Lecture 5 - Psychiatry Flashcards
Define Psychosis
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First Broad Psychiatric Disorder Classifications:
No insight
- Hallucinations and delusions
- Can sometimes have insight that hallucinations are different from reality. Cant have insight into delusions
Define Neurosis
Insight in maladaptive behaviour
- Recognise your maladaptive behaviour
- Depression without psychosis, anxiety disorders
- doesnt make it easy to stop however
- E.g. dissociation - despite having insight, cant do much about it
What are the main disorders of Axis 1 in DSM 5?
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Axis 1 Mental disorders include
- Sz
- Mood disorders with or without psychoses
- Anxiety disorders
- Eating, sleep, sexual, impulse control
- Substance disorders etc
What are each of the axis in the DSM 5 about
Axis 1 = major mental disorders
Axis 2 = Personality disorders
Axis 3 = Disorders related to medical condition
Axis 4 = Psychosocial contributors (Stressors)
- e.g. whats going on in their life and how is this effecting Axis 1 disorder
Axis 5 = Functioning
- in the DSM not considered a disorder unless it impacts on occupational or social functioning
Whats Axis 3?
Disorder related to medical condition
- e.g. personality change related to disease
- having cancer might contribute to anxiety
Outline Cluster A personality disorders
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Odd or eccentric
- abnormal cognitions or ideas, speak/ act strangely, difficulty relating to others
- Paranoid PD (removed in DSM 5)
- suspicious, resentful, blame avoiding, rigid - Schizoid PD (removed in DSM 5)
- Avoid interpersonal interactions, lack empathy - Schizotypal PD
- Depersonalisation, schizotypal cognitions (magical thinking, ideas of reference)
Outline Cluster B personality disorders
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Dramatic, Emotional and Erratic
- Antisocial PD
- no sense of right and wrong, enjoys humiliating others - Narcissistic PD
- grandiosity, need approval, sensitive to criticism - Histrionic PD
- need centre of attention, vanity demanding - Borderline PD
- Emotional and interpersonal instability, self-harm, seperation issues
Outline Cluster C personality disorders
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- Obsessive-Compulsive PD
- perfectionism, minute detail, no compromise, need for control - Avoidant PD
- introverted, timid, sensitive to rejection, social awkwardness - Dependent PD
- need to be taken care off, difficulty with everyday decisions
What are the changes made to DSM 5?
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- Dropped Asperger as a distinct classification
- Loss subtype classifications for various forms of Sz
- PTSD and OCD now seperate from anxiety
What do critics say about the DSM 5?
X - lacks empirical support
X - lacks inter-rater reliability low for many disorders
X - Confusing and poorely written
What changes were made to Personality Disorders in DSM 5?
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Instead of:
pervasive pattern of thinking/ emotionality/ behaving
It now reflects:
adaptive failure, involving:
•Impaired sense of self-identity
•Failure in effective interpersonal functioning
Outline Schizophrenia symptoms
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Positive - at least 1 for 1 month
- Disorganised thoughts
- hallucinations
- delusions (Grandeur, control, love, persecution)
Negative - at least 1 for 1 month
- Flat emotions
- speech poverty
- Anhedonia (no pleasure)
- No motivation
- Disorganised behaviour
- Catatonia (too much or little activity, echolalia) - like sit in a chair for hours, or are hyper
If its between 1 and 6 months what might you diagnose sz as? ????????
Schizophreniform (milder condition) or schizoaffective disorder (sz + mood disorder)
What are the 5 types of Sz, not in the DSM?
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- removed
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These were removed as they didnt really cluster, main issue is cognitive issues: they are disordered in form and in content
- Paranoid Sz
- delusions of persecution, threatening/ hostile auditory hallucinations - Catatonic Sz
- Either stuporous or excited (but withdrawn) - Hebephrenic Sz
- bizzare behaviour/ affect, childlike - Simple: Anhedonia, impoverished thought, flat affect
- Unspecified: Mix of all these things
Outline the 2 broad types of Sz
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People might have a mix, but usually one type is more prevalent than another
Type 1: Positive Symptoms
- Hallucinations, delusions, bizzare behaviour, confused thinking
- Supposedly caused by problems in dopamine neurotransmission
- Anti-psychotics really help
Type 2: Negative Symptoms
- Speec poverty, flat emotions, seclusiveness, imparied attention
- Believed to be caused by structural abnormalities - doesnt respond well to anti-psychotics
What are the 2 types of brain abnormalities?
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- Biochemical
2. Structural
Outline Biochemical Brain Abnormalities in Schizophrenia
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Positive symptoms are linked to biochemical abnormalities
- Overactivity in Dompaminergic system in VTA
- Antipsychotics act on this system
- causes anhedonia as it shuts off dopamine (pleasure/ reward) system
Outline Structural Brain Abnormalities in Schizophrenia
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Negative symptoms are linked to Structural abnormalities
- Atrophy: enlarged ventricles (is sz early dementia?)
- Can be caused by low dopaminergic activity in frontal areas - dopamine levels fluctuating causing either positive (high levels) or negative symptoms (low levels)
What are the 4 dopamine pathways?????????
and how do they link to Sz
- Nigro-Striatal system
•Substantia-nigra -> Putamen/ Caudate
•Movement - Mesolimbic System
• VTA -> Limbic structures (Amygdala, NAc)
• positive symptoms - Mesocortical System
• VTA -> frontal/ temporal lobes
•Negative symptoms - Tuberinfundibular Tract????????
•Arcuate Nucues -> median Eminence
How do Anti-psychotics work?
They block the dopamine receptors but dont have an effect themselves
- particularly in pleasure areas, this would cause anhedonia
What are the long term motor side effects of anti-psychotics
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- Long term motor side effects are similar to parkinsons disease
- Old Anti-psychotics used to block ALL DA receptors, so it caused parkinsons symptoms:
- Slow Movement
- Lack facial expression
- Weakness
- Might be due to too much ACH and too little DA in Basal ganglia
Outline Tardive Dyskenisa as a side effect of anti-psychotics
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Opposite to parksinsons
1/3 of patients will develop this
•cannot stop movement/ fly-catching tongue, gurning
•Increased D2 receptor in striatum complex (basal ganglia)
• See the same in PD with too much L-Dopa
• Too little dopamine originally, but now got way too much
Outline Heritability of Sz
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30-50% chance of your offspring also having it to, leads to vulnerability to environmental factors
Outline environmental factors of Sz
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- Seasons of birth (late winter/ early spring increases chances)
- Viral epidemics when born
- Population density
- Prenatal malnutrition
- Maternal stress
- Parental Age
- Complications at birth
What are the theories about why Sz happens
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- environment + genes = accelerated synpatic pruning
- this causes structural deficits
- in healthy people this starts around 16 - Dorsolateral Prefrontal area less active = negative symptoms
- Over activity of Dopaminergic system = positive symptoms or mixed symptoms
Outline Major Depressive Disorders
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•Low mood/ irritability
• Loss interest/ pleasure - anhedonia
- For at least 2 weeks
Reduced energy/ appetite/ sleep/ sex/ activity
Whats an adjustment disorder
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Response to an event/ stressor, low mood between 3-6 months
What are the types of major depressive disorders?
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- Melancholic
- anhedonia, psychomotor retardation, weight loss and guilt - Atypical
- weight gain, sensitive to rejection, mood reactivity - Catatonic
- mute/ no or bizzarre movements - Post-Partum depression
- between 1 and 3 months after birth - Seasonal Affective Disorder
What are the suicide % for mood disorders?
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- Unipolar - 16% risk
- more likely for women to get this, but men more at risk of suicide - Bipolar - 30%
If its less severe, what is Unipolar and Bipolar
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- Unipolar if less severe = dysthymic
2. Bipolar if less severe = Cyclothymic
Outline Bipolar Disorder
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- Major depression
- little energy/ movement/ speech, restless/ no pleasure - Mania: Too much speech, activity, risk taking, unrealstic projects, delusions
- Hypomania
- less severe
- self-esteem, need less sleep, talkative, flight ideas, distractable
People fluctuate between short manic episodes and longer depressive episodes
How is the manic stage different from positive symptoms of Sz?
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They both:
•onset in adolescence
•Social stress + early emotional alterations
- Might play by self, fantasy games etc
• genetic risk overlap
- Sz more in cognitive domain
- Bipolar more in affective domain
• Dopamine may play a role in both
What are potential causes of bipolar?
Heritability increases the risks
What are treatments for Bipolar and positive sz
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•MAO inhibiters (2-3 weeks) for unipolar
•Drugs that block norepinephrine and serotonin reuptake (Tricyclics, SSRI, Prozac)
• Sleep deprivation - start clock over
- exercise too
• Bipolar treatment: medication - lithuim, anticonvulsants, antipsychotic. Wont get manic periods and wont get very low, just like luke warm sad
Lifestyle changes:
•reducing expressed emotion in family (how are you, how did you sleep…)
•Take away smoking, coffee, sleep resetting
- get a sleep routine
Outline sleep problems in depression
- Early wake up
- Problems falling asleep
- Fragmented sleep
- REM Sleep is early
- SAD: light therapy
How do antidepressants help sleep?
SSRI’s inhibit REM sleep, might be why they work so well - stop the period where you are likely to wake up
Which Neurotransmitters are in Monamines?
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- Dopamine
- Norepinephrine
- Serotonin
How do MAO inhibitors work?
MAO is an enzyme that mops up excess Neurotransmitters in the cell and in the synapse
- If you inhibit MAO, more of the NT will be available
Which receptor does SSRI block?
5-HT
- serotonin receptors
- blocks the feed-back mechanism is reduced
Outline Anxiety Disorders
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- Characterised by insight in irrational fear
- Easy to treat if fear is irrational
- Usually avoid exposure to feared stimulus
Give examples of Anxiety disorders
- Panic Disorder
- often comorbid with depression or agoraphobia - Agoraphobia (cant go outside)
- GAD
- Social Phobia
- Animal Phobia
- Obsessive compulsive disorder
- PTSD
- these two are no longer included under anxiety
What are the biological theories about panic disorder
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- Frontal Lobes enhaned in those who do not panic - do these suppress panics?
- Serotonin? - because Prozac helps
- Fewer GABA receptors - because Benzo’s help
X - But CBT helps, either focus on thoughts or behaviours, whilst relaxation
- shows links between Frontal lobes and GABA can be overuled
What are the 2 biological theories about OCD
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- Dopamine
- Dopamine involved in Tourettes syndrome - compulsions / tics
- OCD has similar tics
- Haldol (dopamine antagonist) helps Tourrettes, but its very strong and not recommended - Structural Problems
- Damage to Basal Ganglia, Cingulate Gyrus, Frontal lobes
- Cingulotomy (cut through cingulate gyrus) helps
- Serotonin inhibits Basal Ganglia/ PFC -> prozac helps
- CBT can also help!
Outline ADHD
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- Inattention/ lack of focus
- hyperactivity, impulsivity (linked to other disorders)
- 4-16% of children, more boys
Whats the heritability of ADHD
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10-35% if you have a first degree relative
What are common coexisting disorders for those with ADHD?
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- Oppositional Defiant Disorder
- Conduct disorder
- MDD
- Anxiety disorders
- OCD
- Bipolar
- Learning Disorders
- Substance abuse disorder
Whats a biological theory behind ADHD?
- Dopamine/ D2 deficiency in VTA
- Individual seeks rewards with risks but cannot focus/ organise to get these rewards
What drug can help with ADHD
Ritalin - A dopamine Agonist - helps
- Helps Reward deficiency, can now concentrate and focus
What are the 6 disorder groups that overlap?
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- Medical/ Somatoform (make yourself ill, think you are ill - hypochondriac), sexual/ eating/ sleep
- Anxiety
- ADHD/ Autism
- Mood Disorder
- Schizophrenia
- Substance related disorders, Impulse control, Adjustment disorder
