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Year 3 - Psychiatry (DP) > Depression and Mood Disorders > Flashcards

Depression and Mood Disorders Flashcards

1
Q

What are the risk factors for adult mental illness?

A

Childhood abuse

Neglect

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2
Q

What are the 8 parts of a mental state exam?

A 
Appearance
Behaviour
Speech
Mood/Affect
Thought (form and content [inc. delusions])
Perception
Cognition
Insight
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3
Q

What important schooling aspects are important in a social history?

A

Academic performance
Behaviour
Friends

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4
Q

What are important employment aspects are important in a social history?

A

Jobs:
- Performance
- Sick leave
Reasons for unemployment

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5
Q

What important aspects of relationships are important in a social history?

A 
Length
Details
Reasons for breakup
Children
Sexual history
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6
Q

What is a forensic history?

A

Criminal offences

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7
Q

What are some aspects of assessing general appearance in a mental state exam?

A 
Age
Physique/Build
Dress (Any evidence of self-neglect?)
Effort with appearance
Tattoos
Signs of physical ill-health
Posture
Facial expression
Physical features of alcoholism or drug abuse
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8
Q

What are some aspects of assessing behavour in a mental state exam?

A 
Describe what they're doing (Appropriate for situation?)
Psychomotor agitation/retardation:
- Unintentional and purposeless motions
- Stems from mentail tension and anxiety
Eye contact
Attitude/Raport
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9
Q

What are some aspects of assessing quality of speech in a mental state exam?

A

Clarity

Volume

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10
Q

What are some aspects of assessing of rate of speech in a mental state exam?

A

Pressure

Poverty

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11
Q

What are some aspects of assessing quantity of speech in a mental state exam?

A

Too much/little
Spontaneous
Sudden silences

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12
Q

How do we describe mood in a mental state exam?

A

Objective description

Subjective description

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13
Q

How is mood usually described in a mental state exam?

A

In patient’s own words

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14
Q

What is afferent?

A

The experience of feeling or emotion

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15
Q

What parameters can aid in the labelling of afferent?

A

Appropriateness
Intensity
Range/Reactivity/Mobility

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16
Q

What are the two types of appropriateness in the assessment of affect in a mental state exam?

A

Congruent (appropriate for emotion in context)

Incongruent (inappropriate)

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17
Q

What can a bland affect on describing a distressing situation indicate?

A

Schizophrenia

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18
Q

What can a blunted intensity in the assessment of affect in a mental state exam?

A

Schizophrenia
Depression
PTSD

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19
Q

What can a heightened intensity in the assessment of affect in a mental state exam?

A

Mania

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20
Q

What can an exaggerated intensity in the assessment of affect in a mental state exam?

A

Personality disorder

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21
Q

How can the mobility of affect be described in a mental state exam?

A

Restricted
Labile
Reactive

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22
Q

What is passive suicidality?

A

Thoughts of life not worth living

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23
Q

What is active suicidality?

A

Thoughts of wanting to self-harm/die with methods and plans

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24
Q

How can thought form be inferred in a mental state exam?

A

Speech

Patient’s description

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25
Q

What is flight of ideas (thought form)?

A 
High tempo thoughts
Words associated inappropriately due to:
- Their meaning
- Rhyme
Speech loses aim and patient wanders from theme
Jump from topics to topic with recognisable links:
- Rhyming
- Puns
- Environmental distractions
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26
Q

What is poverty of thought?

A

Global reduction in quantity of thought

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27
Q

What are the features of a formal thought disorder?

A 
Evidence in patient's writing/speech that there is abnormal thought linking
Disturbance in:
- Organisation
- Control
- Processing
NOT a content abnormality
ie. Thought A -> Thought B
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28
Q

What is thought blocking? In what condition is it seen in?

A

Speech suddenly interrupted by silence

Schizophrenia

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29
Q

A patient talks freely but vaguely. Speech is muddled, illogical, difficult to follow and cannot be clarified. A lot is said but no information is gathered.

A

Loosening of associations

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30
Q

What is tangential thinking?

A

Wandering from topic and never returning to it
Patient doesn’t provide the info requested
ie. Thought A -> F -> C

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31
Q

What is circumstantiality?

A

Inability to answer a question without giving excessive and unnecessary detail
Patient will eventually answer
ie. Thought A -> Thought A1 -> Thought A2 -> Thought A

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32
Q

What are neologisms?

A

Patient makes up a new word or phrase using existing words or phrases in a bizarre way

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33
Q

What are though preoccupations?

A

Thought content that are not fixed, false or intrusive

BUT have an undue prominence in patient’s mind

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34
Q

What are overvalued ideas?

A

Unreasonable, sustained beliefs that are held with less than delusional intensity

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35
Q

Give an example of an overvalued idea?

A

Hypochondriasis

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36
Q

What are obsessions?

A

Undesired, unpleasant intrusive thoughts that cannot be suppressed

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37
Q

What is a delusion?

A

A fixed, false belief.
Inappropriate to the patient’s socio-economic background
Firmly held in the face of:
- Logical argument OR
- Evidence to the contrary
Not modified by experience or reason
Usually very individualised or of great personal significance

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38
Q

Where do most delusions originate from?

A

Often an attempt to explain an anomalous experience as hallucinations

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39
Q

What are grandiose delusions?

A

Belief that one is very powerful or even a God

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40
Q

What are nihilistic/cotard delusions?

A

False belief that one does not exist or has died

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41
Q

What are bizarre delusions?

A

Beliefs that are clearly impossible

Not understood by peers and don’t derive from life experiences

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42
Q

What is a delusion of reference?

A

Insignificant events/objects have great personal significance

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43
Q

What are delusions of control? What else can they be called?

A

External forces controlling oneself

Passivity

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44
Q

What are the four main features in assessing perception in a mental state exam?

A 
Derealisation/Depersonalisation:
- Perception that surroundings/self aren't real
Deja vu
Illusions
Hallucinations
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45
Q

What do second person auditory hallucinations indicate?

A

Psychotic depression

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46
Q

What do third person auditory hallucinations indicate?

A

Schizophrenia

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47
Q

How can we assess attention and concentration (cognition)?

A 
Serial sevens (count down from 100 in sevens)
Digit span (give number sequence - ask to recall)
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48
Q

How else can we assess cognition?

A 
Orientation (time/place/person)
Memory
Calculation
Language (name objects)
Visuospatial functioning (copy a diagram/clock face)
Executive functioning:
- Ask what x and y have in common
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49
Q

What are some clues that a patient’s cognition is impaired?

A 
Unable to recall purpose of interview
Vague about:
- Time
- How they came to arrive at interview
Discussing past events/dead relatives as if current
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50
Q

How many points are in the Addenbrookes Cognitive Examination?

A

100

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51
Q

How many points are in the Montreal Cognitive Assessment?

A

30

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52
Q

What can insight be divided into in terms of the mental state exam?

A

The four As:

  • Awareness of one’s own symptoms
  • Attribution of symptoms to appropriate mental disorder
  • Appraisal/Analysis of consequences of symptoms
  • Acceptance of treatment
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53
Q

What is anautognosia?

A

Absence of awareness of ones own symptoms

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54
Q

What is dysautoagnosia?

A

Absence of attribution of symptoms to an appropriate mental disorder

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55
Q

How is early morning wakening described?

A

Waking >= 2 hours before expected/normal time

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56
Q

What is stupor?

A

Absence of relational functions

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57
Q

What is anhedonia?

A

Loss of enjoyment/pleasure

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58
Q

What is appearance and behaviour like in depression?

A 
Reduced facial expression
'Furrowed' brown
Reduced eye contact
Limited gesturing
Difficult rapport
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59
Q

What is speech like in depression?

A

Reduced rate, volume, intonation
Lowered pitch
Increased speech latency
Limited content (short, brief answers)

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60
Q

What is a patient’s mood like in depression?

A

‘Flat’

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61
Q

What is a patient’s affect like in depression?

A

Depressed
Reduced range
Limited reactivity:
- Doesn’t respond/react to changes in subject/context/emotion

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62
Q

How is thought form affected in depressive moods?

A

Flow of thought:

  • Slow and pondering
  • Might be absent
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63
Q

How is thought content affected in depressive moods?

A 
Negative, self-accusatory, guilt
Delusions may occur:
- Guilt
- Poverty
- Nihilism
- Hypochondriasis
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64
Q

What other symptoms tend to be presence alongside paranoia in psychosis?

A

Persecutory ideas/delusions
Altered perceptions
Lost insight

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65
Q

What types of auditory hallucinations can be present in depressive states?

A

2nd person and derogatory

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66
Q

What cognitive deficits are typically present in depressive states?

A

Working memory
Attention
Planning

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67
Q

How is insight affected in depression?

A

Typically preserved

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68
Q

In what conditions is insight often absent?

A

Schizophrenia

Mania

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69
Q

What do patients experiencing depression often attribute their symptoms to?

A

Sins
Physical illness
Personal failing and weakness

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70
Q

What is the lifetime prevalence of depression?

A

14-18% in lifetime

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71
Q

How many cases of depression become chronic?

A

20%

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72
Q

How does DSM-5 classify depressive disorders?

A

Major Depressive Disorder

Persistent Depressive Disorder

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73
Q

How are mood disorders as defined by ICD-10?

A 
F30 - Manic episode
F31 - Bipolar affective disorder
F32 - Depressive episode
F33 - Recurrent depressive disorder
F34 - Persistent mood disorders
F38 - Unspecified mood disorder
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74
Q

How are depressive episodes defined by ICD-10?

A

F32.0 - Mild depressive episode
F32.1 - Moderate depressive episode
F32.2 - Severe depressive episode without psychosis
F32.3 - Severe depressive episode with psychosis
F32.8 - Other depressive episodes
F32.9 - Depressive episode, unspecified

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75
Q

What are the diagnostic features of a depressive illness?

A

Must be clearly abnormal for individual concerned
It must persist
Should interfere with normal function significantly

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76
Q

What are general criteria for depression?

A

Depressive episode lasting >= 2 weeks

No hypomanic/manic symptoms at any point

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77
Q

What are the core features of depression (criterion B)?

A

At least 2 of the 3 following present:

  1. Depressed mood:
    - To an abnormal degree
    - Present for most of day; almost every day
    - Largely uninfluenced by circumstances
    - Sustained for at least 2 weeks
  2. Loss of interest/pleasure in normally fun activities
  3. Decreased energy or increased fatiguability
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78
Q

The following are additional features of depression (criterion C):

  1. Loss of self-confidence/esteem
  2. Unreasonable feelings of self-reproach/excessive guilt
  3. Recurrent thoughts of death/suicide or suicidal behaviour
  4. Diminished ability to think/concentrare
  5. Change in psychomotor activity
  6. Sleep disturbance
  7. Change in appetite (weight change)
A

At least 4

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79
Q

What rating scales can be used to assess the severity of depression?

A

Hamilton Rating Scale for Depression
Montgomery-Asperg Depression Rating Scale
Beck Depression Inventory

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80
Q

How is a moderate depressive episode defined by the F32.0 criteria?

A

At least 2 of the 3 symptoms in criterion B
Criterion C symptoms:
- Enough present to give total of >= 6

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81
Q

How is a severe depressive episode defined by the F32.0 criteria?

A

All 3 symptoms from criterion B
Criterion C symptoms:
- Enough present to give total of >= 8

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82
Q

How can we define a somatic syndrome?

A

Four of the following present:

  • Loss of interest in usually pleasurable activities
  • Loss of emotional reactions to emotional events
  • Early morning waking
  • Depression worse in the morning
  • Objective evidence of psychomotor retardation
  • Marked loss of appetite
  • Weight loss (>=5% in last month)
  • Loss of libido
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83
Q

What do the following define:

  1. Mood reactivity
  2. Two or more of the following:
    - Significant weight gain/increased appetite
    - Hypersomnia
    - Leaden paralysis (heavy feeling in arms/legs)
    - Interpersonal rejection resulting in social/occupational impairment
A

Atypical depression

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84
Q

What is Cotard’s Syndrome?

A

A type of psychotic depression

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85
Q

What are the features of Cotard’s Syndrome?

A

Often nihilistic delusions

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86
Q

In what populations is Cotard’s Syndrome more common?

A

Elderly

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87
Q

What is the median number of lifetime episodes in major depressive disorder?

A

4

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88
Q

What is the mean age of onset of major depressive disorder?

A

27 years

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89
Q

What are the five Rs of depression? At what periods do they occur?

A

Response (acute phase - within 12 weeks)
Remission (at beginning of continuation; 4-9 months)
Recovery (maintenance stage - after 1 year)
Relapse (symptoms again during acute/continuation)
Recurrence (more symptoms after recovery)

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90
Q

How does DSM-V classify Bipolar disorders?

A

Bipolar:
- I
- II
Cyclothymic disorder

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91
Q

How does ICD-10 classify Bipolar disorders?

A

Hypomania
Mania with psychotic features
Mania without psychotic features

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92
Q

How is Bipolar I defined by DSM-V?

A

Has to meet criteria for mania

Represents ‘classic’ form of manic-depressive psychosis

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93
Q

How is Bipolar II defined by DSM-V?

A

Current/past hypomania AND current/past depression

No mania

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94
Q

What is the most common kind of Bipolar disorder (in terms of DSM-V classification)?

A

Bipolar II

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95
Q

What is Bipolar II.5 in terms of DSM-V?

A

Depressions superimposed on cyclothymic temperament

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96
Q

How is Cyclothymic disorder described in the context of DSM-V?

A
  • Cycles of hypomania/depression over at least 2 years
  • Never asymptomatic for more than 2 months during those 2 years
  • No major depression/mania
  • No schizoaffective disorder
  • Not explained by drugs.alcohol
  • Symptoms impair functioning
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97
Q

What is Bipolar III?

A

‘Psuedo-unipolar’

Hypomania ONLY after use of antidepressants for depression

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98
Q

What is Bipolar IV?

A

Depressions arising from a hyperthymic temperament

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99
Q

How is Bipolar Affective Disorder described in ICD-10?

A

Characterised by >=2 episodes in which mood and activity are significantly disturbed:

  • Hypomania/Mania and sometimes depression
  • Repeated hypomania or mania ONLY
  • 1st episode of (hypo)mania -> Not depression
100
Q

How does ICD-10 describe a hypomanic episode?

A
  1. Mood is elevated/irritable
    - To an abnormal degree
    - Sustained for >=4 consecutive days
  2. > =3 of the following; interfering with daily living:
    - Increased activity/restlessness
    - Increased talkativeness
    - Difficulty concentrating or distractability
    - Reduced need for sleep
    - Increased sexual energy
    - Mild spending sprees
101
Q

How does ICD-10 describe a manic episode?

A
  1. Mood predominantly elevated/expansive/irritable:
    - Definitely abnormal
    - Prominent change sustained for >=1 week
    - Or prominent change requiring hospital admission
  2. > =3 of the following (>=4 if only irritable) resulting in severe interference:
    - Restlessness
    - Pressure of speech
    - Flight of thoughts
    - Disinhibition
    - Reduced need for sleep
    - Grandiosity/Increased self-esteem
    - Distractability
    - Reckless behaviour without appreciating risk
    - Marked sexual energy/indiscretions
102
Q

What is F30.1?

A

Mania without psychotic symptoms
Perceptual disorders may occur:
- Subacute hyperacusis
- Appreciations of colours as very vivid

103
Q

What is F30.2?

A

Mania with psychotic symptoms

104
Q

What delusions or hallucinations must not occur in F30.2?

A

Those listed as Typical Schizophrenic:

  • No bizarre delusions
  • No 3rd person/running commentary hallucinations
105
Q

What are the commonest delusions in mania with psychotic symptoms?

A

Grandiose
Self-referential
Erotic
Persecutory

106
Q

When does bipolar disorder tend to onset?

A

Late teens/early 20s

107
Q

If there is a family history of bipolar disorder, how does this affect onset of bipolar disorder?

A

Earlier

Precipitated by lower levels of stress

108
Q

Bipolar disorder that onsets after 60 years of age is often associated with what?

A

Treatment resistance
Progressive decline in functioning
Underlying organic cause

109
Q

What gene is associated with Schizophrenia?

110
Q

What genes are associated with Schizoaffective disorders?

A

NRG1
G72
G30

111
Q

What gene is associated with bipolar disorder?

112
Q

What is the most common mood disturbance in bipolar disturbance?

A

Depression (30-50%)

113
Q

What ICD-10 range defines eating disorders?

114
Q

What is F50.0?

A

Anorexia nervosa

115
Q

What is F50.1?

A

Atypical anorexia nervosa

116
Q

What is F50.2?

A

Bulimia nervosa

117
Q

What are the four features of anorexia nervosa?

A
  1. Weight loss (lack of weight gain in kids):
    - Weight =<15% below normal for age and height
  2. Weight loss in self-induced by fatty-food avoidance
  3. Self-perception of being too fat (intrusive dread of fatness)
  4. Widespread endocrine disorder:
    - Involves hypothalamic-pituitary-gonadal axis
    - Amenorrhoea in females (vaginal bleed while on HRT/COC)
    - Loss of libido and potency in males
118
Q

How can pre-pubertal onset of anorexia nervosa affect development?

A 
Growth ceases
In girls:
- Breasts do not develop
- Primary amenorrhoea
In girls:
- Genitals remain juvenile
119
Q

On recovery of pre-pubertal anorexia nervosa, what can occur?

A

Puberty usually completed normally

Menarche is late

120
Q

What are the DSM-V subtypes of anorexia nervosa?

A

Restricting

Binge-eating/Purging

121
Q

What are the four ICD-10 criteria for Bulimia Nervosa?

A
  1. Recurrent overeating:
    - >=2 times a week over >=3 months
    - Lots of food in a short period of time#2.
  2. Preoccupation with eating and cravings
  3. Counteracting the fattening effects by >=1 of:
    - Self induced vomiting
    - Self induced purging
    - Alternating periods of starvation (use of appetite suppressants/thyroid hormones/diuretics or abandoning insulin in diabetics)
  4. Self-perception of being too fat
122
Q

In terms of DSM-V, how many associated features must occur alongside binge episodes to diagnose a binge eating disorder?

123
Q

What are some high risk indicative behavioural features for anorexia?

A

Feeding problems
Reduced BMI
Social difficulties

124
Q

What are some high risk indicative psychobiological features for anorexia?

A

Reduced reward and increased threat
Sensitivity
Social cognition problems
Cognitive rigidity

125
Q

What are some prodromal features of anorexia?

A 
Coping:
- Avoidance
- Perfectionism
Compulsivity
Anxiety
126
Q

What can indicate a severe enduring anorexia?

A 
Social isolation
Impaired physical and mental QoL
Habits not goal-directed
Threat sensitivity
Reduced social cognition
127
Q

What are some high risk indications for bulimia?

A

Robust feeding
Increased BMI
Increased reward sensitivity
Reduced response inhibition for food

128
Q

What is the Standardised Mortality Ratio?

A

Ratio between number of deaths in a study population and the number of deaths that would be expected?

129
Q

What is the Standardised Mortality Ratio for anorexia?

130
Q

What is the Standardised Mortality Ratio for bulimia?

131
Q

What causes refeeding syndrome?

A

Depletion of already inadequate stores of nutrients:

  • Magnesium
  • Potassium
  • Phosphate
132
Q

What is a low-moderate risk BMI?

133
Q

What is a moderate risk BMI?

134
Q

What is a high risk BMI?

135
Q

What is a very high risk BMI?

136
Q

What do the BMA Guidelines for consenting to treatment say a patient should be able to do?

A
  • Understand in simple language what the treatment is, its purpose and nature and why its propose
  • Understand its benefits, risks and alternatives
  • Understand broadly the consequences of no therapy
  • Retain info long enough to weigh up options and make a decision
137
Q

What is the purpose of the Adults with Incapacity (Scotland) Act 2000?

A

Provides guidance for safeguarding the welfare/finances of adults who lack capacity:

  • Mental illness
  • Learning disability
  • Inability to communicate
138
Q

How does the Adults with Incapacity Act define an adult?

A

Aged >=16 year

139
Q

What is Part 6 of the Adults with Incapacity Act?

A

Welfare/Financial Guardianship:

- Authorises a person to make a decision which the patient can’t

140
Q

What is Part 5 of the Adults with Incapacity Act?

A

Medical treatment

141
Q

When is a person not deemed to have a mental disorder and so won’t be treated as such?

A

Promiscuity
Sexual deviancy
Alcohol/Drug abuse
Acting as no prudent person would

142
Q

What does Section 47 prohibit?

A

Use of force unless immediately necessary and only for as long as is necessary

143
Q

What article of the European Convention on Human Rights protects against arbitrary detention?

144
Q

When would Emergency Detention be used under the Mental Health Act?

A

If there is need for an urgent assessment of the patient’s condition when they post a risk to themselves or others

145
Q

Who can authorise Emergency Detention under the Mental Health Act?

A 
Any doctor
(Preferably under guidance by a mental health officer)
146
Q

How long can a person be detained under an Emergency Detention under the Mental Health Act?

A

72 hours maximum

147
Q

Does Emergency Detention under the Mental Health Act allowed the patient to be treated against their will?

148
Q

When would Short-Term Detention be used under the Mental Health Act?

A

When it is deemed that the patient requires admission to hospital to prevent injury to themselves or others
AND
That there is a need for the provision of medical treatment

149
Q

Who can authorise Short-Term Detention under the Mental Health Act?

A

Recommended by a psychiatrist and agreed by a mental health officer

150
Q

How long can a person be detained under Short-Term Detention under the Mental Health Act?

151
Q

Does Short-Term Detention under the Mental Health Act allowed the patient to be treated against their will?

152
Q

When would a Compulsory Treatment Order be used under the Mental Health Act?

A

The patient has a mental disorder in which treatment:
- Would prevent it worsening OR
- Alleviate symptoms/effects
AND
If the patient wasn’t treated there would be risk to:
- Health/safety/welfare of patient
- Safety/welfare of others

153
Q

How can a Compulsory Treatment Order be approved?

A

A mental health officer must apply to a Tribunal
The application should have:
- Two medical recommendations
- Plan of care (detailing care and treatment proposed)

154
Q

Who is allowed to object to anything under the Compulsory Treatment Order?

A

The patient
The patient’s named person
The patient’s primary carer

155
Q

Are patient’s upon which a Compulsory Treatment Order has been enforced allowed to be detained in hospital?

A

Not initially

There will be specifications in the order where detention can be authorised

156
Q

How long can a Compulsory Treatment Order last?

A

6 months initially
Can be extended for another 6 months
Then for another 12 months

157
Q

Under what age does a person categorically have no consent?

A

If =<12 years

158
Q

When might children younger than 16 have capacity?

A

They understand nature/purpose/consequences of intervention

They understand consequences of not having treatment

159
Q

If a child, deemed competent by a doctor, consents to treatment that their parents do not consent to, can the parents overrule the decision?

160
Q

If a child, deemed competent by a doctor, does not consent to treatment that their parents do consent to, can the parents overrule the decision? What can they do?

A

No.

Can potentially apply for a court order

161
Q

If a child, deemed competent by a doctor, does not consent to treatment that you, as their physician deem life-saving, what should you do?

A

Discuss with MDT

Legal advice might be useful - a court order may be required

162
Q

If parents of a child who is not competent (younger than 12 or cannot understand fully the procedure) do not consent to treatment that physicians deem beneficial to the child’s survival or QoL, what should you do?

A

MDT discussion
Legal advice
Court order

163
Q

What antidepressants are deemed NA-selective?

A

Maprotiline
Protriptyline
Nortriptyline

164
Q

What antidepressants are deemed non-selective?

A

Amitriptyline and Imipramine (1:1 ratio)

Clomipramine

165
Q

What antidepressants are deemed serotonin-selective?

A 
Venlafaxine
Paroxetine
Sertraline
Fluoxetine
Citalopram
166
Q

What class of drugs do Phenelzine, Isocarboxazid and Tranylcypromine belong to?

167
Q

What type of drug is Moclobemide?

A

Reversible Inhibitor of MonoAmine oxidase A (RIMA)

168
Q

Give some examples of TCAs

A 
Amitriptyline
Clomipramine
Imipramine
Nortriptyline
Dosulepin
169
Q

Give some examples of SSRIs

A 
Fluoxetine
Paroxetine
(Es)Citalopram
Sertraline
Fluvoxamine
170
Q

Give some examples of SNRIs

A

Venlafaxine

Duloxetine

171
Q

What type of drug is Reboxetine?

172
Q

What type of drug is Mirtazapine?

A

An atypical antidepressant with NA and specific serotenergic activity (NASSA)

173
Q

What systems function to mediate seeking and approach behaviours (including pleasure)?

A

Ascending DA systems (mesolimbic/cortical)

Ventral striatum

174
Q

What is the dorsal striatum important for?

175
Q

What is the amygdala important for?

A

Conditioning and learning

176
Q

What is the function of the anterior cingulate?

A

Attention
Conflict
Response selection

177
Q

What part of the brain is responsible for relative reward preference and rule learning?

A

Orbitofrontal cortex

178
Q

What systems function to promote survival in event of threat?

A 
Ascending serotonin systems
NA transmitters
Central nucleus of amygdala
Hippocampus
Ventroanterior and medial hypothalamus
Periaqueductal grey matter
179
Q

What do MAOIs prevent?

A

The action of monoamine oxidase which breaks down:

  • DA
  • NA
  • Serotonin
180
Q

How do TCA work?

A

Act at presynaptic membrane to prevent serotonin and NA reuptake

181
Q

In dopamine transmission, how is dopamine produced?

A

Tyrosine -> Levodopa -> DA

182
Q

What effect do amphetamines and MPP+ have on the DA transporter and dopamine?

A

Compete with DNA for reuptake

Force DA out of presynaptic vesicles, resulting in their release into synapse

183
Q

What effect do cocaine, GBR 12935, WIN 35,428 and RTI-121 have on the DA transporter?

A

Bind to receptor and inhibit DA reuptake

184
Q

How is NA produced in a noradrenergic neurone?

A

Tyrosine -> L-DOPA -> DA (cytoplasm) -> DA (vesicle) -> NA

185
Q

How does amphetamine affect the NA transporter (NET)?

A

Substrate
Reverses direction of neurotransmitter
Increases synaptic NA

186
Q

What drugs inhibit the NA transporter?

A

Cocaine
Nisoxetine
Reboxetine

187
Q

How is serotonin produced in a serotonergic neurone?

A

Tryptophan -> 5-Hydroxytrytophan -> Serotonin

188
Q

How does amphetamine and MDMA affect the serotonin transporter?

A

Substrates

Competitive reuptake inhibiton

189
Q

What drugs inhibit the serotonin transporter?

A

Cocaine
Fluoxetine
Paroxetine
Sertraline

190
Q

What are the mechanisms by which amphetamine and MDMA increase synaptic concentrations of DA/NA/5-HT?

A

VMAT2 inhibitors:
- Reduce their transport in vesicles by forcing them out of the vesicles
- Increase concentration in presynaptic neurone
TAAR1 agonists:
- Trigger protein kinases A and C
- Phosphorylate DAT/NET/SERT
- Reverse transport direction
- Increas concentration in synaptic cleft

191
Q

What enzyme converts tryptophan to 5-hydroxytryptophan?

A

Tryptophan hydroxylase

192
Q

What enzyme converts 5-hydroxytryptophan to serotonin?

A

Aromatic-L-amino acid decarboxylase

193
Q

What serotonin receptors are targeted by anti-depressants?

A 
5-HT1a
5-HT2a
5-HT2b
5-HT2c
5-HT3
5-HT6
5-HT7
194
Q

What drugs target 5-HT1b and 5-HT1d?

A

Migraine medications (eg. Triptans)

195
Q

What serotonin receptor is targeted by anti-emetics?

196
Q

What serotonin receptor has GI pro-kinetic effects and what is it used to treat?

A

5-HT4

IBS and chronic constipation

197
Q

On what receptor do fluoxetine and paroxetine at on?

A

5-HT2 (a-c)

198
Q

On what receptors does Amitroptyline act on?

A

5-HT6

5-HT7

199
Q

How long do SSRIs take to have effect? At this time, what are the levels of 5-HT like in the synaptic cleft?

A

2-3 weeks

Normal

200
Q

What circuits are indicated in SSRI use?

A

Limbic-cortical

201
Q

What type of receptors are 5-HT1a receptors?

A

Inhibitory autoreceptors

202
Q

Upon acute antidepressant treatment, what happens in the synapse?

A

5-HT reuptake is inhibited
Increased [5-HT] in cleft
Stimulates 5-HT1a receptors to inhibit presynaptic firing

203
Q

What does chronic occupancy of the 5-HT1a receptor cause?

A

Desensitise it
Return to normal firing
Facilitates serotenergic transmission in presence of reuptake blockade

204
Q

What is wrong with the serotenergic system in depression?

A

Dysregulation in transmission

Serotonin is not low

205
Q

Why are SSRIs typically first line?

A

Almost all can be started at a therapeutic dose
Usually good tolerance
Relatively safe in overdose

206
Q

Why do SSRIs interact with other drugs?

A

Inhibit CYP450

207
Q

What are some side effects of SSRIs?

A

Sexual dysfunction:
- Via DA blockade +/or serotonin activation
GI side effects (nausea, constipation, diarrhoea)
Short-term anxiety
Increased risk of self-harm in first few weeks in young people (=<25 years)

208
Q

What drugs can cause reversal of an SSRI?

A

5-HT2 antagonists

Partial 5-HT1a agonists (eg. Trazodone)

209
Q

When might an SSRI be avoided?

A

Agitated depression
Intolerable GI effects
On warfarin (SSRIs can potentiate bleeding)
If on AEDs

210
Q

When is citalopram specifically avoided?

A

With another medication that may prolong QT
If diagnosed with long QT
If cardiac disease
If on antipsychotics
If on amitriptyline (for neuropathic pain)

211
Q

What drug for depression may be preferred in breastfeeding? (This is also the second choice SSRI in all with depression)

A

Sertraline

212
Q

What is the typical dosing regime for fluoxetine?

A

20mg/day PO initially
Increased after 3-4 weeks if necessary
Max 60mg/day PO

213
Q

What is the typical dosing regime for sertraline?

A

50mg/day PO initially
Increased by 50mg increments at intervals of at least one week
Max 200mg/day PO

214
Q

What monitoring may be needed in high does TCA therapy and why?

A

ECG

QT lengthening

215
Q

What are the side effects of TCAs?

A 
Constipation
Dry mouth
Blurred vision
Effects on cardiac function
Postural hypotension:
- Failure of peripheral orthostatic reflexes
216
Q

What does MAO A metabolise?

A

NA
5-HT
Tyramine

217
Q

What does MAO B metabolise?

A

DA
Tyramine
Phenylethylamine

218
Q

When are MAOI used?

A

3rd or 4th line

Often in atypical depression

219
Q

What are side effects of MAOI therapy?

A

Flushing
Headache
Hypertension
CVA (rarely)

220
Q

Why do MAOIs cause their side effects?

A

Tyramine is usually inactivated in the gut

Since it remains active, NA is released

221
Q

What can cause hypersensitive crises with MAOI therapy?

A 
Tyramine-containing foods:
- Cheese
- Yoghurts
- Meat
- Alcohol
Drugs:
- Sympathomimetics (OTC  cold remedies)
- Pethidine
222
Q

How can the side effects of MAOIs be treated?

A

Alpha-blockade:

  • Phentolamine
  • Chlorpromazine
223
Q

What side effects can some antidepressants (eg. Paroxetine) cause?

A

Extrapyramidal (due to effects on DA):

  • Tremor
  • Dystonia
  • Akathisia
  • Tardive dyskinesia
224
Q

Give an example of an antipsychotic that may be an antidepressant at a low dose.

A

Flupentixol

225
Q

What drug acts as a benzodiazepine receptor inverse agonist on the GABAa receptor complex?

226
Q

What drug acts as a benzodiazepine receptor antagonist on the GABAa receptor complex?

A

Flumazenil

227
Q

What drug acts as a benzodiazepine receptor agonist on the GABAa receptor complex?

228
Q

When is a benzodiazepine receptor antagonist used?

A

Reversal of sedative effects benzodiazepine
OR
Treatment of benzodiazepine overdose

229
Q

What effect does Picrotoxin have on the GABAa receptor?

A

Binds to the picrotoxin site:

  • Channel blocker
  • Stimulant and convulsant effects
230
Q

What other sites (and hence drugs) are on the GABAa receptor (apart from BZD and GAPA sites)? What effects do these have?

A

Barbituate site
Steroid site
Positive allosteric modulators:
- Indirectly affects agonist or inverse agonist action

231
Q

What type of receptor is GABAa?

A

Ligand-gate ion channel

232
Q

What drugs act as GABAa receptor agonists?

A

Ethanol
Benzodiazepines
Propofol
Anaesthetics

233
Q

What drug acts as a GABAa receptor antagonist?

A

Flumazenil

234
Q

What type of receptor is GABAb?

235
Q

What drugs act as GABAb receptor agonists?

A

Baclofen

Propofol

236
Q

What anticonvulsants act as mood stabilisers?

A

Carbamazepine
Valproate
Lamotrigine

237
Q

What second generation antipsychotics can be used as mood stabilisers?

A

Olanzapine
Risperidone
Aripiprazole
Quetiapine

238
Q

What other drugs can be used as mood stabiliers?

A 
Lithium carbonate (citrate)
Nimodipine (calcium channel blocker)
239
Q

How does lamotrigine work?

A

Blocking sodium channels
Doesn’t work directly via GABA:
- Reduces excitability and cell firing

240
Q

How many lithium work?

A 
Inhibition of 5-HT autoreceptors
Increase in anti-apoptotic factor Bcl-2
Inhibition of glycogen synthase kinase-3 (GSK-3)
Depletion of inositol
Up-regulation of glutamate reuptake
241
Q

How do true/1st generation antipsychotics work?

A

Related to D2 receptor affinity

242
Q

What circuit results in the desired effect of true/1st generation antipsychotics?

A

DA blockade in the mesolimbic circuits

243
Q

What causes the adverse effects of true/1st generation antipsychotics?

A

DA blockade in nigrostriatal pathway:
- Movement disorders
DA blockade in the tubero-infundibular pathway:
- Hyperprolactinaemia

244
Q

What are the three mechanisms of action of 2nd generation antipsychotics?

A
  1. Increased D2 receptor-binding affinity:
    - Increased antipsychotic effectiveness
  2. Increased 5-HT2c and a receptor-binding affinities:
    - Increased antipsychotic efficacy
  3. Increased 5-HT1a binding affinity:
    - Reduced antipsychotic efficacy
245
Q

What does structural imagine in bipolar disorder show?

A

Reduced grey matter volume in Brodmann Area 24 (anterior cingulate gyrus)

246
Q

What does functional imaging in bipolar disorder show?

A 
Increased metabolism in amygdala:
- Correlates with outcome
Reduced metabolism:
- OfC
- Medial ventral pfC

Year 3 - Psychiatry (DP) (4 decks)

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