Week 1 Flashcards
What are the 2 classifications for mental disorders used?
ICD-10 and DSM-5
The mental state examination (MSE)
Observing and describing a patient’s current state of mind, under the domains of appearance, attitude, behaviour, mood, affect, speech, thought process, thought content, perception, cognition, insight, and judgement.
ICD-10
Classification of mental disorders - Chapter V of the tenth International Classification of Diseases (ICD-10) produced by the World Health Organization.
DSM-5
Classification of mental disorders - The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) produced by the American Psychiatric Association.
Depression
A common condition characterised by low mood, anhedonia (inability to feel pleasure), and a range of accompanying features.
Aanhedonia
Inability to feel pleasure
Risk factors for depression
o Chronic conditions
o History of depression or other mental health illness
o Female sex, Medication (e.g. corticosteroids)
o Older age, Recent childbirth
o Psychosocial issues (e.g. unemployment, homelessness)
o Genetic factors, History of childhood abuse, History of head trauma
The three classifications of depression
Mild, moderate and severe
What symptoms must be present for the DSM-5 criteria for diagnosis of depression?
The presence of five of the following symptoms, for at least two weeks, one of which should be low mood or loss of interest/pleasure:
- Low mood, Loss of interest or pleasure
- Significant weight change, Insomnia, or hypersomnia (sleep disturbance)
- Psychomotor agitation or retardation, Fatigue
- Feelings of worthlessness, Diminished concentration
- Recurrent thoughts of death or suicide without a specific plan, or a suicide attempt or specific plan for committing suicide
In addition to the presence of 5 symptoms for at least two weeks, one of which should be low mood or loss of interest/pleasure: what others signs must be present for a diagnosis of depression by DSM-5?
- Mild: few or no extra symptoms beyond the five to meet the diagnostic criteria
- Moderate: symptoms and impairment between mild and severe
- Severe: most or all the symptoms (see above) causing marked functional impairment with or without psychotic features
Describe some of the common symptoms of depression?
- Low mood, Loss of interest or pleasure
- Significant weight change, Insomnia, or hypersomnia (sleep disturbance)
- Psychomotor agitation or retardation, Fatigue
- Feelings of worthlessness, Diminished concentration
- Recurrent thoughts of death or suicide without a specific plan, or a suicide attempt or specific plan for committing suicide
Hypersomnia
Excessive daytime sleepiness
Subthreshold depressive symptoms
Describes patients with a number of depressive symptoms (see above) not meeting the criteria described above.
Persistent subthreshold depressive symptoms
Describes subthreshold depressive symptoms that persist for two years or more.
What is a key part of any mental health assessment investigation?
Assess suicide risk
Management of Subthreshold or mild-moderate depression
- Psychosocial therapies
- Antidepressants
- Sleep hygiene
When should antidepressants be given for management of subthreshold or mild-moderate depression?
A history of moderate-severe depression, persistent subthreshold symptoms or subthreshold/mild depression that does not respond to non-pharmacological interventions.
Also consider in those in whom mild depression is complicating the management of other conditions.
What Psychosocial therapies are available for subthreshold or mild-moderate depression?
Low-intensity psychosocial intervention and group CBT.
Management of moderate-severe depression
- Psychological therapies:
- Antidepressants
- Sleep hygiene:
- Follow-up: early follow-up (within 1-2 weeks) and ongoing review tailored to each patient.
What psychosocial therapies are available for moderate-severe depression?
Offer high-intensity psychosocial intervention
Why does the prescribing of SSRIs and SNRIs need to be monitored for at least one month after starting treatment?
SSRIs and SNRIs have been implicated in an increased risk of suicide, suicidal ideation and self-harm, particularly below the age of 30.
All patients commenced in this age group should have review within one week of starting therapy with weekly reviews for at least one month.
What factors need to be considered when prescribing antidepressants?
Toxicity
Side effects
Interactions
What kind of psychological therapies are available to patients?
- Low-intensity psychosocial interventions
- Group-based CBT
- High-intensity psychological interventions -May consist of individual CBT, interpersonal activity, couples therapy and behavioural activation.
- Counselling and short-term psychodynamic therapy
High-intensity psychological interventions examples
Individual CBT, interpersonal activity, couples therapy and behavioural activation.
When can counselling and short-term psychodynamic therapy be offered in depression?
May be offered to those who decline high-intensity psychological interventions or antidepressants.
What scales are available for rating the severity of depression?
- Hamilton Rating Scale for Depression (HRSD, HAM-D)
- Montgomery-Åsperg Depression Rating Scale (MADRS)
- Beck Depression Inventory (BDI)
What are the sub-types of depression?
- Somatic Syndrome
- Atypical Depression
- Psychotic depression
Atypical Depression (sub-type of depression)
Mood reactivity (that is, mood brightens in response to actual or potential positive events)
Atypical Depression symptoms
Two (or more) of the following:
- significant weight gain or increase in appetite
- hypersomnia
- leaden paralysis
- long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment
Leaden paralysis
That is, heavy, leaden feelings in arms or legs
Psychotic depression
Occasionally paranoid, typically ‘mood-congruent’, or hypochondriacal
Cotards syndrome
Psychotic depression symptoms
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“People are out to get me and kill me” “I’m being poisoned to punish me for my sins” “I’ve got cancer…I know I have…It’s because I deserve it” Cotard’s syndrome
Cotard’s syndrome
- More common in the elderly
- Often nihilistic delusions – “I can’t eat because my bowels have turned to dust”
- May be as extreme as “I’m dead…the world doesn’t exist anymore”
Cotard’s syndrome is a rare neuropsychiatric condition in which the patient denies existence of one’s own body to the extent of delusions of immortality. One of the consequences of Cotard’s syndrome is self-starvation because of negation of existence of self.
Somatic Syndrome (Sub-type of depression) symtpoms
- marked loss of interest or pleasure in activities that are normally pleasurable
- lack of emotional reactions to events or activities that normally produce an emotional response
- waking in the morning 2 hours or more before the usual time
- depression worse in the morning
- objective evidence of marked psychomotor retardation or agitation
- marked loss of appetite
- weight loss (5 % or more of body weight in the past month)
- marked loss of libido
Gender incongruence
Gender identity not associated with an observable phenotype
Gender identity
The psychological sense of fitting into social gender categories
Gender role
Is the expression of gender identity by social constructs of dress, mannerism and behaviours
Cis-gender
Gender identity is consistent with assigned sex at birth
Gender dysphoria
A term that describes a sense of unease that a person may have because of a mismatch between their biological sex and their gender identity. This sense of unease or dissatisfaction may be so intense it can lead to depression and anxiety and have a harmful impact on daily life.
Cross-dressing
Wearing clothes of the opposite sex
Non-gender/Agender
No gender experience
Non-binary
For gender identities that are neither male nor female—identities that are outside the gender binary.
Transsexualism
A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one’s anatomic sex, and a wish to have surgery and hormonal treatment to make one’s body as congruent as possible with one’s preferred sex.
Dual-role transvestism
The wearing of clothes of the opposite sex for part of the individual’s existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing.
Gender identity disorder of childhood
A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual’s own sex. The diagnosis requires a profound disturbance of the normal gender identity; mere tomboyishness in girls or girlish behaviour in boys is not sufficient.
Fetishist transvestism
The wearing of clothes of the opposite sex principally to obtain sexual excitement and to create the appearance of a person of the opposite sex. Fetishistic transvestism is distinguished from transsexual transvestism by its clear association with sexual arousal and the strong desire to remove the clothing once orgasm occurs and sexual arousal declines. It can occur as an earlier phase in the development of transsexualism
Bipolar disorder
Is characterised by a significant disruption in mood and behaviour, which includes both periods of elated and depressed mood.
Mania
Elevated, expansive, or irritable mood. May be features of psychosis. Lack of insight with significant impairment in functioning.
Flight of ideas
Flight of ideas is where your thoughts move very quickly from idea to idea, making links and seeing meaning between things that other people don’t.
Features of mania
- Elevated mood, Extreme irritability and/or aggression
- Increased energy, Restlessness
- Decreased need for sleep, Flight of ideas,
- Fast increase in speech with moving from idea to idea which all seem connected
- Increase libido and disinhibition
- Distractibility, poor concentration
- Delusions or hallucinations
Delusions
Fixed belief contradictory to reality or rational argument
Hallucinations
A sensory perception without an external stimulus causing that perception the patient believe is real, e.g hearing sounds when there is no voice speaking
Hypomania
Is characterised by features of mania, but usually not as severe and does not lead to social and/or occupational impairment in function. In particular, there are no psychotic features.
What are the 4 types of episodes in Biploar disorder?
Manic episode
Hypomanic episode
Depressive episode
Mixed episode
Diagnosis of Bipolar disorder by ICD-10 diagnostic criteria
Classifies bipolar as a single entity: bipolar affective disorder: at least two mood episodes, one of which must be mania or hypomania.
Diagnosis of Bipolar disorder by DSM-V diagnostic criteria
Classifies bipolar disorder into three major categories: bipolar I disorder, bipolar II disorder and cyclothymia
Bipolar I disorder
At least one manic episode. Depression episode not required for diagnosis.
Bipolar II disorder
At least one major depressive episode and one major hypomanic episode.
Cyclothymia
refers to chronic mood disturbance with depression and hypomania symptoms that do not meet the criteria for a full episode.
Section 135 of Mental Health Act
Power to remove a person from a dwelling if it is considered they have a mental disorder and they may need care and attention for this. Assessment at dwelling or remove to place of safety.
Section 5(4) of Mental Health Act
Temporary nurse holding power. Use if already in hospital. Ability to detain someone in hospital for up to 6 hours.
Section 5(2) of Mental Health Act
Temporary doctor holding power. Use if already in hospital. Ability to detain someone in hospital for up to 72 hours.
Section 2 of Mental Health Act
Detained in hospital for up to 28 days for assessment.
Section 3 of Mental Health Act
Detained in hospital for up to 6 months for treatment
Management of Bipolar disorder
The choice of treatment depends on the patient’s co-morbidity, current episode (i.e. mania or depression) and side effects.
Pharmacological therapies available for Bipolar disorder
Antipsychotics
Lithium
Antiepileptics
Antidepressants
Psychological therapies used in bipolar disorder
- Individual psychoeducation
- CBT
- Interpersonal and social rhythm therapy
- Group psychoeducation
- Family-focused therapy
Individual psychoeducation
Trained to identify and cope with early warning signs of mania and/or depression.
Psychoeducation refers to the process of providing education and information to those seeking or receiving mental health services, such as people diagnosed with mental health conditions (or life-threatening/terminal illnesses) and their family members
Cognitive behavioural therapy (CBT)
Talking therapy. Focuses on the emotional response to thinking and behaviour.
Interpersonal and social rhythm therapy
Focuses on the role of interpersonal factors (i.e. interpersonal relationships, role conflicts) and circadian rhythm stability (i.e. sleep-wake cycle, work-life balance) in the context of bipolar.
Group psycho education
High frequency and intensity sessions to help patients become experts in their own condition. Aims to improve mood stability, medication adherence and self-management.
Family-focused therapy
Psycho education for families with one individual suffering from bipolar. Looks at risks, communication and problem-solving within the family to prevent relapses.
What are the complications of Bipolar disorder?
Associated with a high lifetime risk of suicide and self-harm.
Examples of Monoamine oxidase inhibitors
Isocarboxazid, phenelzine, tranylcypromine, Rasagiline and selegiline
MAOIs mechanism of action
Block the activity of monoamine oxidase, an enzyme that breaks down norepinephrine, serotonin, and dopamine in the brain and other parts of the body.
What are the adverse effects of MAOIs?
a. MAOIs have dangerous interactions with some foods and drugs and should be reserved for use by specialists.
What are Rasagiline and selegiline used for?
Irreversible MAOB inhibitors used not to treat depression, but to treat Parkinson’s disease as a monotherapy or as an adjunct to co-beneldopa or co-careldopa to manage ‘end-of-dose’ fluctuations.
Tricyclics examples
Amitriptyline, amoxapines, clomipramine, desipramine, doxepin, imipramine, maprotiline, natniptrilyine, protriptyline
Tricyclics mechanism of action
TCAs block the re-uptake of both serotonin and noradrenaline, although to different extents as well as block of muscarinic M1, histamine H1, and alpha adrenoceptors.
Whats a common use of amitriptyline?
The treatment of neuropathic pain, where smaller doses are typically required.
What are the more sedative Tricyclic antidepressants?
Amitriptyline, Clomipramine, Dosulepin, Trazodone*
What are the less sedative Tricyclic antidepressants?
Imipramine, Lofepramine and Nortriptyline
Common side effects of Tricyclic antidepressants
i. drowsiness
ii. dry mouth
iii. blurred vision
iv. constipation
v. urinary retention
vi. lengthening of QT interval
Examples of Selective serotonin reuptake inhibitors
sertraline, citalopram, escitalopram, fluoxetine fluvoxamine, paroxetine,
SSRIs best to use in elderly
Considered to have the best safety profile in the elderly are citalopram, escitalopram, and sertraline (all are SSRIs).
Why are SSRIs first-line in depression?
Better tolerated and are safer in overdose than other classes of antidepressants and should be considered first-line for treating depression.
SNRIs examples
Examples include, venlafaxine, duloxetine, desvenlafaxine, levomilnacipran, milnacipran
SNRIs common side effects
Are nausea, dizziness, and sweating. Other side-effects include tiredness, constipation, insomnia, anxiety, headache, and loss of appetite
What is important to know about SNRIs?
None of these drugs should be prescribed within 14 days of an MAOI (only prescribed by specialists) and at least 7 days should be allowed between stopping their use and administering a MAOI (dangerous drug interactions).
What is a contraindication for Duloxetine?
Use caution when prescribing alongside drugs that increase risk of bleeding.
Duloxetine and milnacipran should not be used in patients with uncontrolled narrow angle or angle-closure glaucoma.
What is a contraindication for Venlafaxine?
Contra-indicated in patients with conditions associated with high risk of cardiac arrhythmia or uncontrolled hypertension.
Long-term effects of ECT
i. memory loss,
ii. difficulty making new memories or
iii. heart problems, in rare cases
What is ECT most commonly used for?
Recurrent Depressive Disorder without Psychosis
What are the pharmacological therapies used in Bipolar?
i. Antipsychotic is first line treatment- quetiapine, olanzapine
ii. Antidepressants can be used alongside antipsychotic, lithium or valproate (to prevent mania)
iii. Lamotrigine can be used but takes time to titrate
iv. Lithium
v. ECT = Electroconvulsive Therapy
What is the gold standard treatment for bipolar maintenance?
Lithium
Examples of Negative automatic thoughts
- Overgeneralising
- Dichotomous thinking
- Selective abstraction
- Personalisation
- Minimisation or magnification
- Arbitrary evidence
- Emotional Reasoning
Overgeneralsing
Rules from isolated incidents then applied in all cases
Dichotomous thinking
“all or nothing” or “black and white thinking”
Selective abstraction
Focus on one negative detail: colours entire experience
Personalisation
Relate external events to self without cause (or little cause)
Minimisation or magnification
Overestimate magnitude of undesirable events (or opposite)
Arbitrary evidence
Draw a conclusion in context of no evidence or contrary evidence
Emotional Reasoning
I feel bad/guilty/therefore I am bad/have something to feel guilty about
Anorexia nervosa
An eating disorder characterised by restriction of energy intake resulting in low body weight and an intense fear of weight gain.
What age does Anorexia nervosa usually occur?
Though anorexia nervosa may occur at any age, the risk is highest in young people between the ages of 13-18 years
Risk factors for Anorexia Nervosa
- Female gender
- Age
- Family history of eating disorders, depression, or substance abuse
- Previous criticism of eating habits and weight
- Increased pressures to be slim (e.g. ballet dancers, models, athletes)
- History of sexual abuse
- Low self-esteem
- Obsessive personality
- Emotionally unstable personality disorder
Clinical features of Anorexia Nervosa
> Restriction of energy intake > Low body weight > Features of body dysmorphia > Intense fear of weight gain > Rapid weight loss > Aggressive weight-loss techniques (laxatives, diuretics, vomiting) > Often a lack of insight or denial > Withdrawal from social settings
What is the SCOFF screening questionnaire?
A short and simple tool that can be used in primary care to help identify patients that may be suffering with an eating disorder. It should not be used alone but as part of a wider assessment of a patient at risk for an eating disorder.
SCOFF screening questionnaire calculation
S – Do you make yourself Sick because you feel uncomfortably full?
C – Do you worry you have lost Control over how much you eat?
O – Have you recently lost more than One stone (6.35 kg) in a three-month period?
F – Do you believe yourself to be Fat when others say you are too thin?
F – Would you say Food dominates your life?
Physiological abnormalities in Anorexia Nervosa
hypokalaemia low FSH, LH, oestrogens and testosterone raised cortisol and growth hormone impaired glucose tolerance hypercholesterolaemia hypercarotinaemia low T3
Examination of Anorexia Nervosa
- Vital signs: bradycardia, hypothermia and postural blood pressure drop are all red flags for severe disease.
- Sit-up, Squat–stand test
Sit-up, Squat–stand test
Tests the patient’s ability to sit up from lying and to squat down and stand back up. Scored from 0-3 with increasing risk with lower scores:
> 0: unable to complete action
> 1: requires the assistance of upper limbs
> 2: noticeable difficulty
> 3: no difficulty
Refeeding syndrome
It occurs in malnourished patients who then receive a sudden increase in their calorific intake resulting in electrolyte abnormalities and fluid retention.
Bulimia nervosa
A type of eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising.
Russell’s sign
Calluses on the knuckles or back of the hand due to repeated self-induced vomiting
Binge eating disorder
Involves regularly eating a lot of food over a short period of time until you’re uncomfortably full. Binges are often planned in advance, usually done alone, and may include “special” binge foods. You may feel guilty or ashamed after binge eating.
Symptoms of Binge eating disorder
The main symptom of binge eating disorder is eating a lot of food in a short time and not being able to stop when full. Other symptoms include:
> eating when not hungry
> eating very fast during a binge
> eating alone or secretly
> feeling depressed, guilty, ashamed or disgusted
Avoidant Restrictive Food Intake Disorder (ARFID)
Similar to anorexia in that both disorders involve limitations in the amount and/or types of food consumed, but unlike anorexia, ARFID does not involve any distress about body shape or size, or fears of fatness.
Children with ARFID are extremely picky eaters and have little interest in eating food. They eat a limited variety of preferred foods, which can lead to poor growth and poor nutrition.
Risk factors for ARFID
- Autism, ADHD and intellectual disabilities.
- Children who don’t outgrow normal picky eating
3 Many children with ARFID also have a co-occurring anxiety disorder, and they are also at high risk for other psychiatric disorders.
Rumination-Regurgitation Disorder
A condition in which people repeatedly and unintentionally spit up (regurgitate) undigested or partially digested food from the stomach, re-chew it, and then either re-swallow it or spit it out.
Symptoms of Rumination-Regurgitation Disorder
- Effortless regurgitation, typically within 10 minutes of eating
- Abdominal pain or pressure relieved by regurgitation
- A feeling of fullness
- Bad breath
- Nausea
- Unintentional weight loss
Purging disorder
Is an eating disorder that involves “purging” behaviour to induce weight loss or manipulate body shape.
Symptoms of Purging disorder
self-induced vomiting
misuse of laxatives or medications
excessive exercise
fasting
Night eating syndrome
Night eating syndrome is not the same as binge eating disorder, although individuals with night eating syndrome are often binge eaters. It differs from binge eating in that the amount of food consumed in the evening/night is not necessarily objectively large nor is a loss of control over food intake required.
Personality
Personality is defined as a cluster of relatively predictable patterns of thinking, feeling, and behaving that is generally consistent across time, space, and context for example we can all get irritable, but we’re not irritable in most situations It is generally a multi-dimensional spectrum rather than rigidly defined categories.
Cluster A Classification of personality disorders
Paranoid – ‘delusional’
Schizoid – ‘socially withdrawn’
Schizotypal – ‘distorted reality’
Paranoid – ‘delusional’personality disorder
- very sensitive/ easily offended
- suspicious
- distrusts loyalty
- holds grudges
- combative sense of personal rights
- self-referential attitude
- unsubstantiated conspiratorial explanations
Schizoid – ‘socially withdrawn’ personality disorder
- No pleasure from any activities
- emotional coldness or flattened affectivity
- limited capacity to express
- indifferent to praise or criticism
- little interest in sexual experiences
- solitary
- fantasize and introspective
Schizotypal – ‘distorted reality’ personality disorder
- social and interpersonal deficits
- magical thinking
- unusual perceptions
- vague
- circumstantial
- suspiciousness
- inappropriate affect
- excess social anxiety
Cluster B classification of personality disorders
Anti-social
Borderline
Histrionic
Narcissistic
Anti-social personality disorder
Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest.
More common in men.
Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure.
Impulsiveness or failure to plan ahead.
Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
Reckless disregard for safety of self or others.
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations.
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
Borderline personality disorder
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self-image
Impulsivity in potentially self-damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
Histrionic personality disorder
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self-dramatization
Relationships considered to be more intimate than they are
Narcissistic personality disorder
Grandiose sense of self importance Preoccupation with fantasies of unlimited success, power, or beauty Sense of entitlement Taking advantage of others to achieve own needs Lack of empathy Excessive need for admiration Chronic envy Arrogant and haughty attitude
Antisocial / Avoidant personality disorder
- tense and apprehensive
- inferiority complex
- preoccupied with sense of rejection and criticism
- unwillingness to get involved
- need of security
- avoidance of social or occupational activities
Dependent / Asthenic personality disorder
- allowing others to important life decisions
- subordination
- unwillingness to make any demands
- uncomfortable or helpless alone
- fear of inability to care for oneself
- preoccupied with fears of being left to take care of oneself
- excessive need for advice and reassurance to make everyday decisions
Cluster C classification of personality disorders
Antisocial / Avoidant
Dependent / Asthenic
