Depression + Anxiety

Question 1

Monoamine hypothesis

Answer 1

Depression results from the depletion of monoamines noradrenaline, serotonin and dopamine. Antidepressants increase the amount of these

Question 2

Organic causes of depression (neuro, endocrine, metabolic, infective, drugs)

Answer 2

Neuro: stroke, Alzheimers, Parkinsons, Huntingtons, MS, tumours Endocrine: cushings, addisons, hypothyroidism, hyperparathyroidism Metabolic: iron deficiency, hypercalcaemia, hypomagnesaemia Infective: infectious mono, hepatitis, HIV Drugs: levodopa, steroids, beta blockers, digoxin, alcohol

Question 3

Beck’s triad

Answer 3

Negative view of yourself, the present and the future

Question 4

S+S depression

Answer 4

Core: low mood, low energy, anhedonia Biological: sleep, appetite, loss of libido, restlessness Psychological: poor self esteem, guilt, self harm/ suicide thoughts, concentration

Question 5

ICD 10 Criteria for depression

Answer 5

Mild: 2 core + 2 other Moderate: 2 core + 4 other Severe: 3 core + 3 other (+ psychosis)

Question 6

Management of depression

Answer 6

Mild: watch + wait, self help, sleep hygiene, counselling Moderate + severe: CBT + SSRI Use SSRI, then try another SSRI, then try an SNRI or Mirtazapine. Can combine mirtazapine with an SSRI or SNRI. Failing that use lithium, sodium valproate or antipsychotic. For severe: can use ECT

Question 7

SSRIs (action, SE, complications, SSRI discontinuation syndrome)

Answer 7

Selectively inhibit reuptake from the presynaptic cleft. SE: nausea, vomiting, diarrhoea, dizziness, sedation, sexual dysfunction, akathisia Can cause GI bleeds - do not take NSAIDs, aspirin or warfarin Can cause hyponatraemia SSRI discontinuation syndrome: headache, dizziness, shock like sensations, paraesthesia, GI symptoms, lethargy

Question 8

Serotonin syndrome (causes, S+S)

Answer 8

Caused by SSRIs, TCA, lithium, tramadol Agitation, confusion, nystagmus, tremor, seizures, hyperthermia, autonomic instability

Question 9

Citalopram + sertraline uses, key SE

Answer 9

Citalopram = least drug interactions, good for the elderly, prolongs QT Sertraline = best for CV patients

Question 10

Fluoxetine + paroxetine uses, key SE

Answer 10

Fluoxetine = best for younger patients, longest HL, good for bulimia Paroxetine = shortest HL, can get discontinuation syndrome

Question 11

SNRIs action, SE + contraindications

Answer 11

Venlafaxine, duloxetine Same SE as TCAs (anticholinergic) + sexual dysfunction Don’t give in uncontrolled HTN - do ECG + BP before starting

Question 12

NASSAs - SE

Answer 12

Mirtazapine - sedative + weight gain More sedative at a lower dose Less sexual dysfunction than others

Question 13

TCAs - names, action, SE, OD, contraindications

Answer 13

Amitryptylline, clomipramine, imipramine Inhibit reuptake of noradrenaline + serotonin SE: anticholinergic (dry mouth, dry eyes, constipation, urinary retention), antihistaminergic (sedation, weight gain) CV (postural hypotension, arrhythmias), neuro (delirium, seizures) Lethal in OD Contraindications: CV disease, liver disease, glaucoma, prostatic hypertrophy

Question 14

MAOi - names, action, cautions, SE, interactions

Answer 14

Phenelzine, isocarboxacid, tranylcypromine Inhibit degradation of monoamines presynaptically Must adhere to strict no tyramine diet (no cheese, game, yeast etc) Can cause HTN crisis SE: anticholinergic, weight gain, insomnia, postural hypotension Interact with insulin

Question 15

ECT - uses, SE

Answer 15

Used for severe depression, catatonia, psychosis SE: headaches, muscle aches, nausea, confusion, temporary memory loss

Question 16

Risk factors for suicide

Answer 16

Male aged 25-44 Single/ widowed/ divorced Unemployed High level occupation (doctor, vet, pharmacist) SES IV, V Physical illness = cancer, AIDS, epilepsy, MS

Question 17

S+S anxiety

Answer 17

Pyschological - fear, feeling of doom, night terrors, poor concentration Physical: CV, GI, resp, genitourinary

Question 18

Neurological cause of anxiety

Answer 18

Noradrenergic neurones in locus coeruleus (pons) + serotinergic neurones in raphe nuclei = act on limbic system to increase anxiety Also can be caused by imbalance in GABA

Question 19

Management of GAD

Answer 19

CBT, SSRI Benzos for short term use only

Question 20

Agoraphobia

Answer 20

Fear of places that are difficult or embarrassing to escape from - may respond to CBT

Question 21

Panic disorder management

Answer 21

SSRI, then TCA

Question 22

OCD - S+S, diagnosis

Answer 22

Obsessional thoughts (recurrent ideas, perceived as senseless, resulting in anxiety) Commonly: doubt, contamination, orderliness, safety Compulsive acts (recurrent behaviour, reduces anxiety, seen as senseless) Commonly: washing, cleaning, arranging, ritualistic behaviours Diagnosis - more than 2 weeks

Question 23

OCD management

Answer 23

CBT such as ERP - exposure + response prevention 1st) SSRI 2nd) Clomipramine 3) + gabapentin, lamotrigine, olanzapine + risperidone

Question 24

PTSD - S+S, management

Answer 24

Hyperarousal, involuntary + intense flashbacks + avoidance Around 6 months post event EMDR - eye movement desensitisation reprocessing Avoid meds but if needed: paroxetine or mirtazapine

Question 25

Somatoform disorder

Answer 25

Physical symptoms not accounted for by physical disorder

Question 26

Factitious disorder

Answer 26

Symptoms manufactured for the purpose of assuming the sick role (Munchausens)

Question 27

Malingering

Answer 27

Symptoms manufactured for a purpose other than assuming the sick role ie to get some gain

Question 28

Somatisation disorder

Answer 28

Symptoms for 2 years

Question 29

Conversion/ dissociative disorders

Answer 29

Traumatic event resulting in disruption of function Conversion of anxiety symptoms into more tolerable symptoms

Question 30

Dissociative amnesia/ fugue/ stupor

Answer 30

Amnesia = loss of memory for an event Fugue = sudden, unexpected journey with memory loss and confusion Stupor = motionless and mute, doesn’t respond to stimuli

Question 31

Dissociative motor/ sensory/ anaesthesia

Answer 31

Motor = paralysis of muscle groups Astasia abasia = inability to stand or walk Loss of sensation - commonly ‘glove + stocking’ distribution

Question 32

Ganser’s syndrome S+S

Answer 32

Absurd statements, confusion, hallucinations - giving approximate answers to questions

Question 33

Cushings syndrome S+S

Answer 33

Depression, weight gain, acne, obesity, polydipsia/ uria, fatigue, muscle pain, amenorrhoea

Question 34

What is an acute stress reaction?

Answer 34

Symptoms of anxiety, secondary to specific trauma, <1 month