Psychotic Conditions Flashcards
What are the types of mood disorders?
Depressive disorder
Bipolar disorder- sustained low and sustained high mood, affecting function of patient.
Persistent mood disorder.
What is depression?
Second largest cause of disability in the world.
2-3x more common in patients with chronic health problems
More common in divorced/separated, chronic alcoholism, redundancy, bereavement etc.
M:F 1:2
Wellbeing- biological, cognitive function, day to day working, planning etc affected at every level.
What are the core symptoms of depression?
Core symtpoms-
Continous low mood for at least 2wks
Lack of energy
Lack of enjoyment-interest anhedonia
Biological (somatic) symptoms-
Sleep changes 2/3rds insomnia, but younger pts hypersomnia (sleeping too much)- EMW (early morning wakeming- 2hrs before roughly)
Appetite and weight loss
Diurnal variation of mood- Morning worse, feel slightly better by evening.
Psychomotor retardation/agitation, dont want to move.
Loss of libido
Cognitive symptoms- negative view of self and project onto future i.e. im no good, no one likes me, my future is no good.
Low self esteem
Guilt/self blame- may focus on a small negative thing we did and multiply it by x100
Hopelessness
Hypochondrial thoughts
Poor concentration/attention so memory may be affected
Suicidal thoughts
What are some biological symptoms of depression?
Biological (somatic) symptoms-
Sleep changes 2/3rds insomnia, but younger pts hypersomnia (sleeping too much)- EMW (early morning awakening ≈ 2hrs before usual)
Appetite and weight loss
Diurnal variation of mood- Morning worse, feel slightly better by evening.
Psychomotor retardation/agitation, don’t want to move.
Loss of libido
Suicidal thoughts
What are some cognitive symptoms of depression?
Cognitive symptoms- negative view of self and project onto future i.e. I’m no good, no one likes me, my future is no good.
Low self esteem
Guilt/self blame- may focus on a small negative thing we did and multiply it by x100
Hopelessness
Hypochondrial thoughts
Poor concentration/attention so memory may be affected
Suicidal thoughts
How is depression diagnosed?
1) Mild- 2 core + 2 others (able to function)
2) Moderate- 2 core + 3/4 others
3) Severe 3 core + at least 4 others
4) Severe with psychotic symptoms
What are the differentials for depression?
Alcohol misuse Borderline personality disorder Dementia Delirium Schizophrenia
Cushing’s syndrome
Thyroid disease
HyperPTH
What is psychotic depression?
Hallucinations (auditory most common and negative)
Delusions (hypochondrial/guilt/nihilistic/persecutory i.e. world is coming to an end, patient says they’re dead
What is post natal deprssion?
10-15% of motherz within 1-2 months post partum
Worried about babys health and ability to care for baby
RF- FHx depression, older mother, single mother, poor social support, previous PND.
How is depression managed?
What are the symptoms of hypomania?
Mildy elevated, expansive or irritable mood. Increased energy/activity Positive view of oneself Increased self esteem Socialibility, talkative, over familiarity Increased sex drive Reduced need for sleep Difficulty of focusing on one task
Some pt enjoy the hypomania state.
What are the symptoms of mania?
Elevated/expansive/irritable mood (1wk)
Increeased energy/activity (inc agitation)
Grasniosity/increased self esteem
Pressure of speech- very apparent symptom
Flight of ideas/ racing thoughts
Distractible
Reduced need for sleep
Increased libido
Social inhibitions lost
Psychotic symptoms- believe they have super powers, think theyre a prophet etc.
Judgement impaired i.e getting loan to order two mercedes because different colours look nice.
What is a persistent mood disorder?
Cyclothymia-
mild periods if elation/ depression (needs ti be present for 2yrs).
Ealry onset/ chronic course
Common in relatives of BPD
Dysthymia-
Chronic low mood not fulfilling the criteria of deprssion
What is a mixed affective state?
Mixture or a rapid alternation (within few hrs) of hypomanic, manic and depressive symptoms.
How is bipolar classified?
1- 1 or > manic epsiodes or mixed episodes +/- 1 or > depressive episodes
2- 1 or > depressive episodes with at least 1 hypomanic episode
ICD 10- at least 2 epsiodes one of which must be hypomanic, manic or mixed episodes.
What is the epidemiology of bipolar?
1-2% prevalence
Onset 25yrs
M=F
Increased suicide rate
What are the differential diagnosis of mood disorders?
Normal fluctuations of mood PTSD Adjustment disroders i.e. bereavement Dementia Personality disorders Anxiety disorders
What are the causes of mood disorders?
Biological- genetics (depression x3 if first degree family relative), brain illnesses, physcial illness (chronic)
Psychological- childhood expereinces, view of yourself and fhe world, personality traits (i.e. obsessive persoanlity)
Social- housing, finance, work, relationships, support etc.
What are the treamtents of mood disorders?
Biological- pharmacological (antidepressants, mood stabilisers (lithium most effective), anti-psychotics, anxiolytics), ECT, rTMS (non invasive), tDCS
Psychological- Psychoeducation (about illness, relapse,medication), CBT, IPT, psychodynamic therapy, mildfullness.
Social- targeted interventions- family, housing, finance, employment, general coping strategies.
What is ECT?
2 times a wk for 12wks
Send electric current thriugh the brain to trigger an epileptic seizure.
Indications: severe depressive illness
Life threatening (food/fluid not), prolongued snd severe manic epsiode, caratonia, high suicide risk, stupor, severe psychomotor rtardation.
Whatbis the prognoiss of derpression?
First epsiode- Continue AD for 6-12 months. 50% chance of a second episode. This increases to 80% after a second epsiodes.
Multiple episodes- Continue AD for much longer
10% chance of severe unremitting depression
What is the prognosis of bipolar disorder?
Poor if:
Severe epiosdes, early onset, cognitive deficits.
Treatment is more effective ealier in the course of illness
80% relapse after first epsiode within 5-7yrs
But inbetween epsiodes will stabilise their moods.
Define personality
Individual differrnces in characteristic patterns of thinking, feeling and behaving.
What shapes a perons personality?
Biological- genes (temeprament), physical appearence, characterisitics, IQ, disability.
Psychological- early attachemnt and environment, siblings, peer relationships, schooling, traumas
Social- socioeconomic status, war, peace, social media, climate, culture, immigration
What is a personlity disorder?
Class of mental disorders
Maladaptive patterns of behaviour, cognition, inner experiences
Exhibited across many contents and deviating significantly from those accepted by an individuals culture.
Develop early, are inflexibek and associated with significant distress or disability.
Peristent
Problematic
Pervasive (across different contexts)
What are the types of personality disorder?
10 types
Common to have more than one
May have traits of one type without the full disorder
Scoring high on severity and acorss differnt types is a sign of increasing complexity.
What cluster A?
Paranoid- suspicious of others, mistrustful, misinteroret events, bear grudges, strong personla rights.
Schozoid- detached, solitary, aloof, little interest in people and sex, lack close friends.
Schizotypal- eccentric, odd behaviour and thinking, unconventional beliefs, can develop schizophrenia.
What is cluster B?
More common
Bordeline- emotionally unstable, mood all over the place, impulsive, enage in parasuicidal act, chronic feelings of emptiness, intense and unstable realtionships, fear of abandonment.
Naricissistic- grandiose, self important, degrade others, cant ask for help,
Antisocial- unconcerened for others feelings, disregard for rules, impulse, low tolerance to frustration, failure to take responsibility.
Histrionic- theatrical, dramatic, exhibit superficial emotionality, seductiveness, suggestibility.
Narcissistic
What is cluster C
Anankastic/ Obsessive compulsive- rigid, stubborn. Perfectionsitic, preoccupied with rules, higher sense of moraliry.
Dependent- need others to make decisions, fear of abandonemnt, ubake to cope alone, need reassurance.
Anxious- avoidant, anxiety, sensitive to rejection, avoid relationships unless acceptance is guaranteed.
Cluster B can develop into cluster C as they age- left with sense of emptiness
How are personlity disorders diagnosed?
ICD-10 or DSM-V
More accurate include IPDE, SKID-II, PDQ-4
Why do personlity diroders develop?
Attachemtn in childhood. Form an emotional bond between baby and parent which is needed to survive, helping the brain develop and emotional developemnt.
Attachement in adults- childhood attachemtn allow you to view the world in a felxible and trusting way, inceasing confidence and capacity to tolerate and resolve conflict.
Attachement in personlity disorders- unsfe and abusive experience of the world- will expect others to be histile, neglect, wont trust others, will feel overwhelmed by feelings osntead of managignhem.
What is the importance of attachemnt?
We are attachement figures.
So ot will relay to us as they do to their parents/caregivers.
What is self harm?
Coping strategy
Common in personlity disroders especially borderline
What are emotional responses?
Hamilton boundary see-saw model.
Pacifier- over involved, too indulging, may feel great satisfaction, may feel special
Controller- under involved +/ too controlling
Stay wihtin negotiator zone- care, be compassionate and firm, flexible balance.
How are personliry disroders trested?
Problem with attachemnt
Need to restore idea of attachment i.e. as attachement figures.
Ensure pt sees same doctor.
Understand with the patient the crisis indicators- what happened before the episode of self harm- feeling rejected etc.
Appropriate boundaries (we have only 20 mins today for the consultation), contract to keep safe (ask for help if feeling unsafe)
Empowerement and recovery focused approach
Well co-ordinated, shared and coherent treatment
Good communication between different clinicians
Reflective practice groups, MDT meetings to understand pt.
Harm minimisation-
Self harm rleases endorphins so try to replace with something else. I.e. holding ice cube, elastic band- still harm but minimised.
Or alternative i.e exercise.
Boundaries- personality disorders have confused boundaries. Need to be clear to explain your rekationships, expectations of the service user and be consistent and reliable in what you said you would do.
Other treatmen
Psychotropic medications are only to treat comorbidities, not the person,iry disroder.
Therapuetic involve-
Group treatment to help people think of relationships.
DBT
MBT
TFT
When would we use the word neurosis?
Functional not organic illnesses
Not psychosis
Essentionally synonymous with anxiety disorders
What is an anixety?
Within a situation we have an interaction beween thoughts, behaviour and feelings.
Anxiety is a natural behavioural response to a threatening situation/when danger is perceived. It is needed for survival and so has remained through natural selection.
Fight/flight/freeze
When does anxiety become a problem?
When the threat doesnt exist in the way it is perceived.
I.e. the response to a psychological threat (imagined)
The brain is unable to distinguish between the physical and psychological threat.
This produces a psychological arousal.
Racing thoughts
Inability to concentrate
Cognitive bias- attentional focus- noticing the anxious preoccupation, i.e. noticing how fast their heart is beating.
What is a simple equation for anxiety?
Anxiety= estimate of danger/estimate of coping
You’re less likely to become anxious about somethingnif you can perceive coping well with the threat/danger.
What are safety behaviours?
Can’t always get away from danger, so people with anxiety disorders will strategies to cope with these potential threats.
I.e. a person may have a fear of getting a dry mouth so will always carry a bottle with them.
Get temporary relief but this reinforces their belief which is not good in the long run. Pt may become reluctant to give up their safety behaviours.
What are the anxiety disorders?
Panic disorder +/- agarophobia Social anxiety disorder Specific phobias Health anxiety (hypochondrias) OCD Body dysmorphic disorders PTSD GAD
What are specific phobias?
A marked fear of specific object/situation.
Inability to be rational about the threat.
Once placed with the stimulus- fight or flight.
The pt will avoid the object/situation which reinforces the phobia.
What is a panic disorder? +/- agarophobia
A feeling of something awful about to happen, causing massive amounts of arousal. Bodily changes can be viewed as signs of impending collapse, insanity or death.
The fear of your own physiological and psychological reactions.
Can often be associated with agarophobia. Once you suffer with panic disorder, you may avoid environments you have little control over, as a safety measure. Home becomes a safe place, whereas outside world is more out of your control.
Sense of dread
Choking
Feeling might go mad
Feeling of collapsing, going to die
What is a cognitive model of panic?
Internal/external trigger-
Internal- change in HR, even change in blood pH etc. More tuned in with self.
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This is perceived as a threat
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Produces anxiety
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Get physical/cognitive symptoms i.e. HR increase, digestive changes (fight or flight)
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Misinterpretation of signs of disaster/stuff going wrong
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Makes anxiety worse- get worse symptoms- misinterpret- get worse anxiety
(PANIC IS STUCK IN THIS CYCLE)
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Start to implement safety measures
What is GAD?
‘Worry problem’
Type 1- everyday worries (normal)
+
Type 2 - worrying about worrying a lot.
Usually accompanied by low level anxiety physical symptoms i.e. insomnia, muscle tension, headache etc.
They experience positive worry beliefs which maintains the GAD. The pt believes if they didn’t worry as much they wouldn’t have come as far as they have, or achieved what they have, lr made them as responsible as they have.
What is social anxiety disorder?
Fear of negative evaluation by other people.
They start to avoid situations which could expose them to that evaluation, may devleop social anxiety. Feeling shy.
Use of safety behaviour if unavoidable- anticapatory anxiety, rehearse what you might say if fear of sounding boring/awkward but then don’t pay attention to the conversation, scared of sweating so much bring extra clothes, ‘post-mortem’ of the social event, may drink alcohol then start to regret things they did- leads to avoidance of social events.
May start to process themselves as how others are viewing them- making them look more awkward.
What is OCD?
Unwanted recurring distressing intrusive thoughts/images. (Obsessions)
E.g. being contaminated, causing harm, behaving inappropriatly i.e. wanting to shout in the middle of silence, sexual imagery.
Often pt will feel disporportionatley responsible i.e. infecting their whole family if they’re contaminated.
Attaching a significance to the thought will lead to anxiety.
These are ego dystonic (these thoughts do not fit in with the actual beliefs/morals of the person).
Managing the distessing/neutralising the anxiety of the obsessive thought with a compulsive behaviour.
Compulsions can be-
Overt- washing, checking, odering/alligning
Covert- (in their head) praying, counting, repeating words.
Should challenge- what would happen if you didn’t do that?
What is body dysmorphic disorder?
Pre-occupied with an imagined defect in appearance.
This leads to time consuming behaviours i.e. mirror gazing, comparing particular features to others, XS camouflaging tactics, skin picking and reassurance seeking.
What is PTSD?
Caused by exposure to event or situation exceptionally threatning which would cause distress to anyone.
I.e. warfare, terrorist, car accident etc.
Features-
Re-experiencing phenomena- Feel as if you are actually there. These can be in the form of nightmares of flashbacks (lost with reality, unresponsive and won’t remember what happened in reality during flashbacks)
Avoidance- i.e. fireworks (can give flashbacks to war), avoid news.
Hyperarousal- more guarded. Unprocessed/raw memory so perceive this as an ongoing threat therefore scan for threats more.
Co-morbidities- other anxiety disirder, depression, substance misuse.
What are the problems associated with anxiety disorder?
Increased autonomical arousal Behavioural changes Avoidance Time consuming anixety behaviours Worry Procrastination Reduced concentration Impaired functioning- work, social, health Impaired sleep pattern Alcohol or drug dependence
What are the differential diagnosis for anxiety?
Adjustment disorders or bereavement (work through the problem)
Other psychiatric disorder i.e. depression- find which came first
Organic disorders i.e. endocrine, neurological, drug induced, alcohol/drugs
What is schizophrenia?
Schizo- split
Phrenia- mind
Split function of the mind, no longer working coherently, mind is falling apart.
A disorder/group characterised by psychotic episodes (positive symptoms) and negative symptoms.
Prevalence 1%
RF include- +ve FHx, may have some relation to cannabis use
What are the diagnostic symptoms of schizophrenia?
1) Thought withdrawal, broadcast and insertion
2) Delusions of control, passivity or influence of thoughts, actions and sensations. i.e. think someone else is controlling their movements, ‘I am a webcam.’
3) 3rd person auditory hallucinations, either running commentary or speaking about the patient amongst themselves.
4) Primary delusions
5) Persistent hallucinations occurring daily for weeks.
6) Breaks in train of thought, resulting in incoherent speech. Neologisms (made up words).
Symptoms also include;
Autism (self absorbed in own world).
Flat affect (no change in mood) or incongruous (sad but laughing)
Ambivalence- hold two opposing ideas at the same time.
Loosening associations (formal thought disorder)
Amotivation or apathy
What is the difference between positive and negative schizophrenia?
Positive- acute onset, prominent delusions and hallucinations, normal brain structure, good response to anti-psychotics and better outcome.
Negative- slow, insidious onset, relative absence of acute symptoms, apathy, social withdrawal, lack of motivation, underlying brain structure abnormalities and poor neuroleptic response.
How is schizophrenia managed?
BIO- Anti-psychotics!!! Refer to pharmacology lectures
PSYCH- supportive counselling, family therapy (role in schizo)
SOCIAL- debts, benefits, housing, OT, CPN, SW
What are the differentials of schizophrenia?
Organic mental disorder- i.e. brain tumour
Mood disorder i.e. mania
Drug psychoses
Personality disorder i.e. schizotypal
