Psych 2 Flashcards
Risk factors/ aetiology for Anorexia nervosa
Bio: Genetics Female (mid-adolescence Early menarche Starvation (endocrine) perpetuates Psycho: Sexual abuse Dieting in adolescence Low self esteem Premorbid anxiety or depression Perfectionism/ anankastic personality Criticism regarding eating/body shape/weight Social: Western society Stress Bullting at school involving weight Occupatione.g. ballet, models
Clinically defining features of Anorexia nervosa as defined by ICD10 and other features
Fear of weight gain
Amenorrhoea and loss of sexual interest and impotence in male.
BMI 15% below expected weight
Deliberate weight loss (food or exercise)
Distorted body image
All features present for 3 months and must be absence of binge eating and a preoccupation with eating/ craving to eat. (if not consider bulimia or EDNOS.
Other
Physical: Fatigue, hypothermia, bradycardia, arrhythmias, peripheral oedema, headache, lanugo hair.
Preoccupation with food: Dieting, making meals for ohers
Socially isolated, sexuality feared
Symptoms of depression and obsession
Anorexia features
bradycardia
hypotension
enlarged salivary glands
most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Appearance and behaviour
x
Speech
x
Appearance and behaviour
Tics Rapport Psychomotor activity e.g. retardation Abnormal behaviours e.g. distracted Physical state Hygiene Eye contact - staring in parkinsonism and averting gaze in depression Body language
Speech
Rate - Latency. Pressured/slow
Quantity of speech – minimal (e.g. only in response to questions) /excessive speech / complete absence of speech
Tone - monotomous (dep), tremulous (anx)
Volume - mania loud, depression low
Fluency and rhythm of speech – articulate / clear / slurred
Formal thought disorder e.g. word salad, tangientality, derailment of thought e.g. knight’s move thinking
Mood
Mood - a patient’s sustained, subjective, experienced emotion over a period of time.
Elated, euthymic or depressed.
May be diurnal e.g. dep
Affect
Affect is assessed on:
Range - restriced, blunted (more severe than restricted), flat (almost no expression)
Appropriateness - appropriate, inappropriate, incongruous
Stability - stable, labile (fluctuating)
If affect is normal = reactive
Perception and good questions to ask
Hallucinations - modalities
Different from:
Pseudohallucinations - Voices in head - no external stimuli reported (know it’s not real?)
Illusion- A false mental image produced by misinterpretation of external stimulus
Depersonalisation - detachment of normal sense of self (neurosis = stress)
Derealization - (neurosis), unreality feeling, people and experiences are unreal/ on a stage.
See things others cant hear or can’t explain?
Hear things others cant hear or explain?
Feel things cant explain?
Voices in head?
Feel like things you see or heard or experience aren’t real?
Thought and questions
Thought
Form:
• Loosening of association (x3 in speech)
• Circumstantiality - drifts but comes back to same idea.
• Perservation (same idea)
• Neologisms - giving words new meanings
Content
• Delusions, preoccupations/ overvalued ideas (Strongly held beliefs but can be put out of mind with some effort).
• Obsessions (distressing thoughts that enter the mind despite the patient’s effort to resist them), compulsions, ruminations
Stream
• Acceleration (pressure of speech/ flight of ideas)
• Retardation (Poverty of thought)
• Thought blocking
Suicidal ideation?
Difference between normal grief and depression?
a normal grief reaction lasts under 6 months whereas depression can last longer.
Side effects of antipsychotics
Extrapyramidal side-effects
Parkinsonism
acute dystonia (e.g. torticollis, oculogyric crisis)
akathisia (severe restlessness)
tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism
Other side-effects
antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin: galactorrhoea, impaired glucose tolerance
neuroleptic malignant syndrome: pyrexia, muscle stiffness
reduced seizure threshold (greater with atypicals)
prolonged QT interval (particularly haloperidol)
Describe Insight?
Intact - accept disorder and treatment
Partial - accept disorder but not treatment or vice versa
Non-existent
Cognition and questions
General - Conscious level Hyper/ hypoactive - sleepy? Orientation Attention Language (right ear with left hand) Calculation Right sided function - draw clock face Abstract thinking - take a horse to water but... Memory Praxis - e.g. copying/ drawing
Where are you? When are you? Touch your right ear with your left hand? Draw a clock face? Take a horse to water... 10x5?
Reporting of MSE
Appeared to be hygienic, suitably dressed, no psuychomotor abnormality
No abnormal behaviours such as staring or distracted with good rapport
Speech
Rate - normal (not pressured or slow)
Normal quantity (not minimal or excessive)
Volume normal
Tone normal (not monotomous or tremulous)
Mood
Objectively
Subjectively - euthymic, low, elated
Affect
Reactive/ restricted/ bluted/ flat range
Appropriate/Congruous
Stabile
Perception
No hallucinations, illusions or derealization/ depersonalization
Thoughts
Normal structure (no neologisms, loosening of association, circumstantiality, formal thought disorder)
No delusions, obsessions or overvalued ideas
No accelaration/ retardardation
No suicidal ideation
Insight present
Cognition
Well orientated, good attention and no obvious impairment of higher functioning. (memory not impaired or trouble understanding language)
Psych history structure
Presenting complaint History of PC Psych history Medical history Medication Family history Personal history: • Infancy • Adolescence • Forensic • Occupational • Sexual and relationships • Living Drugs and Alcohol Premorbid personality MSE
How to get presenting complaint
Ask patient to describe atypical day
Onset, severity, duration, agg/ relieve, associated symptoms.
Patient’s view of the problem
Ask about other symptoms e.g. core in depression, positive and negative in psychosis, biological, psychological, avoidance in anx.
E.g: Do you see/ hear things others can't? Help me to understand this… Do you feel you have any special abilities or powers? Test delusions People interfering with your thoughts? Heard/ seen anything you can't explain. You look a little nervous today? Just get the patient talking
Assess risk - may wait until good time in the conversation - the how and what about killing yourself.
e.g: Sometimes when people feel low… Response to the people following you? Ever hurt so bad that you've thought about killing yourself? What stopped you?
Past psych history
Previous admissions.
Mental Health Act.
Previous self harm
Treatments
Family history
x
Drugs and alcohol use
Always ask about cannabis specifically which naturally follows from smoking.
Cost
Personal history
xInfancy - development/ milestones, serious illnesses. “were you a healthy child”
Adolescence - how was school for you? Friends? Bullying? Teachers? Qualifications?
Occupation - Leaving school going forward. What jobs they prefered? Relationships? Reasons for job changes?
Social - House, finances, changes in circumstances, support network,
Forensic - ever been in trouble with the police? Or not caught for?
Pre morbid personality
How person was before so you can compare to how they are now.
How have experiences impacted on them as a person?
Anorexia thought findings
Preoccupation with food and overvalued ideas concerning dieting, appearance and weight loss (preoccupation differs from obsession in that with severe difficulty the thought can be put out of the mind).
Complication of AN
Metab
Osteoporosis (DEXa), Proximal myopathy (upper and lower limbs)
Arrhythmias e.g. brady, Prolonged QT, changed caused by hypokalemia.
Hypoglycaemia, Hypercholesterolaemia, Hypothyroidism (TFTs)
GI
Hepatitis/ LFTs Pancreatitis (amylase) Renal failure/ stones Enlarged salivary glands Constipation Peptic ulcers
Anaemia (iron), thrombocytopenia, leucopenia
Dry slin, brittle nairs, infections, suicide
Management of anorexia
Risk assessment for suicide and medical comps.
Bio: Treat medical complications. SSRIS for dep or OCD. Graded exposure to food.
Gain 0.5-1kg per week as inpatient and .5kg as outpatient
Psycho: CBT, psychotherapy, DBT, mindfulness, groups, meal plannning, psychoeducation, interpersonal psychotherapy, family therapy
Social: Volunatary organisations or Self-help groups.
Risks of weight gain with anorexia
Refeeding syndrome:
After prolonged starvation or malnourishment due to changes in phosphate, magnesium and potassium.
Insulin surge
Hypokalaemia, hypomag,, hypophos, abnormal glucose metab.
Phosphate depletion causes cardiac failure
How to prevent refeeding symdrome
Dailey bloods, start at 1200cals and gradually increase every 5 days, monitor for tacchycardia and oedema.
If low then oral or IV electrolyte replacement
WHen to hospitalise
MHA if health at serious risk e.g. medical inpatient No absolute threshold Indicators >1kg weight loss a week Needed to observe blood, ECG If carers can support
Define BN
Repeated episodes of binge eating followed by compensatory weight loss behaviours with overvalued ideas regarding ideal body shape/ weight
How does BN aetiology and epidemiology differ from AN?
Less clear role of genetics
Vicous cycle of compensatory weight loss behaviours, sense of compulsion to eat, binge eating, fear of fatness.
AN in higher social class, BN in all.
Common psychiatric disease with BN
Depression Anxiety DSH Substance misuse Emotionally unstable personality disorder
Clinical features of BN
ICD 10:
Compensatory behaviours - vomiting, starvation, drugs, omit insulin, exercise
Preoccupation with eating - compulsion followed by regret and shame.
Fear of fatness
Overeating - x2 per week for 3 months.
Other:
Normal weight
Depression/ low self esteem
irregular periods
dehydration - low bp, increased cap refil, low turgor, sunken eyes.
Hypokalaemia -
Subtypes of BN
Purging and non purging (drugs/ vomiting vs diet and exercise)
Signs of BN and ECG
Russell’s sign - calluses on back of hands from repeated self-induced vomiting
Parotid swelling
Sunken eyes
Dental erosion
ECG - Increased PR, depressed/ inverted T, U wave, tall P
Complications of repeated vomiting
Arrythmias, mitral valve prolapse, peripheral oedema
Mallory-Weiss tears of the oesophagus, increased parotid
Dehydration, renal stones, renal failure
Erosion of teeth
Russells sign
Aspiration pneumonitis
Cognitive impairment, peripheral neuropathy, seizures.
Management of BN
Bio: Fluoxitine can reduce binge
Psycho: CBT, Psychoeducation, interpersonal therapy
Social: Food diary, techniques to avoid binging (eat with others, distractions), small regular meals, self-help programs
Monitor electrolytes.
If suicide risk or electrolyte imbalance then admit to hospital (same as anorexia)
Prognosis in eating disorders
50% full recovery in BN
20% in AN.
Define PD
Deeply ingrained enduring pattern of behaviour that deviates markedly from a persons culture, is pervasive and inflexible, present from adolescenece/ early adulthood (as brain still develops until 17). Leads to distress or impairment
A pervasive inflexible pattern of behaviour and inner experience that deviates from an individuals’ cultural norms. Present from adolescence/ early adulthood. Stable over time and leads to distress or impairment
Clinical features of panic disorder
Severe, unpredictable, episodic panic attacks not associated with a specific situation or object.
Must last more than a couple of minutes (most peak at 10 and last less than one hour).
Starts abruptly.
Intense fear (fear of death often)
1 autonomic manifestation: palpitations, sweating, shaking/ tremor, dry mouth,
Other anxiety symptoms of GAD
Clinical features of GAD (ICD10)
Persistent feeling of worry, agitation for greater than 6 months.
Presence of four symptoms including one autonomic.
Autonomic: Palpitations, sweating, tremor,
CVS/ GI: Butterflies/ abdominal discomfort Palpitations Lump in throat Loose stools
Neuro: Lightheaded/ Dizzy Hot flushing or cold chills numbness or tingling Headache
Symptoms of tension: Muscle tensions Restlessness Feeling n edge Difficulty swallowing Sensation of lump in throat
Thoughts/ higher functions: Sleep problems Irritability Fear of dying/ losing control Derealisation and depersonalisationMind blacks Startled easily Poor concentration
RFs panic disorder
Bio: Asthma, Benzo withdrawal, age 20-30, , female, white, cigarette smoking,
Psycho:adverse life event
Social: Fx
What is catatonia?
State of ultered posure, immobility and stupor.
Seen in severe schizophreni.
It may involve repetitive or purposeless overactivity, or catalepsy, resistance to passive movement, and negativism.
What is stupor
Inability to respond to internal (e.g. hunger) and external stimuli
What is catalepsy
Inability to respond to internal (e.g. hunger) and external stimuli
Pathophysiology of schizo and drugs that can mimic this
Overactivity of D2 mesolimbic pathway - amphetamines, parkinsonism medications.
Describe dopamine pathways in the brain
Mesolimbic/ mesocortical: Addiction Reward Memory Motivation Emotional response (Mesolimbic positive in Schiz and mesocortical = neg)
Nigrostriatal: Motor control (Parkinson's)
Tuberoinfundibular:
Regular of hormones (particularly prolactin), pregnancy, maternal stuff
Describe the neg symptoms of schizophrenia
Avolition (low motivation) Asocial behaviour Anhedonia Affect blunted Alogia (quantiitve and qualiative decrease in speech) Attention deficit
Indications for ECT
Depression that is treatment resistant
Depression with high risk e.g. suicidal ideation or serious risk to others.
Life threathening depression when patient refuses to eat or drink
Catatonia
Prolonged, treatment resistant, manic period
Can only be used under the MHA if an emergency to save life or
How long should a seizure last in ECT?
30 seconds
CI ECT
MI
Severe resp or CVS disease (anaesthetic)
Heart failure/ arrhythmia (hypertension)
History of status
Describe the sympathetic and parasympathetic activity after ECT
Transient parasympathetic followed by sympathetic resulting in raised BP hence contraindications
How many drugs are given during ECT?
2
A general anaesthetic (etomidate or propofol
A Muscle relaxant (suxamethonium)
How is ECT monitored
EEG. Pulse and BP both increase
Describe drugs that affect seizure threshold
Minimum electrical stimulus required to induce a seizure,
Increase threshold: Antiepileptics (mood stab), Benzos, anaesthetics
Decrease threshold: Antipsychotics, antidepresants, lithium
Side effects of ECT
Short term: N/V, Constipation, laryngospasm, sore throat Damaged teeth Muscular aches, headaches Mania in a depressed patient Cardiac arrythmias Confusion Peripheral erve palsies Short term memory impairment Status epilepticus
Long term:
Antereograde and reterograde memory loss
Describe anxious/ avoidant PD
Approval needed before getting involved Social inhibition Embarrasment potential inhibits involvement in activites Restriction in life to maintain security Inadequacy felt
Describe anakastic PD
Perfectionism Loses purpose of tasks and focuses on detail Workaholic at expense of lesure Subborn Inflexible Fussy
Describe dependency PD
Seeks companionship Low self confidence Difficulty expressing disagreement Reassurance requred Needs other to assume responsibility
How can agrophobia and social phobias be differentiated
Agrophobia = fear of a public place whereby immediate escape would be difficult in the event of a panic attack. Fear of crowds, large spaces, leaving the house alone.
Social phobia is fear of social situations which may lead to embarrassing oneself, criticism or humiliation. Fear of being the focus of attention.
Describe the treatment of GAD
Bio:
SSRI (1st sertraline), SNRI (2nd), Pregabalin (3rd)
Psycho:
Psychoeducation (low intensity)
CBT and applied relaxation
Social:
Self help - writing things down and analysing, support groups, exercise
Treatment for phobia
Pharmacological interventions - SSRIs (not for specific). Benzos for specific in emergency.
CBT - graduated exposure (also homework)
Social phobia can benefit from psychodynamic therapy
3 differences between GAD, phobias and panic disorders
Response to stimulivs random ep vs most the time
2 Avoidance in phobias vs worry and agitation vs fear of death
3 Cognition - Constant worry about everyday life events vs fear about a particular situation
Organic DDX for panic disorder
Pheocromocytoma Hyperthyroidism Carcinoid syndrome (neuroendocrine tumours) Arrythmias Hypoglycaemia Alcohol/ substance withdrawral
Differences between PTSD and Adjustment
Catastophic vs non catastrophic event.
Symptom onset within 6 months vs within 1 month.
Symptoms less severe.
Adjustment disorder symptoms end within 6 months.
Adjustment more like depression
PTSD triad of symptoms
Symptoms PTSD
Avoidance
Re living - nightmares and flashbacks
Hyperarousal - hypervigilance, insomnia, startle
Treatment for PTSD
Within 3 months:
- Watch and wait
- Zopiclone for sleep
- Risk assess
> 3 months:
- CBT
- EMDR - Eye movement desensitisation and reprocessing
- Drugs - Paroxetine, Mirtazapine, amitryptilline and phenelzine. Only consider if therapy is not working.
What is an acute stress reaction
Exposure to an acute stressor. Symptom onset within 1 hour.?? Symptoms: - Any of GAD - Agitation/ aggression - Narrowing of attention - Disorientation - Despair or hopelessness - Uncontrollable or excessive grief. Transient stressors then symptoms must begin to diminish within 1 month
Dissociative symptoms unlike PTSD - e.g. detatchment/ derealisation
Avoidance of triggers e.g. people/ conversations
Flashbacks
Reaction <48hrs, Disorder >48hrs (DSM IV) <1 month
More stressful event that adjustment
Adjustment disorder symptoms
Depression symptoms Loss of interest Feelings of hopelessness and crying Not an anxiety disorder Difficulty coping with life event
May get avoidence of fam/friends or anxiety too
Describe obsessions and compulsions
Obsessions = Unwanted intrusive thoughts, images or urges that repeatedly enter the mind. Cause distress. Inidiviual tries to resist them and knows them as absurd (egodystonic) and a product of their own mind.
Compulsion: Repetitive, sterotyped behaviours or mental acts that a person feels driven into performing. Overt or Covert. Gives some relief to anxiety. Exacerbates obsession (operant conditioning)
Epidemiology of OCD
M=F
Early adulthood
Fx
Abuse in childhood
Investigations into OCDx
Questionnaires
DDX OCD
O & C: Anorexia, Bulimia, body dysmorphia Anankastic PD O: Anxiety disorder, depressive disorder, hypochondriacal disorder, schizophrenia C: Tourette's Kleptomania (stealing things) Organic: Dementia Epilepsy Head injury
Treatment of OCD
xCBT in the form of ERP (exposure and response prevention)
SSRIs (can add cloripramine or an antipsychotic)
Psychoeducation, self help material, distracting techniques
Describe Wernike’s and Korsakoffs psychosis
Caused by a thiamine deficiency (B1) Wernike's encephalopathy: Ataxia Ophthalamoplegia Nystagmus Delerium Hypothermia Korsakoff psychosis: Short term memory loss Confabulation (making up things to explain current events) DIsorientation to time
Define delerium
An acute, organically caused impairment of the CNS causing decreased cognition and attention
Presentation of conduct disorder
Sleep problems. Feeding problems - faddiness (fussy) Behaviour problems: Uncooperative Temper tantrums Aggressive, defiant, wilful.
Conduct disorder is different to oppositional defiance disorder as it is more severe and more common in children beyond 10 years old.
Socialised and unsocialised types. (socialised tends to be phasic- only wiht friends). Unsocialised tends to lead to antisocial PD
Commonly have comorbid mental health problems
core conduct disorders symptoms including:
patterns of negativistic, hostile, or defiant behaviour in children aged under
11 years
aggression to people and animals, destruction of property, deceitfulness or theft
and serious violations of rules in children aged over 11 years.
Associated with poor education performance, social isolation, substance misuse.
Management of conduct disorders
Parenting programmes
Systemic therapy
Agency imput
Psychoeducation and support
Describe common emotional disorders in child psych
GAD Separation anxiety disorder Phobic dis OCD PTSD Depressive disorders Conduct disorder is the most common psych presentation
Presentation of GAD in children
Anxiety
Fears of death of themselves or others
Somatic manidestations - Nausea, abdopain, sickness, headaches, sweating, palpitations, tension
Panic attacks - sudden, extreme fear, physical symptoms, faintness
Presentation of separation anxiety
Fear of or anxity with separation from attachment figure
Somatic manifestation
Nightmares
School refusal.
Management of anxiety disorders in children
Behaviour - systemic desensitisation, flooding (expose to painful memory (fast systematic densensitization), response prevention
Psychotherapy - brief dynamic, family and cognitive therapy
Anxiolytics (last resort include beta blockers and diaepam)
