Specific disorders Flashcards
What are the different anxiety disorders?
- Panic disorder
- Social anxiety disorder/social phobia
- Specific phobias
- Health anxiety - hypochondriasis
- Obsessive compulsive disorder/body dysmorphic disorder
- PTSD
- Generalised anxiety disorder
What is specific phobia?
Irrational fear of specific object or situation w avoidance of object or situation.
Avoidant behaviour - autonomic response to get away, then anxiety is reduced.
What is panic disorder? +/- agoraphobia
Fear of physiological and psychological reactions - bodily changes viewed as signs of impending collapse, insanity or death. Experience a catastrophic misinterpretation leading to panic, often unpredictable.
Avoidance of situations that may trigger these reactions = agoraphobia, don’t want to leave the house.
What are the sx of panic disorder?
- Sense of dread
- Choking sensation
- Palpitations and chest pain
- Shaking and wobbly legs and sweating
- Feeling faint, dizziness
- Depersonalisation or derealisation
- Secondary fear of dying, losing control or going mad
- Hyperventilation - tingling in hands, feet or around mouth - can lead to carpopedal spasm if severe
What is GAD? What are the CFs?
Generalised anxiety disorder: free floating anxiety sx
- Apprehension - worries about anything, difficulty conc, feeling on edge
- Motor tension - restlessness, tension headaches, trembling
- Autonomic overactivity - insomnia, muscle tension, GI problems, headaches, sweating, persistent nervousness, trembling
- Often have the belief that worry is useful = positive worry beliefs
- V rarely begins after 35
- Can also get depersonalisation and derealisation
What is social anxiety disorder? What are the CFs?
Fear of a neg evaluation by others - avoidance of feared situations eg. social situations.
- Anticipatory anxiety
- Anxiety following social encounters, debrief
- Blushing, hand tremor, nausea, urgency
- May abuse alcohol or drugs
Obsessions vs compulsions
Obsessions - unpleasant distressing unwanted recurring intrusive thoughts or images. Opposite of what pt want to do = ego dystonic - thoughts inconsistent w ones self concept. eg. being contaminated, causing harm, behaving inappropriately, sexual imagery
Compulsions - behaviour to neutralise the obsessive/intrusive thought, helps to manage distress. Pt recognises the behaviour is pointless and attempts are made to resist but this makes anxiety worse.
Overt vs covert compulsions
Overt - washing, checking, ordering, aligning
Covert - praying, counting, repeating words
What is BDD?
Body dysmorphic disorder - preoccupation w imagined defect in appearance - time consuming behaviours - comparison, reassurance seeking, skin picking
What is PTSD?
Caused by exposure to event or situation that is exceptionally threatening which would be likely to cause distress in almost anyone.
eg. car accident, veterans, natural disasters
What are the cardinal features of PTSD?
- Re experiencing - nightmares or flashbacks, feel like you are back in the situation experiencing it - dissociation
- Avoidance - avoid triggers that experience re experiencing
- Hyperarousal - cont perceiving threat due to unprocessed memory, enhanced startle reaction, hypervigilence, insomnia
Disorder usually starts w/i 3 months of event, need to have had sx for 1 month.
What are some problems associated w anxiety disorders?
- Increased autonomic arousal
- Avoidance
- Time consuming anxiety reducing behaviours
- Worry and procrastination and reduced conc
- Impact on functioning
- Impaired sleep pattern
- Alcohol and drug dependence
What is the diff diagnosis for anxiety?
- Adjustment disorders or bereavement
- Other func psych illness - treat the primary disorder
- Organic - endocrine, neurological, drug induced, alc and drug misuse, other eg. infection, anaemia
What are 4 CF of psychosis?
- Hallucinations
- Delusions
- Fragmentation of behaviour - disorders of the self
- Formal thought disorder
Lack of insight
What are hallucinations?
Perception of an object in the absence of an ex stim:
- Any of the 5 modalities
- Auditory most common
- Visual - more likely to be delirium
- Olfactory - indicates possible frontal lobe pathology
- Can also get tactile and gastrotony (taste hallucination)
What are delusions? What are the types?
Fixed belief, usually false that is held despite evidence to the contrary and is out of keeping w persons’ sociocultural norms:
- Persecutory
- Grandiose
- Reference
- Erotomanic - someone in love w u
- Hypochondriacal
What is formal thought disorder?
Problem w speech:
1. Flight of ideas
2. Loosening of associations
3. Circumstantiality
4. Tangentiality
5. Neoligisms
What are disorders of the self/fragmentation of behaviour?
Pt can’t distinguish between himself and the world, includes:
- Thought broadcast
- Passivity phenomena - someone is moving me
- Thought insertion - someone put those thoughts in their head
What happens following a psychotic episode?
- Never have a psychotic episode again
- Get better and go on to have recurrent episodes of psychosis but always fully recover after
- Never get better, personality change, and then go on to have recurrent episodes
What is shizophrenia?
Disorder characterised by psychotic eps (positive sx) and neg symptoms.
What are the positive sx of schizophrenia?
Psychotic symptoms:
- Auditory hallucinations
- Delusional perceptions
- Formal thought disorder
- Passitivity phenomena
What are the negative sx of schizophrenia?
- Alogia - poverty of speech
- Anhedonia - not enjoying anything
- Flattening/blunting of affect
- Avolition/apathy - poor motivation
- Social withdrawal
- Self neglect
What are the first rank sx of schizophrenia?
- Auditory hallucinations
- Thought disorders - thought insertion, w drawal and broadcasting
- Delusional perceptions - normal object perceived and delusional interpretation of its meaning or abnormal significance from a normal event
- Passivity phenomena
What is the biopsychosocial assessment in psych?
Bio - blood and drug tests, CT, compliance
Psycho - MSE, collateral
Social - carers, housing
What is the biopsychosocial management of schizophrenia and psychosis?
Bio - antipyschotics
Psycho - supportive counselling, family therapy
Social - debts, benefits, housing, CPN and support worker
What are some factors shaping personality?
Biological - genes, temperament, IQ, physical appearance, disability
Psych - early attachment and environment, siblings, school, trauma?, peer relationships
Social - socioeconomic status, living through war/peace, social media, culture, climate
What are personality disorders?
Conditions where individual differs from the avg person in how they think, perceive, feel or relate to others. Deviates markedly from those accepted from individuals culture. Patterns develop early and are inflexible.
How is self harm tried to be minimised?
- Replace self harm w less damaging strategies - elastic bands, holding ice cubes
- Distract themselves eg. go on a walk
- Self harm can be addictive as releases endorphins
- Get pt to be treated for their injuries
What is adjustment disorder? What are the manifestations?
Distress and emotional disturb interfering w social functioning and performance arising in period of adaptation to significant life change or stressful event. Features last for at least one month but onset straight away not more than 6 months after stressor.
Manifestations:
- Depressed mood or anxiety
- Inability to cope, plan ahead or continue in present situation
- Avoidance
What is the prevalence of the anxiety disorders?
- 10% of all pt, most are female
- Comorbidity w depression, substance misuse and personality disorder
- Childhood adversity and FH predispose to anxiety
- If present after 35-40 years more likely to be organic disease or depressive disorder
What is the management of GAD?
- Mild = psycho education, advice and reassurance, self help
- Counselling to address pt worries or CBT
- Other therapy = anxiety management training, relaxation techniques
- Benzos shouldn’t be prescribed for more than 10 days, only really for severe sx that obstruct other treatments, diazepam the least likely to have w drawal sx
- Drug therapy - SSRI, SNRI, B blockers eg. propanolol in somatic anxiety sx, pregab, low dose antipsychotics
What is the management of panic disorder?
BioPsychoSocial
- CBT first line and effective in 80-100% - education about panic attacks and fear of fear cycles, aim to change thought processes
- Controlled exposure to somatic sx - breath in CO2 and exercise
- SSRIs = first line drug, second line to CBTT
- Clomipramine - tricyclic w similar action to SSRI
What is busipirone?
Seratonin agonist, used for short term management of GAD. Has a delayed onset of action but diminished efficacy in prev benzo users. Has minimal sedation
SEs - dizziness, headache, nausea
What is involved in a risk assessment?
- Risk factors
- Protective factors eg. having a pet or children
- Specific suicide inquiry
- Then decide risk level
What are some of the risks of suicide?
- Highest during inpt stay - prev behaviour, violence to property, delusions
- Post discharge - still unwell, uneployment, lack of cont of care
- Physical illness, chronic
- Living alone
- Male
- Unemployment
- Drug and alcohol misuse
- Mental illness and prev self harm - severe depression, schizophrenia, bipolar
- Access to weapons
What is the management of phobias?
BioPyschoSocial
- Exposure techniques using graded hierarchy approach - flooding and modelling
- Agoraphobia, social phobia and panic disorders - CBT
- SSRIs and MAOIs good for agoraphobia and social phobia
- If depressive component - tricyclic antidepressants
- Benzos before a phobic situation
- B blockers for somatic sx
What is an acute stress reaction?
Transient disorder in an individual w no other apparent mental disorder in response to large amounts of stress.
Usually ends w/i hours or days, shouldn’t last longer than a month. Often requires no treatment, some may need trauma focused CBT or EMDR.
What are the sx of ASR?
Behavioural sx - daze, confusion, sadness, anxiety, anger, inactivity/overactivity, social w drawal, depersonalisation and derealisation
Autonomic sx of anxiety also common.
What is EMDR?
Eye movement desensitisation and reprocessing - unprocessed memories are the cause of PTSD or ASR. Eye movements used to help process traumatic events.
What are the sx of PTSD in children?
- Nightmares and difficulties sleeping
- Repetitive trauma related play
- Intrusive thoughts
- Avoidance and increased behavioural difficulties
- Probs conc and hypervigilance
What is the treatment of PTSD in childnre?
- Trauma focused CBT w/i one month of traumatic event to try and prevent PTSD and for those w PTSD diagnosis
- EMDR if don’t respond to PTSD
- No drug treatments for PTSD <18
What is the management of PTSD in adults?
Psycho:
- Prevention if present w/i 1 month - trauma focused CBT
- Treat w diagnosis or >1 month - cognitive processing therapy, trauma focused CBT, narrative and prolonged exposure therapy
- EMDR for non combat related trauma
Bio - venlafaxine or SSRI, antipsychotics if severe hyperarousal or psychotic sx (second line)
Social - manage other issues that may be a bareer eg. housing and substance misuse
What is the diagnostic criteria for OCD
- Obsessions or compulsions or both present most days for at least 2 weeks
- Originate in the pt mind and not imposed by outside persons or influences
- Repetitive and unpleasant - acknowledged as excessive and unreasonable but unsuccessfully resisted
- Cause distress/interfere w subjects functioning - waste time
What is the management of OCD in adults?
Mild func impairment - CBT and exposure and response prevention (ERP)
Mod func impairment - high intensity CBT and ERP or SSRI/clomipramine
Severe func impairment - high intensity CBT and ERP with an SSRI (usually higher doses needed, may take 12 weeks to work)
What is the management of OCD in children?
Mild - self help and info for family, CAMHS
Mod to severe - CBT/ERP involving family
If psych treatment fails consider comorbid conditions.
>8 years old can add SSRI after MDT, only by consultant.
What is TMS?
Transcranial Magnetic Stim - electromagnetic pulses to part of brain w objective of reducing OCD sx (can treat other mental disorders).
What is anorexia nervosa?
Deliberate weight loss induced and sustained by the patient. Concerns around weight and shape, w fear of becoming fat as an intrusive overvalued idea.
Weight and calorie goals made and pt determined to achieve these regardless of impact on physical health.
May also partake in excessive exercise, laxative use or vomitin.
What are the CF of anorexia nervosa?
Physical features - low BMI, hypotension, bradycardia, enlarged salivary glands, lanugo hair, amenorrhoea
Biochem - hypokalaemia, low FSH, LH, O and T, raised GH and cortisol levels, hypercholesterolaemia
Sx - intolerance of cold, fatigue and fainting, constipation, satiety, dysphagia, abdo pains
What is refeeding syndrome?
Rapidly increasing insulin levels - shifts of K, Mg and phosphate from extracellular to intracellular spaces.
CF - oedema, confusion, tachy
What are some physical consequences of anorexia nervosa?
- Cardiac arrhythmias - always perform ECG
- Body attempts to reduce energy expenditure = bradycardia and hypotension and prolonged QT interval - risk of VF
What are some RF of developing anorexia nervosa?
- Female
- Age
- FH eating disorder, depression, substance misuse
- Premorbid experiences - sexual abuse, dieting behaviour in family, pressure to be slim occupationally, onset of puberty
- Personal characteristics - perfectionism, low self esteem, obsessional traits, early menarche, EUPD
What are the ix into anorexia nervosa?
- ESR and TFTs to rule out other causes of weight loss
- U+Es in those w vomiting, diuretics and laxatives behaviours
- BMI <15 or hx of purging - FBC, ESR, U+E, cr, glucose, LFTs and TFTs
- DXA scan
- ECG - bradycardia or prolonged QT interval
What is the management of children w anorexia?
- Anorexia nervosa focused family therapy, 1st = carer givers control of diet, 2nd = child regains some control, 3rd = plan for maintaining recovery and prevent relapse
- CBT if ^ not appropriate
What is the management of adults w anorexia?
- Individual eating disorder focused CBT
- Other psychological interventions
- Physical complications - monitor U+Es and ECG, DXA scans?
- May need urgent admission if electrolyte imbalance, severe malnutrition and dehydration, organ failure or arrhythmia
What are the CF of bulimia? Inc physical signs
Binge eating - loss of control and eating enormous amounts w urge
Purging - binges cause shame and guilt = vomiting, laxatives, diuretics to undo damage
Body image distortion - feeling fat
Physical features - dental erosion, parotid gland swelling, Russell’s sign, reflux, lethargy, bloating
What is the management of bulimia?
Specialist care - CBT is first line.
In children - bulimia focused family therapy.
What are some other forms of disordered eating?
- Overeating associated w psych disturb eg. overeating due to stressful events
- Vomiting associated w psych disturb eg. hypochondriacal vom
- Pica - eating things not considered food, can be linked to nutritional def or children w autism
What are the RF of autism?
- Sibling w autism
- Pre term or birth defects eg. cerebral palsy
- Intellectual disability
- ADHD
- Genetic and chromosomal disorders
What is autism spectrum disorder?
Persistent problems w reciprocal social interaction and communication w restricted inflexible repetitive patterns of behaviour atypical or excessive for individuals age or sociocultural context.
Onset normally during developmental period but sx may not fully manifest until later when social demands exceed limited capacities.
Spectrum - full range of intellectual functioning and language abilities.
What is the presentation of ASD in preschool children?
Spoken lang - delay or loss of speech, flat intonation, echolalia, confusion w pronouns
Response to others - reduced responsiveness to social smiling, others facial expressions and feelings and name, rejection of cuddles initiated by others
Interacting w others - reduced social interest or play, absent enjoyment and sharing of enjoyment
Reduced use of gestures, facial expressions, eye contact
What is the presentation of ASD in 5-18 years old?
Speech - limited, monotonous, talk at others, rude
Response to others - reduced response to facial expressions, their name, demand avoidant behaviour
Interaction - reduced social interest, greeting or farewell behaviours, reduced eye contact and gestures, reduced attention
Unusual/restricted interests and behaviours - stimming, dislike change, routines, sensory issues
When should a diagnosis of ASD in adults be considered?
One or more = persistent difficulties in social interaction and communication, stereotypical behaviours, resistance to change
and
One or more = problems w employment, difficulties w social relationships, prev MH or intellectual disability service contact, hx of neurodevelopmental condition eg. ADHD or ID
What medical problems are associated w ASD?
- Epilepsy
- Visual and hearing impairment
- Mental health - depression, anxiety, OCD
- Neurodevelopmental disorders - ADHD
- General intellectual disability
- Sleep disorders
When can ASD be diagnosed?
Between ages of 2-3 years old can start to diagnose, most diagnoses from 4-5 years old.
What is the management of ASD?
Bio - non pharmacological, may use drugs for co existing conditions, rarely anti psychotics in problem behaviour but no evidence to prove they help, infact have negative impact on on person w ASD
Psycho - play based strategies to help increase attention, engagement and communication, early intensive behavioural intervention programmes, SALT, OT, CBT if anxious
Social - community services and social groups, OT
What is the diagnostic criteria for ADHD/hyperkinetic disorder?
- Inattention
- Hyperactivity and impulsivity
- As well as - several sx present before 12 yo, sx present in 2 or more settings eg. home, school, work, clear evidence sx interfere w functioning
- Sx not only during course of schizophrenia or another psychotic disorder and not better explained by other disorder
What are the inattention sx of ADHD/hyperkinetic disorder?
6+ sx if <16yo or 5+ if >17 and present for 6 months:
- Often makes careless mistakes and doesn’t pay attention to details
- Often has trouble holding attention
- Doesn’t listen when spoken to directly
- Doesn’t follow through on instructions and fails to finish tasks
- Has trouble w organising
- Avoids and dislikes tasks that require sustained mental effort
- Loses things
What are the hyperactivity and impulsivity sx of ADHD?
- Fidgetings
- Leaves situations where remaining in seat is expected
- Runs or climbs, feeling restless in adults
- Unable to play quietly
- Talk excessively and blurt out answers, trouble waiting turn
- Interrupts and intrudes on others
What are the different presentations of ADHD?
- Combined - enough sx of both criteria present for 6 months
- Predominately inattentive
- Predominately hyperactive impulsive
What is the cause of ADHD?
- Reduced activity of frontal lobe - problems w executive function
- Is highly heritable but no single RF or gene identified
- RF - low birth weight, maternal smoke or alc, epilepsy, acquired brain injury, lead exposure, Fe def, being a looked after child, substance misuse
What are the differentials for ADHD?
- Anxiety, depression, bipolar
- ASD or personality disorders
- Oppositional defiant disorder
- Conduct disorder
- Tic disorders
- Fetal alcohol syndrome
What is the management of ADHD?
Bio - pre school = no meds, school age = meds if severe, adult = meds 1st line = methylphenidate
Psycho - pre school = ADHD focused group parent training programme, CBT for young people may help
Social - liase w school to modify learning environment, social skills training
What is involved in monitoring of ADHD meds?
Need titration and dose stabilisation:
- Height check - every 6 months
- Weight check - every 3 months <10, every 6 months >10
- HR and BP every 6 months and before and after dose changes
- If probs w height then can have planned break in school hols for catch up growth
- Medication review once a year
Can you drive when using amfetamines?
eg. dexamfetamine or lisdexamfetamine
Don’t drive if - drowsy, dizzy, unable to conc, blurred vision.
Police may need roadside or blood tests for drug levels.
Can drive if driving not impaired.
What are the CF of antisocial personality disorders?
- Disregard and violation of the rights and feelings of others
- Lack empathy - manipulative and impulsive
- Aggressive and lack remorse
- Irresponsible - fail to obey laws and social norms
- Unstable personal relationships
- Comorbid alcohol and drug misuse
- Criminal behaviour
What are the causes/RF of dissocial personality disorder?
- Parental conflict and harsh inconsistent parenting, often looked after children
- Diagnosis of childhood conduct disorder
- FH of dissocial personality disorder or other mental health disorders
- Experiencing abuse of neglect during childhood
- Men>women
What is the management of dissocial personality disorer?
- People are v unlikely to seek help, most likely diagnosed when in trouble w law or suicidal ideation
- Assess risk - staff training, panic buttons etc
Bio - antidepressants and antipsychotics in crisis situation or comorbid conditions but nothing specifically of DPD
Psych - CBT and group psychotherapy to target reduction in offending and antisocial behaviour, improve perceptions and responses to social and environmental stressors
Social - social cohesion is a preventative factor - help w employment, housing and substance misuse
What are the complications and risks of dissocial personality disorder?
- Suicide
- Substance abuse
- Accidental injury
- Depression
- Homicide
- Abuse in relationship
What are the CF of emotional unstable personality disorder?
- Abrupt mood swings, unstable relationships and instability of self image
- Self harm is common and threats of suicide
- Relationships - idealisation and devaluation
- Inability to control temper and general affect
- Transient psychotic sx
- Female>male
What are the 2 types of EUPD?
- Impulsive type - predominant characteristics = emotional instability and lack of impulse control, commonly violent outbursts and threatening behaviour esp in response to criticism by others
- Borderline type - unclear self image, aims and preferences, involvement in intense and unstable relationships = excessive efforts to avoid abandonment = suicidal threats or acts of self harm
What is the management of EUPD?
Bio - mood stabilisers and atypical antipsychotics but not first line, short term sedatives during crisis while alt plan made
Psycho - psychotherapy, needs to be long term, crisis plan in place
Try to reduce self harming - CBT?
What are delusions and the types?
Fixed false beliefs not shaken by reasoning:
- Persecutory
- Grandiose
- Control
- Reference
What are the neurotransmitters related to depression?
Seratonin, NA, dopamine
What are some screening tools for depression?
Hospital anxiety depression scale
PHQ9 - need to know !!
What is the course of schizophrenia? What is the stereotypical demographic?
Can either be chronic or relapsing and remitting.
Can develop at any age but mostly starts in teens and early 20s. Men and ethnic minorities are at higher risk of all psychotic disorders.
What are some risk factors of schizophrenia?
- Smoking cannabis from a young age
- FH, if multiple members of your family have it your risk greatly increases
- Intrauterine and perinatal complications, viral intrauterine infection
- Abnormal early cognitive or neuromuscular development
- Social isolation
- Abnormal family interactions and traumatic events in childhood
What is the prodromal period?
Period of subclinical signs and sx preceding the onset of psychosis, can last weeks to years. There are changes to persons behaviour and personality. There may also be sx of other psychiatric diseases and often significant alc and substance abuse.
What will you see in an MSE of a patient w schizophrenia?
Appearance and behaviour - wdrawn, suspicious, unkempt
Speech - thought blocking, loosening of associations, knights move thinking
Mood/affect - flattened affect
Thought - auditory hallucinations, delusional perceptions, thought disorder, passivity experiences
Cognition - attention, conc, orientation and memory should be assessed, if impaired significantly = delirium or dementia more likely
What are the ix into a pt presenting w first episode of suspected schizophrenia/psychosis?
- LFTs and FBC - abnormal LFT and macrocytosis FBC = alcohol abuse
- Syphilis and HIV serology
- Urine for drugs of abuse
What are some general management principles for schizophrenia?
- MDT support, particularly collab between primary and secondary care
- Rate of associated physical disease is high and pt have reduced life expectancy
- Antipsychotics = increased risk T2DM
- Need health promotion - diet, smoking cessation and disease screening
What are the bio treatments of schizophrenia?
1st line = atypical antipsychotics eg. risperidone or olanzapine. Consider depots if pt prefers or non compliance w meds.
Benzos for rapid tranquilisation, violent or aggressive pt.
15-17 = aripiprazole for those intolerant of risperidone.
Clozapine for children and young people whose schizophrenia hasn’t responded to adequate doses of 2 diff antipsychotics used for 6-8 weeks.
What are the psychological treatments for schizophrenia?
- Info and education for pt and carers
- Family interventions in psychosis - reduce relapse and admission rates
- CBT
- Support groups
- Art therapy for negative sx in young people
- ECT - if resistant to drugs and rapid sx reduction needed
What are the social factors that affect how schizophrenia is treated?
Rates of homelessness, poverty and economic deprivation high = social support for help w housing, jobs, social isolation and financial aid.
Recover Action Plan.
How long do you continue antipsychotics for?
1-2 years after initial event w close specialist supervision. If the pt is well after 1-2 years of treatment can gradually reduce dose w plan to stop but continue close monitoring for relapses.
What factors effect prognosis in schizophrenia?
Good prognosis - no FH, good premorbid func, clear cause, acute onset, prompt treatment, higher IQ
Poor prognosis - longer duration of untreated psychosis, insidious onset, male, neg sx, FH, social isolation, substance misuse
25% never have another episode, 25% improve substantially, 25% improve somewhat and 25% resistant to treatment
What are the differentials for schizophrenia?
Substance induced psychotic disorder
Organic psychosis - infection, brain injury, CNS diseases
Metabolic disorder - hyperthyroid, hyperparathyroid
Dementia and depression, but can co occur also
What are the different types of psychotic disorders?
- Schizophrenia
- Schizoaffective disorder
- Schizophreniform disorder - only 1-6 months of sx
- Delusional disorder - just the delusion
- Folie a deux
- Drug induced psychosis
- Organic psychosis
- Post partum psychosis
- Stress induced psychosis
- Depressive psychosis - depression and bipolar
What are some causes of organic psychosis?
- HIV, syphilis
- Alzheimer’s and Parkinson’s
- Hypoglycaemia
- Lupus
- MS
- Brain tumour
What is schizoaffective disorder?
Features of schizophrenia and mood disorders = depression or mania, sx occur simultaneously and need to persist for 1 month.
What is the management of pt w schizoaffective disorder?
Bio - antipsychotics - risperidone/olanzapine, antidepressants if depressive sx - sertraline, fluoxetine, ECT?, mood stabilisers - lithium or carbamazepine
Psych - CBT, family interventions, counselling, art therapy
What is post partum psychosis? What are the CF?
Rare but severe mental health problem developing in first 2 weeks after birth
- Paranoid
- Delusions
- Hallucinations
- Mania, depression, confusion
What pt are at high risk of post partum psychosis?
- Prev hx of severe mental illness eg. schizophrenia or bipolar
- FH of PP psychosis
- Personal hx of PP psychosis
What are the red flags of PP psychosis?
- Command hallucinations - may instruct her to harm herself or baby
- Thoughts of self harm or suicide
- Delusional beliefs about baby’s role or identity
What is the management of PP psychosis?
Psych emergency - usually needs admission to specialist mother baby unit
Bio - antipsychotic and/or mood stabiliser but need to take breast feeding into account
Psych - supportive psychotherapy during recovery
What is the criteria for a diagnosis of depression?
Depressed mood or anhedonia most of the day nearly every day for at least 2 weeks accompanied by other sx - ICM 11
Mild - 2 core and 2 others
Mod - 2 core and 3/4 others
Severe - 3 core and at least 4 others
Severe w psychotic sx (ICD 10)
What are the RF for depression?
- Chronic illness
- Comorbid psych problems
- Female, older age, recent childbirth, adverse life event eg. unemployed, divorce
- Personal and FH of depression
- Adverse childhood experiences
What is dysthmia?
Chronic depressive state of more than 2 years duration, doesn’t meet full criteria for major depression, increases w age
What are the core sx of depression?
Cont low mood for 2 weeks, anhedonia and lack of energy
What are the somatic sx of depression?
- Sleep changes - EMW
- Appetite and weight changes
- Dinural variation of mood - mood worst in the morning
- Psychomotor retardation/agitation
- Loss of libido
What are the cognitive sx associated w depression?
- Low self esteem
- Hopelessness
- Guilt and self blame
- Hypochondriacal thoughts
- Poor conc - pseudo dementia, poor memory, reduced cog
- Suicidal thoughts
What is post natal depression?
Usually within 1-2 months post partum. CF - feeling low, tearful and fatigued, thought content = worries about baby’s health and ability to cope as a parent
What is the management of depression?
Assess suicide risk, appropriate monitor and follow up (2-4 weeks between starting treatment), sleep hygiene.
Bio - antidepressants, SSRI first line but go on pt choice, ECT, rTMS, implanted vagus nerve stim
Psych - CBT group or individual, mindfulness and mediation, counselling
Social - ensure have social support and if not offer groups, high suicide risk when first starting antidepressants, group exercise, crisis resolution home treatment if needed
What are the sx of hypomania?
- Mildly elevated, irritable or expansive mood
- Increased energy, self esteem and activity
- Talkative and over familiar
- Increased sex drive
- Reduced need for sleep
- Difficulty focussing on one task alone
What management do you do based on different severity of depression?
Mild - CBT or low intensity psych interventions 1st line then move to antidepressants
Mod - antidepressants in conjunction w psych therapy
Severe - x2 antidepressants, then try and augment w lithium, ECT
Difficult to treat - ECT or rTMS
Children - psych 1st line, fluoxetine, admission if risk
What are the symptoms of mania?
- Elevated expansive irritable mood for 1 week
- Increased energy and agitation
- Grandiosity
- Pressure of speech, flight of ideas
- Reduced need for sleep
- Increased libido
- Social inhib lost - risky behaviour, impaired judgement, over spend and get in debt
- Psychotic sx
What is mixed affective state?
Mixture or rapid alternation, usually within a few hours, of hypomanic, manic and depressive sx
What is bipolar affective disorder?
Periods of depression and periods of hypomania/mania, can have periods of normalcy also.
What are the RF of affective disorders?
Bio - genetic predisposition, physical and brain illnesses
Psych - childhood experiences, personality traits, view of yourself and the world
Social - work, housing, finance, relationships
What are the indications of ECT?
- Severe depression - not moving or eating or drinking for days on end
- Prolonged severe manic episode
- Catatonia
- Treatment resistant depression
What is the acute management of bipolar affective disorder?
Acute mania w agitation - IM therapy usually benzo or neuroleptic, admission to secure unit
Acute mania w/o agitation - antipsychotic, mood stabiliser - lithium
Acute depression - mood stabiliser and or atypical antipsychotic and or antidepressant (but avoid as poor evidence and risk of manic switch)
What is the chronic management of bipolar?
High risk of relapse into depression or mania so pt need follow up and maintenance treatment.
Lithium = gold standard mood stabiliser, Na Valproate is the second line.
Psych - high intensity psych therapy, CBT, interpersonal (IPT) and family/couples
What is the prognosis of the affective disorders?
Depression - 80% will have another episode, 10% severe unremitting depression, for multiple eps cont AD for > 1 year, some say up to 5 years or forever
Bipolar - 80% relapse w/i 5-7 years
What is conduct disorder? What are the types?
Diagnosis to pt <18 who show behaviour and attitudes that continuously disrespect and violate the rights of other people, more common in males.
Aggression - cruelty towards animals, assault, rape
Destruction - theft or vandalism
Deceitfulness - lying or manipulation
Delinquent behaviours - running away from home
What is the prognosis of conduct disorder?
- 50% of children develop antisocial personality disorder
- 50% develop substance misuse issues
- 40% become recurring young offenders
What is the management of conduct disorder?
Bio - methyphenidate or atomoxetine if have ADHD and conduct disorder but not routine for management of behavioural problems, risperidone short term for severe aggressive behaviour
Psych - parent training programme, child focused programme - social and cog problem solving programmes
Social - help at school to prevent children at risk?
What is oppositional defiant disorder?
Children show persistent defiant and hostile behaviour towards figures of authority but not significant enough to disable social function - not serious enough to be conduct disorder
What are some of the emotional disorders of children?
- Seperation anxiety
- Phobic anxiety
- Elective mutism
- Sibling rivalry
- Tic disorder
- ARFID
What are the sleep disorders?
- Insomnia
- Hypersomnia
- Nightmares
- Night terrors
- Sleep walking
Nightmares vs night terrors
Nightmares - dream experiences w anxiety or fear, detailed recall of vivid dream content, some autonomic discharge but no vocalisation or body motility, during REM sleep
Night terrors - extreme terror + panic associated w intense vocalisation, motility and high levels of autonomic discharge, NREM sleep
How do you manage insomnia?
- Sleep hygiene advice
- CBT is 1st line
- Benzodiazepines and Z drugs are only good for short term use
- Melatonin for short term
- Antidepressants and antipsychotics can be used but evidence not great
- Sedating antihistamines - rebound insomnia after long period of use
What are the sx of female sexual dysfunction? How is it caused and treated?
- Low sexual desire
- Sexual arousal disorder
- Orgasmic disorder
- Sexual pain disorder
Untreated anxiety or depression, long term stress and hx of sexual abuse, problems w relationship, cultural and religious issues can cause. Treat w counselling, therapists that specialise in sexual problems.
What are the sx of male sexual dysfunction?
- Erectile dysfunc
- Premature ejaculation
- Delayed or inhibited ejaculation
- Low libido
Same psych causes and treatments as female.
What is autoimmune encephalitis and what are the CF?
Non infectious neuro inflam recognised as cause of progressive mental status change, CF:
- Confusion
- Behavioural changes, emotional lability, psychosis
- Cognitive impairment, reduced con
- Seizures
- Movement disorders
What are the ix into autoimmune encephalitis?
- Full neuro exam
- Bloods - FBC, U+E (low Na = LG1 encephalitis), ab (LGI1, NMDA R, CASPR2)
- MRI
- LP - increased lymphocytes
- EEG
What is the treatment of autoimmune encephalitis?
1st line = steroids and IV immunoglobulin, plasma exchange can be used adjunctive if not responding
2ng line = (not responding in 2 weeks), immunosuppressants eg. rituximab and cyclophosphamide whilst continuing 1st line
If agitated = risperidone
What cancers are autoimmune encephalitis associated w?
Can be a paraneoplastic syndrome, screen for cancer in patients you suspect have underlying tumour:
- Small cell lung cancer
- Ovarian teratoma
- Breast and ovarian tumours
What are the risk factors of self harm?
- Women = 16-24, men = 25-34
- Socio economic disadvantage
- Social isolation
- Stressful life events
- Bereavement by suicide
- Mental health problems
- Chronic illness
- Alcohol and drug misuse
- Involvement in the criminal justice system
- Exposure to those who self harm
What are the RF of suicide?
- 45-49 years old
- Male
- Prev suicide attempt
- Hx of mental illness, esp depression
- Chronic illness
- Criminal/job/financial/relationship issues
- Substance use
- Adverse childhood experiences
- FH/seeing suicidal behaviours of others
- Recent discharge from inpt care
- Bullying
- Living alone
- Planning attempts
What are some protective factors against suicide?
- Social support
- Religious belief
- Responsible for children or pets
- Life skills - able to cope and problem solve
- Sense of purpose
- Good self esteem
What are some sx of atypical depression?
Vegetative - weight gain, sleeping more
Catatonic - not moving
