Psychiatric Disorders

Question 1

What is EUPD?

Answer 1

A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan is minimal and outburst of intense anger may lead to violence or “behavioural explosions

Question 2

What are the characteristics of the borderline type of EUPD?

Answer 2

• Characteristics of emotional instability present, in addition to the patients own self-image, aims and internal preferences (including sexual) are often unclear or disturbed. There are often chronic feelings of emptiness. A liability to become involved in unstable and intense relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-help (although these may occur without obvious precipitants)

Question 3

What are the characteristics of the unstable type of EUPD?

Answer 3

• Emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others.

Question 4

How do you manage EUPD?

Answer 4

Develop a crisis plan

• identify potential triggers
• specify self-management strategies that are likely to be effective
• psychotherapy
• mood stabilisers or second generation antipsychosis

Question 5

What are the characteristics of paranoid personality disorder?

Answer 5

o Excessive sensitiveness to setbacks and rebuffs
o Tendency to bear grudges persistently, e.g. refusal to forgive insults and injuries or slights
o Suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous
o A combative and tenacious sense of personal rights out of keeping with the actual situation
o Recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner
o Tendency to experience excessive self-importance, manifest in a persistent self referential attitude
o Preoccupation with unsubstantiated “conspiratorial” explanations of events both immediate to the patient and in the world at large

Question 6

What are the characteristics of schizoid personality disorder?

Answer 6

o Few, if any, activities provide pleasure
o Emotional coldness, detachment or flattened affect
o Limited capacity to express either warm, tender feelings or anger towards others
o Apparent indifference to praise or criticism
o Little interest in having sexual experiences with another person
o Almost invariable preference for solitary activities
o Excessive preoccupation with fantasy and introspection

Question 7

What are the characteristics of dissocial personality disorder?

Answer 7

o Callous unconcern for the feelings of others
o Gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations
o Incapacity to maintain enduring relationships, though having no difficulty establishing them
o Very low tolerance to frustration and a low threshold for discharge of aggression, including violence
o Incapacity to experience guilt or to profit from experience, particularly punishment
o Marked proneness to blame others, or to offer plausible rationalisations that has brought the patient into conflict with society

Question 8

What are the characteristics of histrionic personality disorder?

Answer 8

o Self-dramatization, theatricality, exaggerated expression of emotions
o Suggestibility, easily influenced by others or by circumstances
o Shallow and labile affectivity
o Continual seeking for excitement and activities in which the patient is the centre of attention
o Inappropriate seductiveness in appearance or behaviour
o Over-concern with physical attractiveness

Associated features may include ego-centricity, self-indulgence, continuous longing for appreciation, feelings that are easily hurt and persistent manipulative behaviour to achieve own needs.

Question 9

What are the characteristics of anankastic personality disorder?

Answer 9

o Feelings of excessive doubt and caution
o Preoccupation with details, rules, lists, order, organisation, or schedule
o Perfectionism that interferes with task completion
o Excessive pedantry and adherence to social conventions
o Rigidity and stubbornness
o Unreasonable insistence by the patient that others submit to exactly his or her way of doing things or unreasonable reluctance to allow others to do things
o Intrusion of insistent and unwelcome thoughts or impulses

Question 10

What are the characteristics of anxious avoidant personality disorder?

Answer 10

o Persistent and pervasive feelings of tension and apprehension
o Belief that one is socially inept, personally unappealing, or inferior to others
o Excessive preoccupation with being criticised or rejected in social situations
o Unwillingness to become involved with people unless certain of being liked
o Restrictions in lifestyle because of the need to have physical security
o Avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection

Question 11

What are the characteristics of dependent personality disorder?

Answer 11

o Encouraging or allowing others to make most of ones important life decisions
o Subordination of one’s own needs to those of others on whom one is dependent and undue compliance with their wishes
o Unwillingness to make even reasonable demands on the people one depends on
o Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself
o Preoccupation with dears of being abandoned by a person with whom one has a close relationship and of being left to care for oneself
o Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others

Question 12

What is generalised anxiety disorder?

Answer 12

A syndrome of ongoing anxiety and worry about many events or thoughts that the patient generally recognises as excessive and inappropriate

Question 13

What are the symptoms of GAD?

Answer 13

A feeling of dread, restlessness/feeling on edge, being easily fatigued, irritability, muscle tension, sleep disturbance for at least 6 months

Question 14

What are the autonomic symptoms of GAD?

Answer 14

Palpitations or pounding heart
Accelerated heart rate
Sweating
Trembling or shaking
Dry mouth (not due to medication or dehydration)

Question 15

What are the chest and abdomen symptoms of GAD?

Answer 15

Difficulty breathing
Feeling of choking
Chest pain or discomfort
Nausea or abdo distress (churning in stomach etc.)

Question 16

What are the GAD symptoms that involve mental state?

Answer 16

Feeling dizzy, unsteady, faint or light-headed
Feeling that objects are unreal (derealisation) or that the self is ‘not really here’ (depersonalisation)
Feeling of losing control, ‘going crazy’ or passing out
Fear of dying

Question 17

What are the general symptoms of GAD?

Answer 17

 Hot flushes or cold chills
 Numbness or tingling sensations
 Muscle tension or aches and pains
 Restlessness and inability to relax
 Feeling keyed up, on edge, or mentally tense
 A sensation of a lump in the throat or difficulty in swallowing

Question 18

What is the management of GAD?

Answer 18

1. Identify, assess, educate and monitor
2. low intensity psychological support, non-facilitated or guided self help
3. CBT/applied relaxation or drug treatment
4. Specialist drug and/or psychological treatment, multi-agency teams, crisis intervention, outpatient or inpatient care

Question 19

What is the pharmacological management for GAD?

Answer 19

Sedative antihistamines/benzodiazepines (RAPID RESPONSE)

SSRI/venlafaxine = first line
Switch SSRI if no response after 12 weeks

Pregabalin can be considered if SSRIs untolerated

Question 20

Name SSRI’s that are suitable for GAD?

Answer 20

Setraline
Esciltalopram
Citalopram
Paroxetine

Question 21

What medical illnesses can mimic anxiety?

Answer 21

Hyperthyroidism
Hypoparathyroidism
Arrhythmia
B12 deficiency
Phaeochromocytoma 
Hypoglcyaemia 
Serotonin syndrome
Carcinoid tumour
Alcohol/drug withdrawal

Question 22

What is panic disorder?

Answer 22

• Attacks of severe anxiety which are not restricted to any particular situation or set of circumstances, and which are therefore unpredictable.

Question 23

What are the symptoms of a panic attack?

Answer 23

Palpitations
Chest pain
Choking sensation
Dizziness
Feelings of unreality (depersonalisation or derealisation)

Question 24

What is the criteria for a panic disorder diagnosis?

Answer 24

o Several severe attacks of autonomic anxiety should have occurred within a period of 1 month:
 In circumstances where there is no objective danger
 Without being confined to known or predictable situations;
 With comparative freedom from anxiety symptoms between attacks (anticipatory anxiety is common)

Question 25

What is the management of panic disorder?

Answer 25

Avoid caffeine, check for alcohol or drug misuse, suggest CBT Drug Therapy - SSRI (paroxetine, sertraline, fluoxetine, esciltalopram) - Imipramine or clomipramine (TCAs) may be useful - Benzodiazepines can be useful for short-term anxiety crisis management and can be an adjunct to SSRI

Question 26

What is OCD?

Answer 26

- A condition characterised by recurrent obsessional thoughts or compulsive acts. Obsessions are ideas, images or impulses that enter the individual’s mind again and again in a stereotyped form. They are often distressing, and the sufferer tries to resist them. Compulsions are acts or rituals that are repeated again and again that are carried out to ease the anxiety caused by the obsessions.

Question 27

What is the criteria for diagnosis of OCD?

Answer 27

- Obsessional symptoms and compulsive acts must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities.

Question 28

What is the management of OCD?

Answer 28

Mild functional impairment - CBT and exposure therapy - SSRI Moderate and Severe Impairment - High intensity CBT or exposure therapy - SSRI - clomipramine

Question 29

What is an acute stress reaction?

Answer 29

- A transient disorder of significant severity which develops in an individual without any other apparent mental disorder in response to exceptional physical and/or mental stress which usually subsides within hours or days.

Question 30

What are the symptoms of an acute stress reaction?

Answer 30

Daze, constriction of consciousness, narrowing of attention Palpitations, nausea, headaches, breathing difficulties, reckless behaviour, emotional numbing, low mood, irritability, mood swings, poor sleep and concentration may be present

Question 31

How long does an acute stress reaction last?

Answer 31

Symptoms usually begin a few minutes after the traumatic event and can last up to 3 days afterwards

Question 32

What is PTSD?

Answer 32

- A delayed and/or protracted response to a stressful event or situation or an exceptionally threatening or catastrophic nature which is likely to cause pervasive distress in almost anyone.

Question 33

What are the symptoms of PTSD?

Answer 33

o Intrusion  Flashbacks, nightmares, intrusive distressing images or sensory impressions, distress after being reminded about the event o Avoidance  Avoiding situations/people that remind them with the event or events associated with their trauma, memory suppression, rumination (why did this happen to me? could it have been prevented? etc) o Hyperarousal  Hypervigilance, exaggerated startle response, irritability, difficulty concentrating, sleeping problems o Emotional Numbing  Difficulty experiencing emotions, feelings of detachments, anhedonia

Question 34

What is the management of PTSD?

Answer 34

EDMR therapy CBT paroxetine mirtazepine

Question 35

What symptoms are present in a depressive episode?

Answer 35

- Mild, moderate and severe depressive episodes are characterised by low mood, anhedonia and reduced energy leading to increased fatiguability and diminished activity. Other symptoms include o Reduced concentration and attention o Reduced self-esteem and self-confidence o Ideas of guilt and unworthiness o Bleak and pessimistic views of the future o Ideas or acts of self-harm or suicide o Disturbed sleep o Diminished appetite - Lowered mood varies little from day to day, and is unresponsive to circumstances. Diurnal variation may occur

Question 36

How long do symptoms need to be present for a diagnosis of depression?

Answer 36

2 weeks but shorter periods are reasonable if symptoms are unusually severe and of rapid onset

Question 37

What is the management for depression?

Answer 37

``` SSRI SNRI TCAs MAOI Psychotherapy - CBT - Interpersonal Therapy - Psychotherapy ECT for severe treatment resistant depression ```

Question 38

What is bipolar affective disorder?

Answer 38

- Repeated episodes in which the patients mood and activity levels are significantly disturbed – sometimes increased energy and activity (mania/hypomania) and sometimes low mood and decreased energy (depression).

Question 39

What are symptoms of mania?

Answer 39

``` o Increased self esteem o Grandiosity o Decreased need for sleep o Pressured speech o Flight of ideas o Distractability o Increase in goal-directed activity o Decreased inhibition ```

Question 40

What is the management of Bipolar Affective Disorder?

Answer 40

Mood stabiliser - lithium, sodium valproate, carbamazepine Anti-psychotic - risperidone, olanzapine, quetiapine Clonazepam Lamotrigene can be added if rapid cycling

Question 41

What is cyclothymia

Answer 41

- A persistent instability of mood, involving numerous periods of mild depression and mild elation. Instability usually develops early in adult life and pursues a chronic course.

Question 42

What is Benzodiazepine Overdose?

Answer 42

Consuming an excessive amount of benzodiazepines

Question 43

What are the signs of a benzodiazepine overdose?

Answer 43

sedation, impaired mental status, ataxia, impaired reflexes, resp depression, coma

Question 44

What investigations should be carried out if a BZD overdose is suspected?

Answer 44

Pulse oximetry, FBC, serum chemistry and glucose, urine tox screen, ECG

Question 45

How are BZD overdoses managed?

Answer 45

Supportive care - airway maintenance and IV fluids Flumanezil can be used in first time or infrequent BZD users as it can reverse CNS depression but risks often do not outweigh the benefits as seizures are common whilst using this drug

Question 46

What is serotonin syndrome?

Answer 46

A potentially life-threatning-drug-induced condition caused by too much serotonin in the synapses of the brain

Question 47

What drugs can cause serotonin syndrome?

Answer 47

SSRI SNRI MAOI St Johns Wort Ondansentron Metoclopramide Illicit drugs - cocaine, MDMA, amphetamine, LSD

Question 48

What are the autonomic symptoms of serotonin syndrome?

Answer 48

``` hypertension tachycardia hyperthermia (>41 oC) hyperactive bowel sounds mydriasis excessive sweating ```

Question 49

What are the neuromuscular abnormalities caused by serotonin syndrome?

Answer 49

``` Tremor Clonus Ocular Clonus Hypertonicity Hyperreflexia ```

Question 50

What are the mental state changes that are seen in serotonin syndrome?

Answer 50

Anxiety Agitation Confusion

Question 51

What investigations are performed if serotonin syndrome is suspected?

Answer 51

Diagnosis of serotonin syndrome is based off clinical findings UsEs and CK levels will be useful to see if there is any renal impairement and to check for rhabdomyolysis FBC LFTs useful too

Question 52

What is the management of Serotonin syndrome?

Answer 52

REMOVE OFFENDING AGENT IV Fluids and control agitation using BZDs Mild SS = supportive measures Moderate SS = correct CV and thermal disturbances, cyproheptadine Severe SS = intensive care with early sedation, neuromuscular paralysis and ventilatory support