Depresssoin, Bipolar, Psychoses Flashcards
1
Q
What are the core Sx of depression
A
Low mood
Loss of energy
Loss of pleasure (anhedonia)
2
Q
Sx other than core in depression
A
Sleep, appetite, libido, concentration, confidence, guild, hopelessness, suicidal
3
Q
How to define mild / moderate depression
A
Mild - 2 core + 2
Moderate - 2 core + 3-4 others
Severe - 3 core + 4 others
4
Q
What is the leading cause of maternal death post partum
A
Suicide - post natal depression
5
Q
What is bi polar
A
Depression + hypo/mania
Rapid cycling
6
Q
Define bipolar 1 ? 2?
A
1- at least two episodes of mania or mania and depression - depressive episodes last longer
2- Many episodes of depression with only hypomania
7
Q
How does a manic person appear ? What signs? What is hypomania?
A
Cheerful and euphoric, grandiose - may be irritable -> anger
Insight impaired, pressure of speech, impaired the judgement and risk taking
Hypomania - mania to lesser extent
8
Q
Risks with schizophrenia ?
A
Life expectancy 25 years less, Suicide, cvd, resp, infection
9
Q
What do people with schizophrenia experience?
A
Hallucinations and delusions
Disordered thinking
10
Q
Negative and positive Sx of schizophrenia ?
A
N - Ahendonia, loss of sleep, motivation, communication, self neglect
P- Hallucinations, delusions, passivity phenomena, thought alienation, lack of insight
11
Q
Differentiate between mania and hypomania?
A
Psychotic symptoms
Auditory hallucinations / delusions of grandiose
12
Q
Investigations in pt with psychotic Sx
A
Bloods - U&Es, LFT, Ca, FBC, glucose
Radiological - CT/MRI if suggested neurological abnormality
Urine - Drugs (stimulants / canabis) / culture for infection
EEG
13
Q
When would you do an EEG in psychotic Sx
A
If Hx of seizure / temporal lobe epilepsy
14
Q
What additional blood tests could you do in pt with psychotic if suggested?
A
PTH, tumour markers, cortisol, Thyroid, UDRC (syphilis)
15
Q
What special investigations could you do in pt with psychotic Sx if the Hx indicated?
A
Cushings - 24hr cortisol
Phaochromocytoma - 24hr catecholamine
Carcinoid syndrome - 24hr 5-HIAA
16
Q
What causes the Sx of Cushing’s syndrome
A
High levels of cortisol
17
Q
Sx of cushings
A
Weight gain, thinning / easy bruising skin, stretch marks, round face, muscle weekness, loss of libido
18
Q
When does Cushing’s syndrome usually occur?
A
Tx with corticosteroids
Tumour
19
Q
What is a phaochromocytoma
A
Tumour of adrenal glands
20
Q
Usual presentation of phaeochromocytoma
A
Sx come in unpredictable sudden attacks that last a few minutes - hour
Sever headache
Sweating
Palpitations
(Many other … irritable, anxious, weight loss, drowsy, tremors, SOB, othostatic hypotension)
21
Q
Which inherited genetic disorders are linked to phaeochromocytoma?
A
Multiple endocrine neoplasia
Von hipped Lindau
Neurofibromatosis type 1
22
Q
What is a carcinoid tumour ?
A
Tumour which produces hormones
23
Q
Sx of carcinoid tumour ?
A
Depends where it is
Bowel - abdo pain, GI Sx, bleeding
Lunch - cough / haemoptsis / SOB / pain
Common are - diarrhoea, abdo pain, loss of appetite
Flushing of skin
Tachycardia , SOB, wheezing
Tend to come on unexpectedly as tumour produces Sx
24
Q
Usual onset presentation of schitzophreia
A
80% get prodromal Sx
20% acute onset
25
When is the first episode of schitz usually ? What are common early signs?
Late adolescence / early adulthood - THEY LACK INSIGHT
Noticeable withdrawn / bizarre behaviour / personality change
Failure to achieve academic potential
Self harm / suicide attempt
Complain to council they can hear neighbours
Via criminal justice system
26
Issues with young adults / adolescents and schitz
Lack of compliance
Drug alcohol
Life stressors
27
2 options to treat acute psychosis ?
Start second gen Eg Olanzapine, risperidone (Can add a benzodiazepine)
Low potency 1st gen Eg chloropromazine and titrate up
28
Why do you not use chlorpromazine over 600mg
Little additional antipsychotic effect but still increases sedation
29
Patient develops ESPEs after antipsychotics what should you give?
Procyclidine (antimuscarinic)
30
What co morbidity s very common with schitz ?
Depression in 70%
31
Management of psychosis after discharge
Continue antipsychotic medication at lowest possible dose
Psychological - Family therapy / compliance therapy
Social - community psychiatric nurses
32
Common side effects of antipsychotics
Sedation
Weight gain
ESPEs
Postural hypotension
33
How to avoid sedation with antipsychotics
Avoid - chlorpromazine / promazine
| Prescribe eg risperidone / amisulphide / haloperidol
34
How to avoid weight gain with antipsychotics?
Avoid phenothiazine , olanzapine, clozapine
| Prescribe haloperidol, fluphenazine
35
Avoid ESPEs
Prescribe 2nd gen
36
Avoid postural hypotension in antipsychotics ?
Avoid phenothiazine
| Prescribe haloperidol, amusulphide, trifluperazine
37
Before using clozapine in treatment resistant schitz what should you do?
Clarify diagnosis
Stop any substance misuse
Stop non compliance Eg could use depot
38
Eg of drugs used for antipsychotic depot? When is depot useful ? How long do they last ?
Risperidone, olanzapine
Non compliance / failure to respond
Release over 1-4 weeks
39
What is schitzoaffective disorder ? How do you treat it?
Schitz and affective Sx present NOT due to substance misuse or medical disorder
Same as schitz but also manic /depressive for bipolar
40
Do you get delusions and hallucinations in schitzotypal disorder ? Explain it simply? Treatment?
No
‘Partial’ expression of schitz phenotype
Risperidone / CBT
41
What is schitzophreniform disorder ? Treatment?
Schitz lasting >1 - <6 months
| Same as acute schitz
42
What is delusional disorder?
Delusions without hallucinations
| No thought disorder / mood disorder / flattening of affect
43
Management of delusional disorder
Separation - from source of delusional ideas
Pharmacological - Eg Antipsychotics, Benzodiazapines, SSRIs
Psychological
44
Medication to treat post psychotic depression?
Lowest possible antipsychotic with an antidepressant
45
What is induced delusional disorder? Management?
Where an individual adopts delusions of another ( could be 2 healthy people developing same delusion)
Separation , psychological, pharmacological
46
How long do Sx need to be present for depressive illness ?
>2weeks
47
Disturbed sleep in depression ?
Insomnia (with early morning waking 2-3 hrs)
| Hypersomnia
48
What is seen in severe depression?>
Psychotic Sx - delusions / hallucinations, catatonic psychomotor
49
Core Sx of depression
Depressed mood
Anhedonia
Lack of energy
50
Non core Sx of depression
Weight change , disturbed sleep, psychomotor agitation / retardation, feelings of worthlessness/guilt/suicide, loss of libido
51
What are the semantic Sx of depression ?
Flattened emotions, diurninal variation, anhedonia, appetite / weight / libido, psychomotor
52
What is non-melancholic depression
Absence of psychotic / somantic Sx
53
2 types of non melancholic depression
Irritable / hostile - younger, Hx of acting out, poor responses to antidepressants
Anxious - Shy + withdrawn “always a worrier” - increased drug / alcohol, better response to antidepressants
54
What is melancholic depression
Has somantic Sx - especially psychomotor disturbance
55
What is psychomotor disturbance ? Egs
Purposeless motions / restlessness
| Eg biting nails, wringing hands
56
1st 2nd 3rd line treatment for depressive illness without psychotic features ?
```
Bio
1 - antidepressant (if CI -> CBT )
2 - try different antidepressant
(Partial responders could add lithium)
3- ECT
```
Psycho - CBT, psychoeducation
Socio - family or carer support, employment, education
MILD - watch and wait, IAPT
MOD - SSRI and IAPT
SEVERE - admission to ward, ECT
57
When could ECT be first line in depression without psychotic features ?
If severe biological features / high risk of self harm
58
1st and 2nd line treatment for depression with psychotic features?
1 - ECT
| 2 - Antidepressant + antipsychotic
59
What is an atypical depressive episode? Sx? Management?
Mood is depressed but able to enjoy some activities but not to ‘normal levels’
Hypersomnia, hyperphagia, heaviness in limbs
SSRI / Phenelzine (MOAI) / other antidepressant
60
Management of seasonal affective disorder?
Light therapy through winter
| Antidepressants
61
What is dysthymia ? Other name? Management?
Chronic low grade depressive Sx
Persistent depressive disorder
SSRIs / CBT
62
Tricyclics pros and cons ?
May be more effective in severe depression
| Toxicity in OD - may slow cardiac conduction / reduce seizure threshold
63
What is cyclothymic disorder?
Like bi polar with chronic mood fluctuations >2years with episodes of depression and hypomania but with insufficient severity to meet diagnosis of bipolar affective
64
What is bipolar 1 ?
One or more MANIC episodes and usually one or more depressive
65
What is bipolar II ?
Recurrent major Depressive and hypomanic episodes
66
Features of bipolar
```
Decreased social inhibition
Often lacks insight
Psychomotor activity
Optimism
Self esteem
Rapid thinking (pressured speech / flight of ideas )
Grandiose
```
67
How long does a manic / depressive episode usually last ?
Manic -3-6 months
| Depressive - 6-12months
68
DDs of bipolar
Substance abuse Eg cocaine
Mood abnormalities from endocrine - Cushings / steroid induced psychosis
Schitzophrenia - both can get delusions, psychomotor activity, hallucinations
Personality disorders
ADHD
69
Risk factors for bipolar ?
Strong genetic component
Prolonged stressors during childhood
Sleep disturbance
70
Physiology in bipolar
Hypothalamic-pituitary-adrenal (HPA) axis - decreased feedback / hypothalamus
Small prefrontal lobes and increased globes pallidus / amydala
71
Treatment of a manic episode? 2nd line?
Haloperidol / olanzapine / risperidone
| 2 - add lithium / valproate
72
Short term management of behavioural disturbance in manic ? Rapid tranquillisation ?
Benzodiazepines
| Lorazepam / antipsychotic
73
Issue with antidepressants in depressive strange of bipolar? How do you avoid this?
May precipitate manic phase
| Prescribe with anti manic / mood stabiliser
74
Management of bipolar affective ? Most effective? What needs to be monitored ?
Bio - lithium (most effective)
Psych - CBT, psychoeducation
Socio - family or carer support, employment, education
Weight / CV
75
Which mood stabilisers are particular teratogenic ?
Valproate / lithium (Epstein's anomaly) - Don’t use if potential of child bearing
76
Syndrome when the Pt thinks someone known to them has been replaced by an imposter
Capgras syndrome
77
What is fregoli syndrome? Usual cause? Management?
Stangers Eg Doctor/nurse are the Pts persecutors in disguise
Schitz, affective disorder, dementia
-> treat underlying cause
78
What is it called when a patient believes insects are colonising their body? Usually found in? Management?
Delusional parisitosis
Schitz / depression
Antipsychotics
79
What is shared delusional disorder also called? What is it ? Commonly found in? Management?
Folie à Deux
Delusional belief shared by 2 people where only 1 has a psychotic illness
(Psychotic individual tends to be more intelligent / dominating influence)
Usually in schitz
Treat - schitz
-period of separation -> supportive / family therapy
80
What is erotomania also called? What is it? Often found in? Management? What is the increased risk in men?
De clerambault’s syndrome
Belief that someone (usually high social status) is in love with them
-> make advances & can become angry when rejected
Found in affective (manic), schitz, women
Men have more forensic risk
Manage - hospitalisation (could be under MHA) to avoid harassment / injury
81
What is othello syndrome? When is it often found? What are the risks?
Pt convinced partner is unfaithful -> tries to produce evidence
Long term alcohol abuse, dementia, schitz, cocaine, dopamine agonists in Parkinson’s
Violence / separation -> may need to hospitalise
Tends to reoccur
82
What is cotards syndome ? Where is it found? Management?
Nihilistic delusions where pt believes part of their body is decaying / doesn’t exist
They may believe they are dead / unable to die
Psychotic depression
ECT - due to severity
83
Other name for factitious disorder ? What is it? What is often seen? Management? DDs ? When is it by proxy
Munchausen’s syndrome
Deliberately faked symptoms Eg abdo pain / hallucinations
Present to different hospitals / have different aliases
Seen in severe personality disorders
Manage - confront without rejection
DD- somatisation / dissociative disorders (Sx not continuously produced)
By proxy - parent fakes illness in child
84
What is couvard syndrome?
Expectant men experiencing Sx of pregnancy
Eg Abdo pain / swelling, Nausea / vomiting
Often reoccurs in subsequent pregnancies
85
What are the Sx of ganser’s syndrome ? Possible cause? Prognosis ? DD?
Approximate inconsistent answers to simple questions Eg 2+2 = 5 , what colour is snow? -> green
Clouding of consciousness
True / pseudohallucinations
Somatic Sx
Underlying depressive disorder -> treat
Often spontaneous improvement with amnesia of abnormal behaviour
Munchausens
86
Can you use 2 antipsychotics concordantly ?
No
87
What things should you monitor 4-6 weeks after commencing antipsychotics ?
Effectiveness, side effects, physical health, weight , lipid / glucose, ECG
88
What ECG change often in antipsychotics
Prolonged QT
89
Risk of what condition during treatment of schitz ? After treatment finishes?
Depression
| Relapse
90
What psychological therapies in schitz
Individualised CBT
Family therapy
Art therapy
Self help groups / forums
91
Parts of CBT for schitz
Learn how to manage hallucinations and not be scared
Challenge delusional beliefs
Coping strategies Eg music / tell voices to go away
92
What is family therapy good for in schitz? Art therapy?
Fam - reduce excessive emotion
| Art - reduce negative Sx
93
What social support do schitz really need
Help return to work/ study -> increase self esteem / quality of life
May need impatient / community support if residual negative Sx
94
What needs to be managed at all severities of depression
Treat co-morbid physical illness
| Treat substance misuse problems
95
1st / second line for mild depression
1- exercise groups, guided self help, computerised CBT
| 2- Individual CBT / IPT, behavioural couples therapy
96
1st / 2nd line for moderate / none responsive mild depression
1- psychological w/antidepressants -> continue for 6/12 after improvement
2- combine antidepressant with lithium / atypical antipsychotic / another antidepressant
97
Management of severe depression
ECT
98
What risks do you need to assess in a psychotic patient
Suicide
Violence
Victimisation
Adherence / leaving treatment early
99
What risks for suicide in a psychotic patient
Male, single, unemployed, chronic illness
Previous attempts, paranoid illness, high IQ, depression, substance abuse, insight
High premorbid psychosocial functioning with high expectations of future
100
Which psychotic patients are of a high risk of violence in the community? Inpatient?
Male, young, hx of untreated illness
| Substance abuse, previous Hx, mania, antisocial personality, hostility, suspicious, agitated, thought disturbance
101
Who is at risk of leaving treatment early in psychosis?
Young, male. Schitz, formal admission, suicidal, mania, paranoia, substance use, hx of re admissions
102
How to avoid victimisation after admission ?
Try to avoid admission if possible and ensure staffing levels are sufficient for adequate monitoring and care
