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Year 3 - Psychiatry (DP) > Anxiety and Schizophrenia > Flashcards

Flashcards in Anxiety and Schizophrenia Deck (275)
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1

What are some acute signs of anxiety?

Palpitations
Sweating
Tremor
Dizziness
Shortness of breath

2

What are some chronic signs of anxiety?

Muscle pains
Weakness

3

What is Globus hystericus?

Feeling of a lump in your throat

4

When does anxiety become a problem?

If it results in isolation

5

Under what heading does ICD-10 classify anxiety disorders? What does this include?

Neurotic disorders:
- PTSD
- Adjustment disorder
- OCD
- Hoarding disorder

6

How are PTSD and Adjustment disorder classed in DSM-V?

Under trauma and stressor-related disorders

7

How are OCD and Hoarding disorder classed in DSM-V?

OCD and Related Disorders (OCARD)

8

Under ICD-10, what does F40 describe?

Phobic anxiety disorders:
- Agoraphobia (F40.0)
- Social phobia (F40.1)
- Specific phobies (F40.2)

9

Under ICD-10, what does F41 describe?

Other anxiety disorders:
- Panic disorder (F41.0)
- Generalised Anxiety Disorder (GAD) (F41.1)

10

Under ICD-10, what does F42 describe?

OCD

11

Under ICD-10, what does F43 describe?

Reaction to severe stress and adjustment disorders:
- PTSD (F43.1)
- Adjustment disorder (F43.2)

12

What is the full ICD-10 range which describes 'Neurotic, Stress-Related and Somatoform Disorders'?

F40-F48

13

Under the proposed ICD-11, what does OCARD also include?

Olfactory reference disorder
Hypochondriasis

14

What are the key features of Generalised Anxiety Disorder?

Excessive and inappropriate woryring that is persistent
Not restricted to certain circumstances
Symptoms include:
- Autonomic arousal (eg. palpitations, sweating)
- Thorax symptoms (eg. SoB0
- Brain/Mind symptoms (eg. Dizziness)
- General symptoms (eg. Hot flushes)
- Symptoms of tension (eg. Aches and pains)

15

What ICD-10 number is Generalised Anxiety Disorder?

F41.1

16

How is a panic attack defined?

Discrete periods of intense fear alongside physical and psychological anxiety symptoms
Reach peak within 10 minutes
Last around 30-45 minutes

17

What fraction of people with panic disorder develop agoraphobia?

2/3

18

What is the other name for social phobia?

Social anxiety disorder

19

What is agoraphobia?

Fear in places/situations in which:
- Escape might be difficult
- Help might not be available

20

How is social phobia characterised?

A persistent and unreasonable fear of being evaluated negatively by others
This fear is in social/performance situations

21

What are common physical symptoms of social phobia?

Blushing
Fear of vomiting
Urgency/Fear of micturition/defaecation

22

What sort of history is present in PTSD?

Exposure to trauma:
- Actual/Threatened death
- Serious injury
- Threats to physical integrity of self/others

23

What symptoms develop later in PTSD?

Intrusive symptoms (eg. Flashbacks)
Avoidance symptoms
Negative alterations in cognitions and mood
Hyperarousal

24

What are the features of hyperarousal?

Disturbed sleep
Hypervigilance
Exaggerated startle response

25

How is OCD characterised?

Recurrent obsessive ruminations/images/impulses
+/or recurrent rituals
Symptoms are:
- Distressing
- Time consuming
- Interfering with social and occupational function

26

How is an obsession described?

Intrusive and inappropriate
Excess and unreasonable (not in kids)

27

How is an obsession ego-dystonic?

Product of own mind but experienced as alien
Outwith own control

28

What is a compulsion?

Repetitive behaviour/mental act
Aim to reduce anxiety
Not pleasurable in themselves

29

What is F40.00?

Agoraphobia without panic disorder

30

What if F40.01?

Agoraphobia with panic disorder

31

What is F40.8?

Other phobic anxiety disorders

32

What is F40.9?

Phobic anxiety disorder, unspecified

33

Marked and consistently manifested fear/avoidance of how many places is needed to diagnose agoraphobia? What sort of places?

>=2 of the following:
- Crowds
- Public spaces
- Travelling alone
- Travelling away from home

34

Apart from fear/avoidance of certain situations in agoraphobia, what other two features must be present?

- Anxiety in a situation with >=2 symptoms on >1 occasion from the key features symptoms of GAD
- Significant emotional distress due to avoidance/anxiety

35

To diagnose a social phobia, what insight should the patient have?

Recognising that the symptoms and avoidance are excessive or unreasonable

36

What percentage of patients with social phobia with abuse alcohol?

20%

37

How many symptoms of generalised anxiety disorder must be present for a panic attack to be classed as such?

>=4 symptoms
At least one from each of:
- Autonomic symptoms
- Thorax symptoms
- Brain/Mind symptoms
- General symptoms

38

How is general anxiety disorder diagnosed?

>=6 months with prominent tension/worry/feeling of apprehension about every-day events
>=4 symptoms
At least one from each of:
- Autonomic symptoms
- Thorax symptoms
- Brain/Mind symptoms
- General symptoms

39

How is OCD diagnosed?

Obsessions +/or compulsions present on most days for >=2 weeks

40

In OCD, what features of obsessions and compulsions MUST be present to be diagnosed as such?

Acknowledged as originating from patient's mind
Repetitive and unpleasant
Subject tries to resist
Carrying out a compulsion is not pleasurable

41

In diagnosing PTSD, following an initial stressor event, when must criteria 2-4 be met?

Within 6 months of:
- Event OR
- The end of a period of stress

42

What kind of stressor event is associated with the highest incidence of PTSD?

Rape

43

When is the 'freeze' response initiated?

When limbic system judges that neither fight nor flight is possible and death/severe injury is inevitable

44

What happens during a 'freeze' response?

Altered state of reality
Body becomes immobile
Pain responses reduced

45

What are the types of trauma?

Type 1 = Simple
Type 2 = Complex

46

What symptoms can run alongside typical PTSD symptoms to classify it as complex PTSD?

Cognitive disturbance
Mood/Emotional disturbances
Somatisation
Identity disturbance
Chronic interpersonal difficulties
Dissociation
Tension reductive activities

47

How is the stress response resolved?

PNS kicks in:
- Muscles relax
- Skin warms
- Pupils constrict to normal (SNS dilates them)
- Refocusing
- HR slows
- BP reduces
- Eat, digest and rest

48

What part of the brain is responsible for locating memories in the right time, place and context?

Hippocampus

49

What part of the brain stores emotionally charged memories?

Amygdala

50

Where does the limbic brain connect to?

Medial prefrontal cortext

51

What to the limbic connections enable it to do?

Regulate emotional and fear responses

52

How many connections are there from limbic brain to medial prefrontal cortex?

Many

53

How many connections are there from the medial prefrontal cortex to the limbic brain?

Fewer

54

How do sense of danger and logic interact?

Sense of danger overrides logic

55

What can potentially trigger flashbacks in PTSD?

Insomnia
Tiredness
Stress

56

Why can nightmares result in insomnia?

Delay in going to sleep
Bedroom associated with nightmares:
- Bedroom avoidance
- Poor sleep hygeine

57

When is dissociation more likely to occur in PTSD?

If trauma is:
- Severe
- Prolonged
- Repeated/Horrific/Shaming
- Affecting a very young victim

58

How does dissociation present in PTSD?

Patient may feel like they're watching themselves
May feel like it isn't happening
Dissociative flashbacks
Fugue states
Dissociative Identity Disorders

59

What can indicate dissociation?

Things look strange
Changes in sound
Rocking/Tapping
'Slow-motion'
Feel like a robot/observer

60

When does an acute stress reaction occur following trauma?

48 hours after

61

When does an acute stress disorder occur following trauma?

Up to 4 weeks

62

When does acute PTSD occur following trauma?

Up to 3 months

63

When does chronic PTSD occur following trauma?

Over 3 months

64

How can acute stress disorder be diagnosed?

The following symptoms occurring within 1 months of the trauma and lasting at least 2 days:
- Dissociative symptoms
- Persistent re-experiencing
- Increased arousal

65

What treatment should not be undertaken in acute stress disorder?

Debriefing

66

When is watchful waiting and monthly reviewing appropriate in an acute stress disorder?

If symptoms are mild and present for <4 weeks

67

What psychotherapeutic models can be employed in the treatment of acute stress disorder/PTSD?

Trauma focused CBT
Eye Movement Desensitisation and Re-Programming
Prolonged exposure
Cognitive processing therapy

68

What drugs are licensed for use in PTSD?

Antidepressants:
- Paroxetine
- Other classes if SSRIs don't work

69

What specialist alternative drugs can be used in PTSD?

Prazosin
Atypical antipsychotics
Mood stabilisers

70

Under DSM-V, what is included under OCARD?

Excoriation
Hoarding
Body dysmorphic disorder
Tic disorder

71

What is the most common comorbid condition in OCD?

Anxiety disorders

72

What is the mean age of onset of OCD?

20 years

73

What is the median age of onset of OCD?

19 years

74

When is the peak incidence of OCD in males?

13-15 years

75

When is the peak incidence of OCD in females?

24-25 years

76

What populations have an increased incidence of OCD?

General hospital populations

77

What autoimmune conditions may contribute to developing OCD?

Beta-Haemolytic Strep. infection (PANDAS)
Autoantibodies to basal ganglia

78

What does neuroimaging show in OCD?

Increased metabolism and blood flow in:
- Orbitofrontal cortex
- Caudate nucleus
- Cingulate cortex

79

What five screening questions can be used for OCD?

1. Do you wash or clean a lot?
2. Do you check things a lot?
3. Is there any thought that keeps bothering you that you wanna get rid of but can't?
4. Do your daily activities take a long time to finish?
5. Are you concerned about orderliness/symmetry?

80

When would benzodiazepines be used in anxiety disorders?

Specific occasions (eg. flights)

81

What anxiety disorders can graded exposure be used to treat?

Simple phobias (eg. spiders)
Agoraphobia

82

How would the exposure in graded exposure be described?

Gradual and progressive

83

What is flooding?

Full exposure to feared stimulus and staying with it until fear reduces

84

What are the issues with flooding?

Generally less popular
Fear may spontaneously reoccur

85

What are the principles of CBT?

Suggest that underlying thoughts affect emotions which then affect behaviour
Involve patient in questioning/testing their thoughts

86

What BZDs can be used in PTSD?

Bromazepam
Clonazepam

87

What anticonvulsants can be used in PTSD?

Gabapentin
Pregabalin
Onlanzapine

88

What form of CBT is used in PTSD?

Trauma-Focused CBT

89

What are the typical first line medications used in OCD?

Serotonergic antidepressants:
- SSRIs
- Clomipramine (TCA)

90

What antipsychotics can be used to augment treatment in OCD?

Risperidone
Aripiprazole

91

What anticonvulsant might be used in OCD?

Lamotrigine

92

What psychological therapies are very frequently employed in OCD?

Exposure and Response Prevention >=20 hours
CBT:
- Heavy emphasis on exposure

93

How would OCD with mild functional impairment be treated?

Brief CBT (+ERP); <10 therapist hours

94

How would OCD with moderate-severe functional impairment OR when patients with mild impairment cannot engage with CBT/it fails, be treated?

Offer choice of:
- More intensive CBT (+ERP); >10 therapist hours
- Course of SSRI

95

Following treatment of OCD with moderate-severe functional impairment, when would it be upgraded to definite severe impairment?

If there is inadequate response at 12 weeks an MDT review is carried out

96

How is OCD with severe functional impairment treated?

Offer combo of:
- CBT (+ERP) AND
- SSRI

97

If first line treated of OCD with severe functional impairment fails, how can it be treated?

Offer either:
- Different SSRI
- Clomipramine
(Continue CBT [+ERP])

98

If second line treated of OCD with severe functional impairment fails, how can it be treated?

Refer to MDT with OCD experience

99

If third line treated of OCD with severe functional impairment fails, how can it be treated?

Additional CBT (+ERP) or cognitive therapy
Add antipsychotic to SSRI/Clomipramine; combine clomipramine and citalopram

100

What dose of fluoxetine is used in OCD?

60mg/day

101

What dose of paroxetine is used in OCD?

60mg/day

102

What dose of citalopram is used in OCD?

60mg/day

103

What dose of sertraline is used in OCD?

>=200mg/day

104

What dose of fluvoxamine is used in OCD?

300mg/day

105

What dose of escitalopram is used in OCD?

>=20mg/day

106

What dose of clomipramine is used in OCD?

>=250mg/day

107

How does ERP work?

Repeatedly keeping anxiety in check:
- Provides powerful reinforcement for avoidance
- Sustains avoidance
Conversely:
- Increase exposure to feared stimulus
- Develops habituation to anxiety

108

What is the first line pharmacological treatment for Generalised Anxiety Disorder?

SSRIs

109

What is the second line pharmacological treatment for Generalised Anxiety Disorder?

SNRIs:
- Venlafaxine
- Duloxetine

110

What is the third line pharmacological treatment for Generalised Anxiety Disorder?

Pregabalin

111

What psychological therapies can be used in Generalised Anxiety Disorder?

Guided self-help (if mild)
CBT
Relaxation (usually short-term)

112

What medications can be used to treat social phobia?

Most SSRIs
Venlafaxine, Phenelzine
Some BZDs (Bromazepam, Clonazepam)
Anticonvulsants (Gabapentin, Pregabalin)

113

What psychological therapies can be used to treat social phobia?

CBT with emphasis on exposure
Cognitive restructuring
Social skills training

114

When would an SSRI be used in management of a specific phobia?

If anxiety is moderate-severe and hasn't responded to behavioural therapy

115

What psychological therapies are used frequently in management of a specific phobia?

Exposure therapy:
- Graded exposure
- Flooding

116

What medications can be used to treat panic disorder +/- agoraphobia?

All SSRIs
Some TCS (Clomipramine, Imipramine)
Venlafaxine (SNRI)
Some anticonvulsants (Gabapentin, Pregabalin)

117

What psychological therapies are used frequently in management of panic disorder +/- agoraphobia??

CBT
Graded exposure therapy if agoraphobia present

118

How long is maintenance treatment continued for in responders in GAD?

>=18 months

119

How long is maintenance treatment continued for in responders in panic disorder?

>=6 months

120

How long is maintenance treatment continued for in responders in social phobia?

>=6 months

121

How long is maintenance treatment continued for in responders in PTSD?

>=12 months

122

How long is maintenance treatment continued for in responders in OCD?

>=12 months

123

What are the worldwide suicide rates?

15 per 100,000 per annum

124

What are the suicide incidence rates in England and Wales?

15.9/100,000 in men
4.5/100,000 in women

125

What are the suicide incidence rates in Scotland?

26.8/100,000 in men
7.4/100,000 in women

126

Levels of what are lower in patients with a history of deliberate self-harm?

CSF 5-HIAA (5-Hydroxyindoleacetic acid)

127

There is reduced binding of 5-HT transporter sites in deliberate self-harm; where in the brain does this occur?

Ventral Prefrontal Cortex-PM

128

In the PM there is an increase in what receptors in deliberate self-harm?

Post-synaptic 5-HT1a

129

What does neuroimaging show in deliberate self-harm patients?

In high lethality patients:
- Different prefrontal cortex activity
SPECTs of recent deliberate self-harm patients showed reduced frontal activity

130

In what populations is deliberate self-harm more common?

Northern Europe
Women
Low socio-economic status

131

How do deliberate self-harm patients die prematurely?

Suicide
IHD
Cancer
RTAs
Homicide

132

In what European country is deliberate self-harm more common in males?

Finland

133

What is the initial stage of managing deliberate self-harm?

Calm the patient; emotional release is good:
- Crying is good; Aggression is not
- Be supportive but firm
Direct interview:
- Privacy
- Distract
- Deep breathing

134

What is it important to ask about in deliberate self-harm?

Antecedants
The episode of DSH
Mental state then and now

135

How can self-esteem be bolstered and problem-solving be initiated in deliberate self-harm?

Tell patient that discussing personal matters is brave
Any relief indicates more discussions needed
Look at what resolved past episodes
Use family or friends

136

What may a manipulative patient use as a threat?

Threat of suicide to change environment:
- Powerlessness
- Compromise
- Boundaries

137

What are the types of manipulative patients?

1. Dependent clingers
2. Entitled demanders
3. Manipulative help-rejecters
4. Self-destructive deniers

138

How else can deliberate self-harm be referred?

Passive death wish
Suicidal ideation vs. Suicidal intention

139

What are the positive symptoms of Schizophrenia?

Delusions
Hallucinations
Thought disorder

140

What are the negative symptoms of Schizophrenia?

Apathy
Lack of volition
Social withdrawal
Cognitive impairment

141

When are negative symptoms in Schizophrenia prominent?

Prior to illness atrting

142

What symptoms in Schizophrenia respond better to treatment?

Positive symptoms

143

What symptoms in Schizophrenia have more impact on functioning and QoL?

Negative symptoms

144

Schizophrenia can be diagnosed by ONE of what symptoms (according to ICD-10)?

Thought interference
Passive phenomena
Hallucinatory voices:
- Running commentary OR
- Third person
Impossible, persistent delusions

145

Schizophrenia can also be diagnosed by TWO of what symptoms (according to ICD-10)?

Formal thought disorder
Catatonic behaviour
Negative symptoms
Loss of interest/Idleness/Self-absorbed/Social withdrawal

146

How long must either of the ONE symptoms or the TWO symptoms last to diagnose Schizophrenia?

>=1 month

147

What are Schneider's First Rank Symptoms of Schizophrenia?

Auditory hallucinations:
- Thoughts spoken aloud
- Third person voices
- Running commentary
Passivitiy:
- ?Explained by delusions
- Experience that acts are imposed by an outsider
Delusional perception
Though broadcasting, withdrawal and insertion

148

What is the typical kind of delusion in Schizophrenia?

Bizarre

149

Are delusions in Schizophrenia mood-congruent or mood-incongruent?

Congruent

150

What are delusions often related to in Schizophrenia?

Current affairs

151

Hallucinations in Schizophrenia are often believed to be public (ie. others can perceive them too). If a patient with Schizophrenia realises that others can't perceive them, what might happen?

Development of new delusions

152

How can flow of thought be affected in Schizophrenia?

Disruption of association
Thought blocking
Crowding (Flight of ideas with passivity)
Neologisms

153

What sort of affect is seen in Schizophrenia?

Blunted:
- Limited range of emotion
- Lack of sensitivity/connection to surroundings

154

Is the affect of a patient with Schizophrenia congruent or incongruent with surroundings?

Incongruent

155

What is catatonia (as seen in Schizophrenia)?

Increased tone at rest (abolished by voluntary movement)
Other motor activity and posture abnormalities:
- Stupor
- Hyperactivity
- Mutism
- Stereotypes
- Waxy flexibility

156

What is the peak incidence of onset of Schizophrenia in men?

15-25 years

157

What is the peak incidence of onset of Schizophrenia in women?

25-35 years

158

What is the incidence of Schizophrenia?

15/100,000

159

What is the suicide rate in Schizophrenia?

10-15%

160

What factors contribute to a good prognosis in Schizophrenia?

Older onset
Female
Marked mood disturbance (esp. elation)
FHx of mood disorder

161

What factors contribute to a poor prognosis in Schizophrenia?

Longer duration of untreated psychosis
Poor premorbid adjustment
Insidious onset
Earlier onset
Cognitive impairment
Enlarged ventricles

162

What does psychosis involve?

Inability to distinguish between subjective experience and reality

163

What is psychosis characterised by?

Lack of insight

164

Why is it important to recognise the importance of the experience in consulting with a psychotic patient?

Don't give the impression that it is "All in your head."
Try and understand:
- "I want to check that I understand, I think what you're saying is that..."

165

In consulting with a psychotic patient, it is important to think of creative ways to challenge their beliefs. How can this be done?

"What would you say if someone said to you that [these beliefs] weren't true?"
"Can you just explain to me how this is possible?"

166

If it is clear that a psychotic patient will not accept that the delusions/hallucinations are not real (and they are becoming agressive/stubborn), what might it be necessary to say?

"I think this is evidence that you are unwell and I think you need to be in hospital and receive treatment - although I recognise you disagree with this."

167

What is Schizophrenia typified by?

Prodromal symptoms and gradual functional decline

168

How present are depressive and manic symptoms in Schizophrenia?

Absent or minimal

169

What is F20.0?

Paranoid Schizophrenia

170

What is F20.1?

Hebephrenic Schizophrenia

171

What is F20.2?

Catatonic Schizophrenia (catalepsy catatonia)

172

What is F20.3?

Undifferentiated Schizophrenia

173

What is F20.4?

Post-Schizophrenic depression

174

What is F20.5?

Residual Schizophrenia

175

What is F20.6?

Simple Schizophrenia

176

What is F20.8?

Other Schizophrenia

177

What is F20.9?

Schizophrenia, unspecified

178

What is Simple Schizophrenia?

Insidious progressive development of:
- Oddities of conduct
- Inability to meet societal demands
- Decline in total performance
Negative features develop without being preceded by overt psychotic symptoms

179

What is F10?

Mental and behavioural disorders due to the use of alcohol

180

What is F11?

Mental and behavioural disorders due to the use of opioids

181

What is F12?

Mental and behavioural disorders due to the use of cannabinoids

182

What is F13?

Mental and behavioural disorders due to the use of sedatives or hypnotics

183

What is F14?

Mental and behavioural disorders due to the use of cocaine

184

What is F15?

Mental and behavioural disorders due to the use of other stimulants (including caffeine)

185

What is F16?

Mental and behavioural disorders due to the use of hallucinogens

186

What is F17?

Mental and behavioural disorders due to the use of tobacco

187

What is F18?

Mental and behavioural disorders due to the use of volatile substances

188

What is F19?

Mental and behavioural disorders due to the use of multiple drug use and use of other psychoactive substances

189

When any disorder under F10-F19 is followed by a .0, what does this indicate?

Acute intoxication

190

When any disorder under F10-F19 is followed by a .1, what does this indicate?

Harmful use

191

When any disorder under F10-F19 is followed by a .2, what does this indicate?

Dependence

192

When any disorder under F10-F19 is followed by a .3, what does this indicate?

Withdrawl

193

When any disorder under F10-F19 is followed by a .4, what does this indicate?

Withdrawal with delirium

194

When any disorder under F10-F19 is followed by a .5, what does this indicate?

Psychotic disorder

195

When any disorder under F10-F19 is followed by a .6, what does this indicate?

Amnesic syndrome

196

When any disorder under F10-F19 is followed by a .7, what does this indicate?

Residual and late-onset psychotic disorder

197

What delusions are seen in depressive psychosis?

Worthlessness
Guilt
Hypochondriasis
Poverty

198

What hallucinations are present in depressive psychosis?

Accusing/Insulting/Threatening
2nd person (usually)

199

What is F32.2?

Severe depressive episode with psychotic symptoms

200

How is F32.3 defined?

An episode as described in F32.2
But with:
- Hallucinations
- Delusions
- Psychomotor retardation
- Stupor

201

What may the symptoms of F32.3 result in that can be life-threatening?

Suicide
Dehydration
Starvation

202

Are psychotic symptoms in depressive psychosis congruent or incongruent?

Congruent

203

Are psychotic symptoms in mania with psychosis congruent or incongruent?

Congruent

204

What kind of delusions are seen in mania with psychosis?

Grandeur
Special ability
Persecution
Religiosity

205

What sort of hallucinations are seen in mania with psychosis?

Auditory

206

How is F30.2 (mania with psychosis) described according to ICD-10?

An episode as in F30.1
But with:
- Delusions (usually grandiose)
- Hallucinations
- Flight of ideas
- Excitement
- Excessive motor activity

207

What is Schizoaffective Disorder?

Presence of both symptoms typical of:
- Schizophrenia AND
- Affective disorder

208

Can mood-incongruent psychotic symptoms in an affective disorder justify a diagnosis of Schizoaffective Disorder?

No

209

What is F25.0?

Schizoaffective Disorder, manic type

210

What is F25.1?

Schizoaffective Disorder, depressive type

211

What is F25.2?

Schizoaffective Disorder, mixed type

212

What is F25.3?

Other Schizoaffective Disorder

213

What is F25.9?

Schizoaffective Disorder, unspecified

214

What are affective symptoms superimposed on a pre-exisiting schizophrenic illness classified under in ICD-10?

Somewhere else in F20-F29

215

What sort of delusions are seen in delirium?

Persecutory

216

When is clouding of consciousness worse in delirium?

At night

217

What hallucinations are seen in delirium?

Visual
+/- auditory (often threatening)

218

What is the ICD-10 for delirium (not induced by alcohol/psychoactive substances)?

F05

219

Delirium can also include acute or subacute conditions. Give examples.

Brain syndrome confusional state (non-alcoholic)
Infective psychosis
Organic reaction
Psycho-organic syndrome

220

What is the ICD-10 for delirium tremens?

F10.4

221

What is F05.0?

Delirium not superimposed on dementia

222

What F05.1?

Delirium superimposed on dementia

223

What is F05.8?

Other delirium:
- Of mixed origin
- Postoperative delirium

224

What are functional disorders?

Symptoms unexplained by conventional physical disease processes

225

Under ICD-10 and DSM-IV, what are functional disorders called?

Somatoform Disorders

226

What is the conversion process to a functional disorder referred to under ICD-10 and DSM-IV?

Somatisation

227

What dissociative disorders exist under ICD-10?

Dissociative amnesia
Dissociative fatigue
Dissociative stupor
Trance and possession disorders
Dissociative disorders of movement and sensation

228

How do dissociative disorders of movement and sensation present?

Like a physical disorder:
- Doesn't explain symptoms
- Can represent patient's concept of physical disorder

229

What are somatoform disorders? What is their ICD-10 number?

F45
Repeated presentation of physical symptoms WITH
Persistent requests for medical investigations:
- In spite of repeated negative findings
Usually resist attempts to discuss psychological basis
Any physical disorder present:
- Do not explain patient's distress

230

What is F45.0?

Somatisation disorder:
- Repeated and changing physical symptoms
- Present over >=2 years
- Long + complicated Hx of medical contact
- Any body part affected
- Disruption of social and family functioning

231

What GI symptoms can somatisation present with?

IBS:
- Low mood
- Abdominal pain
- Nausea
- Bloating
Dysphagia/GORD

232

What neurological symptoms can somatisation present with?

Non-epileptic attack disorder
Weakness +/- sensory disturbance

233

What rheumatological symptoms can somatisation present with?

Fibromyalgia
Chronic fatigue syndrome

234

What other symptoms can somatisation present with?

Cardiology - Atypical chest pain
Dermatology - Chronic vulval pain
Gynaecology - Chronic pelvic pain
Orthopaedics - Chronic lower back pain

235

What percentage of somatisation patients present with apparent status epilepticus?

50%

236

What impact do chronic somatisers have?

Spend an average 7 days/month in bed
Use 9 times more healthcare resources
Have ~22 abortive/unnecessary lifetime hospital admissions

237

In what populations is somatisation most common?

F > M
3rd to 6th decade
FHx of functional disorders
Allied Health Professionals
Patients with learning difficulties

238

What indicates poor prognosis in somatisation?

Long duration
Motor symptoms
Personality disorder

239

What is the biopsychological perspective of how IBS can result in symptoms?

1. Psychological distress
2. Stimulation of ANS
3. GI motility changes
4. Symptoms

240

What biological changes occur in chronic pain syndromes?

Adaptive changes in nervous system:
- eg. Arborisation of dorsal horn cells

241

What psychosocial symptoms can occur in chronic pain syndromes?

Distress
Anxiety
Depression

242

What childhood experiences can predispose to somatisation?

Exposure to excessive family illness
Exaggerated family health concers
Hospitalisation
Parental neglect
Exposure to 'figure of identity'
Abuse

243

What stressful life events can precipitate somatisation?

Major threats to health
Personal losses
Psychiatric illness

244

What secondary gains can perpetuate somatisation?

Illness accrued benefits
Exemption from work
Manipulation of others

245

What SPECT abnormalities are seen in functional disorders?

Functional hemiparesis
Increased activity in rCBF (when resting) bilaterally in:
- Frontal cortex
- Parietal cortex
Reduced rCBF to contralateral:
- Thalamus
- Basal ganglia
Hypoactivation resolved with recovery

246

What is Hoover's sign?

1. Ask patient to push their "weak" heel down against hand -> No effect
2. Do straight leg raise of "normal" leg against resistance -> "Weak" heel will press into hand as "weak" hip extends

247

What does Hoover's sign indicate?

Inconsistency of examination

248

What external inconsistency may be seen in functional disorders?

Tubular field defect:
- Inconsistent with laws of optics

249

What percentage of patients with Non-Epileptic Attack Disorder also have epilepsy?

10%

250

What can predispose to Non-Epileptic Attack Disorder?

Female
Traumatic experiences (in 90%):
- Esp. childhood abuse/neglect

251

What is Non-Epileptic Attack Disorder often comorbid with?

Depression
Anxiety
PTSD

252

How can Non-Epileptic Attack Disorder be differentiated from epilepsy?

Witness contact
EEG

253

How can functional disorders be treated?

Positive diagnosis and explanation
Physical rehab (physio and OT)
Treat any anxiety/depression/PTSD
Psychological therapies
Laxatives/Antispasmodics

254

What symptoms can antidepressant treatment improvement in functional disorders?

Diarrhoea in IBS
Insomnia in chronic pain
Analgesia

255

What is hypochondriasis?

F45.2
Often called "health anxiety"
Focuses on diagnosis of serious and progressive physical disorders

256

What is Munchausen's Syndrome?

Factitious disorder (F68.1):
- Feigning symptoms for no reasons
- May self-harm to produce signs/symptoms

257

What is malingering?

Z76.5
Feigning illness for secondary aim:
- Often there is some actual structural/functional symptoms

258

What is the first line drug for severe anxiety for short-term use?

Diazepam (BZDs)

259

What pharmacological effects do BZDs have in anxiety?

Reduce anxiety and aggression
Hypnosis/Sedation
Muscle relaxation
Anticonvulsant effect
Anterograde amnesia

260

When are BZDs used?

Acute treatment of severe anxiety
Hypnosis
Alcohol withdrawal
Mania
Delirium
Rapid tranquilisation
Premedication before:
- Surgery
- During minor procedures
Status epilepticus

261

What substances all exhibit anxiolytic properties?

Ethanol
Neurosteroids
Barbituates

262

What drugs can have anxiogenic properties?

Inverse BDZ agonists:
- Beta-carbolines
Flumazenil

263

How can BZD overdose be treated?

Flumazenil

264

What are some side effects of BZD treatment?

Paradoxical aggression
Anterograde amnesia and reduced coordination (beware Rohypnol)
Tolerance and dependence

265

What can happen on BZD withdrawal?

Rebound anxiety:
- Confusion
- Toxic psychosis
- Convulsions

266

Why do the effects of BZD withdrawal occur?

Neuroadaptation of GABA response:
- Treatment reduces response to GABA
- Withdrawal results in anxiety/convulsions due to decreased density of BZD receptors

267

What is the process by with BZDs are withdrawn?

1. Transfer to equivalent dose of diazepam/chlordiazepam (take at night)
2. Reduce dose every 2-3 weeks in steps of 2 or 2.5mg (maintain dose until symptoms improve)
3. Reduce dose further in smaller steps if necessary
4. Stop completely

268

When can BZD withdrawal occur?

From ~4 weeks to >=1 year

269

In what anxiety disorders are SSRIs used?

Panic disorder, OCD, PTSD, phobias
GAD:
- Escitalopram
- Paroxetine

270

In what anxiety disorders are TCAs used?

2nd line for panic disorder
OCD

271

What TCAs are usually used in anxiety disroders?

Clomipramine
Imipramine

272

In what anxiety disorder is Venlafaxine used?

GAD

273

In what anxiety disorder is Moclobemide?

Social anxiety

274

What acute affect can SSRIs have in anxiety?

Anxiogenic

275

What effect do beta-blockers have in anxiety disorders?

Somatic symptoms:
- Palpitations
- Tremor