Topics Not in Core Conditions Flashcards
How are psychiatric disorders classified?
Organic –> organic and psychoactive substance use disorders
Functional –> psychoses (mood/schizo) and neuroses (OCD/phobia)
Difference between psychoses and neuroses?
Psychoses = loss of contact with reality - symptoms not readily understandable
Neuroses = symptoms understandable and possible to empathise with them. Symptoms differ from normal in a quantitative but not qualitative way.
Diagnostic hierarchy of psychiatric disorders?
Organic/substance use –> functional psychoses –> non-psychotic disorders –> personality disorders
Psychoses take precedence over neuroses, schizophrenia takes precedence over mood disorders.
What are the 5 Ps of formulation
- Presenting Problems/Issues
- Precipitating Factors
- Perpetuating Factors
- Predisposing Factors
- Protective Factors
Sociodemographic risk factors for suicide?
Male sex Age (25-44) Marital status (alone) Employment status (unemployed or retired) Occupation SE status Poor level of social support
Clinical risk factors for suicide?
History of DSH
Mental disorder
Physical illness
FH of DSH
How to assess suicidal risk after episode of DSH?
- What was the precipitant for the attempt?
- Was it planned?
- What was the method of self-harm?
- Did the patient leave a suicide note?
- Was he or she alone?
- Was he or she intoxicated?
- Did he or she take any precautions against discovery?
- Did he or she seek help after the event?
- How did he or she feel when they were found?
Management of suicide attempt?
- Patient should be admitted to hospital, compulsorily if need be. Patient should be encouraged to be open at all times.
- Anything that could be used in a suicide attempt (sharp objects, belt) should be removed.
- Depending on degree of risk judged to exist, the frequency of observation can be varied – 15 mins, 5 mins, continuous observation.
- May be useful to nurse very high risk patients in bed clothes (without pyjama cord, which could be used as a noose) throughout the day, to make it more difficult to abscond without being noticed.
- Any psychiatric disorder should be treated appropriately.
When is risk of suicide greatest?
combined presence of (1) suicidal thoughts, (2) the means to commit suicide, and (3) the opportunity to commit suicide.
Biggest group for DSH?
Females - <45, 15-25 years
Risk factors (life events) for DSH?
Break up of relationship
Trouble with the law
Physical illness
Illness of loved one
Predisposing factors for DSH?
Martial difficulties Unemployment Physical illness Mental retardation Death of a parent at a young age Parental neglect or abuse
Psychiatric disorders associated with DSH?
Depressive disorders
Dysthymia
Alcohol dependence
PD
Common methods of DSH
- 90% of cases involve deliberate self-poisoning with drugs (prescribed) – alcohol taken as part of act in 30% of cases. Safer to prescribe SSRIs, SNRIs, a RIMA or NaSSA than a tricyclic or MAOI, as they are toxic in overdose.
- Paracetamol overdose of 10g (20 tablets) can –> hepatocellular necrosis; patients who change their minds or did not want to die develop encephalopathy, haemorrhage, cerebral oedema and die anyway. Can only buy in packs of 16.
- Self-cutting makes up significant proportion of remainder.
What do you need to do when assessing seriousness of self-harming behaviour?
Ascertain degree of suicidal intent that existed at the time
Factors associated with repeated attempt of DSH?
- Previous act of parasuicide
- Previous psychiatric treatment
- Dyssocial or antisocial personality disorder
- Alcohol dependence
- Other psychoactive substance use disorder
- Criminal record
- Low social class
- Unemployment
Factors associated with increased risk of sucicide following parasuicide?
- High suicidal intent as elicited by assessment
- Psychiatric disorder (depressive episodes), alcohol dependence, other psychoactive substance use disorders, schizophrenia and dissocial or antisocial personality disorder
- A history of previous suicide attempt(s)
- Social isolation
- Age over 45
- Being male
- Being unemployed or retired
- Chronic painful illness
Advice to patient following DSH?
- Take mind off thoughts of self-harm by using coping strategies or distraction techniques – sharing feelings with people, engaging in creative activities, reading, listening to music, watching comedy or nature programmes, cooking a meal or going out.
- Deep breathing, yoga or meditation.
- Avoid alcohol and drugs
- If urge is too great, minimise risks involved – hold ice cubes in palm and attempt to crush them, fit an elastic band round wrist and flick it, pluck hairs on arms and legs. If you have harmed yourself and are in pain or cannot stop the bleeding or have taken an overdose, call 999 immediately or get someone to take you to A&E.
- CBT can help understand why you feel the way you do and come up with solutions and coping strategies.
Advice to patient following suicide attempt?
“Remember you have not always felt this way, and you will not always feel this way.”
“Many people who have attempted suicide and survived ultimately feel relieved that they did not end their lives.”
Risk is greatest in combined presence of (1) suicidal thoughts, (2) the means to commit suicide, and (3) the opportunity to commit suicide. If prone to suicidal thoughts, make sure means (tablets, sharp objects) are removed. Or make sure opportunity is lacking – remain in close contact with friends/relatives.
If nobody available, there are emergency telephone lines for use at any time. 999 or go to A&E.
Do not use alcohol or drugs – can make behaviour more impulsive and significantly increase likelihood of attempting suicide. Do not drink or take drugs alone, or end up alone after drinking or taking drugs.
Make a list of all the positive things about yourself and your life, including things that have prevented you from committing suicide – read this when assailed by suicidal thoughts. Write a safety plan for the times when you feel like acting on suicidal thoughts.
Commonest method of suicide in men?
Hanging/strangulation
Most common psychiatric diagnosis in suicide victims?
Affective disorder, then schizophrenia
Employment group at highest risk of suicide?
Unemployed (43%)
Peak time for suicide upon discharge from hospital?
2 days after, then risk next increases at day 6
What is personality?
lifelong persistent and enduring characteristics and attitudes of an individual, including that person’s ways of thinking, feeling and behaving.
When does personality development occur?
in one’s early years and remains modifiable up to adolescence and early adulthood – change after such an age may be much more limited (like the way adult body shape changes in size and shape with age).
What is normal personality?
Considered to have five major dimensions: extroversion, emotional stability (in contrast to ‘neuroticism’), agreeableness, conscientiousness and intellectual open-mindedness.
What is personality disorder?
Defined as an extreme persistent variation from the normal (statistical) range of one or more personality attributes, causing the individual and/or family and/or society to suffer.
When is diagnosis or PD inappropriate?
Diagnosis before age 16/17 inappropriate as personality remains malleable.
Pathogenic and pathoplastic PDs?
Pathogenic = make individuals more vulnerable to a particular mental illness or to a drug or alcohol abuse
Pathoplastic = may colour the clinical presentation of an episode of mental illness
What are the withdrawn personality disorders?
Paranoid and schizoid
What are the dependent personality disorders?
Anxious (avoidant)
Dependent (Inadequate, passive, asthenic)
Passive-aggressive
What are the inhibited personality disorders?
Anankastic (obsessive compulsive)
What are the antisocial personality disorders?
Histrionic Emotionally unstable (impulsive/borderline) Dissocial/Antisocial Narcissistic Psychopathic
Paranoid PD?
Oversensitivity, tendency to bear grudges, suspiciousness, misconstrues neutral or friendly actions of others as hostile or contemptuous, make ‘mountains out of molehills’, blame their own failures on others (projection) and overvalue their own abilities.
May be predisposed to more prolonged episodes of paranoid psychosis.
Schizoid PD?
Emotional coldness, preference for fantasy, introspective reserve, little interest in having sexual experiences with others, lack of close, confiding relationships.
Resent being pushed into social situations such as at parties. May have an eccentric interest. May have a preference for numbers rather than people.
Isolation may make them prone to depression.
May be some overlap with Asperger’s.
Anxious (avoidant) PD?
Common. Pervasive tension and apprehension, self-consciousness, hypersensitivity to rejection, enters into relationships only if guaranteed uncritical acceptance.
Exaggerates potential dangers and risks in everyday situations and avoids certain activities, leading to restricted lifestyle.
Associated with depression, anxiety, development of specific phobias and social phobia, and anger at oneself for failing to develop social relationships.
Dependent (inadequate, passive, asthenic) PD?
Encourages or allows others to assume responsibility for major areas of individuals’ life; subordinate to, compliant with and unwilling to make demands on those on whom they depend.
Perceives self as helpless, fears being abandoned and alone, devastated when close relationships end. Low self-esteem, may refer to themselves as ‘stupid’.
Predisposes to dysthymia and depressive disorder.
Passive-aggressive PD?
Related condition characterised by passive resistance to demands for adequate social and occupational performance, procrastination, childish obstruction and sulkiness. Such individuals tend to work slowly on tasks that they do not wish to perform, and often believe they are doing a better job than others think.
Anankastic (obsessive compulsive) PD?
Indecisiveness, perfectionism, excessive conscientiousness, pedantry and conventionality, rigidity and stubbornness, plans all activities far ahead in immutable detail.
Obsessional personalities, although insecure, may be conscientious and hardworking professionals. Alternatively, may be obsessional ditherers. May wish others would be as efficient as they see themselves, and may become angry when their rigid views are challenged.
Corresponds to Freudian ‘anal’ personality – reflecting anal stage of development.
More common in males. More prone to developing depression, OCD/neurosis, hypochondriasis, anorexia nervosa, migraine and duodenal ulcer.
Histrionic PD?
Tendency to theatricality, overemotional, suggestible, shallow and labile affectivity, craves attention, manipulative.
Insecurity results in such individuals attempting to become the focus of attention – everyday events described as ‘just fantastic’ and greetings to others are ‘over the top’. Can be entertaining and the life of the party – are often empathic and sexually flirtatious, although sometimes frigid.
Interpersonal relationships are often stormy and ungratifying: they may select spouses who are ‘doormats’.
Diagnosed more commonly in females - may reflect sexual stereotyping, males may be seen as suffering from antisocial personality disorder instead.
More liable to take overdoses of medication under stress, and to develop conversion and somatisation disorders.
Impulsive type emotionally unstable PD?
Emotionally unstable, episodic lack of aggressive impulse control, outbursts of violence or threatening behaviour common. Results in serious assaultive acts or destruction of property disproportionate to any precipitating psychosocial stresses. May batter spouse/children, from which they may at the time, derive feelings of power, countering those of inadequacy. May subsequently show genuine regret for and self-reproach about such behaviour.
More common in males of females, more common in first-degree biological relatives of those suffering from such a disorder.
Borderline type emotionally unstable PD?
Unclear or disturbed self-image, intense and unstable relationships, which may lead to repeated emotional crises that may be associated with a series of suicidal threats or acts of self-harm. Chronic feelings of emptiness and boredom. Primitive defence mechanisms, such as splitting and projective identification.
Under extreme stress, transient psychotic symptoms may develop in such individuals. ‘Borderline’ loosely used to describe individuals with severe personality disorder on the ‘borderline’ of psychosis.
More common in females than males. Individuals prone to dysthymia, depressive episodes, psychoactive substance abuse and brief reactive psychosis.
Dissocial/antisocial PD?
Irresponsibility, cannot maintain relationships, low tolerance of frustration and low threshold for discharge of aggression, including violence.
Incapacity to experience guilt and to profit from experience (including punishment), blames others of offers plausible rationalisations for antisocial behaviour.
Narcissistic PD?
Characterised by grandiosity, in fantasy and behaviour, hypersensitivity and lack of empathy. Such individuals react poorly to disfigurement due to physical illness or surgery.
