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Psychiatry (2) > Depression and Anxiety > Flashcards

Depression and Anxiety Flashcards

1
Q

Define inequality.

A

• Inequality = lack of equality, fairness or evenness

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2
Q

Describe the term health inequalities.

A

• Health inequalities = systematic, avoidable and unfair differences in health outcomes observed between populations, social groups or gradients across population ranked by social position

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3
Q

List 3 key areas of the Black Report.

A

Artefact explanations

Natural/Social Selection

Materialist explanations

Cultural/Behavioural Explanations

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4
Q

Give two socioeconomic ranking systems.

A
  1. NS-SEC
    • 1-9 (9 is full-timer students): Descending ‘importance’
    • 1: Higher managerial administrative/Professional Occupations
    • 2: Lower managerial administrative/Professional Occupations
    • 7: Routine occupations: Cleaners, Refuse collectors
  2. SIMD
    • Area measure using: income, employment, education, health, access to services, crime and housing
    • SIMD1-5
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5
Q

Name two examples of people who have changed the face of Public Health. Give the example to accompany the individual.

A

Ada Salter (Improvements in landscape of Bermondsey)

Aneurin Bevan (NHS 1948)

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6
Q

Outline 3 waves of Public Health.

A

• Cultural: Culture for health
• Social: Social determinants**
• Clinical: Lifestyle-related diseases
• Biomedical: ABX/vaccines/interventions
• Structural: Clean water/Sewers/Drainage and policy/systemic/organisational
-> Structural Competence: Identification of inadequacies within a healthcare system

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7
Q

Give 3 benefits of Medicating for Psychiatric illness.

A
  • Quickly prescribed
  • Available
  • Measurable effects
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8
Q

Give 3 negatives of Medicating for Psychiatric illness.

A
  • Cost
  • Side-effects
  • Withdrawal effects
  • Disenfranchised patients (‘by-stander’)
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9
Q

List 3 non-pharmacological approaches to the management of Psychiatric illness.

A
  • Physical Exercise
  • Bibliotherapy (reading books)
  • Self-support groups
  • Counselling
  • Psychotherapy: CBT/Mindfulness
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10
Q

Describe CBT.

A

Type of psychotherapy focusing on behaviours, thoughts and feelings and teaching coping skills for dealing with different problems – focus on behavioural therapy. Combination of cognitive therapy and behavioural therapy.

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11
Q

Outline the Cognitive Triangle

A

• Cognitive Triangle: Behaviour, Feelings and Thought

  • Behave ≈ thoughts about something ≈ feelings about something
  • E.g. Fail exam ≈ knew I wasn’t good at something ≈ feel hopeless + dreadful
  • Core Beliefs (about self): Yourself, others and future (all interlinked)
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12
Q

List 3 of the thought distortions.

A

Mnemonic: SAM-MOP
Self-Abstraction: Conclusion from one
Arbitrary interference: Conclusions with no evidence
Minimisation: Downplay achievements
Magnification: Overplay worries
Overgeneralisation: Sweeping generalisations
Personalisation: Self-blame

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13
Q

Give the 2 psychiatric conditions for which CBT is NICE recommended.

LIst 3 others.

A
  • Anxiety/Panic Attacks***
  • Depression***
  • Bipolar
  • Eating problems
  • OCD
  • Phobias
  • PTSD
  • Psychosis
  • Schizophrenia
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14
Q

List 5 potential issues with the provision and conduction of CBT.

A
  • Staff: Who, What, Why, Personal Specification
  • Training and Accreditation: Quality maintained and training provision
  • Position in NHS service: Public vs Private provision
  • Medical training required: No, but useful even in other practices
  • Abuse and neglect:
  • Supervision
  • Relapse rates
  • Tailoring of interventions
  • Manualised or flexible
  • Group or individual
  • Booster sessions
  • Internet
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15
Q

What is mindfulness?

A

Type of psychotherapy using mindfulness (awareness of thoughts, feelings and actions hindering daily life) to promote good mental, physical and social healthy. Can often be couples with other therapies – CBT, ACT etc.

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16
Q

Outline the MOA of MOAi.

A

• Inhibit MAO enzymes ≈ reduce breakdown of NE/serotonin and dopamine ≈ increase levels of serotonin/dopamine/NE

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17
Q

Which of the following is an MOAi?

A. Sertraline

B. Fluoxetine

C. Nortryptaline

D. Selegiline

A

D. Selegiline

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18
Q

Which of the following is an MOAi?

A. Sertraline

B. Duloxetine

C. Venlofaxine

D. Phenelzine

A

D. Phenelzine

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19
Q

Which of the following is an MOAi?

A. Sertraline

B. Tranylcypromine

C. Venlofaxine

D. Duloxetine

A

B. Tranylcypromine

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20
Q

List a MAOi.

A
  • Phenelzine
  • Selegiline
  • Tranylcypromine
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21
Q

List 3 side effects of MAOi.

A
  • Weakness
  • Headache
  • Weight gain
  • Dizziness
  • Fatigue
  • Impotence
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22
Q

Give the main prescribing points of an Rx of a MAOi.

A
  • Not used with SSRI/TCA + Opioids (morphine/tramadol) –> increase serotonin to high levels = Confusion, hypertension, tremor, coma and death i.e. neuroleptic malignant syndrome
  • 14 days washout before starting other antidepressants
  • High-tyramine foods (cheese/venison/meats/alcohol/green vegetables) –> hypertensive crisis
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23
Q

Which of the following is a RIMA?

A. Sertraline

B. Tranylcypromine

C. Selegeline

D. Moclobemide

A

D. Moclobemide

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24
Q

Name a RIMA.

A

Moclobemide

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25
Q

How does a RIMA work?

A

• Reversible inhibition of MAO type A reduce breakdown of NE/serotonin and dopamine ≈ increase levels of serotonin/dopamine/NE

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26
Q

List 3 side effects of a RIMA.

A
  • Weakness
  • Headaches
  • Dizziness
  • Fatigue
  • Weight gain
  • Impotence
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27
Q

Outline the main prescribing points for a RIMA.

A
  • Reduced effect of tyramine (alcohol/meat – venison/green vegetables/cheese)
  • Short acting thus 7 days prior to change to another antidepressant
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28
Q

Which of the following is a TCA?

A. Sertraline

B. Amitryptiline

C. Selegeline

D. Moclobemide

A

B. Amitryptiline

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29
Q

Which of the following is a TCA?

A. Sertraline

B. Fluoxetine

C. Nortryptiline

D. Moclobemide

A

C. Nortryptiline

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30
Q

Which of the following is a TCA?

A. Sertraline

B. Fluoxetine

C. Imipramine

D. Moclobemide

A

C. Imipramine

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31
Q

Which of the following is a TCA?

A. Sertraline

B. Fluoxetine

C. Clomipramine

D. Moclobemide

A

C. Clomipramine

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32
Q

Which of the following is a TCA?

A. Duloxetine

B. Diazepam

C. Lofepramine

D. Moclobemide

A

C. Lofepramine

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33
Q

Outline the MOA of TCAs

A

• Inhibit re-uptake of NE and Serotonin via blocking transporters (5-HT re-uptake transporter/ NE re-uptake transporter/ mAChR) responsible for re-uptake and block action of ACh (anti-cholinergic) ≈ increase [NA] + [Serotonin] in synapses

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34
Q

List 3 uses for TCAs.

A
  • Depression
  • Anxiety
  • OCD
  • Chronic pain
  • Neuralgia
  • IBS
  • Nocturnal enuresis
  • PTSD
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35
Q

Give 5 side effects of Amitriptyline.

A
  • Blurred vision
  • Dry mouth
  • Constipation
  • Bronchodilation
  • Reduced bronchial secretions
  • Urinary retention
  • Weight gain/loss
  • Hypotension
  • Rash
  • Hives
  • Tachycardia
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36
Q

Which of the following should you be cautious of when prescribing amitriptyline?

A. A healthy individual

B. A patient with IBD

C. A patient with anxiety in low dose to prevent OD

D. A patient with CVD

A

D. A patient with CVD

• Caution with CVD due to arrhythmias

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37
Q

Which of the following should you be cautious of when prescribing amitriptyline?

A. A healthy individual

B. A patient with IBD

C. A patient with severe depression who has attempted suicide recently

D. A patient with compensated liver failure

A

C. A patient with severe depression who has attempted suicide recently

• Check amount prescribed in pt with suicidal ideation –> suicide risk

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38
Q

What is the mechanism of action of SSRIs?

A

• Bind to Serotonin re-uptake transporter ≈ reduce reuptake ≈ increase [Serotonin]

  • > Weak affinity for NE and DA transporters thus fewer side-effects
  • > 5-HT (serotonin) receptors in peripheral and central nervous systems with both excitatory and inhibitory neurotransmission mediating release of numerous NTs: GABA/Dopamine/Epinephrine/Norepinephrine/Acetylcholine
  • > Influence: Aggression/Anxiety/Cognition/Learning Memory/Mood and Sleep
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39
Q

List 3 SSRIs.

A
  • Citalopram
  • Escitalopram
  • Paroxetine
  • Sertraline
  • Fluoxetine
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40
Q

Which of the following SSRIs is most likely to precipitate LQTS?

A. Sertraline

B. Escitalopram

C. Citalopram

D. Fluoxetine

A

C. Citalopram

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41
Q

Which of the following SSRIs is most likely to precipitate sleep difficulties?

A. Sertraline

B. Escitalopram

C. Citalopram

D. Fluoxetine

A

D. Fluoxetine

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42
Q

List 5 side effects of SSRIs.

A 
•	Nausea 
•	Rash
•	Muscle aches
•	Insomnia*** -> Sleep difficulties (Fluoxetine)
•	Aggression
•	Anxiety
•	Cognition
•	Learning memory
•	Mood
•	Sleep 
•	Sweating 
•	Epilepsy
 No driving for 12 months (be weary)
  • Reduced libido
  • Sexual dysfunction

• LQTS (Citalopram)

• Haemorrhage
• GI bleed risk increased
-> Raynaud’s Disease off license and Systemic Sclerosis ≈ improve blood flow

• Overdose
• Suicide
-> Do not prescribe for u18s unless Consultant Supervision

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43
Q

What is the MOA of an SNRI?

A

• Serotonin Norepinephrine Reuptake Inhibitor (SNRI) -> Bind Serotonin and Norepinephrine Re-Uptake Transporters -> increase [Serotonin] + [Norepinephrine]

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44
Q

Which of the following is an SNRI?

A. Sertraline

B. Duloxetine

C. Citalopram

D. Fluoxetine

A

B. Duloxetine

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45
Q

Which of the following is an SNRI?

A. Sertraline

B. Venlafaxine

C. Citalopram

D. Fluoxetine

A

B. Venlafaxine

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46
Q

Which SNRI is indicated for social phobia?

A. Sertraline

B. Venlafaxine

C. Duloxetine

D. Fluoxetine

A

B. Venlafaxine

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47
Q

Which SNRI is indicated for stress urinary incontinence?

A. Sertraline

B. Venlafaxine

C. Duloxetine

D. Fluoxetine

A

C. Duloxetine

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48
Q

Which SNRI is indicated for neuropathic pain?

A. Sertraline

B. Venlafaxine

C. Duloxetine

D. Fluoxetine

A

C. Duloxetine

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49
Q

Which SNRI is indicated for panic?

A. Sertraline

B. Venlafaxine

C. Duloxetine

D. Fluoxetine

A

B. Venlafaxine

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50
Q

List 5 side effects of SNRIs.

A
  • Nausea
  • Headaches
  • Insomnia
  • Hypersomnia/Drowsiness
  • Dizziness
Low % of Anticholinergic effects
•	Dry mouth
•	Sweating
•	Blurred vision
•	Constipation
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51
Q

What is the main prescribing point for a patient on SNRIs?

A

• Metabolised in liver –> desvenlafaxine (CP206 isoenzyme)

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52
Q

Name a Tetracyclic antidepressant.

A

• Mirtazapine

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53
Q

Which of the following is tetracyclic antidepressant?

A. Sertraline

B. Mirtazapine

C. Duloxetine

D. Fluoxetine

A

B. Mirtazapine

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54
Q

Outline the MOA of a Tetracyclic Antidepressant.

A

• Presynaptic alpha-2 adrenoceptor antagonist ≈ increase [NE] + [5-HT]

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55
Q

List 3 side effects of Tetracyclic Antidepressants.

A

Orexigenic

Weight gain

Drowsiness

Stimulant

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56
Q

Which is most likely to occur at a 15mg dose of Mirtazapine?

A. Tachycardia

B. Insomnia

C. Somnolence

D. Loss of libido

A

C. Somnolence

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57
Q

Which is most likely to occur at a 30mg dose of Mirtazapine?

A. Bradycardia

B. Insomnia

C. Somnolence

D. Loss of libido

A

B. Insomnia

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58
Q

Outline the main prescribing points for Tetracyclic antidepressants.

A
  • 15mg: sedative thus take at night

* 30mg: stimulant thus take in morning

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59
Q

Which drug is most likely to precipitate LQTS?

A. Sertraline

B. Citalopram

C. Mirtazapine

D. Duloxetine

A

B. Citalopram

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60
Q

Which of the following user groups is most likely to experience LQTS when prescribed Citalopram?

A. Males

B. Young people

C. Elderly

D. SE Asian

A

C. Elderly

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61
Q

Which of the following user groups is most likely to experience LQTS when prescribed Amitriptyline?

A. Males

B. Young people

C. Women

D. SE Asian

A

C. Women

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62
Q

Which of the following user groups is most likely to experience LQTS when prescribed Amitriptyline?

A. Males

B. Young people

C. Previous history of CVD

D. SE Asian

A

C. Previous history of CVD

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63
Q

What is tolerance best described as?

A. Induces reward thus required

B. Has adverse effects when stopping

C. Reduced effect with time

D. Acceptance of change

A

C. Reduced effect with time

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64
Q

What is withdrawal best described as?

A. Induces reward thus required

B. Has adverse effects when stopping

C. Reduced effect with time

D. Acceptance of change

A

B. Has adverse effects when stopping

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65
Q

What is dependence best described as?

A. Induces reward thus required

B. Has adverse effects when stopping

C. Reduced effect with time

D. Acceptance of change

A

A. Induces reward thus required

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66
Q

Outline the MOA of benzodiazepines.

A

Bind BZD binding site on pentameric GABA (GABRA1-3/GABRB1-2) ≈ Cl- ion influx ≈ hyperpolarisation

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67
Q

Binding to which of the following receptor subunits will induce somnolence?

A. GABAa2

B. GABAa1

C. GABAb1

D. GABAb2

A

B. GABAa1

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68
Q

Binding to which of the following receptor subunits will induce anxiolytic effects?

A. GABAa2

B. GABAa1

C. GABAb1

D. GABAb2

A

A. GABAa2

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69
Q

Binding to which of the following receptor subunits will induce anxiolytic effects?

A. GABAa3

B. GABAa1

C. GABAb1

D. GABAb2

A

A. GABAa3

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70
Q

List 3 examples of benzodiazepines.

A
  • Diazepam
  • Lorazepam
  • Loprazolam
  • Nitrazepam
  • Temazepam
71
Q

Which of the following benzodiazepines have the fasted speed of onset?

A. Chlordiazepoxide

B. Diazepam

C. Lorazepam

D. Temazepam

A

B. Diazepam

72
Q

Which of the following benzodiazepines have the slowest speed of onset?

A. Chlordiazepoxide

B. Diazepam

C. Lorazepam

D. Temazepam

A

A. Chlordiazepoxide

73
Q

Which of the following benzodiazepines have the slowest speed of onset?

A. Chlordiazepoxide

B. Zaleplon

C. Lorazepam

D. Temazepam

A

B. Zaleplon

74
Q

What are the uses of benzodiazepines?

A
  • Anxiolytics
  • Insomnia (sleep assistance)
  • Acute alcohol withdrawal
  • Enable uncomfortable diagnostic and therapeutic procedures
  • Anticonvulsant
75
Q

Outline the pharmacokinetics of Benzodiazepines.

A

• Lipophilic -> Absorbed well orally (1/2-2 hours) -> Protein bound (95%) -> Hepatic metabolism (CP450) -> Active metabolites (high T1/2) -> Excreted as glucuronide conjugate -> Renal excretion

76
Q

List the side effects of Benzodiazepines.

A

• Tolerance: Sedative&raquo_space;> Anxiolytic/Anticonvulsant via desensitization of inhibitory GABA receptors + sensitization of excitatory NMDA receptors
- GABA desensitized
- NMDA sesnitised
• Dependence: Elicits rewarding feeling suggestive of physical or physiological dependence
• Withdrawal effects

Anxiety/sleep disturbance/ mood changes/ stiffness/ muscle aches/ convulsions)

77
Q

List 3 Z drugs.

A
  • Zopiclone
  • Zolpidem
  • Zaleplon
78
Q

What are the uses of Z-drugs?

A
  • Anxiolytics
  • Insomnia (sleep assistance)
  • Acute alcohol withdrawal
  • Enable uncomfortable diagnostic and therapeutic procedures
  • Anticonvulsant
79
Q

Outline the MOA of Z-drugs.

A

• Binds GABAa receptor (GABA-A1-2) ≈ Cl- influx ≈ hyperpolarize ≈ reduced AP chance

80
Q

Outline the major pharmacodynamic effects of Z-drugs.

A
  • Anxiolytic (a2 + a3 of GABA)
  • Hypnotic (a1 GABA)
  • Reduced muscle tone
  • Anterograde amnesia
  • Anticonvulsant effect
81
Q

Which of the following is a Z-drug?

A. Chlordiazepoxide

B. Zaleplon

C. Lorazepam

D. Temazepam

A

B. Zaleplon

82
Q

Which of the following is a Z-drug?

A. Chlordiazepoxide

B. Zopiclone

C. Lorazepam

D. Temazepam

A

B. Zopiclone

83
Q

Which of the following is a Z-drug?

A. Chlordiazepoxide

B. Zolpidem

C. Lorazepam

D. Temazepam

A

B. Zolpidem

84
Q

During tolerance to drugs, which of the following happens?

A. NMDA desensitised, GABA sensitised

B. GABA desensitised, NMDA sensitised

C. Kainate desensitised, AMPA sensitised

D. AMPA desensitised, Kainate sensitised

A

B. GABA desensitised, NMDA sensitised

85
Q

Which Questionnaire system can be used to assess someone’s Alcohol Dependence?

A. RAGE

B. CAGE

C. SAGE

D. BEIGE

A

B. CAGE

CAGE:
• Cut Down?
• Annoyed by people criticizing drinking?
• Guilty?
• Eye-opener – drinking in the morning/loosen nerves?

86
Q

List 5 symptoms of Acute Alcohol Withdrawal.

A
  • Insomnia
  • Anxiety
  • Restlessness/Agitation
  • Tremor
  • Nausea
  • Vomiting
  • Sweating
  • Palpitations
  • Hallucinations auditory/visual/tactile
  • Seizures
87
Q

What is the management for a patient with acute alcohol withdrawal?

A
  • ABCDE
  • Sleep hygiene
  • Chlordiazepoxide
88
Q

What is depression?

A

Depressive orders (MHD), characterized by persistent low mood, anhedonia, neurovegetative disturbance, reduced energy and varying levels of social and biological dysfunction.

89
Q

Mrs. Jones, a 43 year old single mother presents with persistent low mood. She says she has gained 10kg, taking her up to 80kg. She is constantly tired due to poor sleep. Additionally, she recently got a promotion at work however did not feel any enjoyment. She has had thoughts of killing herself but says her children and religion keep her going however she remains pessimistic about the future and her friends.

i) What condition and category does she have?
ii) What is the criteria for this category of disease?
iii) What factors contribute towards Mrs. Jones’ placing into this category?
iv) What are her protective factors against suicide?
v) What investigations might you conduct?
vi) What management would you suggest?

A

i) Severe depression
ii) Major Depressive Disorder: ≥ 5 Sx –> Mild to Severe for 2+ weeks

iii)
- Persistent low mood
- Anhedonia
- Significant weight gain
- Poor sleep
- Suicidal ideation
- Fatigue
- Negative cognitive triad

iv)
- Family
- Religion
- Dependants

v)
• Clinical Diagnosis: DSM-5 Diagnostic Criteria
• Patient Health Questionnaire-2 (PHQ-2): Positive result screens for depression in primary care

  • Metabolic Panel: Normal
  • FBC: Normal – rule out causes of fatigue e.g. anaemia
  • HbA1c
  • TFTs: Normal – rule out causes of fatigue e.g. hypothyroidism
  • Serum Cortisol: Normal – rule out Cushing’s Disease
  • Cobalamin (B12)/Folate (B9): Normal – rule out macrocytic anaemia/paraesthesia/numbness and impaired memory; Normal
  • Syphilis Serology

vi)
• Hospital Referral
• SSRI: Citalopram (20mg PO OD); Escitalopram (10mg PO OD)
+
• Benzodiazepine: Lorazepam/Clonazepam/Trazodone
OR
• ECT
+
• SSRI: Citalopram (20mg PO OD); Escitalopram (10mg PO OD)

90
Q

Mr. Taku, a 43 year old single father presents with persistent low mood. He says he has gained 10kg, taking him up to 100kg. He is constantly tired. Additionally, you notice fresh cut marks on his thighs and arms but he says he fell. He has been feeling this way for the last 3 years but didn’t want to trouble the doctor.

i) What condition and category does he have?
ii) What is the criteria for this category of disease?
iii) What factors contribute towards Mr. Taku placing into this category?
iv) What are his risk factors for suicide?
v) What investigations might you conduct?
vi) What management would you suggest?

A

i) Persistent Depressive Disorder
≥ 2 years of ¾ dysthymic symptoms for more days than not

ii) ≥ 2 years of 3/4 dysthymic symptoms for more days than not

iii)

  • Persistent low mood
  • Significant weight gain
  • Fatigue
  • Weight gain
  • Lasting more than 2 years

iv)
- Male
- Self-harm
- Financial? (single-parent)

v)
• Clinical Diagnosis: DSM-5 Diagnostic Criteria
• Patient Health Questionnaire-2 (PHQ-2): Positive result screens for depression in primary care

  • Metabolic Panel: Normal
  • FBC: Normal – rule out causes of fatigue e.g. anaemia
  • HbA1c
  • TFTs: Normal – rule out causes of fatigue e.g. hypothyroidism
  • Serum Cortisol: Normal – rule out Cushing’s Disease
  • Cobalamin (B12)/Folate (B9): Normal – rule out macrocytic anaemia/paraesthesia/numbness and impaired memory; Normal
  • Syphilis Serology

vi)
• SSRI: Citalopram (20mg PO OD); Escitalopram (10mg PO OD); Fluoxetine (20mg PO OD); Sertraline (50mg PO OD); Mirtazapine (15mg PO OD)
+
• Psychotherapy: CBT/Mindfulness

91
Q

What is anxiety?

A

Generalised anxiety disorder (GAD) is ≥ 6 months of excessive worry about disproportionate everyday issues + 3/6 of the DSM-5 criteria.

92
Q

List 5 risk factors for anxiety.

A
  • FHx
  • Female
  • Increased stress
  • PMHx trauma/emotional trauma
  • Comorbid depression
  • Substance abuse/dependence
  • Other anxiety disorders
93
Q

List the signs and symptoms of anxiety.

A
  • Excessive worry ≥ 6 months
  • Poor concentration
  • Restlessness
  • Irritability
  • Sleep disturbance
  • Muscle tension
  • Fatigue
  • Headache
  • Sweating
  • Dizziness
  • GI Symptoms: Nausea/Vomiting/Increased urinary urge/Tenesmus
  • Rash
  • Muscle aches
  • SOB
  • Trembling
  • Exaggerated startle response
94
Q

List the DSM-5 criteria for anxiety

A

≥ 6 months of excessive worry AND 3/6 PRISM-F

  • Nervousness/Restlessness
  • Fatigued
  • Poor concentration
  • Irritability
  • Muscle tension
  • Sleep disturbance
95
Q

Mr. Tripp presents with a fast heart rate. O/E there is nothing remarkable. During his social history, you identify he has been consumed by worry for the last 7 months. He has noticed his eczema exacerbated and his rash has appeared in other places. He also notes that he has been restless and irritable, during the day but increasing prior to the evening, disturbing his sleep.

i) What is your differential?
ii) What criteria contribute towards your DDx?
iii) What investigations might you conduct?
iv) What management would you suggest?

A

i) Generalised Anxiety Disorder

ii) ≥ 6 months + 3/6 DSM-5 criteria
- Irritable
- Restless
- Sleep disturbance
- Tachycardia
- Rash

iii) • Clinical Diagnosis

• TFTs: Normal
–> (if Sx suggestive of Thyroid disease: Weight loss/Exopthalmos/Goitre/PMHx)
• Urine drug screen: Negative
• ECG: Normal sinus rhythm
–> If suggestive of cardiac cause: PMHx/FHx/RFs
• 240hour urine for vanillylmandelic and metanephrines: Normal
–> If severe HTN or Tachycardia, rule out Phaeochromocytoma

iv)
• Lifestyle: Reduce caffeine/Reduce alcohol/Sleep hygiene/Exercise/Self-help
• Psychotherapy: CBT/ Mindfulness
• SSRI/SNRI/Antidepressant: Escitalopram/Duloxetine/Venlafaxine/Sertraline/Fluoxetine/ Mirtazapine
- Consider withdrawal
- Consider SE profile: Nausea/Diarrhea/Insomnia/Sexual dysfunction/Suicidal behavior
• TCA/Gabapentin/Pregabalin: Imipramine/Pregabalin
• Melatonin

96
Q

Mr. Chipotle presents with a fast heart rate. O/E there is nothing remarkable. During his social history, you identify he has been consumed by worry for the last 7 months. This worry is predominantly present in public places, around his friends or wider social circle. He has noticed his eczema exacerbated and his rash has appeared in other places. He also notes that he has been restless and irritable, during the day but increasing prior to the evening, disturbing his sleep.

i) What is your differential?
ii) What criteria contribute towards your DDx?
iii) What investigations might you conduct?
iv) What management would you suggest?

A

i) GAD + Social Anxiety

ii) ≥ 6 months + 3/6 DSM-5 criteria
- Happens in public/social
- Irritable
- Restless
- Sleep disturbance
- Tachycardia
- Rash

iii) • Clinical Diagnosis

• TFTs: Normal
–> (if Sx suggestive of Thyroid disease: Weight loss/Exopthalmos/Goitre/PMHx)
• Urine drug screen: Negative
• ECG: Normal sinus rhythm
–> If suggestive of cardiac cause: PMHx/FHx/RFs
• 240hour urine for vanillylmandelic and metanephrines: Normal
–> If severe HTN or Tachycardia, rule out Phaeochromocytoma

iv)
• Lifestyle: Reduce caffeine/Reduce alcohol/Sleep hygiene/Exercise/Self-help
• Psychotherapy: CBT/ Mindfulness
• SSRI/SNRI/Antidepressant: Escitalopram/Duloxetine/Venlafaxine/Sertraline/Fluoxetine/ Mirtazapine
- Consider withdrawal
- Consider SE profile: Nausea/Diarrhea/Insomnia/Sexual dysfunction/Suicidal behavior
• TCA/Gabapentin/Pregabalin: Imipramine/Pregabalin
• Melatonin

97
Q

What is the most common age of onset for generalised anxiety disorder?

A. Age 11 to early adulthood?​
B. Age 35 to 55?​
C. Over age 65?​
D. Any age after a significant life stressor

A

A. Age 11 to early adulthood?​

98
Q

A 72 year old widowed woman with osteoarthritis and chronic obstructive pulmonary disease says she is finding life a huge struggle. Everything is a worry and an effort. She cannot face people, is not keeping up with the housework, has lost interest in and stopped watching the TV programmes she used to enjoy, and cannot concentrate on anything. She feels tired all the time and is sleeping poorly. She has always worried about things (paying bills, deciding what to cook, her children and grandchildren, what the neighbours might think), but always previously coped. Now she feels unable to cope and feels like she is sinking, at times becoming uncontrollably tearful.

What is the likely diagnosis?​

A. Major depressive disorder​

B. Generalised anxiety disorder​

C. Social anxiety disorder​

D. Generalised anxiety disorder and major depressive disorder​

E. Social anxiety disorder and major depressive disorder

A

D. Generalised anxiety disorder and major depressive disorder​

99
Q

A 25 year old single man describes being beset by worries. He describes worries that he is going to harm someone by some violent action, which is completely against his principles. He doesn’t have any sharp knives in his house and avoids being near small children as he considers them more vulnerable to a possible attack by him. You ask him about other worries and he describes feeling anxious around people he doesn’t know, worried that he will shake and show he is anxious around them. As a result he does not speak up at meetings at work.

A. Generalised anxiety disorder and obsessive compulsive disorder

B. Generalised anxiety disorder and social anxiety disorder

C. Social anxiety disorder and obsessive compulsive disorder

D. Generalised anxiety disorder, social anxiety disorder, and obsessive compulsive disorder

A

C. Social anxiety disorder and obsessive compulsive disorder

100
Q

In patients who have comorbid generalised anxiety disorder and depression, which should be treated first as the primary disorder?

A. Treat the generalised anxiety disorder first

B. Treat the depression first

C. Treat first whichever is the more troublesome to the patient

D. Treat both equally

A

C. Treat first whichever is the more troublesome to the patient

101
Q

You have diagnosed a 35 year old woman working in a high pressure executive role with moderate generalised anxiety disorder, comorbid with mild social anxiety disorder. She identifies the generalised anxiety disorder as most troublesome for her, and you have agreed that this should be the focus of treatment. She has not previously had any treatment for generalised anxiety disorder.

What first line treatment would you recommend?

A. A self help “low intensity” psychological intervention

B. Cognitive behavioural therapy (CBT)

C. Cognitive behavioural therapy (CBT)

D. Medication for generalised anxiety disorder

E. Cognitive behavioural therapy (CBT) or medication for generalised anxiety disorder

A

B. Cognitive behavioural therapy (CBT)

102
Q

You review the 35 year old woman with moderate generalised anxiety disorder and mild comorbid social anxiety disorder after she has completed a self help online treatment, supported by telephone and email by a psychological wellbeing practitioner. She reports that she has found this useful, but that there has been minimal improvement in her generalised anxiety disorder symptoms.

What further treatment for generalised anxiety disorder would you recommend?

A. An alternative self help “low intensity” psychological intervention

B. Cognitive behavioural therapy (CBT)

C. Medication for generalised anxiety disorder

D. Choice of cognitive behavioural therapy (CBT) or medication for generalised anxiety disorder

A

D. Choice of cognitive behavioural therapy (CBT) or medication for generalised anxiety disorder

103
Q

Your 35 year old patient, who did not improve following a self help treatment, chooses medication over CBT, as she feels unable to take time away from her high pressured executive job to attend CBT​

What medication for her generalised anxiety disorder should you recommend?

A. A benzodiapine

B. A selective serotonin reuptake inhibitor (SSRI)

C. A serotonin noradrenaline reuptake inhibitor (SNRI)

D. Pregabalin

A

B. A selective serotonin reuptake inhibitor (SSRI)

104
Q

You start your patient on escitalopram 20 mg once a day. After two days she returns to the surgery and tells you she feels more anxious than before​

What should you do next?

A. Increase the dose of escitalopram

B. Stop the escitalopram and refer for CBT

C. ​​Stop the escitalopram and try a different medication for generalised anxiety disorder

D. Reduce to 10mg escitalopram and emphasise it may take 2-3 weeks to have a beneficial effect

A

D. Reduce to 10mg escitalopram and emphasise it may take 2-3 weeks to have a beneficial effect

105
Q

Your patient tolerates the escitalopram after titration. After eight weeks at 20 mg, she still reports no improvement in her generalised anxiety disorder symptoms. She feels increasingly desperate as she is finding her generalised anxiety disorder symptoms are beginning to interfere with the demands of her job, and colleagues have been commenting on this.​

What should you now recommend?

A. Continuing on escitalopram

B. Trying an alternative medication (another SSRI or an SNRI)

C. Referral for cognitive behavioural therapy (CBT)

D. Choosing either an alternative medication or CBT

A

D. Choosing either an alternative medication or CBT

106
Q

Which one of the following medications should NOT be offered in primary care for patients with generalised anxiety disorder?

A. Benzodiazepines

B. Beta blockers

C. Low dose antipsychotics

D. Pregabalin

A

C. Low dose antipsychotics

107
Q

Which of the following is one of the two required criteria required for a diagnosis of major depression?

A. Significant weight loss when not dieting, weight gain or decrease, or increase in appetite nearly every day

B. Insomnia or hypersomnia nearly every day

C. Psychomotor agitation or retardation nearly every day

D. Diminished interest or pleasure in all or almost all activities most of the day, nearly every day

E. Fatigue or loss of energy nearly every day

A

D. Diminished interest or pleasure in all or almost all activities most of the day, nearly every day

108
Q

According to the majority of studies, what is the relationship between physical activity and depression?

A. There is a positive relationship

B. There is an inverse relationship

C. There is no relationship

A

B. There is an inverse relationship

109
Q

Which of the following is not a screening tool for depression?

A. PHQ-9

B. GAD-7

C. PHQ-2

D. Edinburgh post-natal depression scale

A

B. GAD-7

110
Q

Which of the following is not a risk factor for depression?

A. Having a family history

B. Being male

C. Taking corticosteroids

D. Age over 65

A

B. Being male

111
Q

Which of the following is NOT an SSRI?

A. Paroxetine

B. Fluoxetine

C. Venlafaxine

D. Citalopram

A

C. Venlafaxine

112
Q

After the resolution of symptoms of a first episode major depression, medication should be continued for at least:

A. 3 months

B. 2 years

C. 1 year

D. 6 months

A

D. 6 months

113
Q

A PHQ-9 score of 4 signifies:

A. Mild depression

B. Severe depression

C. No depression

D. Moderate depression

A

C. No depression

114
Q

A 24 year old man has been suffering depressive symptoms for over 2 months. In spite of being on fluoxetine for a week he feels worse. He feels suicidal, and is hearing voices telling him to hang himself. He has written a note for his girlfriend explaining why he decided to kill himself. He has been drinking heavily. He does not want to go to hospital. Do you -

A. Increase his dose of fluoxetine?

B. Change to a different antidepressant?

C. Arrange a compulsory admission?

D. Prescribe an antipsychotic medication?

A

C. Arrange a compulsory admission?

115
Q

What is Panic Disorder?

A

Recurrent panic attacks over 1 month associated to worry which leads to behavioural change

116
Q

Define a panic attack

A

discrete period with sudden onset of intense apprehension, fearfulness and marked autonomic arousal ± impending doom (angor animi)

117
Q

What two types of Panic Disorder are there?

A

Panic disorder with Agoraphobia

Panic disorder without Agoraphobia

118
Q

Give 5 Sx for Panic Disorder

A
  • Rapid onset
  • Discrete time period
  • Worry/Fear/Apprehension
  • Behavioural avoidance: External + Internal situations
  • Nausea and vomiting
  • Dizziness
  • SOB
  • Tachycardia
  • Palpitations/Pounding heart
  • Tremulous
  • Sweating
  • Hyperventilation/SOB/Choking
  • Chills/Hot flushes
  • Muscle shaking
119
Q

Give the Clinical Assessment tool used for patients with Panic Disorder.

A

PRIME-MD Screen: Positive if ≥ 4/11 Yes

120
Q

Give the Tx for Panic Disorder

A

• Supportive: Reassurance/CBT
±
• SSRIs/SNRIs: Sertraline/Paroxetine/Fluoxetine/ Citalopram/ Venlafaxine

121
Q

What is Agoraphobia?

A

Fear of a place/setting from which escape may be difficult

122
Q

Give 5 Sx or S of Agoraphobia

A
  • Rapid onset
  • Discrete time period
  • Worry/Fear/Apprehension regarding a place
  • Behavioural avoidance: External + Internal situations
  • Nausea and vomiting
  • Dizziness
  • SOB
  • Tachycardia
  • Palpitations/Pounding heart
  • Tremulous
  • Sweating
  • Hyperventilation/SOB/Choking
  • Chills/Hot flushes
  • Muscle shaking
123
Q

Give the Tx for Agoraphobia

A

• Supportive: Education + Monitoring/ CBT + Exposure therapy
+ (Concurrent vasovagal syncope)
• Applied tension: Tensing and releasing large muscle groups to increase BP and promote circulation
± (Frequent Sx interfering in Life)
• Benzodiazepines: Diazepam/Lorazepam/Clonazepam/Alprazolam

124
Q

What is specific phobia?

A

Specific intense fear of specific objects or situations that are triggered upon exposure to phobic stimuli resulting in fear avoiding behaviour of phobic cues

125
Q

What is agoraphobia?

A

• Agoraphobia = places/settings

126
Q

What is a social phobia?

A

• Social = Social situations/Performance in social settings

127
Q

What is acrophobia?

A

• Acrophobia = Heights

128
Q

What is aerophobia?

A

• Aerophobia = Flying

129
Q

What is Astraphobia?

A

• Astraphobia = Thunder/Lightning

130
Q

What is arachnophobia?

A

• Arachnophobia = Spiders

131
Q

What is claustrophobia?

A

• Claustrophobia = confined spaces/places

132
Q

What is auto phobia?

A

• Autophobia = Alone

133
Q

What is homophobia?

A

• Hemophobia = Blood

134
Q

What is ophidiopobia?

A

• Ophidiophobia = Snakes

135
Q

Give 5 Sx or S for phobias?

A
  • Rapid onset
  • Discrete time period
  • Worry/Fear/Apprehension regarding a place
  • Behavioural avoidance: External + Internal situations
  • Nausea and vomiting
  • Dizziness
  • SOB
  • Tachycardia
  • Palpitations/Pounding heart
  • Tremulous
  • Sweating
  • Hyperventilation/SOB/Choking
  • Chills/Hot flushes
  • Muscle shaking
136
Q

Give the Tx for Phobias

A

• Supportive: Education + Monitoring/ CBT + Exposure therapy
+ (Concurrent vasovagal syncope)
• Applied tension: Tensing and releasing large muscle groups to increase BP and promote circulation
± (Frequent Sx interfering in Life)
• Benzodiazepines: Diazepam/Lorazepam/Clonazepam/Alprazolam

137
Q

What is OCD?

A

Anxiety disorder characterised by obsessions, unwanted excessive or impulsive desires, compulsions, repetitive mental acts and behaviours to reduce obsessions and emotional distress, which causes significant distress and impairment on daily functioning.

138
Q

What is the difference between obsessions and compulsions?

A

Obsession = Unwanted excessive or impulsive desires and thoughts which are seen as irrational or unwanted

Compulsions = Repetitive behaviours which aim to neutralise obsessions and emotional distress

139
Q

Give the Tx for OCD

A

• CBT
±
SSRIs: Fluoxetine/Paroxetine/Sertraline/Clomipramine

140
Q

What is PTSD?

A

Anxiety disorder characterised a traumatic event(s) causing 1-month of symptoms of intense fear, helplessness or horror, intrusive recollection of event, acting as if the event were occurring, distress from exposure to event cues, avoidance of trauma-associated stimuli and persistent increased arousal which wasn’t present prior to traumatic event.

141
Q

Outline the process of PTSD

A 
Traumatic event
Re-experience
Avoidance
Unable to function  Sx
Month (at least)
Arousal
142
Q

Give 5 Sx and S of PTSD

A

• Exposure to traumatic event
• Intrusion Sx: Re-experiencing in vivid ways -> Flashbacks; Intrusive images; Intrusive thoughts; Sensory impressions; Dreams/Nightmares; Emotional and physiological reactivity to internal and external cues
• Avoidance Sx: Effortful avoidance of trauma cues -> Push memories out; Avoid news; avoid events; avoid settings
 May ruminate excessively about questions to prevent coming to terms with event
• Hyperarousal: Hypervigilance; Exaggerated startle response; irritability; angry outbursts; self-destructive; reckless behaviours; poor concentration; sleep problems
 Must impair function
• Negative cognition and mood: Asocial behaviours; Distorted beliefs; Ideas of blame; Anhedonia; Poor trauma-related memory (events of trauma)
• Depression (Anhedonia + Persistent low mood + Anergia…)
• Anxiety (Intense fear + ∆ Behaviours + Systemic symptoms)
• Substance misuse: Alcohol/Drugs

143
Q

A patient experiences PTSD Sx for 2 months, wha tis your Tx

A

• Supportive: Monitoring

144
Q

A patient experiences PTSD Sx for 4 months, wha tis your Tx

A 
•	Supportive: Monitoring
\+ (≥ 3 months Sx) 
•	CBT- Trauma focused (TFCBT)
±
•	SSRIs: Paroxetine/Fluoxetine/Sertraline/Venlafaxine
145
Q

What is Generalised Anxiety Disorder?

A

Anxiety disorder typified by ≥ 6 months of excessive fear/worry about disproportionate everyday issues + 3/6 of the DSM-5 criteria

146
Q

What are the Sx and S of GAD?

A
  • Poor concentration
  • Restlessness
  • Irritability
  • Muscle tension
  • Easily fatigues
  • Sleep Disturbance
147
Q

Outline the Tx for GAD

A

• Lifestyle: Reduce caffeine/Reduce alcohol/Sleep hygiene/Exercise/Self-help
• Psychotherapy: CBT/ Mindfulness
±
• SSRI/SNRI/Antidepressant: Escitalopram/Duloxetine/Venlafaxine/Sertraline/Fluoxetine/ Mirtazapine
- Consider withdrawal
- Consider SE profile: Nausea/Diarrhea/Insomnia/Sexual dysfunction/Suicidal behavior
±
• TCA/Gabapentin/Pregabalin: Imipramine/Pregabalin
± (Sleep difficulties)
• Melatonin

148
Q

What is a Psychosis?

A

Umbrella term for a disorder whereby patient loses contact with external reality, associated with abnormal functioning of frontal and temporal lobes and disorganised thoughts and actions

149
Q

Outline the possible causes of a Psychosis

A
  • 1º (Caused by MHDs) Schizophrenia/ BPD/ Schizoaffective Disorder/ Persistent Delusional Disorders/ Schizophreniform Psychosis
  • 2º (Other factors): Drug/Toxin exposure/Recreational drugs/Organophosphates/ Trauma/ Delirium/ Brain tumour/ SOL/ Steroids (high dose)/ Lead/ Mercury/ Cannabis/ Mushrooms/ LSD/ Infection/ Delirium/ Vitamin Deficiency (B12/ B1/ B3)/ Endocrine disorders/ Metabolic disorders/ Chromosomal Disorders (PWS/Klinefelter’s)
150
Q

What is Schizophrenia?

A

1 Positive Sx and 1 Negative Sx for 1 month with continuous problem over > 6 months

151
Q

Give the Sx of Schizophrenia?

A 
Tangentiality/ Thought processing 
Hallucinations (auditory/visual)
Reduced reality (Delusions)/Repetition of words (Verbigeration)
Emotional control: Incongruous effect?
Arousal 
Disorganised/ Catatonic Behaviour
Loss of volition/social settings/ Pleasure
Emotional flatness (Affective Blunting) 
Speech reduced (Alogia)
Slowness in thought (cognitive deficit)/Somatisation (physical Sx – expressed in body)
152
Q

Give the Tx for Schizophrenia

A

• Anti-psychotic medication: Aripiprazole
+
• Psychological Interventions: Family/CBT/Social-skills training

153
Q

What type of Antipsychotic would you give for Positive Sx in Schizophrenia?

A

FGA

154
Q

What type of Antipsychotic would you give for both Positive and Negative Sx in Schizophrenia?

A

SGA

155
Q

What is the difference between Schizoaffective Disorder and Schizophrenia?

A

Schizoaffective Disorder ≠ Schizophrenia as the symptoms may be transient and episodic, fluctuating and simultaneously prominent cf Schizophrenia, the Sx are present throughout (e.g. Paranoia, Delusions and Hallucinations)

156
Q

What is Schizoaffective Disorder?

A

Mental health illness characterised by schizophrenia symptoms concurrent with affective symptoms lasting for ≥ 1 months - which may be present in the absence of schizophrenia symptoms at times.

157
Q

What is the difference between schizotypical disorder and schizophrenia?

A

Schizotypal Disorder ≠ Schizophrenia as Schizotypal Disorder have insight into illness and awareness that experiences are false cf delusions in Schizophrenia

158
Q

What is a brief psychotic disorder?

A

MHD characterised by co-occurrence of: delusions, hallucinations, disorganised speech, catatonic/disorganised behaviour or negative symptoms (anhedonia/affective flattening/avolition/cognitive deficit or alogia) occurring for between one day and one month.

159
Q

Give the Tx for Brief Psychotic Disorder?

A

• Aripiprazole (10-15mg PO OD)/Risperidone (1mg PO BD)/ Quetiapine (25mg PO BD)
+ (adjunct)
• Lorazepam: 1-2mg IM per 8 hours

160
Q

What is Persistent Delusional Disorder?

A

Umbrella term for mental health disorders typified by persistent, often life-long, delusions which have an insidious onset usually in later adult life. The conditions may be stratified as Eponymous or Non-Eponymous e.g. Capgras Syndrome or Paranoia.

161
Q

What is a Mood Disorder?

A

Umbrella term for Mental Health Diseases (MHD) typified by a distortion in mood (affect) which impacts on lifestyle and activities. Can be categorised into Unipolar Mood Disorders (Depression/ Dysthymia/ Substance-induced Mood Disorder) or Bipolar Mood Disorders (Bipolar Disorder/Cyclothymia).

162
Q

What is Depression?

A

Depressive orders (MHD), characterized by persistent low mood, anhedonia, neurovegetative disturbance, reduced energy and varying levels of social and biological dysfunction.

163
Q

What are the categories of Depression?

A
  • Major Depressive Disorder: ≥ 5 Sx -> Mild to Severe for 2+ weeks
  • Minor Depression: 2-4 Sx for 2+ weeks
  • Persistent Depressive Disorder (Dysthymic Disorder): ≥ 2 years of ¾ dysthymic symptoms for more days than not
164
Q

Give 5 RFs for Depression

A
  • Chronic Health Conditions
  • History of Depression/MHD
  • Medication – Glucocorticoids
  • Female gender
  • Older age
  • Recent childbirth – post-partum depression
  • Pychosocial issues
  • Genetic factors
  • History of childhood abuse
  • History of Head Trauma
165
Q

Give 5 Sx or S of Depression

A

• Persistent Low Mood
• Anhedonia (marked loss of interest/pleasure)
• Anergia
+
• Tearfulness
• Irritability
• Poor concentration
• Anxiety (Physical + Mental components)
• Slowed thought (cognitive impairment/decline)  ‘Depressive pseudodementia’
• Thought blocking
• Reduced speech
• Reduced tone of voice
• Thought content (negative cognitive triad): Self-blame (self)/ Negativism (world)/ Pessimism (future)
• Suicidal ideatio
• Sleep disturbance: insomnia/hypersomnia
• Weight gain
• Psychomotor agitation/retardation (restlessness)
• Fatigue

166
Q

What assessment tool can be used to diagnose depression?

A
  • Clinical Diagnosis: DSM-5 Diagnostic Criteria

* Patient Health Questionnaire-2 (PHQ-2): Positive result screens for depression in primary care

167
Q

Give the Tx for Depression

A
  • SSRI: Citalopram (20mg PO OD); Escitalopram (10mg PO OD); Fluoxetine (20mg PO OD); Sertraline (50mg PO OD); Mirtazapine (15mg PO OD)
  • Psychotherapy: CBT/Mindfulness
168
Q

What is Dysthymia?

A

Mood disorder that is a form of Unipolar Depression, featuring the same symptoms however the duration is for more than 2 years, with symptoms present for more days (4/7) than they are absent. Dysthymia is less acute and less severe than Major Depressive Disorder

169
Q

What is Bipolar Disorder?

A

Bipolar mood with 1≤ manic episodes over 1 week followed by hypomanic ≥ 4 days or MDD

170
Q

What is the Sx and S of Bipolar Disorder?

A
  • Major depressive disorders
  • Episodes of mania (mania Sx) -> Bipolar I = 1+ manic/mixed episodes
  • Episodes of hypomania (1 or more hypomania episodes) -> Bipolar II = 1 or more hypomania episodes
  • Grandiosity
  • Decreased need for sleep
  • More talkative
  • Flight of ideas
  • Increase in goal-directed activity
  • Risk-taking behaviours: buying sprees/sexual indiscretions/foolish business investments
  • No underlying medical cause
171
Q

What is the Difference between Bipolar I Disorder and Bipolar II Disorder?

A

Bipolar I = 1 manic/mixed episode

Bipolar II = 1 hypomanic

172
Q

What is the difference between Mania and Hypomania?

A

Intensity and Severity (1 week vs several days)

173
Q

What Cyclothymia?

A

Cyclothymia (Chronic, fluctuating course of mood disturbance – numerous periods of hypomania and depressive episodes)

Psychiatry (2) (13 decks)

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