Topics Not in Core Conditions

Question 1

How are psychiatric disorders classified?

Answer 1

Organic –> organic and psychoactive substance use disorders

Functional –> psychoses (mood/schizo) and neuroses (OCD/phobia)

Question 2

Difference between psychoses and neuroses?

Answer 2

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.

Question 3

Diagnostic hierarchy of psychiatric disorders?

Answer 3

Organic/substance use –> functional psychoses –> non-psychotic disorders –> personality disorders

Psychoses take precedence over neuroses, schizophrenia takes precedence over mood disorders.

Question 4

What are the 5 Ps of formulation

Answer 4

1. Presenting Problems/Issues
2. Precipitating Factors
3. Perpetuating Factors
4. Predisposing Factors
5. Protective Factors

Question 5

Sociodemographic risk factors for suicide?

Answer 5

Male sex
Age (25-44)
Marital status (alone)
Employment status (unemployed or retired)
Occupation
SE status 
Poor level of social support

Question 6

Clinical risk factors for suicide?

Answer 6

History of DSH
Mental disorder
Physical illness
FH of DSH

Question 7

How to assess suicidal risk after episode of DSH?

Answer 7

• 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?

Question 8

Management of suicide attempt?

Answer 8

• 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.

Question 9

When is risk of suicide greatest?

Answer 9

combined presence of (1) suicidal thoughts, (2) the means to commit suicide, and (3) the opportunity to commit suicide.

Question 10

Biggest group for DSH?

Answer 10

Females - <45, 15-25 years

Question 11

Risk factors (life events) for DSH?

Answer 11

Break up of relationship
Trouble with the law
Physical illness
Illness of loved one

Question 12

Predisposing factors for DSH?

Answer 12

Martial difficulties
Unemployment
Physical illness
Mental retardation
Death of a parent at a young age
Parental neglect or abuse

Question 13

Psychiatric disorders associated with DSH?

Answer 13

Depressive disorders
Dysthymia
Alcohol dependence
PD

Question 14

Common methods of DSH

Answer 14

• 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.

Question 15

What do you need to do when assessing seriousness of self-harming behaviour?

Answer 15

Ascertain degree of suicidal intent that existed at the time

Question 16

Factors associated with repeated attempt of DSH?

Answer 16

• 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

Question 17

Factors associated with increased risk of sucicide following parasuicide?

Answer 17

• 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

Question 18

Advice to patient following DSH?

Answer 18

• 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.

Question 19

Advice to patient following suicide attempt?

Answer 19

 “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.

Question 20

Commonest method of suicide in men?

Answer 20

Hanging/strangulation

Question 21

Most common psychiatric diagnosis in suicide victims?

Answer 21

Affective disorder, then schizophrenia

Question 22

Employment group at highest risk of suicide?

Answer 22

Unemployed (43%)

Question 23

Peak time for suicide upon discharge from hospital?

Answer 23

2 days after, then risk next increases at day 6

Question 24

What is personality?

Answer 24

lifelong persistent and enduring characteristics and attitudes of an individual, including that person’s ways of thinking, feeling and behaving.

Question 25

When does personality development occur?

Answer 25

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).

Question 26

What is normal personality?

Answer 26

 Considered to have five major dimensions: extroversion, emotional stability (in contrast to ‘neuroticism’), agreeableness, conscientiousness and intellectual open-mindedness.

Question 27

What is personality disorder?

Answer 27

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.

Question 28

When is diagnosis or PD inappropriate?

Answer 28

Diagnosis before age 16/17 inappropriate as personality remains malleable.

Question 29

Pathogenic and pathoplastic PDs?

Answer 29

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

Question 30

What are the withdrawn personality disorders?

Answer 30

Paranoid and schizoid

Question 31

What are the dependent personality disorders?

Answer 31

Anxious (avoidant)
Dependent (Inadequate, passive, asthenic)
Passive-aggressive

Question 32

What are the inhibited personality disorders?

Answer 32

Anankastic (obsessive compulsive)

Question 33

What are the antisocial personality disorders?

Answer 33

Histrionic
Emotionally unstable (impulsive/borderline)
Dissocial/Antisocial
Narcissistic 
Psychopathic

Question 34

Paranoid PD?

Answer 34

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.

Question 35

Schizoid PD?

Answer 35

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.

Question 36

Anxious (avoidant) PD?

Answer 36

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.

Question 37

Dependent (inadequate, passive, asthenic) PD?

Answer 37

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.

Question 38

Passive-aggressive PD?

Answer 38

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.

Question 39

Anankastic (obsessive compulsive) PD?

Answer 39

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.

Question 40

Histrionic PD?

Answer 40

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.

Question 41

Impulsive type emotionally unstable PD?

Answer 41

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.

Question 42

Borderline type emotionally unstable PD?

Answer 42

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.

Question 43

Dissocial/antisocial PD?

Answer 43

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.

Question 44

Narcissistic PD?

Answer 44

Characterised by grandiosity, in fantasy and behaviour, hypersensitivity and lack of empathy. Such individuals react poorly to disfigurement due to physical illness or surgery.