PassMed Flashcards
What medication to treat tardive dyskinesia? repetitive involuntary movements including grimacing and sticking out the tongue.
Tetrabenezine
Which antipsychotic results in prolonged QT syndrome?
haloperidol
what reduces the seizure threshold?
atypical (2nd gen) > typical antipsychotics
e.g. clozapine
antipsychotic side effects
Antipsychotics: mechanism of action, adverse effects, examples
examples of acute dystonia?
sustained muscle contractions torticollis and oculogyric crisis
examples of acute dystonia?
sustained muscle contractions (torticollis and oculogyric crisis)
risks of antipsychotics in the elderly
- increased risk of stroke
- increased risk of venous thromboembolism
anti-muscarinic side effects
examples of anti-muscarinics
dry mouth, blurred vision, urinary retention, constipation
clozapine, TCAs, anti-parkinson drugs
ECT: side effects (immediate and long term)
Immediate side effects
Short term:
- Drowsiness
- Confusion
- Headache
- Nausea
- Aching muscles
- Loss of appetite
- SHORT TERM MEMORY IMPAIRMENT = RETROGRADE AMNESIA
- CARDIAC ARRHYTHMIA
Long term side effects
- Apathy
- Anhedonia
- Difficulty concentrating
- Loss of emotional responses
- Difficulty learning new information
ECT: side effects (immediate and long term)
Immediate side effects
Short term:
- Drowsiness
- Confusion
- Headache
- Nausea
- Aching muscles
- Loss of appetite
- SHORT TERM MEMORY IMPAIRMENT = RETROGRADE AMNESIA
- CARDIAC ARRHYTHMIA
Long term side effects
- Apathy
- Anhedonia
- Difficulty concentrating
- Loss of emotional responses
- Difficulty learning new information
When do we use ECT?
Catatonia
Prolonged or severe manic episode
Episode of moderate depression known to respond to ECT in the past
Severe depression that is life-threatening
NOTE: it is effective in pregnant women
How long is a depressive episode?
more then 2 WEEKS
depressive disorder criteria
more than 2 weeks AND
Mild Depressive Episode:
- At least 2 of the main 3 symptoms of depression, and at least two of the other symptoms, should be present for a definite diagnosis. None of the symptoms should be present to an intense degree
- Minimum duration of the whole episode is about 2 weeks
- Individuals may be distressed by symptoms, but should be able to continue work and social functioning
Moderate Depressive Episode:
- At least 2 of the main 3 symptoms of depression, and at least three (and preferably four) of the other symptoms, should be present for a definite diagnosis
- Minimum duration of the whole episode is about 2 weeks
- Individuals will usually have considerable difficulty continuing with normal work and social functioning
Severe Depressive Episode:
- All three of the typical symptoms should be present, plus at least four other symptoms, some of which should be of severe intensity
- The minimum duration of the whole episode should last at least 2 weeks, but if the symptoms are particularly severe then it may be appropriate to make an early diagnosis
- Can also experience psychotic symptoms with severe depressive episodes
- Individuals show severe distress and/or agitation
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Obsessions vs compulsions
Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.
An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind. Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.
OCD associations
Associations
- depression (30%)
- schizophrenia (3%)
- Sydenham’s chorea
- Tourette’s syndrome
- anorexia nervosa
OCD mx
Management
- If functional impairment is mild
- low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
- If this is insufficient or can’t engage in psychological therapy, then offer choice of either a course of an SSRI or more intensive CBT (including ERP)
- If moderate functional impairment
- offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
- If severe functional impairment
- offer combined treatment with an SSRI and CBT (including ERP)
Notes on treatments
- ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
- if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
- If SSRI ineffective or not tolerated try either another SSRI
OCD: what is the medication and for how long, and what is the next medication
FLUOXETINE for 12 weeks
if first SSRI not effective after 12 weeks → CLOMIPRAMINE or alternative SSRI
Personality disorders: what are the three clusters?
What is cluster A?
Odd or Eccentric = paranoid, schizoid, schizotypal
Paranoid
- Hypersensitivity and an unforgiving attitude when insulted
- Unwarranted tendency to question the loyalty of friends
- Reluctance to confide in others
- Preoccupation with conspirational beliefs and hidden meaning
- Unwarranted tendency to perceive attacks on their character
Schizoid
- Indifference to praise and criticism
- Preference for solitary activities
- Lack of interest in sexual interactions
- Lack of desire for companionship
- Emotional coldness
- Few interests
- Few friends or confidants other than family
Schizotypal
- Ideas of reference (differ from delusions in that some insight is retained)
- Odd beliefs and magical thinking
- Unusual perceptual disturbances
- Paranoid ideation and suspiciousness
- Odd, eccentric behaviour
- Lack of close friends other than family members
- Inappropriate affect
- Odd speech without being incoherent
What is cluster B?
Dramatic, Emotional or Erratic = Antisocial, Borderline (EU), Histrionic
Antisocial
- 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 the 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 - also known as Emotionally Unstable
- 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
- 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
- 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
What is cluster C?
Anxious and Fearful = OCD, Avoidant, Dependent
Obsessive-compulsive
- Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
- Demonstrates perfectionism that hampers with completing tasks
- Is extremely dedicated to work and efficiency to the elimination of spare time activities
- Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
- Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
- Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
- Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
Avoidant
- Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
- Unwillingness to be involved unless certain of being liked
- Preoccupied with ideas that they are being criticised or rejected in social situations
- Restraint in intimate relationships due to the fear of being ridiculed
- Reluctance to take personal risks due to fears of embarrassment
- Views self as inept and inferior to others
- Social isolation accompanied by a craving for social contact
Dependent
- Difficulty making everyday decisions without excessive reassurance from others
- Need for others to assume responsibility for major areas of their life
- Difficulty in expressing disagreement with others due to fears of losing support
- Lack of initiative
- Unrealistic fears of being left to care for themselves
- Urgent search for another relationship as a source of care and support when a close relationship ends
- Extensive efforts to obtain support from others
- Unrealistic feelings that they cannot care for themselves
How do we manage personality disorders?
What is Cotard Syndrome?
Cotard syndrome is a rare mental disorder where the affected patientbelieves that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.
Cotard syndrome is associated with severe depression and psychotic disorders.
A 60-year-old male is admitted to the in-patient psychiatric unit last night. On reviewing him this morning, he is a poor historian, answering most questions minimally and stating he does not need to be here as he is deceased, and hospitals should be for living patients.
Atypical antipsychotics: adverse effects
- weight gain
- clozapine is associated with agranulocytosis
- hyperprolactinaemia
Specific medications:
- clozapine
- olanzapine: higher risk of dyslipidemia and obesity
- risperidone
- quetiapine
- amisulpride
- aripiprazole: generally good side-effect profile, particularly for prolactin elevation
What does clozapine cause? (2 and others)
Agranulocytosis and neutropenia
- agranulocytosis (1%), neutropaenia (3%)
- reduced seizure threshold - can induce seizures in up to 3% of patients
- constipation
- myocarditis: a baseline ECG should be taken before starting treatment
- hypersalivation
When should you introduce clozapine?
Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs(one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.
When would you dose adjust clozapine?
Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.
smoking cessation causes a rise in clozapine blood levels
When is Lithium used + normal range
Lithium is mood stabilising drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys.
Lithium adverse effects
- nausea/vomiting, diarrhoea
- fine tremor
- nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
- thyroid enlargement, may lead to hypothyroidism
- ECG: T wave flattening/inversion
- weight gain
- idiopathic intracranial hypertension
- leucocytosis
- hyperparathyroidism and resultant hypercalcaemia
Monitoring patients on lithium therapy
- when checking lithium levels, the sample should be taken 12 hours post-dose
- after starting lithium levels should be performed weekly and after each dose change until concentrations are stable
- once established, lithium blood level should ‘normally’ be checked every 3 months
- after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.
- thyroid and renal function should be checked every 6 months
- patients should be issued with an information booklet, alert card and record book
What is anxiety disorder?
Anxiety is a common disorder that can present in multiple ways. NICE define the central feature as an ‘excessive worry about a number of different events associated with heightened tension.’
Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include hyperthyroidism, cardiac disease and medication-induced anxiety (NICE). Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine
- Fatigue.
- Trouble sleeping.
- Muscle tension or muscle aches.
- Trembling, feeling twitchy.
- Nervousness or being easily startled.
- Sweating.
- Nausea, diarrhea or irritable bowel syndrome.
- Irritability.
How do we manage GAD?
NICE suggest a step-wise approach:
- step 1: education about GAD + active monitoring
- step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
- step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
- step 4: highly specialist input e.g. Multi agency teams
Drug treatment
- NICE suggest sertraline should be considered the first-line SSRI
- if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI)
- examples of SNRIs include duloxetine and venlafaxine
- If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
- interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm.
- Weekly follow-up is recommended for the first month
How do we manage panic disorder?
Again a stepwise approach:
- step 1: recognition and diagnosis
- step 2: treatment in primary care - see below
- step 3: review and consideration of alternative treatments
- step 4: review and referral to specialist mental health services
- step 5: care in specialist mental health services
Treatment in primary care
- NICE recommend either cognitive behavioural therapy or drug treatment
- SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
Korsakoff’s syndrome (NB: WEKS)
Korsakoff’s syndrome (NB: WEKS)
What is panic disorder?
Panic disorder is a mental health condition where you have regular panic attacks.
Symptoms of panic disorder include feeling anxious and having sudden panic attacks.
Panic disorder is usually treated with talking therapies and medicines. Things like exercise, massage, breathing techniques and yoga can also help.
Panic may be triggered by misinterpretation of physical anxiety symptoms as signs of major catastrophe
Safety behaviours may be adopted which reinforce beliefs (e.g. avoiding situations)
CBT educates the patient on the true meaning of the symptoms (i.e. panic not perish)
Helps them test whether their behaviours keep them safe and whether their beliefs are true or misinterpretations
What is panic disorder?
Panic disorder is a mental health condition where you have regular panic attacks.
Symptoms of panic disorder include feeling anxious and having sudden panic attacks.
Panic disorder is usually treated with talking therapies and medicines. Things like exercise, massage, breathing techniques and yoga can also help.
Panic may be triggered by misinterpretation of physical anxiety symptoms as signs of major catastrophe
Safety behaviours may be adopted which reinforce beliefs (e.g. avoiding situations)
CBT educates the patient on the true meaning of the symptoms (i.e. panic not perish)
Helps them test whether their behaviours keep them safe and whether their beliefs are true or misinterpretations
examples of unexplained symptoms
poor oral compliance with antipsychotics → what next?
Patients with poor oral compliance to antipsychotics should be considered for once monthly IM antipsychotic depot injections
Depression vs dementia
Factors suggesting diagnosis of depression over dementia
- short history, rapid onset
- biological symptoms e.g. weight loss, sleep disturbance
- patient worried about poor memory
- reluctant to take tests, disappointed with results
- mini-mental test score: variable
- global memory loss (dementia characteristically causes recent memory loss)
anorexia nervosa: epidemiology and diagnosis
Epidemiology
- 90% of patients are female
- predominately affects teenage and young-adult females
- prevalence of between 1:100 and 1:200
Diagnosis is now based on the DSM 5 criteria. Note that BMI and amenorrhoea are no longer specifically mentioned:
1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
- Intense fear of gaining weight or becoming fat, even though underweight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
anorexia nervosa: features
Anorexia nervosa is associated with a number of characteristic clinical signs and physiological abnormalities which are summarised below
- most things low
- G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Features
- reduced body mass index
- bradycardia
- hypotension
- enlarged salivary glands
- lightheaded, hair loss, dry skin
- taking medicine to reduce hunger (appetite suppressants)
Physiological abnormalities
- hypokalaemia
- low FSH, LH, oestrogens and testosterone → oligomenorrhoea/amenorrhoea
- raised cortisol and growth hormone
- impaired glucose tolerance
- hypercholesterolaemia
- hypercarotinaemia
- low T3
hx taking anorexia nervosa
fear of gaining/becoming weight
weight loss relative
self-perception
control, self-esteem, perfectionism
appetite suppressants, laxatives, diuretics
making themselves sick
excess exercise
missing meals, eating little, avoiding certain foods
bowels/sex drive/weak/tired/concentration/memory/swelling
sx: lightheaded, hair loss, dry skin, oligo/amenorrhoea
protective factors
school/work
depression/OCD/substance misuse
SUICIDE RISK/SELF-HARM
anorexia nervosa tx
what’s raised and what’s reduced in anorexia nervosa?
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Everything else low:
- reduced body mass index
- bradycardia
- hypotension
- lightheaded, hair loss, dry skin
- hypokalaemia
- low FSH, LH, oestrogens and testosterone → oligomenorrhoea/amenorrhoea
Anti-psychotics: monitoring
Carbamazepine
Anticonvulsant
Can cause toxicity at high doses
Induces liver enzymes
Close monitoring of carbamazepine levels is essential Check for drug interactions before prescribing
- P450 enzyme inducer
- dizziness and ataxia
- drowsiness
- headache
- visual disturbances (especially diplopia)
- Steven-Johnson syndrome
- leucopenia and agranulocytosis
- hyponatraemia secondary to syndrome of inappropriate ADH secretion
Carbamazepine is known to exhibit autoinduction, hence when patients start carbamazepine they may see a return of seizures after 3-4 weeks of treatment.
Pseudohallucinations
A 44-year-old man attends his GP surgery. He explains that his long term partner died last month. When he woke up this morning he thought he was lying next to her. He claims he heard her voice saying his name. Although he realizes this is not possible it has caused him significant distress. He is worried that he may be ‘going mad.’ He has no other psychiatric history of note.
pseudohallucination is a false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating.
There is disagreement among specialists about not only the definition but also the role in the treatment of pseudohallucinations. Many specialists feel that it is more appropriate to think about hallucinations on a spectrum from mild sensory disturbance to hallucinations to prevent symptoms from being mistreated or misdiagnosed.
An example of a pseudohallucination is a hypnagogic hallucination which occurs when transitioning from wakefulness to sleep. These are experienced vivid auditory or visual hallucinations which are fleeting in duration and may occur in anyone. These are pseudohallucinations as the affected person is able to determine that the hallucination was not real.
The relevance of pseudohallucinations in practice is that patients may need reassurance that these experiences are normal and do not mean that they will develop a mental illness.
Pseudohallucinations commonly occur in people who are grieving.
Type 1 vs type 2 BPAD
- type I disorder: mania and depression (most common)
- type II disorder: hypomania and depression
Mani vs hypomania
- both terms relate to abnormally elevated mood or irritability
- with mania, there is severe functional impairment or psychotic symptoms for 7 days or more
- hypomania describes decreased or increased function for 4 days or more
- from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
Organic co-morbidities of BPAD
there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD
Primary care referral for BPAD
- if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)
- if there are features of mania or severe depression then an urgent referral to the CMHT should be made
BPAD Mx
Why is sertraline good?
- sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants
What do we have to be careful with with citalopram?
- It advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
- the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment
Which SSRI for children?
SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of choice when an antidepressant is indicated
Adverse effects of SSRIs
- gastrointestinal symptoms are the most common side-effect
- there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
- patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
- fluoxetine and paroxetine have a higher propensity for drug interactions
SSRI and interactions with other drugs
- NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
- warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine (NaSSA)
- aspirin: see above
- triptans - increased risk of serotonin syndrome
- monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
How long to gradually reduce SSRI when stopping it
How long to continue SSRI when good response
4 weeks
6 months
What are some discontinuation symptoms?
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
GI symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
Which SSRI has a high incidence of discontinuation symptoms
Paroxetine
SSRIs and pregnancy
which SSRI specifically
BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- *- Paroxetine** has an increased risk of congenital malformations, particularly in the first trimester
What is Munchausen syndrome (factitious disorder)?
intentional production of physical or psychological symptoms
What is malingering?
Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
what is somatisation disorder?
Multiple physical symptoms present for at least 2 years
patient refuses to accept reassurance or negative test results
What is illness anxiety disorder (hypochondriasis)?
Persistent belief in the presence of an underlying SERIOUS DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
What is conversion disorder?
loss of motor or sensory function
may be caused by stress
patient doesn’t consciously feign the symptoms (factitious disorder) or seek maternal gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
What is dissociative disorder?
‘separating off’ certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. amnesia, fugue, stupor
DID is the new term for multiple personality disorder as is the most severe form of dissociative disorder
Risk of developing schizophrenia (Fhx and other RFs)
The strongest risk factor for developing a psychotic disorder (including schizophrenia) is family history. Having a parent with schizophrenia leads to a relative risk (RR) of 7.5.
Risk of developing schizophrenia
- monozygotic twin has schizophrenia = 50%
- parent has schizophrenia = 10-15%
- sibling has schizophrenia = 10%
- no relatives with schizophrenia = 1%
Other selected risk factors for psychotic disorders include:
- Black Caribbean ethnicity - RR 5.4
- Migration - RR 2.9
- Urban environment- RR 2.4
- Cannabis use - RR 1.4
How do we differentiate between severe depression and dementia
Severe depression can mimic dementia but gives a pattern of global memory loss rather than short-term memory loss - this is called pseudodementia
Depression vs dementia
- short history, rapid onset
- biological symptoms e.g. weight loss, sleep disturbance
- patient worried about poor memory
- reluctant to take tests, disappointed with results
- mini-mental test score: variable
- global memory loss (dementia characteristically causes recent memory loss)
What are the features of EUPD/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
feelings of emptiness, unstable relationships, and an unpredictable affect with threats/acts of self-harm.
What can cause hyponatraemia regarding psych?
SSRIs
What is the criteria for PTSD?
Sx present for more than a month following a traumatic event
- re-experiencing = flashbacks, nightmares, repetitive and sdistressing intrusive images
- avoidance = avoiding people, situations or circumstances resembling or associated with the event
- hyperarousal = hyper vigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentration
- emotional numbing = lack of ability to experience feelings, feeling detached
Others = depression, drug or alcohol misuse, anger, unexplained physical symptoms
Acute stress disorder vs PTSD
Acute stress disorder is less than 4 weeks
How do we manage PTSD?
Panic Disorder Mx
Borderline/EUPD
- efforts to avoid real or imagined abandonment
- unstable interpersonal relationships which alternate between idealisation 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
Mx: DBT
- Understand and accept your difficult feelings
- Learn skills to manage them
- Become able to make positive changes in your life
Scoring system for OCD?
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression
For these patients NICE recommends an antidepressant (normally a selective serotonin reuptake inhibitor, SSRI)
The following ‘high-intensity psychological interventions’ may be useful:
Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression
For these patients NICE recommends an antidepressant (normally a selective serotonin reuptake inhibitor, SSRI)
The following ‘high-intensity psychological interventions’ may be useful:
What should monitor closely for schizophrenia management?
cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
QRISK3 Scoring
What is Wernicke-Korsakoff Syndrome?
If not treated Korsakoff’s syndrome may develop as well. This is termed Wernicke-Korsakoff syndrome and is characterised by the addition of antero- and retrograde amnesia and confabulation in addition to the above symptoms.
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Social mx of schizophrenia
Baby blues vs postpartum depression
Post partum psychosis
Anorexia nervosa vs bulimia nervosa
Schizophrenia diagnosis: positive and negative symptoms
1 month, Sx’s present most of the time
- POSITIVE = passivity (external influence), hallucinations, delusions, thought disorder (chaotic thinking, tangentiality, flight of ideas, word salad)
- Catatonia (lack of movement, communication, agitation, confusion, restlessness) disorganised behaviours)
- NEGATIVE = poor volition, poor cognition, blunted affect
ED Ix
Protective factors = peers partner, work, supportive family
Stressors = school, work, peers, unsupportive family
Bulimia Mx
Fluoxetine + CBT for ED
Management of refeeding syndrome
Section laws
HTT IS THE CRISIS TEAM
Alcohol misuse: detoxification dn after successful withdrawal
Alcohol misuse mx summary
More sedative, less sedative TCAs
More sedative, less sedative TCAs
GABAa drugs 2 types
How do we manage acute stress disorder
TF-CBT
BDZPs for acute sx (e.g. agitation, sleep disturbance)
use with caution
ICD-11 Personality Disorders
Depression mx
Cognitive distortions
