12 - Pshchiatry intro 4 lectures Flashcards
organic vs functional in psychiatry
Functional – neurotic disorders (e.g. depression, anxiety, phobias) or psychotic disorders (e.g. schizophrenia, bipolar disorder) we may all experience for a while
Organic- e.g. dementia, psychiatric
manifestations of epilepsy or Parkinson’s or
stroke, acquired or traumatic brain injury,
Huntington’s disease, drug-induced states,
etc.
define anxiety, what are its symptoms
a feeling of worry about an uncertain outcome
- Palpitations
- Sweating
- Trembling or shaking
- Dry mouth
- Difficulty breathing
- Chest pain or discomfort
- Nausea or abdominal distress (e.g. butterflies in stomach)
- Feeling dizzy, unsteady, faint or light-headed
anxiety is a normal response of the limbic system stimulating the sympathetic NS in response to a threat
outline how the limbic system responds to stressors
o This response is mediated primarily by the limbic system, which has neural and endocrine targets
Neural elements of the stress response (limbic system)
• Hippocampus
o Receives inputs from many parts of the cortex and
processes their emotional content
o Ultimately projects to the thalamus and also to the
hypothalamus
(causing autonomic features of
emotional responses, since the hypothalamus send
projections down through the cord to autonomic
preganglionic neurones – the hypothalamospinal tract.
This will lead to sympathetic nervous system activation,
as well as release of adrenaline from the adrenal
medulla – the acute stress response)
• Amygdala
o Almond shaped structure sitting near the tip of the
hippocampus
o Receives many inputs from the sensory system
o Major outputs to cortex and hypothalamus
Endocrine elements of the stress response
• The limbic system is able to act on the hypothalamus to
stimulate the secretion of stress hormones
o Via the familiar hypothalamo-pituitary-adrenal axis
o Release of cortisol from the adrenal cortex is part of
the ‘chronic’ stress response
key facts on the hippocampus
Folded into medial surface
of temporal lobe
Occupies floor of temporal
horn of lateral ventricle
Three parts: subiculum,
hippocampus proper,
dentate gyrus
Involved in memory and
expressions of emotion
key facts on the amygdala
Buried in the roof of lateral ventricle
Collection of nuclei
Inputs of sensory information, brainstem, thalamus, cortex
Outputs to cortex, brainstem and hypothalamus
Drive related behaviours and processing of associated emotions
anxiety pathologically is when we gain a stress response to a threat that cannot be ran away from ie work ect
bonus
what are the key anxiety disorders ?
PTSD
OCD
Panic and socail disorders
generalised anxiety
briefly outline the 3 stages of the general adaptation syndrome to stress
The general adaptation syndrome refers to three stages that the body goes through
during prolonged exposure to stressors
o Stage 1: The alarm reaction
Release of adrenaline and cortisol as well as sympathetic activation
(described above)
o Stage 2: Resistance (effect of adrenaline starts to wear off)
Chronic stress response, prolonged release of cortisol
o Stage 3: Exhaustion (when you cannot escape an ongoing stressor)
Chronic side effects of prolonged cortisol secretion start to occur
o The stress response can become pathological when you cannot escape a
stressor(s), or when ‘trivial’ stressors elicit a strong stress response.
However, patients with anxiety disorders may go through all of the stages
above
what is GABA and its role in stress
it is the main inhibitory neurotransmitter
it is lower in patients with panic disorders
we can treat with benzodiazepines(short term only) to increase gaba transmission decreasing anxiety
long term we also can increase seretonin with ssri’s
and give patient CBT
outline OCD
obsessions - they dominate the thoughts and are unpleasant
compulsions - are motor acts to neutralise the obsessive impulse
the patient acknowledges the obsession is unreasonable or excessive but cannot stop it
repetitive and unpleasant
side fact - PANDAS - a strep infection in a child can trigger OCD symptoms due to antibody cross reaction with neurons of basal ganglia - kinda mad
treatment of OCD is …
o Treatment Biological • SSRIs +/- antipsychotics - help block basal ganglia re entry loops ? • Deep brain stimulation? Psychological • CBT and variety of other interventions Social • Family support • Groups etc
outline PTSD
o Features
Can occur within six months following an exceptionally severe traumatic event (e.g. rape, battlefield trauma)
Causes repetitive, intrusive recollection or re-enactment of the event in memories, daytime imagery, or dreams
There is conspicuous emotional detachment, numbing of feeling, and avoidance of stimuli that might arouse recollection of the trauma
o Pathophysiology
Unclear
• Evidence of amygdala hyperactivity causing exaggerated behavioural responses
• However, low levels of cortisol!
PTSD treatment
Treatment Biological • SSRIs • Maybe short term benzodiazepines Psychological • CBT • Eye movement desensitization reprocessing therapy Social • Charities are particularly active, such as ‘Help for Heroes’
what are the features of Depression
more than two weeks
core of low mood, low energy, lack of enjoment in anything
depressive throughts
may stop eating
some somatic biological symptoms
most severe - psychotic symptoms possible
depression vs adjustment reaction
in a ADR - energy is not low time is limited onset sudden after event not gradual no sleep disturbance pattern anger is common unlike depression
outline the features of mania / a mainic episode
Elated Mood • Increased energy • Pressure of speech • Decreased need for sleep • Flight of ideas • Normal social inhibitions are lost • Attention cannot be sustained • Self esteem is inflated, often grandiose • May have psychotic symptoms
how do we diagnose bipolar affective disorder
2 types
• Diagnosis is made following 2 episodes of a mood disorder at least one of which is mania or hypomania.
- Bipolar 1 – discrete episodes of mania only or mania and depression
- Bipolar 2 – discrete episodes of hypomania or hypomania and depression.
dont need all of this - give some examples of physical differentials that may look like mania or depression
Physical health differentials: depression
• Hormone disturbance such thyroid dysfunction
• Vitamin deficiencies such as vitamin B12
• Chronic disease e.g. renal, CVS & liver failure
• Anaemias
• Substance misuse e.g. alcohol, cannabis & stimulants
• Hypoactive delirium
Physical health differentials: Mania • Iatrogenic e.g. steroid induced • Hyperthyroidism • Delirium • Infection e.g. encephalitis, HIV, syphyllis • Head injury • (intoxication with stimulants)
3 brain structures involved in a mood disorder are
elaborate on their roles
limbic system - runs emotion, some memory with hippocampus and motivation - all of these are reduced in depression
frontal lobe - The ventromedial prefrontal cortex – is thought to be involved in the
generation of emotions.
• While the orbital prefrontal cortex is thought to be involved in emotional responses – possibly via connection with the amygdala.
basal ganglia - Motor function; malfunction of the basal ganglia are implicated in neurological illnesses such as - Parkinson's disease - Wilson’s disease - Huntington's disease • Psychological function: - Emotion - Cognition - Behaviour
The main hypothesis is that mood is determined by functional circuits between these brain areas. E.g. the frontal lobe projects to parts of the limbic system which in turn connects to the basal ganglia and the brainstem. This affects: • Cognitive processed (thoughts) • Sympathetic output • Parasympathetic output • Motor systems
bonus info
Overall – involvement several circuits could
account for symptoms
• For depression:
• Prefrontal cortex: Slowing of thought, executive dysfunction.
Altered emotional processing.
• Amgydala: Abnormal emotional processing
• Basal ganglia: Impaired incentive behaviour. Psychomotor changes
the 2 main neurotransmitters affected in depressive diorders are …
seretonin Produced in the brain stem (Raphe nuclei) and transported to cortical areas and limbic system • Thought to have roles in: – Sleep – Impulse control (link with suicide) – Appetite – Mood thought to be low in depression - hence we use ssri's
Noradrenaline
• Produced in the locus coeruleus (pons) and projects to limbic system and the cortex
Functions in the brain:
• Mood
• Suggests a role in behaviour (arousal and attention) – fight or flight response
• Implicated in memory functions
NA is thought to be lowered in depression
outline the treatment for depression
think biopshycosocial
Treatment of Depression
• Biological - First line = Selective Serotonin Reuptake inhibitors.
Other options: SNRI’s, TCA’s etc
Life threatening/treatment resistant: ECT
- Psychological – First line treatment for depression: CBT
- Social – Help with e.g. isolation, social stressors (including housing,finances)
treatment of bipolar
biopshycosocial
difficult
aim for a steady maintinance state
treat the mania then the depression then mania ect
treat the maina
Biological – First line: antipsychotics
Alternatively: mood stabiliser
• Psychological – Acutely unlikely to be helpful, longer term – psychoeducation re. BPAD, triggers and signs of relapse.
• Social – Treat in a place of safety – where risk to self and others is
minimal. Consideration of implications of mania e.g. debts
(excessive spending).
treat the bipolar depression
Biological – Can use antidepressant – but ONLY with mood stabiliser cover. ECT Lithium • Psychological – CBT • Social – as for unipolar depression
Maintaining stability in bipolar disorder
• Biological – Mood stabilisers e.g. lithium, sodium valproate
Antipsychotic (used as a mood stabiliser e.g.Quetiapine)
• Psychological – Psychoeducation re. bipolar affective disorder.
CBT – to help prevent relapses
• Social – Consideration of BPAD on employment e.g. shift work.
Involvement of family, education of family etc.
define psychosis
the presence of halluscinations or dellusions - mostly auido or sometimes visual
a hallucination is a perception without a stimulus
a delusion is a fixed false belief which is unshakeable.
what are the key (first rank symptoms) of schizophrenia
• Auditory hallucinations - ie a third person - he brushes his teeth
• Passivity experiences - patient belives an external force (MI5) causes an action - put chip in tooth
• Thought withdrawal, broadcast or
insertion - the adding, removing of your thoughts by others
• Delusional perceptions
• Somatic hallucinations
what are some positive and negative symptoms ?
Positive symptoms:
Delusions, hallucinations, thought disorder, lack of
insight
Added symptoms
Negative symptoms: Underactivity, low motivation, social withdrawal, emotional flattening, Self neglect Symptoms that take away from the patient
bad idea to just remove all the + and leave the -, then then are mega depressed
outline the pathology of schizophrenia
just outline this, not the details
Dopamine (DA) theory of Schizophrenia
• Drugs e.g. amphetamines which
cause the release of DA induces
psychotic symptoms.
• All medications that antagonise DA receptors, help treat psychosis & those with the strongest affinity to D2 receptions are most clinically effective.
• 4 DA pathways in the brain.
Mesolimbic pathway
From Ventral tegmental area To Limbic structures
(amygdala, septal area, hippocampal formation)
and
Nucleus accumbens
both Thought to be overactive in schizophrenia
Mesocortical pathway
From Ventral tegmental area To Frontal cortex
and
Cingulate cortex
both Thought to be underactive in schizophrenia
Brain changes
Enlarged ventricles
Reduced grey matter (with reduced brain weight)
Decreased temporal lobe volume
Reduced hippocampal formation, amygdala, parahippocampal gyrus and prefrontal cortex
Neuropathology of Schizophrenia • Decreased pre-synaptic markers • Decreased oligodendroglia • Fewer thalamic neurons • Together these changes have led to a theory of “aberrant connectivity” causing schizophrenia.
outline how we may treat schizophrenia
Typical antipsychotics
• Block D2 receptors in all CNS dopaminergic pathways
• Main action as antipsychotics is on mesolimbic and mesocortical pathways.
But side effects come from antagonising D2 receptors in other pathways
Atypical antipsychotics
• Lower affinity for D2 receptors
• Milder side effects as dissociate rapidly from D2 receptor
• Also block 5HT2 receptors
bonus
if we block DA receptors - we are blocking the basal ganglia - Sub niagra - putamen ect loop
this leads to movement inhibition increase and stimuli decrease
causing parkinsonism
what are some side effects of antipsycotics
Hyperprolactinaemia & antipsychotics
• Dopamine normally inhibits prolactin release from the pituitary.
• DA antagonists, which lower DA lead to loss of DA’s inhibitory function, and therefore increased prolactin levels.
• This can lead to: amenorrhoea, galactorrhoea, decreased fertility, reduced libido and long term can lead to osteopenia/osteoporosis
what is a key issue of treating schizophrenic patients?
due to the nature of the disease they do not trust health professionals , so will often try and hide and not take medications
give in many forms to avoid this -ie in food, liquid ect
outline prognosis for schizophrenia
- Earlier someone is treated the better the prognosis.
- Moderately good long term global outcome in about 50%
• Mortality is twice as high as in general
population
• Shorter life expectancy
• Higher incidence of CVS disease, respiratory
disease and cancer
• Suicide risk is 9x higher than in general
population
• Death from violent incidents in 2x as high
• About 50% have a substance misuse
problem
• Higher rate of cigarette smoking
