to treat anxiety only . Its is a Serotonin 5-HT1A receptor agonist

Answer 60

Agoraphobia: irrational intense fear related to specific environments. Primary management for agoraphobia includes CBT and SSRIs. Benzodiazepines may sometimes be used but are not the primary treatment of choice. Social anxiety disorder is the fear of embarrassment or poor performance in social or work settings. Performance type social anxiety disorder is often associated with work settings involving meetings, presentations, and speeches. Primary management for social anxiety in these settings is typically a prophylactic beta-blocker (e.g., propranolol) before giving a speech or presentation.

Answer 61

- Olanzapine is an antipsychotic medication that improves the psychological symptoms associated with anorexia nervosa as well as promotes weight gain.

Answer 62

Refeeding syndrome occurs when a malnourished patient is administered a sudden increase in caloric intake. This causes a sharp increase in insulin levels leading to intracellular shift and subsequent serum decreases in potassium, magnesium, and phosphate. Complications of refeeding syndrome include seizures, dysrhythmias, and rhabdomyolysis. The destruction of muscle cells in rhabdomyolysis causes elevations in serum creatinine kinase levels.

Answer 63

-OCD is recurring obsessive thoughts or feelings relieved by reactionary compulsions. Obsessive-compulsive disorder (OCD) is an urge disorder characterized by recurring thoughts or feelings (obsessions) that are only relieved through reactionary actions (compulsions). These behaviors are ego-dystonic, meaning that they do not line up with the goals and desires of the patient. -Trichotillomania is the urge to pull out one's hair. It is most common in children and presents with hair loss that causes significant distress or social impairment.

Answer 64

Adjustment Disorder: Derangement in emotional management in response to a stressor. Symptoms begin within 3 months of stressor and subside before 6 months. PTSD: Symptoms last from 1 month after events to indefinitely Acute stress disorder: Symptoms last between 3 days and 1 month

Answer 65

Drug class: nonbenzodiazepine hypnotic Indication: used for the short-term management of insomnia. Mechanism: - zopiclone binds to the benzodiazepine receptor on GABA. -Which enhances the inhibitory effect of GABA by increasing Cl- ion in the post synaptic neuron resulting in hyperpolarization. - zopiclone binds to a1, a2, a3, a5 GABA receptors as full AGONISTS