all notse Flashcards
mitrazapine what class of drug?
NASSA
side effect of this drug?
weight gain
what does it prevent reuptake of?
5HT, NA (5N taru mitra) - varyingly inhibit
what class of drug is clomipramine?
TCA
what peptide transmitters are involved in aversive defensive systems?
NA/CRF
hippocampus - approach or defensive?
defensive
biosynthesis of serotonin?
try 5 - tryptophan -> 5 hydroxytryptophan -> serotonin
5HT2 receptors - where are they found?
everywhere basically
5HT1 ?
blood vessels/CNS - (a-f) alan
receptor effect of 5HT1?
inhibitory
effect of 5HT2?
excitory
an agonist of 5HT2?
LSD
Some biological functions of 5HT?
cooker - mood, apetite, sleep, anxiety, aggression, memory, learning, addiction
what can SSRIs be used to treat?
panic attacks, OCD, eating disorders, premature ejaculation, PTSD, chronic pain (knee), social anxiety disorder, DEPRESSION
how long does it take to increase synaptic 5HT?
hours
how long does it take to imove mood?
2-3 weeks
what does the increased concentration of extracellular 5HT stimulate?
5HT1a autoreceptors to inhibit firing
when do you get return to norma firing?
in chronic treatment
what sort of dose can you start an SSRI at?
ev therapeutic dose
side effects?
anxiety, sexual dysfunction, increased risk of suicude initial with young patients, dyspepsia, vomiting, diarrhoea, constipation.
which SSRIS inhibit CYP450?
fluoxetine and paroxetine
what drugs do SSRIs therefore have an interaction with>
drugs metabolised via the same pathway i.e. CYP450 pathway
sexual dysfunction in pathophysioogy?
can be dopamine blockade and/or 5HT2 activation
how can this be reversed?
5HT2 antagonists or 5HT1a partial agonists
TCA - block reptake of?
5HT and NA
titration?
require a bit more individualised dose titration
at higher doses, patients might need ECGs, what could be seen on ECG?
QT prolongation
adverse effects?
constipation, dry mouth, blurred vision, effects on cardiac function, postural hypotension.
CHAD. what does cholinergic and adrenergic blockade cause failure of?
peripheral orthostatic reflex
3 MAOIs?
Phenelzine, isocaroxazid, tranylcypromide
what does mono oxidase A metabolise?
5HT, NA, tyramine
MAO B, what does it metabolise?
DA, tyramine, phenylethylamine
which drug causes sympathy mimetic effects?
tranylcypromide
what are MAOIs used to treat?
atypical depression
what does MAO do in the gut?
inactivates tyrosine
how do patients on MAO inhbitors get hypertensive crisis ?
tyramine (in food like cheese) cause more NA to be released. under normal circumstances it would be broken down by MAO. increased levels of NA caused constriction of blood vessels
foods that contain tyrosine?
cheese, yoghurt, yeast extracts, broad beans, pickled herring, alcohol
can also cause high serotonin. symtptoms of high serotoin?
flushed, headache, increased BP
treatment? up hill ruri
chlorpremazine and phentolamine (prem, ph a)
what is akathisia?
inner restlesness
tremor, dystonia, akathisia and TD can occur which which anti depressant?
paroxetine
which hormone plays a key role in reward and motivation
dopamine
what is the main inhibitory neurone in developing brain
GABA
GABA actions in developing brain?
excitatory
GABA binding causes flow of which ions into post synaptic cell?
chlorine
do you get hyperpolarisation/depolarisation?
hyperpolarisation (cl-)
which ions flow into post synaptic cell from glutamate?
ca 2 +, causing depolarisation
two receptors that glutamate bind to?
NMDA and AMPA
which is faster?
AMPA
which one lets calcium through?
NMDA
GABA binding allows flow of either cl ions in to the cell or K ions out of the cell
yeah
antagonist of GABAa receptor?
flumazenil
agonists?
benzos, anaesthetics, ethanol, propofol
**GABA B agonists (GEE PROTEIN)
me and my back pack going to the show (baclofen, propofol)
Mood stabilisers? anti convulsants?
lamotrigine, valproate, carbamazepine
are they more effective at reducing manic episodes or depressive episodes?
manic
would you rather have type 1 BP or type 2?
type 1
ATYPICAL MOOD STABILISERS?
olanzepine, risperidone, quetiapine, ariprazole
other mood stabilisers?
lithium carbonate and nimodipine
what does lamotrigine do? Drug action)
blocks sodium channels
what overall effect does this have?
reduces cell firing
what also inhibit uptake of?___________
serotonin (MM)
Lithium. what does it do to BCL2? to 5HT auto receptors? inositol? GSK3?
increases apoptotic factor for BCL2, inhibition of 5HT autorecetors, depletion of inositol, inhibition GSK 3
what do you get in lithium overdose?
toxicity
there is a risk of inadvertent toxicity
y
what does lithium treatment require?
blood monitoring
anti psychotics show affinity for which receptor?
D2
in which circuit?
mesolimbic
movement disorders due to DA blockade in which pathway>
nigrostratial
hyperprolactinaemia?
tubero inffandibular
which part of the brain (in approach system) is involved in relative reward preference and rule learning?
OFC
periaqueductal grey matter - in approach or defence?
defence
average onset depression? bipolar?
27, 21
male to female ration depression, bipolar?
depression f2:1m , bipolar 1:1
in major depression what happens to cortisol?
increased
how would you test for this clinically?
increased cortisol in urine, saliva
what would the adrenal glands look like?
enlarged
in depression, TRH levels? TSH levels?
TRH up, TSH (pituitary) blunted
6 key regions implicated in mood disorders
orbital frontal cortex, hippocampus, ventromedial and prefrontal cortex, anterior cingulate nucleus, amygdala, DorsoLateral prefrontal cortex. down low
dense coactivation with AIC and ACC during almost all studies of emotion
y
there is dense connectivity with the anterior insular cortex and what?
anterior cingulate cortex
DO NOT use anti depressants to treat persistant sub threshold depressive symptoms or mild depression - risk benefit ratio is poor.
y
when do you consider anti depressants?
past history of moderate/severe depression, initial presentation of sub threshold depressive symptoms that have been present for a long period i.e. 2 years. also for sub threshold or mild depression that persists after other interventions
what is the typical treatment started for moderate or severe depression (top of page (yellow and red)
combination of anti depressant and high intensity pharmacological intervention
rules from isolated incidents that apply in all cases?
pat dog bite - overgeneralising
dichotomous thinking?
all or nothing or black and white thinking
what is the term for focusing on one negative detail and this colours entire experience?
selective abstraction
Personalisation?
relate external events to self without cause
Minimisation/magnification
over estimating/underestimating magnitude of undesirable events
drawing a conclusion in context of no evidence or contrary evidence
arbitrary evidence
what is emotional reasoning?
i feel bad/guilty, therefore i am bad/have something to feel guilty about
anorexia - BMI?
less than 17.5
how do people with anorexia lose weight?
strict dieting/vomiting/excessive exercise/medication
amenorrhoea
y
starvation effects on the brain?
loss of grey and white matter, increased compulsive behaviour, decreased social skills, poor concentration and new learning stunted, enhanced response to hedonic and neurostat signals
Investigations in anorexia?
haeatology/biochemistry/ecg/dxa
people with anorexia can be more at risk of?
heart disease
what heart problem can be picked up on egg?
long qt syndrome
what is the name of the scheme to manage patients with anorexia?
MARSIPAN
high risk AN?
13-14.9
v high risk?
less than 13
moderate
15-16
age of onset ?
9-24 years
moratlity rate?
20 percent - up to half are suicides
aetiology? biological
puberty, weght loss, starvation effects
physiological? (3)
brain atrophy, reduced attention and memory, hypothalamus dysfunction
physiological? (4)
low self esteem, childhood sexual abuse, perfectionist, adolescence, black and white thikning
renal complications of anorexia?
nocturia, acute or chronic renal failure, increased thirst (polydipsia)
physical signs?
lanugo hair, dry skin, bruising, hair loss, muscle wasting,
blood pressure and heart rate?
LOW and SLOW - bradycardia, low blood pressure
Metabolic complications? blood sugar, temp, hydration status, LFTs? electrolytes?
hypoglycaemic, hypothermia, dehydrated, raised LFTs, low K, PO4, Mg, Ca
Haematological?
anaemic (low b12, iron and foalate), low WBC, thrombocytopenia (low platelet)
cortisol, TOG, thyroxin?
increased cortisol, decreased test, oest, gonadotrophin), decreased thyroxin
co morbidities of AN? dance floor ***
DODS, diabetes, depression, OCD and Substance misuse
what happens to the muscles and bones in anorexia?
muscle cramps, tetany, spasm, ospeoperosis and possible fractures
Risk assessment - bad signs
BMI less than 13 with weight loss of over 1kg per week, prolonged QT, heart rate less than 40, SBP less than 80, core temp less than 34, unable to rise from squat position without using arms or legs, cognitive impairment
refeeding syndrome is caused by?
Depletion of MPP. magnesium, phosphate and potassium.. already inadequate stores are used up as body starts to repair itself.
GI side effects?
swollen salivary glands, dental caries, delayed gastric emptying, bloating and constipation
Bullemia - 4 criteria? jamie 3 and attempts
persistant pre occupation with eating, irreversible craving for food, binges then attempt to counter the effects of binges.
4 ways they attempt to counter?
NO EXERCISE!!! (model) starvation, laxatives, vomiting, drug misuse
hydration status? K?
dehydration and hypokalaemia
signs in the eyes?
subconjunctival haemorrhage
what are the callouses on knuckles called?
russells sign
hypertrophy of what?
parotid gland
teeth?
dental caries (acid)
what proportion make good recovery with tx?
50 percent
evidence based treatment?
CBT, SSRI (send step brother to table)
Binge eating disorder - more males or females?
females
compensatory behaviour?
no
what is important about the food?
taste and quality
which gene codes for glutamine?
CAG
what happens if there are more CAG repeats in the genome?
bigger glutamine chains are present in the huntington protein. protein is misshapen.
what do misshapen huntington proteins do to the brain?
gradually damage the brain. neuronal loss leads to huntingtons disease
is there a genetic test?
yes, very easy
what is life exp of alzheimers after diagnosis?
7 years
what is one of the first areas in the brain to be affected in al?
nucleus basalis of meynert?
early onset familial disease accounts for what percentage?
2 percent
tend to have 3 affected individuals in family under the age of 60
y
sensation of a lump in throat indicative of?
anxiety problem
numbness/tingling sensation
same
cognitive problems in anxiety?
mind going blank, self distant, racing thoughts
which part of the brain acts as an emotional filter for brain assessing whether sensory material via the thalamus requires a stress or fear response?
amygdala
where is cortisol released from?
adrenal
GAD - how long do you have to have it? control? impact?
6 months, can’t control, significant impact
what is the course of the condition like?
fluctuating
what is dissipation? (genetic)
know you’re going to get a disease faster than your parents
age of onset?
20-40
free floating anxiety, what are the 4 main symptoms?
nervousness, trembling, muscular tensions, sweaty/lightheaded
f:m ratio?
2 females to 1 male
balanced translocation - what test?
fish (normally do ACGH, but that only picks up imbalances)
what is GAD associated with (bedroom)
feeling restless, keyed up or on edge, difficulty concentrating, mind going blank, muscle tension, sleep disturbance
GAD is associated with disability, medically unexplained physical symptoms, over utilisation of health care responses
y
what antidepressant can be used in GAD?
venlafaxine
what class of drug is this ?
SNRI
Panic disorder - are they restricted to any particular place or set of circumstances?
no, they are unpredictable
symtoms? including onset
sudden onset palipations, chest pain, choking sensation, diziness, feelings of unreality
secondary fear of?
dying, losing control, going mad
can be with/without what condition?
agoraphobia
what can panic disorder NOT be due to?
a drug or effect of a drug. also not correct if it is better accounted for by another medical condition
what percentage have agoraphobia?
50-67%
waxing and weaning (moon) what does it mean?
usually moving towards full or past full blown
at 10 year follow up, statistics?
1/3 well, 1/3 moderate improvement, 1/3 worse
what other conditions can it be co morbid with? (sack bin)
other anxiety disorders, depression, alcohol , drug (DAD)
what can trigger it in susceptible individuals ?
lactate infusions (weight in bike shelter) - by product of muscular activity
what else?
rebreathing air (by increasing carbon dioxide)
what would you see on a PET scan? increased metabolism where?
parahippocampal gyrus
three types of phobia?
agorophobia, specific phobia, social phobia
fear of being in siutations where escape might be unavoidable?
agoraphobia
what are the symtptoms of agoraphobia while on public transport/shopping centre/leaving home?
panic attack
what does this often involve to avoid anxiety?
other people doing things for them or online (i.e. internet shopping)
specific phobia cued by?
specific object or situation
do they have insight?
yes, recognise the fear as excessive/unreasonable
what is social phobia?
persistent fear of social or performance situations in which someone is exposed to scrutiny by others
what does the individual fear?
they will act in a way that is embarrassing or humiliating
common symptoms
blushing or shaking, fear of vomiting, urgency, fear of urination and defacation
increase in bilateral activation of?
amygdala
what happens in terms of cerebral blood flow?
increases bilaterally
what RIMA anti depressant can you use?
meclobomide
what drug class is this?
RIMA
defence has a _________ origin?
midbrain
when do you get tonic immobility? (freezing)
inescapable threat
what sort of situation would it happen in?
sexual assault case
symptoms?
decreased vocalisation, intermittent EC, rigidity and paralysis, muscle tremors in extremities, unresponsiveness to pain
what is the orientating response?
immediate response to change in environment
with increasing proximity to a predator, brain activation shifts from _________ to the ___________. (football pitch)
prefrontal cortex to the midbrain (defensive)
which specific 2 areas in the midbrain?
PAG, SC (superior colliculi)
acute stress leads to increase in what?
catecholamines and cortisol
what is the purpose of cortisol release in stress?
to shut down the stress response
what sites does it exert negative feedback on?
pituitary, hypothalamus, hippocampus, amygdala
cortisol levels in PTSD?
low
acute stress increases cortisol levels, but the RISE in cortisol levels are lowest in PTSD
y
what psychiatric problems are co morbid?
depression, drug and alcohol misuse
risk of suicide in PTSD?
6 x higher (c note, suicide note)
DSM IV criteria?
traumatic event. INTRUSIVE symtoms (1) or more avoidance symtoms 3 or more hyper arousal (2 or more)
duration has to be?
4 weeks (red arrow to head)
they also have to have distress and impairment in social/occupational functioning)
y
avoidance and emotional symptoms?
avoid thinking about it, avoid reminders about event i.e. places, amnesia for important aspect of trauma, loss of interest in activities, detachment, emotional numbing
hyerarousal?
sleep disturbance, irritability/anger, concentration difficulties, hyper vigilance, exaggerated startle response
intrusive symptoms?
nightmares, flashbacks, physiological reactions, recurrent distressing recollection
where are defence and orientating responses generated
midbrain
what do high levels of cortisol damage?
the hippocampus
brocas area in PTSD, what happens?
reduced blood flow
how are memories described?
fragmented
which part of the brain has a role in memory and the stress response?
hippocampus
which part is involved in the role of fear during trauma and recollection?
amygdala
“it feels like yesterday” i had that last broca
reduces bloodflow
the emotional memory in PTSD is in which side of the brain?
RHS
impairment of emotional event memory related to which part of brain? green box around it?
amygdala
therapy treatment used ? C notE
CBT and EMDR should be used
4 drugs that can be used?
first 2 - mitrazipine and paroxetine. 2nd take trip to pond. amytriptyline and phenelzine
