Conditions Flashcards
Name the 3 core symptoms of depression?
Low mood, anhedonia (loss of pleasure in activities) and anergia (loss of energy)
How would you describe the low mood?
Constant, diurnal variation (worse in morning, better at night)
Name 8 other (non-core) symptoms of depression?
Lack of libido, lack of sleep, lack of appetite, weight loss, lack of concentration, feelings of hopelessness for future, feelings of guilt, loss of confidence
How do you describe the sleep pattern in depression?
Early morning wakening (waking up 3/4 hours before alarm) and not getting back to sleep. Or initial insomnia
How would you diagnose mild depression?
2 out of 3 core symptoms. and 2-3 other symptoms. Very mild impact on functioning
How would you diagnose moderate depression?
2 out of 3 core symptoms and 4 other symptoms. Marked impact on functioning
How would you diagnose severe depression?
3 out of 3 core symptoms and 5 other symptoms. Severe impact on functioning.
What are important negatives to rule out before diagnosing depression?
Bipolar?- any episodes of elated mood etc. Drug/alcohol induced? Psychosis?- any hallucinations etc
Name 5 risk factors for depression
Unemployed, chronic physical illness, genetic, childhood trauma eg. abuse/loss of parental care, personality- anxious, obsessional, low self esteem
Name 5 risk factors for depression?
Unemployed, chronic physical illness, genetic, childhood trauma eg. abuse/loss of parental care, personality- anxious, obsessional, low self esteem
What is the cause of depression?
Decreased serotonin function (& GABA, dopamine, noradrenaline)
What is the first line treatment of depression (& mild depression)?
CBT, self help, group therapy, IAPT
What is the 2nd line treatment of depression (& moderate depression)?
psychological therapies AND antidepressants
What is the first line anti-depressant used? and why? and give 3 examples
SSRIs eg. citalopram, sertraline, fluoxetine. They are first line because they are the safest in an overdose.
What is the mechanism of action of SSRIs?
They stop the re-uptake of serotonin by inhibiting the re-uptake pumps leaving more free serotonin in the synapse
Name 4 side effects of SSRIs?
sexual dysfunction, weight loss, D&V, hyponatraemia
What is the main thing to tell patients before starting them on anti-depressants?
That they will feel worse initially before they get better
What are the 2nd line anti-depressants used? (2) and give examples
Mirtazipine, SNRIs - venlafaxine, duloxetine
How does mirtazipine work?
It’s a NASSA (noradrenergic and specific serotonergic antidepressant). Antagonist to adrenergic and serotonergic receptors to increase it’s neurotransmission (adrenergic receptors are inhibitory)
How long does it generally take anti-depressants to work?
Around 4 weeks.
How do SNRIs work?
Selective noradrenaline reuptake inhibitors- Inhibit the re-uptake pumps and noradrenaline transporter increasing the amount of free noradrenaline in the synapse
Name 3 side effects of mirtazipine.
Drowsiness, weight gain, dry mouth
Name 3 side effects of SNRIs
Sexual dysfunction, nausea, insomnia
Name 3 TCAs
Amitryptilline, nortryptilline, clomipramine
How do TCAs work?
Block both serotonin and noradrenaline pumps to increase the amount of free serotonin and noradrenaline. But also blocks muscarinic and cholinergic receptors
Name 4 side effects of TCAs?
Constipation, dry mouth, blurred vision, urinary retention ‘can’t shit, can’t spit, can’t see, can’t pee’
Name 2 MAOIs
Rasagiline, phenelzine
How do MAOIs work?
Block the monoamine oxidase enzyme to stop the breakdown of monoamines - higher levels of serotonin and noradrenaline in the synapse
Why are MAOIs potentially dangerous?
Tyramine is a monoamine present in many things and is a potent vasoconstrictor. It is not broken down due to MAOIs so can cause hypertensive crisis.
What are 3 side effects of MAOIs?
Constipation, headache, postural hypotension
Why are MAOIs not used as much anymore?
Lots of dietary restrictions - couldn’t eat foods with tyramine in eg. beer, white wine, cheese, smoked meat/fish
What is the leading cause of maternal death post partum?
Suicide.
What is discontinuation syndrome?
Symptoms that occur when antidepressants are stopped abruptly or the dose is decreased too quickly
What symptoms do you get in discontinuation syndrome?
GI disturbances, flu like symptoms, anxiety, sweating, dizziness, electric shocks down spine and neck
What 2 drugs are the main culprits of discontinuation syndrome and why?
Venlafaxine and paroxetine- they have the shortest half lives so are excreted from the body very quickly
When are patients deemed to be treatment refractory on anti-depressants?
When 2 or more anti-depressants haven’t worked
How do you treat treatment refractory depressed patients
Combine anti-depressants, Mood stabiliser- lithium, anti-psychotics, Vortioxetine (serotonin modulator), ECT
When is ECT indicated?
For severe depression- when medication hasn’t worked and it is becoming potentially life threatening
What is the mechanism of action of ECT?
Unknown. Think maybe it increases release of neurotransmitters or enhances response of post-synaptic receptors to neurotransmitters
Name 6 side effects of ECT
Memory loss, confusion, drowsiness, headache, nausea , aching muscles, loss of concentration in longer term
Define ‘bipolar disorder’
A disorder characterised by 2 or more episodes of alternating mood - either elated with increased energy (mania) or low mood with decreased energy (depression)
Define Bipolar I disorder
Mania and depression (sometimes only mania)
Define Bipolar II disorder
More episodes of depression and only hypomania
Give 7 symptoms of mania
‘DIGFAST’: distractibility, indiscretion (impaired judgement and reduced social inhibitors), grandiose delusions (can be psychotic sx= diagnostic of mania), flight of ideas, activity increase, sleep deficit/increased sexual activity, talkative (pressure of speech)
What is the difference between mania and hypomania?
Hypomanic symptoms last 4+ days, manic sx last over a week. Hypomania only partially affects functioning, mania fully affects the patient’s functioning and life
What is cyclothymia?
Disorder similar to bipolar but they have milder symptoms so switch between episodes of mild depression and hypomania
What is the gold standard treatment of Bipolar? (medication)
Lithium. Works best on mania and works to reduces relapses
How does Lithium work?
Mechanism of action is unknown. Thought to inhibit cAMP production (which inhibits monoamines), overall increasing monoamines
Why is it important to monitor drugs and diet etc while on lithium?
Anything that causes the body to lose sodium and water can be damaging because lithium already causes water loss and can lead to toxicity eg. Diuretics, NSAIDs, ACEi low salt diet,
Name 6 side effects of Lithium
LITHIUM: diabetes insipidus, fine tremor, hydration - increased thirst and polyuria, increased GI disturbances, underactive thyroid (hypothyroidism), metallic taste in mouth
What 3 aspects need careful monitoring when on Lithium?and when are they checked?
Lithium levels- every week until the dose is stable, on every dose change and 3 monthly once stable. Thyroid function at the start and every 6 months. Renal function at the start and every 6 months
What is the biggest risk while on lithium?
Lithium toxicity
What level does lithium have to be to be toxic?
> 1.5 mmol/L
Name 4 causes of lithium toxicity
Overdose, sudden dehydration, diarrhoea and vomiting,, new drugs/interactions eg. NSAIDS, diuretics, ACEi, change in salt level in diets
Name 6 symptoms of lithium toxicity
Coarse tremor, diarrhoea, vomiting, myoclonic jerks, seizures, confusion
Between what ages is the commonest onset of schizophrenia?
15-35 years old
What is the cause of schizophrenia?
Overactivation of dopamine receptors leading to excessive dopamine production
Name 3 risk factors of schizophrenia?
Birth injury - such as infant hypoxia or viral infections in pregnancy, substance misuse especially cannabis, childhood/family dysfunction
What is the definition of schizophrenia?
A disorder characterised by a distortion in thinking and loss of contact with reality.
Name the first rank symptoms of schizophrenia?
3rd person auditory hallucinations ‘running commentary’, delusional perceptions (delusions of reverence), passivity phenomena, thought alienation- thought insertion, thought withdrawal, thought broadcast
What is the definition of delusional perceptions?
A true perception to which a patient has attributed a false meaning eg. patient will see the traffic light turn green and believe the government is after them
What is the definition of passivity phenomena?
The belief that external agents are controlling the patient’s thoughts and movements.
What is the definition of thought insertion?
Patient’s believe that thoughts are being put into their head by external agents
What is the definition of thought withdrawal?
Patients’ believe that thoughts are being taken out of their head by external agents
What is the definition of thought broadcast?
Patients believe that everyone around them can hear what they are thinking
Name 5 secondary symptoms of schizophrenia?
Delusions. 2nd person auditory hallucinations, hallucinations in any other modality eg. tactile, visual. Negative symptoms- apathy, blunted emotional responses, social isolation, poverty of speech, self-neglect. Catatonic behaviour- either motor rigidity or severe excitement.
How do you diagnose schizophrenia?
Need 1 first rank symptom lasting 1 month or more
What investigations would you do when a patient presents with a mental illness?
FBC- WCC, U&Es, CRP/ESR, glucose, urine drug screen, LFTs, TFTs. CT/MRI brain- exclude structural causes. ECG.
What examinations would you do when a patient presents with a mental illness?
Cardiac exam- listened to heart sounds, respiratory exam- any infection? normal breath sounds. Neurological exam- any neurological sx from any disorders? Abdominal- any masses? Urological- UTI eg
How do typical anti-psychotics work?
They antagonise dopamine 2 receptors so artificially decrease the amount of dopamine in the brain
Name 4 typical/first generation anti-psychotics?
Haloperidol, chlorpromazine, sulpiride, prochlorperazine
Name 6 atypical/2nd generation anti-psychotics?
Clozapine, Amisulpiride, Quetiapine, Olanzipine, Risperidone, Aripriprazole
How do atypical anti-psychotics work? And why are they more advantageous?
They block dopamine 2 and serotonin (5HT) receptors which reduce the number of EPSEs
When is clozapine used?
For treatment resistant schizophrenia.
When are patients declared treatment resistant and requiring clozapine?
When 3 antipsychotics have been tried and failed
What is the biggest risk to the patient when on clozapine?
Agranulocytosis so need mandatory monitoring of FBC monthly
Name 3 other side effects of clozapine (other than agranulocytosis)
Constipation, myocarditis, hyper salivation
What are the side effects of first gen/typical anti-psychotics? (4)
ESPEs - acute dystonic reaction, tardive dyskinesia, Parkinsonism, akathisia
What are the symptoms of acute dystonic reaction? (3)
Sustained involuntary muscular contractions affecting any part of body eg. Muscle spasm, ocular gyrate crisis (eyes rolled up), acute torticollis (twisted neck)
How do you treat acute dystonic reaction?
ABCDE. Treat with fluids and IV anticholinergics- procyclidine (blocks Ach so stops parasympathetic impulse causing s/m contraction)
What are the symptoms of tardive dyskinesia? (3)
Tongue protrusion, lip smacking, grimacing
How do you treat tardive dyskinesia?
Stop the anti-psychotic.
What are the symptoms of Parkinsonism (4)
Bradykinesia, resting tremor, rigidity, shuffling gait
How do you treat the symptoms of Parkinsonism?
Change the anti-psychotic/reduce dose, anticholinergic- procyclidine
What are the symptoms of akathisia?
‘inner restlessness’, pacing, agitation
How do you treat akathisia?
Change anti-psychotic/ reduce dose to lowest possible, may need propranolol
What are the side effects of atypical/2nd generation antipsychotics (9)
They are more anticholinergic side effects - dry mouth, constipation, blurred vision, urinary retention, palpitations, weight gain, diabetes, erectile dysfunction, HYPERPROLACTINAEMIA
What are 2 emergency side effects of antipsychotics?
Long QT syndrome, neuroleptic malignant syndrome
Name 7 things that need regularly monitoring while on antipsychotics
Bloods- FBC, U&E, Lipids, HbA1c, LFTs. ECG- long QT, prolactin, BP, weight, efficacy and adherence, side effects
What psychological treatment is used in schizophrenia?
CBT, family therapy, substance misuse clinic (if needed), social- housing, occupation
What is schizoaffective disorder?
Condition which has symptoms of a mood disorder and psychotic symptoms at the same time with the same intensity
How do you treat schizoaffective disorder?
With antipsychotics and a mood stabiliser
What is the triad of symptoms in serotonin syndrome?
Autonomic hyperactivity- tachycardia, sweating. neuromuscular abnormality- hyperreflexia, clonus, tremor. Mental state change- confusion, anxiety, agitation
What is the cause of serotonin syndrome?
Excessive stimulation of serotonin receptors. Can be due to normal drug dose, overdose, drug interactions
What drugs cause serotonin syndrome?
Antidepressants- SSRIs, TCA. analgesics- tramadol, pethidine. Recreational- amphetamine, cocaine. Anti-emetics
What investigations would you do in someone presenting with symptoms of serotonin syndrome?
Toxicology screen to find cause. Diagnosis is clinical.
How do you treat serotonin syndrome?
If mild- supportive tx: IV fluids and benzodiazepines for agitation. If severe- ITU for ventilatory support and sedation
What is the cause of neuroleptic malignant syndrome?
Greatly reduced function and amount of dopamine. Side effect of anti-psychotics.
What are the symptoms of neuroleptic malignant syndrome?
Fever, muscle rigidity- dyspnoea, dysphagia, difficulty walking, altered mental state- confusion, agitation, autonomic dysfunction- pallor, tachycardia, sweating
What is the main sign found on investigation in neuroleptic malignant syndrome
Very raised creatinine kinase
What is the treatment of neuroleptic malignant syndrome?
Supportive- IV fluids, cooling blankets for fever, Benzos for agitation. Dopaminergic drugs eg. bromocriptine.
What is the definition of personality disorder?
Prevailing, chronic, abnormal disturbances in personality and behaviour
Name 4 characteristics of a paranoid PD?
Suspicious of others, holds grudges, distrusting, preoccupied with conspiratorial explanations
Name 4 characteristics of a schizoid PD?
Emotionally cold- withdrawn from others and can’t show emotion. Socially isolated- no interest in others. Prefer to be in a fantasy world. Excessive introspection.
Name 4 characteristics of a dissocial PD?
Aggressive, callous unconcern for other people, lack of guilt for what they’ve done, criminal activity is common
Name 4 characteristics of borderline (emotionally unstable) PD?
Unpredictable mood and affect- prone to outbursts of emotion, unclear sense of self/aims, unstable/intense relationship. Pseudohallucinations. Self harm/suicide attempts.
Name 4 characteristics of borderline (impulsive) PD?
Impulsive behaviour- acts without thought for consequences, unpredictable mood and affect- prone to outbursts. Inability to control anger- lash out. Tendency to conflict with others.
Name 4 characteristics of a histrionic PD?
Over-dramatise with exaggerated expression of emotions self-centred, seeks attention and excitement, manipulative behaviour, easily hurt feelings
Name 4 characteristics of anankastic PD?
(Obsessive compulsive) Worries and doubts, perfectionist, repeated checking and preoccupation with details, rigidity and stubbornness
Name 4 characteristics of an anxious PD?
Feelings of tension/anxiousness, fear of rejection- wants to be liked, insecure, tendency to avoid everyday situations by exaggerating dangers of it.
Name 4 characteristics of a dependent PD?
Reliance on other people, clingy and submissive to wishes of others, fear of abandonment, feels helpless and incompetent (especially when not in relationship)
What are 5 risk factors/causes of developing PD?
Growing up : Abuse (physical, sexual, verbal), neglect, trauma eg. death of parent, unstable family life- parent is alcoholic/ mental health issues, being bullied
What is the main treatment of PD? and how does it work?
DBT- dialectical behavioural therapy. Emphasis on developing coping skills to improve affective stability and impulse control and on reducing self-harm behaviours
Are medications useful in PD?
Useful in symptom management eg. aggression- short term benzodiazepines, mood stabilisers- antipsychotics, antidepressants if comorbid depression
What is the definition of anxiety disorder?
Excessive anxiety (feeling fearful, worried and tense) constantly, across different situations and lasting >6 months
What are 7 symptoms of anxiety?
Insomnia, feeling fearful, worried and tense in all situations, irritability, poor concentration, Sweating, nausea, hyperventilation, dependence on 1 person, avoidance
What are 3 causes of anxiety?
Stress at work/home eg. lots of work/relationship troubles, genetics, stressful events- lost job, moving house etc
What is the first line treatment of anxiety?
Symptom control. Regular exercise, mediation. Psychological therapies.
Name 3 psychological therapies that can be used in the treatment of anxiety?
CBT with relaxation. Progressive relaxation training- teaches deep breathing and relaxing muscles. Behavioural therapy- with exposure to anxiety provoking stimuli
Name the first line medication given for anxiety?
SSRIs- eg. sertraline or benzodiazepines eg. diazepam (but only in short term bursts)
What other medications (not first line) given for anxiety?
Pregabalin. 2nd line- SNRI/TCA. Beta blockers can be used to treat physical symptoms of anxiety eg. sweating ,palpitations, tremor.
Define panic disorder
Acute onset of intense panic and anxiety symptoms that don’t usually last longer than 20 minutes
Name 6 physical symptoms that occur in panic disorder?
Palpitations, tachypnoea, chest pain, dry mouth, choking, dizziness
Name 5 psychological symptoms that occur in panic disorder?
Feeling of impending doom, fear of dying ,fear of losing control, depersonalisation (thoughts/feelings don’t belong to them), derealisation (altered perception that world isnt real)
Define OCD.
Obsessive compulsive disorder. Patient will have obsessive thoughts and do compulsive acts and will try to be resisted by patient initially.
What are obsessions?
Stereotyped, purposeless words or thoughts eg. if dont wash hands 40 times a day ,she will get a severe infection
What are compulsions?
Sensless repeated rituals eg. repeated hand washing
Name 3 characteristics about the obsessions
Irrational (recognised by pt), repetitive and intrusive
What are the 3 most common compulsions?
Checking things repeatedly, counting and washing
How do you diagnose OCD?
Obsessions/compulsions on most days for at least 2 weeks and interfering with life - usually by wasting time
What is the pathophysiology behind OCD?
Abnormalities in orbitofrontal cortex and caudate nucleus
What are 5 causes of OCD?
Genetics, developmental factors- abuse, neglect, bullying. Stress eg. pregnancy. Personality characteristics- obsessive type. Neurological conditions- frontotemporal dementia/ tumour
Which psychiatric patients are at risk of OCD? (4)
Depression, anxiety ,substance misuse, eating disorders
What is first line treatment for OCD?
CBT- exposure and response prevention. Expose them to the trigger.
What is the medication treatment for OCD?
First line- SSRI eg. fluoxetine. or Clomipramine - TCA
What is the definition of a phobia?
Anxiety that is experienced only/predominantly in situations that aren’t dangerous
When does a phobia become a phobic disorder?
When it begins to significantly impair function
Name 4 symptoms of phobia
Palpitations, feeling faint, losing control, fear of dying
What is agoraphobia?
Fear of big areas eg. crowds, supermarkets, travel, events away from home. They fear something bad will happen so tend to avoid this.
What are social phobias? What are 3 symptoms?
Triggered by certain situations eg. small dinner party. Worried about judgement from other people. Sx= blushing, hand tremor, nausea
What is a simple phobia?
Phobia is triggered by certain situations only eg. spiders, clowns, heights, small spaces
What is the main treatment for a phobia?
Exposure therapy
What is the definition of acute stress reaction?
It’s a transient condition that develops as a response to exceptional physical/ mental stress that usually lasts hours-days.
What are the symptoms of acute stress reaction?
Immediate dissociation- disorientated, loss of attention, decreased consciousness. Followed by mixed emotions -anger, anxiety, confusion
What is the treatment for acute stress reaction?
TRICK QUESTION! Sx usually resolve without intervention
What is PTSD?
Post traumatic stress disorder. It develops after an exceptionally stressful, life threatening or catastrophic event.
Name 7 symptoms of PTSD.
Flashbacks in day time and nightmares replaying the past trauma, hypervigiliance, insomnia, paranoia, detachment from others, anhedonia, poor concentration, suicidal thoughts
What is the pathophysiology of PTSD?
Failure to inhibit amygdala which is responsible for fear and decreased amygdala threshold for fearful stimuli
What is the first line treatment for PTSD?
Trauma focused CBT. Eye movement desensitisation and reprocessing (uses rhythmic eye movements to decrease anxiety associated with traumatic events), Anxiety management, relaxation/de-stress techniques.
What medications can be given for PTSD?
SSRI- fluoxetine! Mirtazipine. Benzos can be given for sleep and irritability- short term.
