core conditions - 1

Question 1

PSYCHOSIS

• what is it?
• three clusters of symptoms?

Answer 1

an umbrella term

—> Described as experience of being out of touch with reality, struggling to distinguish what is real from what is not.

There are THREE clusters of psychotic symptoms (may have one or a combination of these):

• hallucinations
• delusions
• thought disorder.

Psychosis is an umbrella term for a group of symptoms. It is not a diagnosis in itself but a feature of many other diagnoses.

—> Presence of psychosis is not confined to mental illness.

Question 2

Definition of delusion?

Answer 2

False, unshakeable belief, despite evidence to contrary, not held by others in the same culture and held with intense personal conviction and certainty.

Question 3

List types of delusions? 8

nb 3 are arround thoughts, the rest are more general

nb don’t need definitions yet

Answer 3

• nihilistic
• grandiose
• control
• delusional perception
• reference delusions
• thought insertions
• thought withdrawal
• thought broadcast

nb the bottom four are delusions of thought interference

nb thought echo is an auditory halluciantion and thought blocking is a thought disorder

Question 4

Definition of:

• nihilistic delusions?
• grandiose delusions?

Answer 4

Nihilistic delusions

Extremely negative delusions of being dead or part of the body decaying.

Grandiose delusions

Delusion of having of a higher status or significance, special powers or a secret mission.

Question 5

Definition of delusion of control / passivity?

Answer 5

The subject believes their thoughts, feelings and/or actions are not their own but are being imposed/controlled by an outside force

Remember in passivity experiences the subject is ‘passive’ as they believe they are being controlled by another agent

nb this is not the same as auditory hallucinations where someone is telling them to do something/threatening them, in delusions of control the person believes they are being controlled and have no agency over their own thoughts/feelings/actions

Question 6

Definition of:

• delusional perceptions?
• ideas/delusions of reference?

and what’s the difference?

Answer 6

Delusional perception

The subject receives a normal perception but it’s interpreted with delusional meaning and has immense significance (e.g. I know I’m the king as I saw the traffic light turn green)

ideas of reference

The belief that innocuous events have direct personal significance to the subject (e.g. believing something on the TV is a direct message to them). With ideas of reference they take special meanings from inanimate stimuli.

so teachnically a idea of reference is a type of delusional perception

Question 7

Describe the 3 main delusions of thought interference?

Answer 7

Thought insertions

Thoughts which are not believed to be the subject’s own infiltrate their mind. They often have bizarre explanations of how it’s happened.

Thought withdrawal

The subject believes their thoughts have been removed from their mind by an external agency.

Thought broadcast

The belief that others can hear or are aware of an individual’s thoughts (e.g. a person may believe that other people can hear or read her thoughts)

Question 8

Definition of hallucination?

Answer 8

A perceptual experience in the absence of an object or stimulus, that appears subjectively real but uncontrollable by the patient. To the person this has the impact of a real perception and is indistinguishable. It occurs externally (not in the mind).

Can be in any sensory modality:

• Auditory
• visual
• olfactory
• gustatory
• sensory / tactile (touch)
• —kinaesthetic (movement)
• —somatic (sensation within the body)

nb visual halluciantions normally always have an organic cause

Question 9

Definition of:

• pseudo-hallucination?
• illusion?

how are these different from a hallucination?

Answer 9

Pseudo-hallucination

A sensory experience vivid enough to be a hallucination but recognised by the subject not to be real.

Illusion:

False perception of a real stimulus. Three types: affect, completion and pareidolia.

An illusion is based on a real sensory stimulus that is interpreted incorrectly whereas a hallucination is created by the mind without any stimulus.

hallucinations occur without a stimulus and are peceived by the patient to be real

nb don’t put effort into learning these: types of illusion:
PAREIDOLIA
Seeing shapes in inanimate objects (e.g. faces in clouds)
COMPLETION
The mind completes partial images (e.g. seeing white triangle in > image)
AFFECT
Based on current affect (e.g. see a monster in the cupboard when scared)

Question 10

Three main types of auditory hallucination?

Answer 10

2nd person auditory hallucination:

The subject hears voices which talk to them directly (e.g. “you’re going to die, you need to kill the baby”)

3rd person auditory hallucination:

The subject hears voices talking about them in the third person or commentating on their actions (e.g. ”he’s having a drink, now he’s going to the bathroom”)

Thought echo:

The subject experiences his own thoughts as if they were being spoken aloud. The repetition may be subtly or grossly changed.

Question 11

definitions of:

• depersonalisation?
• derealisation?

when can they often occur acutely?

what diagnosed with if occur chronically?

Answer 11

Depersonalisation

A change in awareness of self, in which the individual feels they’re not real and are detached from the world. They are aware this is abnormal.

Derealisation

To the subject the external world appears unreal or artificial. They’re aware this is abnormal.

Though degrees of depersonalization and derealization can happen to anyone who is subject to temporary anxiety or stress (eg during a panic attack), chronic depersonalization is more related to individuals who have experienced a severe trauma or prolonged stress/anxiety (called a dissociative disorder).

nb depersonalisation and derealisation can occur in other psychiatric conditions but if this is the predominant symptom then diagnosed with a dissociative disorder

Question 12

Definition of thought disorder?

Answer 12

Thought Disorder:

• An abnormality in the mechanism of thinking
• To the observer their speech doesn’t make sense

Question 13

What thought disorder is being described:

Loss of structured thinking. The subject seems muddled and doesn’t become clearer with further questioning, things often seem more confusing the more you ask them.

Answer 13

Loosening of associations

Question 14

What thought disorder is being described AND what condition often seen in?

Rapid flow of thought, manifested by accelerated speech with abrupt changes from topic to topic. There is often some form of link between topics.

Answer 14

flight of ideas

often seen in mania but can also be seen in psychosis

Question 15

What thought disorder is being described AND what condition often seen in?

Give the same answer to different questions

The repetition of a particular response (phrase, word, or gesture) despite the absence or cessation of the stimulus.

Answer 15

perservation

Often seen in organic brain disorders eg dementia

Question 16

What thought disorder is being described AND what conditions often seen in?

A new, made up word that has no real meaning

Answer 16

neologism

mania and psychosis - normally as part of a delusion

can occur in autism too though

BE CAREFUL - may not be a made up word - you just might not have heard it before - always ask!

Question 17

Define circumstantiality and tangentality and the difference between them

Answer 17

Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return the original point.

Tangentiality refers to wandering from a topic without returning to it.

Question 18

What thought disorder is being described

when ideas are related to each other only by the fact they sound similar or rhyme

Answer 18

clang associations

Question 19

What thought disorder is being described

completely incoherent speech where real words are strung together into nonsense sentences

Answer 19

Word salad

Question 20

What thought disorder is being described AND what often a feature of?

there are unexpected and illogical leaps from one idea to another

Answer 20

Knight’s move thinking

severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another

a feature of schizophrenia

Question 21

What thought disorder is being described

repetition of someone else’s speech, including the question that was asked.

Answer 21

Echolalia

Question 22

Groups of differential diagnoses for psychosis? 5

Answer 22

1) ORGANIC
2) SUBSTANCE USE OR WITHDRAWAL
3) PSYCHOTIC CONDITIONS
4) OTHER MENTAL HEALTH CONDITIONS
5) OTHER

Question 23

Differential diagnosis for psychosis:

• organic disorders? 5
• substance use or withdrawal? 4 (incl one medication)
• psychotic conditions? 3
• other mental health conditions? 2
• other? 2

Answer 23

1) ORGANIC
- dementia
- delirium
- encephalitis
- post-partum
- metabolic disorders

2) SUBSTANCE USE OR WITHDRAWAL
- acute intoxication (drugs or alcohol)
- alcohol withdrawal (delirium tremens)
- cannabis-induced psychosis (or other psychosis from chronic drug use
- steroids! (also levodopa!)
(nb often get physical hallucinations with drugs)

3) PSYCHOTIC CONDITIONS
- schizophrenia
- shizo-affective disorder
- delusional disorders

4) OTHER MENTAL HEALTH CONDITIONS
- depression
- mania

5) OTHER
- sleep deprivation
- bereavement

Question 24

definition of:

• positive symptoms?
• negative symptoms?

examples of negative symptoms? 7

way to remember negative symptoms?

Answer 24

POSITIVE SYMPTOMS

• A cluster of psychotic symptoms including hallucinations and delusions.
• A positive symptom is something added on to what most people experience (eg a hallucination)

NEGATIVE SYMPTOMS

• A cluster of symptoms that often occur in chronic schizophrenia including poverty of speech, flat affect, poor motivation, poor attention and neglect.
• negative symptoms are the lack of a normal experience (i.e. lacking concentration)

EXAMPLES OF NEGATIVE

• marked apathy
• paucity/poverty of speech
• blunting or incongruent affect
• social withdrawal
• poor motivation
• poor attention / concentration
• neglect

THINK OF THE As
Avolition (lack of motivation)
Anhedonia
Alogia (poverty of speech)
Asociality 
Affect = blunt

negative symptoms often a late feature, less treatment responsive and have a poorer prognosis

Question 25

SCHIZOPHRENIA - diagnostic criteria? (be specific) - incl how long symptoms go on for before give diagnosis? (what called if shorter than this?)

Answer 25

``` ONE OR MORE OF: - delusion - delusional perception - 3rd person auditory hallucination - thought insertion/ echo/ withdrawal/ broadcast - delusion of control / passivity ^ie scheiner's first rank ``` OR TWO OR MORE OF: - any other hallucination - negative symptoms - loosening of assciations - catatonia lasting persistently for AT LEAST ONE MONTH (even with medication) - AND not in acute intoxication or withdrawal OR evidence of overt brain disease (eg lewy body) if <28 days then = acute psychotic disorder nb often called undifferentiated psychosis for longer than a month in practice as some people recover and don't want to give them that label nb diagnosis of schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedated the affective disturbance

Question 26

Definition of schizoaffective disorder? how is it different to schizophrenia?

Answer 26

Combination of psychosis and an affective disorder (ie depression or mania) if affective symptoms predominant then depression with psychosis, if psychosis predominant then schizophrenia - if equal impact of both AND start at the same time = schizoaffective disorder diagnosis of schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedated the affective disturbance. If both schizophrenic and affective symptoms develop together and are evenly balanced, the diagnosis of schizoaffective disorder should be made, even if the schizophrenic symptoms by themselves would have justified the diagnosis of schizophrenia. nb better prognosis in those with a predominant manic presentation

Question 27

Epidemiology of Schizophrenia: - gender ratio? - peak age of onset? - % prevelence in UK?

Answer 27

M:F 1:1 - but men have earlier onset and often more severe Peak onset: male = 20-28years. Female = 26-32 years prevelence = 1%

Question 28

Epidemiology of Schizophrenia: - biggest risk factor? - other risk factors? (2 peri-natal, 5 around life events, 2 substance misuse)

Answer 28

1) GENETIC (40% have FHx) - winter births - perinatal viral infection/trauma/hypoxia (or other pregnancy complications) - Social exclusion - Low SES - Childhood trauma or abuse - Migration - Urban environment - Cannabis (4x risk if regular use <15yo) - Amphetamines nb although not causes, first episodes of psychosis are often triggered by a stressful life event (bereavement, unemployment, divorce etc) in people who are susceptible

Question 29

Describe the dopamine theory of schizophrenia AND the 4 related brain pathways - which responsible for positive and negative symptoms and side effects of A/Ps

Answer 29

Dopamine Theory: ---> Schizophrenic patients show greater occupancy of DA receptors. Thus, antipsychotics are all antagonists at dopamine post-synaptic receptors – mainly D2 MESOLIMBIC = motivation, emotion, reward - high levels in schizophrenia -> positive symptoms MESOCORTICAL = cognition + executive function - low levels in schizophrenia -> negative symptoms NIGROSTRIATAL = stimulation of movements - normal levels in schizophrenia (but A/Ps -> EPSEs) TUBERINFUNDIBULAR = dopamine acts as prolactin inhibitory hormone (PIH) - normal levels in schizophrenia (but A/Ps -> elevated prolactin)

Question 30

5 main types of schizophrenia? describe each briefly

Answer 30

1) PARANOID - eg a beautiful mind - most common - paranoid delusions usually with auditory hallucinations and perceptual disturbances 2) HEBEPHRENIC - affective changes prominent (shallow + inappropriate mood) - Irresponsible and unpredictable behaviour - Delusions and hallucinations fleeting and fragmentary - Thought and speech disorganised - Tendency to social isolation - Rapid development of negative symptoms 3) CATATONIC - A state of immobile stupor with cardinal features such as posturing and waxy flexibility 4) SIMPLE - Characterised by profound negative symptoms without any delusions or hallucinations. - ie only have the negative symptoms 5) UNDIFFERENTIATED

Question 31

what is the term for schizophrenia which intially presents over age 45?

Answer 31

paraphrenia

Question 32

assessment of psychosis: - when do they need to be assessed by a psychiatrist? 2 (what's the urgency of this?) - what should be done before referring to secondary care? 3 - how is psychosis diagnosed? 2 - what investigation can be done if suspect that psychosis is drug induced? 1

Answer 32

need to be seen by a psychiatrist - 1st episode psychosis - decline in functioning / relapse in someone being managed in primary - review medication to check not iatrogenic - take hx to check for infective signs or other signs of an organic cause - RISK ASSESS! (if high risk, refer same day/section) need to see URGENTLY - espeically if initial presentation as faster you treat, better the prognosis - full psych Hx - mental state exam urine drug screen ALSO always think about delirium if 1st presentation and acute onset - eg sepsis etc

Question 33

Management of psychosis/schizophrenia: - short-term biological? (1 + route, 1 sometimes) - short-term psycho-social? 2 - long-term biological (1 always, 2 possible) - long-term psycho-social? 5

Answer 33

SHORT-TERM BIO - antipsychotics (oral/IM) - (sedatives) SHORT-TERM PSYCHO-SOCIAL - psychoeducation (CBT/family interventions) - care planning LONG-TERM BIO - anti-psychotic (oral/monthly depot) - (mood stabilisers) - (antidepressants) LONG-TERM PSYCHO-SOCIAL - CBT for psychosis - art therapy - family interventions - supported employment (always ask about finances) - care planning FAMILY THERAPY especially important in families where there is high expressed emotion as there is good evidence that lots of intense emotion in the household increases the risk of relapse COGNITIVE BEHAVIOURAL THERAPY - Doesn’t reduce symptoms but can help manage the distress associated with these symptoms (e.g. derogatory hallucinations) - Helps with an individuals understanding of their disorder ART THERAPY Recommended by NICE for those with negative symptoms

Question 34

First presentation of psychosis - objectives in the acute management? 4 - what team will they be under and for how long?

Answer 34

1) therapuetic trial of A/P medication 2) monitoring of mental state + response to therapy until stable 3) formulation of a care plan, allocated a care coordinator (incl a crisis plan) 4) family intervention / psychoeducation under early intervention in psychosis team (ASPIRE in leeds) for 3 years nb in subsequent presentations they will remain under services until they’re stable enough to be transferred back to the care of their GP

Question 35

Prognosis following a first psychotic episode? (ie outcomes and proportion of those outcomes)

Answer 35

1/3rd recover and never have another episode 1/3rd have relapse & remitting schizophrenia but can function between relapses 1/3rd have chronic schizophrenia

Question 36

Risk factors for relapse in psychosis/schizophrenia? 5

Answer 36

- On-going symptoms - Poor compliance - Lack of insight - Substance use - Stopping medication suddenly Taking an antipsychotic reduces the risk of relapse by a third Stopping an antipsychotic within 6 months increases risk of relapse by four times

Question 37

poor prognostic factors for psychosis / schizophrenia? - FHx of schizophrenia? - FHx of affective disorder? - gender? - marital status? - pre-morbid intelligence + personality? - age of onset? - speed of symptom onset? - presence of negative symptoms? - response to treatment? - ongoing substance use?

Answer 37

- FHx of schizophrenia = POOR - FHx of affective disorder = GOOD - gender MALE = poor - marital status SINGLE = poor - pre-morbid intelligence + personality = good = good, SCHIZOID = poor - age of onset EARLY = POOR - speed of symptom onset INSIDIOUS = POOR - presence of negative symptoms = POOR - response to treatment, poor = poor - ongoing substance use = POOR

Question 38

SCHIZO-AFFECTIVE DISORDER | - two ways to differentiate between this and psychotic depression/mania?

Answer 38

1) TIMING OF SYMPTOMS - in schizoaffective, psychotic symptoms start at same time as change in mood (in depression/mania, affective symptoms first, then psychosis) 2) INCONGRUENT DELUSIONS - in depression or bipolar with psychosis, the delusions are congruent with mood (eg grandiose with mania, nilhilstic with depression) - in schizoaffective they are more likely to be incongruent

Question 39

Biological management of schizo-affective disorder? 2

Answer 39

medication norm = mood stabiliser PLUS antipsychotic nb psycho-social management is same as schizophrenia

Question 40

DELUSIONAL DISORDERS - definition? (incl features + length of symptoms) - what type of delusions not compatible with? - gender more common in?

Answer 40

Delusions are the most prominent feature - typically well formed and long standing (they can be life-long!) - Hallucinations aren’t present or are only fleeting - no marked blunting of affect. - Symptoms >1 month. Delusions of control/passivity experiences aren’t compatible with this diagnosis more common in females.

Question 41

sub-types of delusional disorder: | - describe PERSECUTORY

Answer 41

Belief that they, or someone close to them is being mistreated, or that someone is planning to harm them.

Question 42

sub-types of delusional disorder: | - describe OTHELLO SYNDROME

Answer 42

- Morbid jealousy - Delusional belief that partner is having affair - No evidence/ misinterprets minor evidence - Association with alcohol dependence/ sexual dysfunction - Risk of stalking/ violence "always get jealous partners in shakespeare plays"

Question 43

sub-types of delusional disorder: | - describe DE CLERAMBAULT'S SYNDROME (what aka?)

Answer 43

- Aka erotomania Delusional belief a famous person/ of higher social status, is in love with them. - Cannot declare love, so communicate via secret signs. "CLERAM = like CLAMBER - you clamber over all the other fans to get to the celebrity"

Question 44

sub-types of delusional disorder: | - describe CAPGRAS SYNDROME

Answer 44

Delusional misidentification Belief that relative/ spouse/ close friend has been replaced by identical looking double or impostor "someone has taken loved one's CAP and is trying to interpret them"

Question 45

sub-types of delusional disorder: | - describe FREGOLI'S SYNDROME

Answer 45

Different people are a single person who changes appearance or is in disguise. Often believe they are being persecuted by that person "can't be FREE of the person who is shape-shifting to continue persecuting you"

Question 46

sub-types of delusional disorder: | - describe COTARD'S SYNDROME

Answer 46

A nihilistic delusion without other psychotic symptoms. Delusion of being dead/ dying/ non-existent/ rotting patient believes 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. Associated with severe depression and psychotic disorders "COT-death - believe they are dead or dying"

Question 47

sub-types of delusional disorder: - describe EKBOM'S SYNDROME - what associated with?

Answer 47

Delusional Parasitosis – infested with parasites No evidence – only small marks/ freckles Risk of self-harm through excoriation to get rid of parasites. Often present to Derm. Associated with Cocaine. "tiny BOMBS of insects under their skin"

Question 48

sub-types of delusional disorder: - describe FOLIE A DEUX - aka?

Answer 48

aka Induced delusional disorder – psychosis shared by two people. The dominant partner has a delusional belief and then the dependent partner develops the same belief. The dominant partner requires treatment but the dependent partner recovers upon separation. "DEUX = two, delusion shared by 2 people"

Question 49

DELUSIONAL DISORDER: - biological management? - psycho-social management? - prognosis?

Answer 49

anti-psychotics psych-social = same as schizophrenia Is particularly difficult to treat - even with intensive treatment People often retain some aspect of the delusion or continue to hold the belief but are less preoccupied with it

Question 50

Acute psychotic disorder: | - definition?

Answer 50

person has psychosis for LESS THAN 28 DAYS | ie too short in duration to diagnosis schizophrenia, delusional disorder, schizoaffective disorder

Question 51

Depression: - porportion of people who will have an episode in their lifetime? - gender more common in?

Answer 51

1/5th more common in female (2:1)

Question 52

DDx for depression: - psych? 10 - if been present for 'all their life'? 2 - organic? 8 what should always be reviewed before giving a diagnosis of depression?

Answer 52

PSYCH - seasonal affective disorder - adjustment disorder (eg grief) - drug-induced affective disorders (eg alcohol, cannabis) - dementia (incl parkinsons) - anxiety (may be co-morbid) - OCD - eating disorders - bipolar - schizo-affective - schiophrenia (esp if negative symptoms) ALL LIFE - dysthymia - emotionally unstable personality disorder ORGANIC - hypothyroidism - cushings (incl med-induced) - anaemia - cancer - IBD - EBV - chronic fatigue (>6mo) - MS (or stroke or other CNS disorder) ALWAYS REVIEW MEDICATION LIST (as some medications can mimic depression)

Question 53

Common groups of medications that can mimic / cause depression? 7

Answer 53

- anti-psychotics - anti-convulsants (incl gabapentin) - beta-blockers - PPIs + H2 blockers - corticosteroids - contraceptives - retinoids (for severe acne)

Question 54

What proportion of pts with depression will also meet criteria for another psychiatric disorder? - what other co-morbid psych conditions should be screened for when doing a psych hx? 4 (incl example of how would ask about each)

Answer 54

2/3rds 1) MANIA - 'have you ever had a period when you've had a lot of energy and managed to do a lot of things, despite having very little sleep?' 2) PSYCHOSIS - 'sometimes when people are feeling really low they can hear voices or see things that others can't hear or see - has that ever happened to you? do you have any beliefs that you don't think are shared by others?' 3) ANXIETY - 'many people who feel low in mood also experience feelings of anxiety and feel anxious, nervous or on edge about things - do you feel like this? have you ever had any panic attacks?' (get them to describe the latter) 4) ALCOHOL/SUBSTANCE MISUSE - 'sometimes when people are feeling very low, they find that they start drinking more alcohol or using other medications to escape from those feelings, is that something you experience? how much alcohol do you drink? do you use any recreational drugs?'

Question 55

RISK FACTORS FOR DEPRESSION - biggest risk factor for an episode of depression? - bio? 5 - psycho? 3 - social? 7

Answer 55

BIGGEST = previous depressive episode BIO - genetic / FHx - female - chronic disease eg stroke (esp ones causing disability or pain) - post-partum - heavy alcohol or illicit substance use PSYCHO - adverse childhood experience (parental bereavement, neglect, parental alcoholism, childhood sexual abuse) - personality traits (anxiety, obsessive, impulsive) - low self-esteem SOCIAL - unemployment - low socio-economic status - seperation or divorce - bereavement (seperate from normal adjustment reaction) - adverse life event - migration - LGBT+

Question 56

What are the 4 Ps for causes of a psychiatric illness

Answer 56

BIO, PSYCH and SOCIAL for: 1) PREDISPOSING 2) PRECIPITATING 3) PERPETUATING 4) PROTECTIVE

Question 57

SYMPTOMS OF DEPRESSION: - core? 3 - psychological? 10 - biological / somatic? 6 - social? 3 duration of symptoms to make a diagnosis?

Answer 57

CORE 1) anhedonia 2) low mood (often diurnal variation) 3) low energy / fatigue PSYCHOLOGICAL - worthlessness - low self-esteem - tearful - guilt - irritable / intolerant of other - low motivation - struggle to make decisions - poor concentration - hopelessness + helplessness - suicidal thoughts BIOLOGICAL - Change in APPETITE (decrease is typical, increase is atypical) - SLEEP disturbance (early morning waking is typical - but can get hypersomnia = atypical) - low SEX drive - PSYCHOMOTOR retardation (moving or speaking slowly) - CONSTIPATION - ACHES and PAINS SOCIAL - avoiding friends - neglecting hobbies/interests - having difficulties in home, work or family life symptoms must be present for at least TWO WEEKS - (not secondary to effects of drug/ alcohol misuse, organic illness, or bereavement (before 6 months) nb pt w bipolar more likely to have atypical sleep and apetite compared to unipolar depression

Question 58

How assess severity of depression? - what additional group of symptoms can occur in severe depression?

Answer 58

mild depression – has some impact on your daily life moderate depression – has a significant impact on your daily life severe depression – makes it almost impossible to get through daily life; a few people with severe depression may have psychotic symptoms nb can do based on symptom count, PHQ-9 etc - but in reality do based on level of functioning

Question 59

Two key differentiators between grief and depression?

Answer 59

People who are grieving find their feelings of sadness and loss come and go, but they're still able to enjoy things and look forward to the future. In contrast, people who are depressed constantly feel sad. They find it difficult to enjoy anything or be positive about the future

Question 60

Patients over 55 may present differently with depression - some symptoms / features that are more likely in this age group? 6

Answer 60

- Psychomotor retardation - Pseudodementia - Hypochondriacal overvalued/delusions - Obsessive-compulsive symptoms - Agitated depression - Apathy

Question 61

PSEUDODEMENTIA: - what is it? - how differ from dementia?

Answer 61

depression in older people (ie depression can often present very similar to dementia) symptoms incl: - memory loss - imparied executive functioning ONSET - fast in pseudodementia - insidious in dementia MEMORY LOSS - global in pseudodementia - short-term initially in dementia COGNITIVE TESTS - say 'i don't know' in peudodementia - try to answer Qs but fail in dementia depressed mood in pseudodementia, incongruity of affect in dementia

Question 62

How to screen for 3 core symptoms of depression? (ie what Qs to ask)

Answer 62

MOOD 'During the last month, have you often been bothered by feeling down, depressed or hopeless?' ANHEDONIA 'During the last month, have you often been bothered by having little interest or pleasure in doing things?' FATIGUE 'during the last month, have you often felt very fatigued or that you had no energy?'

Question 63

INVESTIGATION OF LOW MOOD / SUSPECTED DEPRESSION - hx + exam to do? (what assessment should this include) - bedside investigation? 1 - other investigations to consider to rule out organic causes?

Answer 63

- full psych hx (and systems review) - including FULL risk assessment (to self, to others incl safeguarding, from others) - MSE - PHQ-9 if suspect organic cause: - physical exam - review meds - bloods (esp TFTs + FBC) - (imaging if neuro signs)

Question 64

possible effects of despression on physical health? 4 what % of depression in general hospital patients goes undetected?

Answer 64

- pain can be harder to control - may have less motivation to engage in treatment or take medication - self-neglect (incl not attending appts etc) - doubles risk of getting type 2 DM 50% of depression in general hospital pts goes undetected

Question 65

NICE management of depression: - lifestyle changes for all? 3 - bio/psycho for mild-moderate depression? 1 - bio/psycho for moderate-severe? 2 - what other aspect of management? - where to look for how to manage in primary care?

Answer 65

LIFESTYLE - reduce alcohol intake - sleep hygiene - regular exercise MILD-MODERATE - low-intensity psychological interventions (eg via IAPT) (ie not medication) MODERATE-SEVERE - high-intensity psychological intervention - antidepressant (SSRI 1st line) plus SOCIAL management (see other flashcard) NICE CKS on initial management of depression is very good! - incl leaflets etc

Question 66

Areas to focus on to help social management of depression? 6

Answer 66

OTHER MEDICAL CONDITIONS - get these under control, incl pain etc ADLs - 'take me through a typical day' - address holes eg older people may need additional support - also CARERs need support too! HOUSING - isolated? - issues? EMPLOYMENT - working? problems at work? - can provide letters/reports of support FINANCES - any debts? - citizen's advice re debt management plans - referral to food banks ACTIVITIES - if lonely/isolated/bored - gardening? social group? - social prescribing! "if easier to remember can go through ASD OHA DOT"

Question 67

Examples of low-intensity psychological support for depression? 4

Answer 67

- individual guided self-help (norm CBT-based) - CCBT - group-based CBT - structured group-based physical activity programme

Question 68

examples of high-intensity psychological support for depression? 4

Answer 68

- individual CBT - interpersonal therapy (IPT) - behavioural activation - couple therapy (although not commonly used) nb each of the above norm 16-20 sessions over 3-4 months Counselling and short-term psychodynamic therapy — these can be considered for people who decline antidepressants and high-intensity psychological interventions - but counsel patients on the uncertainty of effectiveness of these interventions

Question 69

How to explain CBT to a patient

Answer 69

- type of talking therapy - structured and practical - involves problem and goal definition - use diaries to monitor and identify problematic thoughts, or other problems and monitoring progress - help you learn to think in more helpful ways, includes behavioural experiments - based on the here and now (not exploring past) - based on the cognitive model (how we think affects how we feel, behave and our biology) nb see my notes for more infor on CBT

Question 70

How to describe interpersonal therapy (IPT) to a patient?

Answer 70

structured talking therapy that typically works intensely on established interpersonal issues. The underlying belief of interpersonal therapy is that psychological symptoms (such as depression) are often a response to difficulties we have interacting with others. The resulting symptoms can then also affect the quality of these interactions, causing a cycle. The thought process behind the therapy is that once a person is capable of interacting more effectively with those around them, the psychological symptoms can improve. IPT focusses on: - conflicts - life changes - grief and loss - relationship problems

Question 71

How to describe behavioural activation to a patient?

Answer 71

Focuses on addressing behaviour: - When we are depressed we stop doing the things that usually give us pleasure which makes us even more depressed. - We isolate ourselves and avoid interactions with others as this might be difficult e.g. going back to work after time off sick - We wait until we feel better before doing things - unfortunately we never feel better so never do things Treatment involves getting people to act according to a plan rather than how they feel and involves doing things! - Simple goals to start e.g. walk dog every day and build up

Question 72

Indications for ECT? 4 describe what happens

Answer 72

- life-threatening depression - moderate-severe depression that has responded to ECT in the past - prolonged or severe mania - catatonia 2 x weekly treatment - approx 12 in total unilateral vs bilateral short GA and muscle relaxant - then short induced controlled seizure nb 70-80% response in depression

Question 73

Side effects of ECT? 4

Answer 73

- short-term memory loss - headache - nausea - muscle pain

Question 74

Prescribing anti-depressants: - expectations to tell patients? 5 - when to follow up? - how long to continue for? why? how to stop?

Answer 74

- try for at least 4-6 weeks - effects will take a few weeks and energy improve first, then mood (also get SEs before therapeutic effect) - warn about suicide risk (give crisis numbers) - different ones work for different people, try this one first and can try another if this doesn't work - not addictive but don't stop suddenly as may get discontinuation symptoms FOLLOW UP after 2 weeks, 1 week if under 30 (as higher suicide risk) continue for 6-9 months AFTER resolution of symptoms - to reduce risk of relapse - reduce dose gradually (to avoid discontinuation symptoms) nb if multiple episodes, consider for at least 2 years

Question 75

Possible discontinuation symptoms with antidepressants? 7 What % of patients experience these?

Answer 75

- restlessness - problems sleeping - unsteadiness - sweating - abdominal symptoms - altered sensations (for example electric shock sensations in the head) - altered feelings (irritability, anxiety, confusion) 1/3rd pt experience these when coming off treatment

Question 76

If antidepressants aren't working after 4-6 weeks: - what should be reviewed / checked? 6 - what to do/consider if still not working and all the above have been addressed? 4 nb this is assuming they are already having psychological therapy

Answer 76

REVIEW - Review DIAGNOSIS - Check COMPLIANCE (they may not but be too embarrassed to say that they forget) - Check taking correct DOSE - Review ALCOHOL intake (will stop antidepressants being effective) - Check for OTHER DRUGS - Address PSYCHOLOGICAL and SOCIAL factors ONLY THEN: 1) INCREASE dose 2) SWITCH drugs 3) AUGMENT with lithium or A/Ps 4) ECT if severe and not responsive

Question 77

When to refer someone with depression to secondry care: - as an emergency? 4 - for routine? 3

Answer 77

EMERGENCY 1) significant risk of self-harm 2) danger to others 3) psychotic symptoms 4) severe agitation ROUTINE 1) significant depression with functional impairment persisting despite adequate treatment in primary care 2) when additional community support from community mental health team or day hospital staff is required 3) indication for specialist psychological treatment (eg ECT, lithium)

Question 78

Prognosis for depression: - average length of episode? - chance of recurrence after initial episode? - what % have a manic episode?

Answer 78

---> Average length of depressive episode = 6 months - after a first episode of depression, 50% chance of having another one chance of recurrence increases if have second episode Median is 4 episodes in lifetime 10 % go on to have manic episode

Question 79

SYMPTOMS OF MANIA - possible moods? 3 - activity? 7 - cognition/thoughts? 2 - additional signs on MSE? 2

Answer 79

MOOD = - abnormally ELEVATED - extreme IRRITABILITY - sometimes AGGRESSION ACTIVITY - INCREASED energy / activity - RESTLESSNESS - decreased need for SLEEP - DISTRACTIBILITY / poor concentration - IMPULSIVITY - increased LIBIDO / sexual indiscretions - DISINHIBITION THOUGHTS - extravagant or impractical PLANS (eg business investments, spending sprees) - PSYCHOTIC symptoms (norm grandiose delusions, auditory hallucinations) - these are CONGRUENT with mood nb if ingongruent with mood then suspect schizoaffective MSE (all of the above plus:) - pressured or incomprihensible speech - flight of ideas or racing thoughts

Question 80

Three main differences between mania + hypomania?

Answer 80

MANIA - at least 7 days - may have psychotic symptoms - severe enough to cause marked impairment in social or occupational functioning - may need hospitalisation HYPOMANIA - at least 4 days - no psychotic symptoms - not severe enough to cause marked impairment in social or occupational functioning - no hospitalisation so as soon as an episode has ANY of the below things, it is, by default a manic episode: - lasts 7 days - psychotic symptoms - has severe impact on functioning - requires hospitalisation

Question 81

What is a 'mixed episode' in bipolar disorder?

Answer 81

A mixed episode is: 1) A mixture or rapid alternation of manic and depressive symptoms, or 2) A period of time (at least 1 week) in which the criteria are met for either a manic or hypomanic episode and at least three symptoms of depression are present during the majority of the days of the current or most recent episode of mania or hypomania, or 3) A period of time (at least 2 weeks) in which the criteria for a major depressive episode are met and at least three manic or hypomanic symptoms are present during the majority of days of the current or most recent episode of depression. basically: what it suggests - is a mix of manic and depressive symptoms

Question 82

Give an example of what level of symptoms someone with a hypomanic episode would have?

Answer 82

- Mild elevation of mood, or irritability. - Increased energy and activity, which may lead to increased performance at work or socially. - Feelings of well-being, or physical and mental efficiency. - Increased sociability, talkativeness, and over-familiarity.

Question 83

BIPOLAR AFFECTIVE DISORDER (BAD) - definition? - what are the 4 types of episodes? (how long should each last to 'count' as an episode) - % who start with a depressive episode?

Answer 83

Mood disorders in which pts experience bouts of mania, hypomania, depression and mixed states - may be long periods (years) of recovery between DEFINITION: - after at least 2 episodes of disturbed mood - one of which should be manic or hypomanic NB usually complete recovery between episodes - depression (2 weeks) - mania (7 days) - hypomania (4 days) - mixed (7-14 days - depends) - 50% start with depressive episode - don’t give them diagnosis of bipolar until have a manic episode (always screen for past mania if depression) nb in DSM-5 have type 1 and 2 (2 is hypomanic, don’t need manic episodes - type 1 must have manic episodes - this is the main difference between them) - but in ICD-10 (use in UK) don’t distinguish between type 1 and 2

Question 84

BIPOLAR AFFECTIVE DISORDER: - prevelence? - gender difference? - mean age onset?

Answer 84

1% prevelence M=F 21 mean age of onset "both men & women go on a spending spree for their 21st"

Question 85

BIPOLAR AFFECTIVE DISORDER: - biological etiology theory? - biggest risk factor? - common triggers of initial presentation? 2

Answer 85

MONOAMINE THEORY - mania results from INCREASED levels of noradrenaline, serotonin + dopamine GENETICS / FHx = biggest risk factor (largest heritability of any COMMON INITIAL TRIGGERS - severe stress / disruption - drugs (eg cocaine, amphetamines)

Question 86

what things someone presenting with depression make you suspect this might be bipolar? 3

Answer 86

features of depression that make bipolar more likely - FHx of bipolar - hypersomina - hyperphagia

Question 87

Differences between bipolar and unipolar depression: - FHx - Hx of mania - sex ratio - age of onset - speed of onset - psychosis - activity - sleep

Answer 87

FHx of BAD - BD = yes - UD = no Hx of Mania - BD = yes - UD = no sex ratio - BD = M=F - UD = F>M Age of onset - BD = early - UD = 30-50 (can be earlier) Onset - BD = abrupt - UD = insidious Psychosis - BD = more common - UD = less common activity - BD = retardation - UD = agitation sleeo - BD = hypersomnia - UD = insomnia (same w appetite)

Question 88

DDx for manic symptoms: - psych? 4 - medications/substances? 4 - other organic? 8

Answer 88

PSYCH - BAD - schizoaffective disorder - schizophrenia - ADHD MEDS/SUBSTANCES - stimulants - alcohol - steroids - dopamine agonists ORGANIC - hyperthyroidism - cushings - epilepsy (ask re focal features) - frontal lobe disease - multiple sclerosis - huntington's disease - HIV - sleep deprivation

Question 89

Presentations of mania: - hx and exam to do? - assessment to always do? - bedside investigations? 2 - bloods to do? (4 always, 1 if already on treatment) - other investigation to consider?

Answer 89

- full psych hx - MSE - ECG - Urine drug screen BLOODS - FBC - U+E - LFT - Calcium (high or low can trigger) - LITHIUM LEVELS (if on, to assess compliance) consider CT head if first presentation or any focal or abnormal signs

Question 90

Acute management of MANIA - biological options? 4 - psycho/social? 3

Answer 90

BIOLOGICAL - atypical antipsychotic (if psychotic) OR - benzos to manage initial hyperactivity then TITRATE up lithium (or other mood stabiliser) consider short-term hypnotics (z drugs) if sleep deprived 1) ADMIT pt while tirating up mood stabiliser for own safety 2) risk assessment before discharge 3) stop driving (if relevant) - also consider restricting access to finances

Question 91

LONG TERM MANAGEMENT of BIPOLAR AFFECTIVE DISORDER: - biological (1 norm, 1 sometimes) - incl length of this - psychological? 2 - social? 3 - management for intractible mania? 1

Answer 91

BIOLOGICAL - mood stabilisers, lithium 1st line - (antipsychotics) length of treatment depends on sevrity and frequency of episodes, need regular follow up to manage, can consider weaning off if been symptom-free for mnay years but this may provoke a relapse nb can use antidepressants in some pts but tend to avoid as can trigger mania/hypomania PSYCHOLOGICAL - psycho education to pt + family (incl compliance aids, recognising triggers + symptoms etc) - BAD-specific psychotherapies (eg CBTetc) SOCIAL - crisis management plan / care coordinator - avoid recreational drugs - address financial, employmert etc issues ECT for intractible / severe mania (but rarely used)

Question 92

Risks in BIPOLAR AFFECTIVE DISORDER (esp Mania) - most important risks to self? 2 - other risks to self? 6 - risk to others? 2 - risk from others? 1

Answer 92

TO SELF = self-harm = suicide - financial difficulties (overspending) - damage to reputation/occupation/relationships - traumatic injuries/accidents - STIs/unplanned pregnancy - self-neglect / exhaustion / dehydration - alcohol and substance misuse TO OTHERS - reckless driving / injuries - neglect of children/dependants FROM OTHERS - exploitation (dt lack of insight) nb much higher risk of suicide than in unipolar depression! - risk is highest in post-manic depressive phase nb hypomanic patients are at risk too but this often goes unnoticed life charts and symptom diaries may also be helpful for some people

Question 93

NEUROTIC, STRESS-RELATED AND SOMATIFORM DISORDERS: - phobic anxiety disorders? 3 - other anxiety disorders? 2 - other? 1 - reactions to severe stress? 3 - examples of features of dissociative / conversion disorders? 7 - somatoform disorders? 2

Answer 93

PHOBIC ANXIETY - agoraphobia - social phobia - specific phobias OTHER ANXIETY - panic disorder - generalised anxiety disorder OTHER - obsessive compulsive disorder REACTIONS TO SEVERE STRESS - acute stress reaction - post-traumatic stress disorder - adjustment disorders ``` DISSOCIATIVE / CONVERSION DISORDERS - Amnesia - fugue - stupor - motor - convulsions - trance & possession states - anaesthesia and sensory loss (this include depersonalisation, derealisation, conversion disorders) ``` SOMATOFORM DISORDERS - somatisation disorder - hypochondrial disorder

Question 94

Generalised anxiety disorder (GAD) - definition? (incl length of time) - 3 groups of features?

Answer 94

The essential feature is anxiety, which is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is "free-floating"). As in other anxiety disorders the dominant symptoms are highly variable, but complaints of continuous feelings of nervousness, trembling, muscular tension, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort are common. Fears that the sufferer or a relative will shortly become ill or have an accident are often expressed, together with a variety of other worries and forebodings. ICD-10: The sufferer must have primary symptoms of anxiety MOST DAYS for at least SEVERAL WEEKS at a time, and usually for several months (DSM IV says 6 mo). These symptoms should usually involve elements of: 1) APPREHENSION (worries about future misfortunes, feeling "on edge", difficulty in concentrating, etc.); 2) MOTOR TENSION (restless fidgeting, tension headaches, trembling, inability to relax); and 3) AUTONOMIC OVERACTIVITY (lightheadedness, sweating, tachycardia or tachypnoea, epigastric discomfort, dizziness, dry mouth, etc.). could also split into 4 groups: - psychological - arousal - motor - autonomic

Question 95

psychological symptoms of GAD? 4

Answer 95

- Worry/ Apprehension/ Fear - Persistent nervousness - Poor Concentration - Irritability

Question 96

arousal symptoms of GAD? 4

Answer 96

- hypervigilance - increased startle response - restlessness - insomnia (struggle geting to sleep)

Question 97

motor tension symptoms of GAD? | nb these don't include autonomic symptoms

Answer 97

- musle tension - headaches - trembling - purposeless activity

Question 98

autonomic symptoms of GAD: - CVS? 3 - resp? 2 - GI? 6 - urinary tract? 1 - neuro? 3 - other? 3

Answer 98

CVS - palpitations - chest tightness - chest pain RESP - difficulty inhaling - hyperventilation GI - dry mouth - loss of appetite (or craving food) - nausea - 'butterflies' - epigastric pain - loose stools URINARY - frequent micturation NEURO - blurred vision - light headedness - pins and needle OTHER - sweating - depersonalisation - derealisation

Question 99

EPIDEMIOLOGY OF GAD - which gender more common in? - predisposing risk factors? 4 - precipitating risk factors? 2 - what patient to suspect GAD in who dosn't actually present with anxiety?

Answer 99

more common in female PREDISPOSING - FHx of anxiety - Hx of physical or emotional trauma - Hx of other anxiety disorders (panic, social phobia, specific phobias) - Hx of substance abuse PRECIPITATING - current physical or emotional trauma - Chronic pain or physical illness (such as arthritis, cancer, coronary heart disease, cerebrovascular accident, or COPD). Have high level of suspision for GAD in patients who make repeated visits with the same physical symptoms which do not respond to treatment (for example insomnia, headache, or fatigue)

Question 100

What psychological conditions are often co-morbid with GAD? 8

Answer 100

- depression - panic disorder - agoraphobia - social phobia - specific phobias - health anxiety - OCD - alcohol (and other substance, incl cannabis) misuse

Question 101

What medications / substances can mimic / exacerbate GAD: - prescribed? 5 - not-prescribed? 4

Answer 101

PRESCRIBED - salbutamol - theophylline - beta-blockers - steroids - some antidepressants (esp initially) NOT-PRESCRIBED - alcohol use or withdrawal - other illicit substances (use or withdrawal) - caffeine - herbal medicines (including ma huang, St. John's wort, ginseng, guarana, belladonna)

Question 102

Assessment for suspected GAD: - history and 2 exams to do? - possible findings on physical exam? 4 - bedside tool to assess severity? 1 - what else to assess? 1

Answer 102

- psych hx - MSE - physical exam (to exclude DDx) possible findings on physical exam: - increased HR - SOB - trembling - exaggerated startle response GAD-7 questionnaire ALWAYS risk assess (to self, to others, from others)

Question 103

DDx for GAD - psych? (see other flashcard for organic DDx)

Answer 103

PSYCH - SITUATIONAL anxiety (controllable anxiety that is not generally associated with pathological symptoms and relates to a particular life event, such as an upcoming exam) - ADJUSTMENT disorder (temporary anxiety that has occurred in response to a life stressor and persists for no longer than 6 months after the stressor ends) - DEPRESSION (can be co-morbid) - PANIC disorder (recurrent episodes of sudden onset anxiety, in the absence of multi-themed worry - can be co-morbid) - SOCIAL phobia (anxiety or persistent fear that is limited to social situations and fear of social scrutiny or embarrassment. Avoidance behaviour is commonly present.) - OCD (anxiety due to compulsions or obsessions) - PTSD (anxiety that is caused by exposure to reminders of past trauma) - SOMATOFORM disorders (anxiety related to specific physical complaints, which have no medical basis) - ANOREXIA NERVOSA (axiety related to fear of gaining weight) - SUBSTANCE and ALCOHOL misuse / withdrawal (frequently associated with anxiety, especially among men) - MEDICATION-INDUCED anxiety (anxiety triggered by exposure to medications including salbutamol, theophylline, corticosteroids, antidepressants, and some herbal medicines. Caffeine may also be a trigger. Withdrawal from CNS depressants can also trigger anxiety)

Question 104

ORGANIC DDx for GAD? 7 incl how to exclude on symptoms / physical exam (see other flashcard for psych DDx)

Answer 104

CARDIAC DISEASE - symptoms such as palpitations, sensation of rapid or skipped heartbeat, dizziness, dyspnoea and chest pain on exertion, and numbness - Examination may reveal hypertension, hypotension, tachycardia or bradycardia, or S3 or S4 gallops RESP DISEASE - suggested by a hx of lung conditions such as asthma or COPD, the person being a current or previous smoker, and signs/symptoms such as wheezing, cough, respiratory distress, or sputum production, and a feeling of suffocation. - Pulse oximetry may reveal low oxygen sats HYPERTHYROIDISM - weight loss, warm moist skin, heat intolerance, ophthalmopathy, or goitre ANAEMIA - fatigue, dyspnoea, and palpitations INFECTION - anxiety and additional symptoms of fever, night sweats, or cough, which resolve following successful treatment IRRITABLE BOWEL - alteration of bowel habit associated with pain, and abdominal discomfort, bloating, or distention PHAEOCHROMOCYTOMA - anxiety that co-exists with hypertension and/or tachycardia

Question 105

GAD - bio management options? 2 - psych management? 1 - social management? 4 which should you do first? what to monitor for with bio treatment? 2

Answer 105

BIO - SSRIs - (benzos - short term only!) PSYCH - CBT (group, CCBT, 1-to-1) SOCIAL - address substance misuse - regular exercise - sleep hygiene - practically address stressors (financial, relationships, work) (also make sure any co-morbid medical conditions are managed) do: - 1) social - 2) psych - 3) meds (although can do meds + psych simultaneously) nb people w GAD are particularly prone to ADR - so tend to start with lower doses and rise slower than, eg for depression - expect result in 6-12 wks monitor for: - increased anxiety or akasthesia - suicidal ideation 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 (sertraline 1st line) step 4: highly specialist input e.g. Multi agency teams

Question 106

Describe a panic attack

Answer 106

PANIC ATTACK = discrete episode of intense fear or discomfort. which are not restricted to any particular situation or set of circumstances, and which are therefore unpredictable Starts abruptly, reaches maximum with few minutes. Features at least 4 specific symptoms of anxiety. dominant symptoms vary from person to person, but sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization) are common. There is also, almost invariably, a secondary fear of dying, losing control, or going mad. frequent and unpredictable panic attacks produce fear of being alone or going into public places. A panic attack is often followed by a persistent fear of having another attack. nb one panic attack doesn't mean you have a disorder

Question 107

PANIC DISORDER | - definition? (incl time frame)

Answer 107

several (norm 4) severe attacks of autonomic anxiety should have occurred within a period of about 1 month: (a) in circumstances where there is no objective danger; (b) without being confined to known or predictable situations; and (c) with comparative freedom from anxiety symptoms between attacks (although anticipatory anxiety is common). ie differentiate from GAD and specific phobias Panic disorder should not be given as main diagnosis if the patient has depressive disorder at the time the attacks start (panic attacks are probably secondary to depression) can occur with or without agoraphobia

Question 108

PANIC DISORDER | - risk factors? 5

Answer 108

- FHx of panic or other anxiety disorder - stress - life changes / traumatic event - smoking - excess caffeine

Question 109

PANIC DISORDER - organic DDx of a panic attack that are potentially life threatening? 5 - other groups of organic conditions which could be mistaken for panic disorder? - psych DDx? 5

Answer 109

LIFE THREATENING - anaphylaxis (or other airway obstruction) - asthma attack - PE - ACS - arrythmia / SVT OTHER ORGANIC - CARDIOvascular diseases (incl angina, heart failure) - PULMonary diseases (incl asthma) - NEUROlogical diseases (incl epilepsy, TIA, huntingtons) - ENDOCRINE diseases (addisons, thyroid, menopause, hypoglycaemia) - drug INTOXICATION (amphetamines, hallucinogens, cocaine) - drug WITHDRAWAL (alcohol, opiates, sedatives) PSYCH - GAD - agoraphobia - specific phobia - PTSD - depression

Question 110

PANIC DISORDER assessment: - history and 2 exams? - what trying to identify during hx?

Answer 110

- psych hx - MSE - physical exam (esp heart and lungs) try and identify any triggers (may lead to specific phobia instead of panic disorder) Panic disorder should not be given as main diagnosis if pt has depressive disorder

Question 111

PANIC DISORDER - bio management options? 2 - psych management? 1 - social management? 2 what is 1st line?

Answer 111

- SSRIs (may increase panic initially) - propranolol ('pill in pocket' - not sure how often used) - CBT (go through IAPT) - psychoeducation (what to do during a panic attack) - reduce alcohol and caffeine intake 1) social 2) psych 3) bio

Question 112

Definition of a phobia? (incl 2 specific types of behaviours that occur) when do patients present to doctors?

Answer 112

--> Anxiety that is situational – initiated by experience or anticipation of phobic stimulus. Anxiety is restricted to a specific situation or object Anxiety out of proportion to a specific stimulus Fear cannot be reasoned or explained away. ANTICIPATORY behaviour: People tend to worry leading up to the situation: anticipatory anxiety AVOIDANCE behaviour: Avoidance of stimulus/ situations where it may arise Patients present when causing loss of function nb can have panic attacks but not panic disorder as in reaction to a specific stimulus

Question 113

PHOBIAS: - what are the 3 main types? - norm age of onset and gender split for each?

Answer 113

SPECIFIC PHOBIAS - F=M - childhood SOCIAL PHOBIA - F>M - adolescence AGORAPHOBIA - F>M - 20-35 years nb specific phobias are 'simple' phobias, whereas social and agoraphobia are 'complex' phobias

Question 114

AGORAPHOBIA - describe it? - what fears does it normally involve? 4

Answer 114

Anxiety provoked by open spaces or large crowds where escape is difficult - “fear of the marketplace” - Fear of space (open or closed) Usually involve fears of: - leaving home / being away from home - entering shops, queues - crowds and public places, being trapped - travelling alone in trains, buses or planes Avoidance of the phobic situation is often prominent - Some people with agoraphobia experience little anxiety because they are able to avoid their phobic situations. Concerns with fainting, dying, not able to escape etc.

Question 115

AGORAPHOBIA - what makes it better/more manageable? 2 - common co-morbid features/diagnoses? 4

Answer 115

Better if: - way out - accompanied e.g. pets Often occur with panic attacks = panic disorder with agoraphobia Depressive and obsessional symptoms, and social phobias are also commonly present as subsidiary features

Question 116

SOCIAL PHOBIA - describe it? - when does it become a problem? - what personality features often associated with? 2 - what can trigger it? - what are most common adverse outcomes? 2

Answer 116

The fear is of being judged or “scrutinised” by others in a negative way - can lead to avoidance This is on a spectrum with normality as everyone has this to a certain extent - Is only problematic if it interferes with your life and causes you distress May present as a complaint of blushing, hand tremor, nausea, or urgency of micturition - Symptoms may progress to panic attacks. usually associated with low self-esteem and fear of criticism. May have triggering incident e.g. embarrassing event ADVERSE OUTCOMES - Withdrawal from society - Alcohol abuse common to overcome phobia

Question 117

SPECIFIC PHOBIA - describe what scared of? - risk factors? 2 - give some examples

Answer 117

Specific or simple phobias centre around a particular object, animal, situation or activity They often develop during childhood or adolescence and may become less severe as you get older. RISK FACTORS - triggering / traumatic event - learned phobia from parents/siblings animal phobias – such as dogs, spiders, snakes or rodents environmental phobias – such as heights, deep water and germs situational phobias – such as visiting the dentist or flying bodily phobias – such as blood, vomit or having injections sexual phobias – such as performance anxiety or the fear of getting an STI

Question 118

SPECIFIC PHOBIA - how majority diagnosed? - how most people manage? - effect if goes untreated?

Answer 118

Phobias are not usually formally diagnosed. Most people with a phobia are fully aware of the problem. A person will sometimes choose to live with a phobia, taking great care to avoid the object or situation they're afraid of. But if you have a phobia, continually trying to avoid what you're afraid of will make the situation worse.

Question 119

When taking a hx of someone with a simple or complex phobia, what are important things to eillicit? 5

Answer 119

- any triggering/precipitating factors? when did it start? - any anticipatory behaviour / anxiety? - any avoidance behaviour (or coping, like alcohol)? - severity - how severe is it now? - psych comorbidities - any GAD, depression, OCD, PTSD etc

Question 120

Important psych differential diagnosis for phobias to screen for? 1

Answer 120

PTSD (also OCD) (also panic disorder if no trigger, GAD if all the time etc)

Question 121

MANAGEMENT OF PHOBIAS: - bio options? 3 - psych option for specific? 1 - psych option for agoraphobia + social phobia? 1 - social management? 2 prognosis?

Answer 121

BIOLOGICAL - SSRIs (social + agor) - propranolol (pill in pocket) - benzos (short term - eg if flying) bio options are just to manage symptoms - real treatment is psych! PSYCH - graded exposure (specific) - CBT (complex) SOCIAL MANAGEMENT - psychoeducation: avoidance reinforces the phobia, can use self-help to do own graded exposure - reduce alcohol use (esp social phobia) PROGNOSIS is really good if psychotherapy!

Question 122

DEFINTIONS / DESCRIPTIONS: - obsession? (+ common examples) - compulsion? (+common examples

Answer 122

OBSESSION: - ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form - almost invariably distressing (because they are violent or obscene, or simply because they are perceived as senseless) and the sufferer often tries, unsuccessfully, to resist them. - They are, however, recognized as the individual's own thoughts, even though they are involuntary and often repugnant. - This causes anxiety and distress and leads to an attempt to neutralise ie the compulsion. Obsessions may include: - Fear of getting disease - Fear of coming to harm - Fear of causing harm to others nb 90% popn experience obs, difference is that people with OCD can’t dismiss these thoughts as insignificant - they view them as significant and meaningful - eg “Having this thought means that it will come true” COMPULSION: - strong urges to repeatedly perform an action, even though it is unnecessary. - stereotyped behaviours that are repeated again and again. - not inherently enjoyable, nor do they result in the completion of inherently useful tasks. - function is to prevent some objectively unlikely event, often involving harm or danger to or caused by the patient, which they fear might otherwise occur. (ie cancel out the obsessional thought) - recognised by the patient as symbolic, pointless or ineffectual - Anxiety is almost invariably present. - Repeated attempts are made to resist but if acts are resisted the anxiety gets worse Compulsions can involve: - Cleaning/handwashing - repeated checking (to ensure that a potentially dangerous situation has not been allowed to develop e.g. turning off electrical switches) - orderliness and tidiness.

Question 123

OCD: - definition? (incl time frame) - four main features / characteristics? - common comorbididty/differential?

Answer 123

obsessional symptoms or compulsive acts, or both, must be present on MOST DAYS for at least TWO successive WEEKS and be a source of distress or interference with activities. The obsessive-compulsive symptoms should have the following characteristics: (a)they must be recognized as the individual's own thoughts or impulses; (b)there must be at least one thought or act that is still resisted unsuccessfully, even though others may be present which the sufferer no longer resists; (c)the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense); (d)the thoughts, images, or impulses must be unpleasantly repetitive close relationship between obsessive + compulsive symptoms, particularly obsessional thoughts, and DEPRESSION. Individuals with OCD often have depressive symptoms, and patients suffering from recurrent depressive disorder may develop obsessional thoughts during their episodes of depression. In either situation, increases or decreases in the severity of the depressive symptoms are generally accompanied by parallel changes in the severity of the obsessional symptoms. Differentiating between OCD and a depressive disorder may be difficult because these two types of symptoms so frequently occur together. In an acute episode of disorder, precedence should be given to the symptoms that developed first; when both types are present but neither predominates, it is usually best to regard the depression as primary. In chronic disorders the symptoms that most frequently persist in the absence of the other should be given priority

Question 124

OCD: - gender split? - main risk factor? - norm age of onset? - normal course / prognosis?

Answer 124

M=F often prominent ANANKASTIC (ie OCD) features in the underlying personality ‘anankastic’ is derived from the Greek word meaning ‘compulsion’. Onset is usually in childhood or early adult life. The course is variable and more likely to be chronic in the absence of significant depressive symptoms. - compulsions are more easily treatable than the obsessions nb can subcategorise by if obsessions or compulsions are more prominent or if is mixed

Question 125

Differences between OCD and ankastic or obsessive compulsive personality disorder (OCPD)?

Answer 125

1) INSIGHT - People with OCD are typically distressed by the nature of their behaviors or thoughts, however much they are unable to control them (ie have insight). - People with OCPD believe that their actions have an aim and purpose. (ie don't have insight) 2) ADDITIONAL BEHAVIOUR - OCPD tend to think their way of doing things is the “right and best way,” and they are fixated with following set procedures or routines in their work or daily living, even when these routines are inefficient. - they tend to be overly controlling of their environments or relationships, wanting others to conform to the strict rules they set. - maladaptive traits and behaviors, including perfectionism that interferes with completing tasks, rigid following of moral or ethical codes, hoarding behaviors, and an excessive fixation with lists and rules 3) PERVASIVENESS - OCPD is pervasive in all areas of life (not just with one type of thought or behaviour)

Question 126

OCD: - biological options ? 2 - psychological? 2

Answer 126

BIOLOGICAL - SSRIs (fluoxetine, sertraline) - TCA (clomipramine) PSYCH - CBT sometimes - exposure and repeated prevention eg: - stimulus control: patient given specific time of day where allowed to think about obsessional thoughts - Apps eg NOCD: pts can watch videos e.g. hand washing, which reduces anxiety and compulsion Combined psychotherapy AND drug treatment generally better than each alone

Question 127

PTSD: - definition? - time of onset following event? - lifetime prevelence?

Answer 127

= Delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone e.g. RTA, severe assault, military violence, rape Symptoms develop in aftermath --> Approx. 1-6 months after event (see other flashcard for exactly which type of symptoms needed for diagnosis) lifetime prevelence = 1-10%

Question 128

PTSD: - predisposing risk factors? 3 - high risk groups of people? 3 - risk factors of the event/after the event which increase likelihood of developing PTSD? 3

Answer 128

PREDISPOSING - personality traits (compulsive, asthenic) - previous history of neurotic illness - genetic: sensitive amygdala & hippocampus – decreased hippocampus size on MRI nb predisposing factors may lower the threshold for the development of the syndrome or aggravate its course (but they are neither necessary nor sufficient to explain its occurrence) HIGH RISK GROUPS - Traumatic occupation: soldiers, doctors, police - disaster victims - rape, torture and assault victims = ASK about forensic Hx RISK FACTORS SURROUNDING EVENT - scale of trauma - pt’s previous experience - low level of social support available

Question 129

PTSD: - main groups of symptoms experienced? 5 (incl which needed for diagnosis + which norm found) - common psych co-morbidities? 2

Answer 129

1) RE-EXPERIENCE (flashbacks, nightmares, intrusive memories) 2) HYPERAROUSAL / anxiety with hypervigilance and increased startle reaction (ie jumpy) 3) NUMBNESS 4) EMOTIONAL BLUNTING / detachment from others 5) AVOIDANCE of activities associated with trauma (scroll down for comorbidities) In addition to evidence of trauma, there must be a repetitive, intrusive recollection or re-enactment of the event in memories, daytime imagery, or dreams. Conspicuous emotional detachment, numbing of feeling, and avoidance of stimuli that might arouse recollection of the trauma are often present but are not essential for the diagnosis. The autonomic disturbances, mood disorder, and behavioural abnormalities all contribute to the diagnosis but are not of prime importance. PSYCH CO-MORBIDITIES - depression + suicidal ideation - substance misuse

Question 130

Assessment for PTSD: | - things to ellicit from hx?

Answer 130

- Hx of traumatic event - when onset of symptoms - what symptoms present - screen for depression - screen for substance misuse - RISK ASSESS (esp for suicide!)

Question 131

Management of PTSD: - bio option? 1 (be specific) - psych option? 1 - other treatment? 1 - social? 2 prognosis?

Answer 131

BIO - antidepressants, esp PAROXETINE PSYCH - trauma-focused CBT (multiple sessions, repeated graded exposure) OTHER - EMDR (eye movement desensitisation + repreocessing) - move eyes side to side whilst thinking of event SOCIAL - treat substance abuse - crisis management plan 65% recover in 18 months

Question 132

Adjustment disorder - definition? (incl time period) - what does it include? - common triggers?

Answer 132

States of subjective DISTRESS and emotional disturbance, usually interfering with social functioning and performance, and arising in the period of adaptation to a SIGNIFICANT LIFE CHANGE or to the consequences of a STRESSFUL LIFE EVENT (including the presence or possibility of serious physical illness). The stressor may have affected the integrity of an individual's social network (through bereavement or separation experiences) or the wider system of social supports and values (migration or refugee status). The stressor may involve only the individual or also his or her group or community. manifestations vary, and include: - depressed mood - anxiety - worry (or a mixture of these) - poor concentration - avoidance / denial - feeling of inability to cope, plan ahead, or continue in the present situation - some degree of disability in the performance of daily routine. - irritability - dramatic behaviour or outbursts of violence, but these rarely occur. - autonommic arousal (eg palpitations and sweating) However, conduct disorders (e.g. aggressive or dissocial behaviour) may be an associated feature, particularly in adolescents. None of the symptoms is of sufficient severity or prominence in its own right to justify a more specific diagnosis. In children, regressive phenomena such as return to bed-wetting, babyish speech, or thumb-sucking are frequently part of the symptom pattern. The onset is usually within ONE MONTH of the occurrence of the stressful event or life change, and the duration of symptoms does not usually exceed SIX MONTHS includes NORMAL GRIEF REACTION

Question 133

Assessment of suspected adjustment disorder: - important things to ascertain in hx? 2 - psychiatric conditions to screen for? 3

Answer 133

- what was the stressful event and when did it happen (ie how long ago) - how does it continue to affect life now (incl level of functioning) SCREEN FOR - depression - anxiety - substance misuse nb if no stressful event, situation or life change has occured then seek alternative diagnosis - by definition, adjustment disorder requires an event/change to 'adjust' to

Question 134

Management of adjustment disorder: - treatment aim? - psycho? 2 - social? 2

Answer 134

Treatment aims to accelerate the natural process of adjustment. Working through the life-change reduces anxiety and allows denial and avoidance to decline. Anxiolytics are rarely required. PSYCHO - problem solving psychotherapy - crisis intervention SOCIAL - address any ongoing social issues (eg finances, housing, other relationships etc) - address substace misuse make sure to keep following up

Question 135

abnormal grief reaction/prolonged grief disorder: - main features which differentiate between normal and abnormal grief? - common symptoms of grief?

Answer 135

1) SEVERITY - increased distress and disability (ie functioning - eg meets criteria for depression) 2) LENGTH - more than 6 months (can also be delayed in onset) SYMPTOMS OF GRIEF: - longing for deceased - emotional pain - preoccupation with deceased (incl pseudohallucinations) - difficulty accepting death - disbelief/denial - bitterness/anger - blame/guilt - feeling one has lost a part of oneself - difficulties engaging with acitivities or making plans for the future - sadness - emotional numbness - inability to experience positive mood - impairment in important areas of functioning (family, personal, educational, occupational) nb these symptoms often occur transiently in many bereaved individuals, but it is only when these reactions are experienced on more days than not, causing severe distress and impairment in important areas of functioning more than six months after loss that a PGD diagnosis is applicable

Question 136

abnormal grief reaction: - predisposing risk factors? - risk factors surrounding death?

Answer 136

PREDISPOSING - female - low educational level - insecure attachment + neurotic personalities - PMHx of psych conditions PRECIPITATING - very close to deceased (esp partner or child) - unnatural / violent death - unexpected death

Question 137

abnormal grief reaction: | - important DDx? 2

Answer 137

- depression | - PTSD (esp if they witnessed death)

Question 138

management options for abnormal grief reaction: - bio? 1 - psycho? 2 - social? 3

Answer 138

BIO - consider antidepressants (but not always) PSYCHO - CBT - other psychological therapies SOCIAL - social prescribing etc to increase engagement in social activities - address social issues, eg finances, occupation etc - specialist grief charities or support groups nb not a lot of research has been done about this so use clinical judgement

Question 139

describe: - 5 stages of grief - grief task model

Answer 139

One of the most popular models of grief divides it into 5 stages. 1) DENIAL: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them 2) ANGER: this is commonly directed against other family members and medical professionals 3) BARGAINING 4) DEPRESSION 5) ACCEPTANCE It should be noted that many patients will not go through all 5 stages. The GRIEF TASK MODEL proposes that normal grief is the successful achievement of certain “grief tasks,” whereas complications in managing these tasks might indicate disturbed grief. There is no recommended or specific order in which to achieve these tasks. Grief tasks include: - to accept the reality of the loss - to process the associated pain - to adjust to a world without the deceased - to find an enduring connection with the deceased in the midst of embarking on a new life.

Question 140

Acute stress reaction: | - describe! (incl length)

Answer 140

transient disorder develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress Symptoms mixed but could include being in a daze, disorientation, panic, amnesia Initial state of shock +/- symptoms of anxiety and depression Symptoms usually appear within MINUTES of the impact of the stressful stimulus /event - usually subsides within HOURS or DAYS (2-3).

Question 141

MEDICALLY UNEXPLAINED SYMPTOMS, define: - somatisation disorder - hypochondrial disorder - conversion disorder - dissociative disorder - factitious disorder - malingering

Answer 141

SOMATISATION DISORDER - multiple physical SYMPTOMS present for at least 2 years - patient refuses to accept reassurance or negative test results - "S for symptoms" HYPOCONDRIAL DISORDER - persistent belief in the presence of an underlying serious DISEASE, e.g. cancer - patient again refuses to accept reassurance or negative test results - "C for cancer" CONVERSION DISORDER - typically involves loss of motor or sensory function the patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering) - patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies DISSOCIATIVE DISORDER - dissociation is a process of 'separating off' certain memories from normal consciousness - in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor - dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder FACTITIOUS DISORDER - aka Munchausen's syndrome - the intentional production of physical or psychological symptoms MALINGERING - fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain (eg to get drugs)

Question 142

Somatisation disorders: | - describe the two most common forms of somatisation and the differences between them and how they present?

Answer 142

SOMATISATION DISORDERS ARE PSYCHOLOGICAL DISORDERS THAT EXHIBIT PHYSICAL SYMPTOMS OR TAKE THE FORM OF PHYSICAL DISORDERS There will be no discernable physical or organic reason for these symptoms and this leads to the presumption that they are caused by a psychological disorder FEATURES OF SOMATISATION - These physical symptoms do NOT HAPPEN VOLUNTARILY and are completely beyond the individuals control FORMS OF SOMATISATION - The two most common forms of somatisation are SOMATISATION DISORDER and HYPOCHONDRIAL DISORDER. The two have distinct psychologies… In SOMATISATION DISORDER (AKA Briquet's Syndrome) people have specific symptoms that they complain of - You can remember this because it's S for Somatisation and S for symptoms In HYPOCHONDRIAL DISORDER people are convinced of having a specific disease - E.g. they think they’ve got cancer or HIV HYPOCHONDRIACAL DISORDER - This disorder is distinct form somatisation disorder but it is quite subtly different In hypochondriacal disorder patients misinterpret normal bodily sensations and think that they mean that they've got a serious medical disease. A key difference from somatisation disorder is: - Often patients with somatisation disorder will ask for TREATMENT for their symptoms whereas patients with hypochondriacal disorder will become fixated on the diagnosis and so they will often be demanding INVESTIGATIONS to confirm this diagnosis Again, patients with hypochondriacal disorder will refuse to accept information an reassurance from doctors that there is not organic cause or disease process. BODY DYSMORPHIC SYNDROME is a specific type of hypochondriacal disorder where people become concerned/preoccupied with a specific defect or deformity e.g. crooked nose or ugly hands.

Question 143

Common symptoms of somatisation disorders: - GI? - skin? - sexual? - urinary? - neurological?

Answer 143

GI: - Nausea - vomiting - diarrhoea - food intolerance - belching - regurgitation - abdo pain - constipation Skin: - itching - burning - numbness Sexual: - loss of libido - ejaculatory or erectile dysfunction - irregular menses - dysmenorrhoea Urinary: - dysuria - frequency - urinary retention Neurological: - paralysis - sensory loss - hearing or vision loss - double vision - seizures - difficulty swallowing - impaired coordination ***patients should have numerous symptoms from more than one of these groups not just one symptom in isolation

Question 144

What complications are people with somatisation disorders at high risk of?

Answer 144

Patients with somatisation disorders are highly at risk of having iatrogenic complications - a key example is a patient with multiple abdominal adhesions from having multiple explorative laparoscopies.

Question 145

ICD-10 criteria for somatisation disorder? (incl time frame)

Answer 145

In order for somatisation disorder to be diagnosed the ICD-10 suggests all of the following should be present: - At least 2 years of symptoms with no organic explanation found - Persistent refusal by the patient to accept reassurance from several doctors that there is no physical cause - Some degree of functional impairment due to the symptoms and resulting behaviour

Question 146

Describe conversion syndrome

Answer 146

This is when there is a perceived loss of motor or sensory function - describes the situation whereby psychological pain is converted into the somatic or physical form. Often neurological symptoms (paralysis, blindness, sensory loss) It is distinct from factitious disorder where the patient purposefully feigns symptoms. In conversion disorder the motor and sensory loss are involuntarily experienced A common thing that patients seem to experience is profound loss of peripheral visions. They state that is is 'like looking down a tube'. Again patients might seem indifferent (see below) Patients might be experiencing La belle Indifference - they might be completely indifferent to their symptoms but this is not well backed up by research

Question 147

Management of somatoform disorders: - who to manage? - frequency of visits? - general principles of management? 6 - social management to consider? 4 - psych treatment to consider? 1 - bio treatment to consider? 1

Answer 147

manage by GP - see same dr every time to build rapport - Schedule frequent visits (e.g. 15 minute visit/month) This has the effect of: - Replaces emergency visits and telephone calls - Allows patient attention without a new symptom - Not contingent on new complaints - Not focused on symptoms GENERAL PRINCIPLES: - Do not suggest "it's all in your head" - Encourage patient to assume active role in their care - Focus on function (not symptoms) - Manage comorbid psychiatric conditions - Provider reassurance that serious conditions have been ruled out (avoid additional lab testing and subspecialist referral) - Spend most of the encounter listening (aknowledge that what they are feeling is real, allow the "sick role") SOCIAL (focus on stress reduction) - exercise - manage financial / relationship stress - social gatherings / pleasurable activities (incl social prescribing) - relaxation (nature walks, yoga) PSYCH - CBT (but need to encourage them to come to this idea - eg suggesting pts own strategies haven't been working - is 'worth a try') BIO - SSRIs have shown some benefit! Can also do 'benign' management, eg: - Hot and cold packs - Bandages - Canes - Lotions - Vitamins or Nutritional - Supplements - Acupuncture - Chiropractic massage therapy - Biofeedback

Question 148

Definition of a 'binge'

Answer 148

= A ‘binge’ is the consumption of a large number of calories in a relatively short space of time- can be up to 6000 calories in 1-2 hours - with a sense of a ‘loss of control’ while doing this - binge will only end when can find no more food in house or feel in so much pain from all food that have to purge - then get huge guilt and regret and try to purge Subjective over eating is different! An episode of binge eating is characterized by both: 1. Eating in a discrete period of time (e.g. within any 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances; 2. A sense of lack of control over eating during the episodes (e.g. a feeling that one cannot stop eating or control what or how much one is eating). Binge eating episodes are associated with three or more of the following: 1. Eating much more rapidly than normal. 2. Eating until feeling uncomfortably full. 3. Eating large amounts of food when not feeling physically hungry. 4. Eating alone because of feeling embarrassed by how much one is eating. 5. Feeling disgusted with oneself, depressed, or very guilty afterwards.

Question 149

Core psychopathology in eating disorders? ***LEARN THIS REALLY WELL***

Answer 149

1) FEAR of fatness 2) PURSUIT of thinness 3) Body DISSATISAFACTION 4) Body image DISTORTION 5) SELF-EVALUATION based on weight and shape 'imagine facing your worst fear 3x a day, every day'

Question 150

General psychopathology in eating disorders? 7 | ie effect on psychology of being starved

Answer 150

when human body is starved, direct effect on psychology: - Fixation on food – starvation, restriction - Depression - Anxiety, social phobia - Suicidal ideation - OCD symptoms - rigidity Rumination about food, incl: - bizarre beliefs about good and bad food, calories, fat etc - beliefs around miasmatic calories (thinks can absorb calories through skin or breath them in)

Question 151

Diagnostic criteria for: - anorexia nervosa? 3 - bulemia nervosa? 3 - binge eating disorder?

Answer 151

ANOREXIA NERVOSA 1) BMI <18.5 (or 17.5?) 2) weight loss is self-induced by food-avoidance etc behaviour 3) presence of core psychopathology BULIMIA NERVOSA 1) BMI >18.5 (or 17.5?) 2) presence of at least one episode of binging and purging per week for at least 3 months 3) presence of core pathology BINGE EATING DISORDER 1) At least one binge eating episode per week for 3 months 2) marked distress regarding binge eating 3) binge eating is not associated with recurrent use of compensatory/purging behaviours 4) presence of core psychopathology nb see other flash card for definition of a 'binge' ie the presence of CORE PSYCHOPATHOLOGY is present in all eating disorders!!!

Question 152

What are Other Specified Feeding or Eating Disorder (OSFED) | - give examples? 6

Answer 152

Symptoms characteristic of a feeing or eating disorder that cause clinical distress or impairment in social, occupational, or other important areas of functioning predominate. However DO NOT meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class ATYPICAL ANOREXIA NERVOSA: all of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range. BULIMIA NERVOSA (of LOW FREQUENCY and/or LIMITED DURATION): all of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/ or for less than 3 months. BINGE-EATING DISORDER (of LOW FREQUENCY and/or LIMITED DURATION): all of the criteria for binge-eating disorder are met, except that the binge occurs, on average, less than once a week and/ or for less than 3 months. PURGING DISORDER: recurrent purging behavior to influence weight or shape (e.g. self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating. NIGHT EATING SYNDROME: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness of recall of the eating. The night eating causes significant distress and/or impairment in functioning. EXCESSIVE COMPULSIVE EXERCISE - significant amount of time dedicated to physical activity to detriment of other factors in goal of achieving an unrealistic desired weight nb don't need to learn these by heart but just be aware

Question 153

Physical complications of eating disorders: - CVS? (2 AN, 2 BN, 1 both) - renal? (4 both) - GI? (2 AN, 2 BN, 2 both) - skeletal? (1 AN, 2 both) - endocrine? (3 AN, 1 BN) - haem? (2 AN, 1 both) - neuro? (2 both) - metabolic? (2 both) - derm? (2 AN, 1 BN)

Answer 153

``` CVS AN - Bradycardia AN - Hypotension BN - arrythmias BN - heart failure BOTH = Sudden death (in AN norm dt QTc prolongation, in BN norm dt arrythmias) ``` ``` RENAL (all BOTH) = Oedema (severe in BN) = Electrolyte abnormalities = Renal calculi = Renal failure ``` ``` GASTROINTESTINAL AN - Delayed gastric emptying AN - Nutritional hepatitis BN - Dental erosion BN - Oesophageal erosion / perforation BOTH = Parotid swelling BOTH = Constipation ``` SKELETAL AN - Short stature BOTH = Osteoporosis BOTH = Pathological fractures ``` ENDOCRINE AN - Amenorrhoea AN - Infertility AN - Hypothyroidism BN - oligo / amenorrhoea ``` HAEM AN - Anaemia AN - Thrombocytopenia BOTH = Leukopenia (sometimes lymphocytosis in BN) NEURO (all BOTH) = Generalised seizures = Confusional states METABOLIC (all BOTH) = Impaired temperature regulation = Hypoglycaemia DERM AN - lanugo AN - brittle hair and nails BN - Calluses on dorsum of hands (Russell's sign)

Question 154

Screening tool used for eating disorders in primary care? 5 when to refer for more detailed assessment?

Answer 154

SCOFF Screening: S = SICK: do you ever make yourself SICK because you feel uncomfortably full? C = CONTROL: do you worry you have lost CONTROL over how much you eat? O = ONE: have you lost more than ONE stone in a 3-month period? F = FAT: Do you believe yourself to be FAT when others say you are too thin? F – FOOD: would you say that FOOD dominates your life? primary care screening tool (if 2 or more positive, refer for more detailed assessment)

Question 155

What are the two biggest risks with eating disorders? (ie causes of death)

Answer 155

1) cardiac arrest / sudden death 2) suicide (20-40% of deaths) so manage risk of both anorexia nervosa has highest mortality of any psych condition

Question 156

What are the 4 components for a physical risk assessment in eating disorders? (ie what 4 things do you need to do/know in order to make an accurate assessment?)

Answer 156

1) Clinical Hx and physical examination 2) BMI 3) ECG 4) Bloods (see other flashcards for which ones) can’t do a valid risk assessment if haven’t got all of these 4 components - ie don't base risk on BMI alone!!!

Question 157

Differential diagnoses for anorexia / significant weight loss: - psych? 6 - organic? 4 - other? 3

Answer 157

PSYCH: - ANOREXIA NERVOSA - FOOD AVOIDANCE EMOTIONAL DISORDER (an ED that affects children which involves a fear of eating which is not accompanied by a fear of weight gain) - PHAGOPHOBIA (anxiety disorder characterized by a fear of eating, it is usually initiated by an adverse experience while eating such as choking or vomiting, Individuals with this disorder may present with complaints of pain while swallowing) eg Pt saw with liaison with NG tube - had never been good eater then struggled with constipation and was so scared that she’d have it again - scared of the pain - DEPRESSION - stop eating and drinking, form of self-neglect - ANXIETY - if really anxious - trigger fight or flight, don’t want to eat (similar to post-intensive exercise) Somali pt saw with liaison - never eaten much but anxiety just caused her to stop eating- hated how skinny her arms looked (also access to food - dad just having takeaways, didn’t like rice, didn’t know how to eat healthily) - PSYCHOSIS / DELUSIONAL BELIEFS - paranoid beliefs of being poisoned ORGANIC CAUSES: - MALIGNANCY - anorexia is a core feature partially due to nausea (also comorbid anxiety or depression) - IBD / COELIAC - eat sufficient amounts but not put on weight so may be a clinical suspicion that not eating - INFECTIONS - make nauseous - eg flu can shed weight off very healthy people - also TB - METABOLIC CONDITIONS - diabetes type 1, hypo/hyperthyroidism, addisons OTHER PAST TRAUMA Pt in becklin who kept throwing up - but because he ate food so quickly, parents had berated him about eating (also parental pressure may -> ED) AUTISM SPECTRUM DISORDER Man just ate kidney beans boiled in oil - struggled to put on weight - his autism, restrictive and repetitive behaviour DRUG ABUSE Long term cannabis use can suppress appetite (saw on medical show - always take drugs hx - pt didn’t realise this was the reason so didn’t tell staff as thought irrelevant)

Question 158

In addition to a normal psych hx, what additional things to ask about in a person with suspected eating disorder: - what groups of behaviours to ask about? - what other things to ask about? 5

Answer 158

GROUPS OF BEHAVIOURS TO ASK ABOUT: - restricting food intake - increasing calorie burning - suppressing appetite - behaviours around obsession over body - binge/purge behaviours - other social / self harm (list examples of all of the above on a different flashcard) OTHER THINGS - explore core psychopathology - screen for other mental health conditions (eg depression, social anxiety) - ask about CVS symptoms (CP, dizziness, palpitations, blackouts) - rule out organic DDx (will have other symptoms, and not have core psychopathology) - risk assess (physical and DSH/suicide) also any physical comorbidities - esp insulin-dependent diabetes or pregnancy = very high risk!

Question 159

Common behaviours in eating disorders: - restricting food intake? 5 - increasing calorie burning? 6 - suppressing appetite? 2 - obsession over body? 3 - binge / purge behaviour? 5 - social behaviours? 4

Answer 159

RESTRICTING FOOD INTAKE - Dieting - Fasting - Calorie counting - chewing and spitting - other culinary behaviour (bizarre combinations of food, spoiling food) INCREASING CALORIE BURNING - Excessive exercise - over-activity (fidgeting, twitching, pacing, fetching one thing at a time) - Thyroxine - Diet pills - ritalin - cooling (wearing less clothes) SUPPRESSING APPETITE - Water loading - Appetite suppressants (gum, cigarettes) OBSESSION OVER BODY - Excessive weighing - body checking - mirror gazing or avoidance BINGE / PURGE BEHAVIOUR - binging - purging - starve-bing-purge cycle - misuse of insulin - laxatives SOCIAL - Avoidance - Isolation - deliberate self-harm (DSH) - Substance misuse.

Question 160

Physical examination for eating disorder: - obs that may be abnormal? 3 - other physical examination things to look for / test? 6

Answer 160

OBS - bradycardia - hypotension - hypothermia OTHER - irregular pulse - postural hypotension - enlarged salivary glands - dentition - skin on knuckles - test for proximal myopathy basically do a full examination but look out for these specific things

Question 161

How do you test a patietn with suspected ED for proximal myopathy?

Answer 161

SQUAT TEST get them to squat right down and then stand up (without using arms) if can't do, concerned about protein malnutrition

Question 162

BMI and risk: - cut off for anorexia? - cut off for moderate risk? - cut off for high risk? what to be aware of when measuring BMI?

Answer 162

BMI = wt(kg)/ht(m)2 <18.5 = AN (?changed to 17.5) <15 = moderate risk <13 = high risk (start seeing organ failure) Proxy measure of physical risk with clear limitations - can be manipulated, eg water loading, so don’t use in isolation

Question 163

Possible ECG findings in eating disorders? 3 how to manage these abnormalities?

Answer 163

- Bradycardia (<40bpm) - t wave changes (hypokalaemia) - QTc prolongation (>450ms) only way to reverse these abnormalities is adequate nutrition, don’t need cardiac drugs most deaths due to cardiac arrest. - nb Cardiac abnormalities in up to 85% of anorexia pts.

Question 164

Eating disorder: - initial bloods to get? 8 - findings? (way to remember findings)

Answer 164

standard - FBC - U+E - LFT - glucose more specialist - CK - phos, Mg, Ca - TFTs - Zn (^get all of these, just split them up so easier to remember) ``` also in anorexia: - low FSH, LH, oestrogens, testosterone - raised cortisol + growth hormones - imppaired glucose tolerance - hypercholestoraemia - hypercarotenaemia (raised beta-carotene) low T3 (if not taking thyroxine) ``` "in ANOREXIA = most things low BUT G's and C's raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, CK, carotinaemia"

Question 165

blood findings in eating disorder behaviours: - starvation? 1 - vomiting? 1 - water-loading? 1 - laxatives misuse? 2 - diuretics misuse? 2 - thyroxine misuse? 2 other findings in bloods: - bone marrow hypoplasia? 2 - proximal myopathy? 2

Answer 165

bloods can show what behaviours patients have been doing - even if they don’t admit it Starvation = Hypoglycaemia Vomiting = Hypokalaemia Water-loading = Hyponatraemia Laxative misuse = Hyperkalaemia + Hyponatraemia Diuretics misuse = Hypokalaemia, hyponatraemia Thyroxine misuse = ↑T3/T4, ↓TSH Bone marrow hypoplasia = Normocytic anaemia + Leucopenia Proximal myopathy = ↑ CK, ↑ LFTs

Question 166

blood findings in refeeding syndrome?

Answer 166

Re-feeding syndrome - Hypophosphataemia - Hypomagnesaemia - Hypocalcaemia - Hypokalaemia so low of all the positive ions (except sodium)

Question 167

Management of eating disorders: - where most managed? - referral criteria (in yorkshire) for specialist ED unit? 3 - other hospital wards sometimes found/managed in?

Answer 167

Usually managed as outpatient - Most AN require specialist Rx - BN + OSFED/EDNOS will mainly be treated either in primary care or secondary services SPECIALIST ED UNIT (yorkshire) - moderate/severe AN (bmi <17) - severe BN (daily bingeing + purging) - OSFED/EDNOS with comorbid IDDM or pregnancy OTHER WARDS: - Gastro-enterology ward (for initial refeeding) - Acute medical ward (if electrolyte disturbances) - General psychiatric ward (avoid if possible!!!) Match needs to appropriate setting - clinical state, level of risk - local resources - capacity to consent to treatment - motivation to change - patient and family’s views

Question 168

Name of MDT group who normally manage people with severe AN? | - who is in this group?

Answer 168

MARSIPAN = Management of really sick patients with anorexia nervosa MARSIPAN group: - Physician with special interest in ED - ED/Liaison Psychiatrist +/- CMHT - Dietician and nutrition support team - Nursing team Have regular MARSIPAN meetings - coordinated care

Question 169

MAIN STAGES OF MANAGEMENT OF EATING DISORDERS? 3 in which order should they be done? (don't describe in detail - on other flashcard)

Answer 169

1) nutrition (if super low) 2) motivational enhancement 3) formal psychological support

Question 170

1st stage of ED management: NUTRITION: - why do this first? - who mainly involved? - what teach? (1 to all, 1 to BN) - last resort?

Answer 170

because when low weight, psychology is more rigid, need to increase nutrition first before can manage psychopathology use dieticians a lot EDUCATION on what body needs, eg: - carbs at every meal to stabilise blood sugar - dairy 2-3x a day for clcium, vit D and phosphate - protein 2-3x a day for growth + repair (incl immune systm, skin integrity, tissue restoration) explaining the binge-purge cycle - explain to BN that need regular meals to avoid purging (typically binges happen later in the day) NG feed as last resort

Question 171

2nd stage of management of eating disorders: MOTIVATIONAL ENHANCEMENT - what is this? what's the aim? why necessary? - what sort of questions to ask? - how long?

Answer 171

- before any in-depth psychotherapy - most pts are initially not distressed - it’s their relative who are - At point of referral they don’t realise that they have a problem AIM - to understand the psychological functions of the ED - weigh up how the individual feels about change - to increase motivation to change (lots of motivational interviewing techniques) - to make an informed decision about whether this is the right time to change ``` TECHNIQUES / Qs: = Affirmations = Reflective listening = Open ended questions --- Why Change? --- Advantages/Disadvantages? --- What do you like about your ED? --- What do you dislike about your ED? --- Write a list of all the things you have stopped doing because of your ED --- Barriers to change – What would stop me giving up your ED? = Summaries = Elicit change talk ``` Brief therapy, usually lasting 4-6 sessions - Beneficial in the initial phase of treatment with promotion of responsibility and a commitment to change

Question 172

What are the steps of the change cycle? 7 what % of people referred to specialist ED are at action phase?

Answer 172

1) PRE-CONTEMPLATION - unwilling to change 2) CONTEMPLATION - considering change 3) DETERMINATION - preparing to change 4) ACTION - implementing change 5) MAINTENANCE - maintaining change 6) either PERMANENT EXIT or RELAPSE At point of referral they don’t realise that they have a problem (<50% referred to specialist ED are in action phase)

Question 173

3rd stage of eating disorder management: FORMAL PSYCH SUPPORT - best options for AN? 3 - best options for BN? 2 - main initial management of OSFED? - what medication management is sometimes considered? and for what?

Answer 173

ANOREXIA NERVOSA - MANTRA (maudsley approach to treating anorexia) - CBT - SSCM (specialist supportive counselling) nb all of equal efficacy, try others if don't work BULIMIA NERVOSA - CBT - IPT nb both of equal efficacy, try others if don't work nb BN much easier to treat than AN ALSO can use FLUOXETINE 60mg daily in BN (not in AN, nb dose is higher than for depression) OSFED = mainly GUIDED SELF-HELP - Education (e.g. physical and psychological risks of disordered eating) - Increased awareness and responsibility (e.g. food/thought diaries) - Structured eating - Identify and challenge beliefs - Promote self-management skills

Question 174

What can primary care doctors do to help in the management of eating disorders? 8

Answer 174

- Develop therapeutic alliance - Diagnosis & screening - Risk assessment and coordinate medical monitoring (BMI, bloods, ECG) - Medication review - Use motivational enhancement techniques - Knowledge of local care pathways and MARSIPAN - Guided self help and support groups - Encourage self-monitoring (e.g. diaries) and structured eating *see my full psych notes for additional resources for GPs