Primary Care - Psychiatric Flashcards
What are the core symptoms of depression?
Persistent low mood
Anhedonia
Fatigue
How long should a patient have had the core symptoms of depression for in order to classify it as depression?
Longer than 2 weeks
What are some other symptoms of depression?
SPISS
Social - loss of interest, social withdrawal, affecting relationships
Physical - sleep disturbance, appetite, libido
Intellectual - concentration, cognition
Spiritual - self-esteem, pessimism about future, self-critical
Suicide - ideation, plans, previous attempts
What is first line pharmacological treatment of depression?
SSRIs
- fluoxetine - CYP450 inhibitor
- citalopram
- sertraline
How long should antidepressants be taken for?
Should be trialled for minimum 6 weeks (unless intolerable side-effects)
After recovery, continue for 6 months before tapering off
Aside from SSRIs, what antidepressants are there?
Tricyclics e.g. amitryptiline, lofepramine
NaSSA e.g. mirtazapine - better sleep
NARI e.g. reboxetine - used in severe depression
SNRI e.g. venlafazine - used in treatment resistant depression
What is generalised anxiety disorder?
A high level of background anxiety (excessive uneasiness, worrying and apprehension)
What is a panic attack?
A sudden overwhelming intense fear and anxiety, associated with physical symptoms, for a short duration (5-20min)
What are some physical symptoms of anxiety?
‘Fight or flight’ response
Cardio - palpitations, angina, tachycardia
Respiratory - hyperventilation, breathlessness
GI - dry mouth, dysphagia, abdominal pain, loose/frequent stools
Neuro - dizzy, nausea, tingling
Motor - tremor, muscle tension
Other - sweating, flushing
Diagnosis based on at least 4 of the above
What are some psychiatric symptoms of anxiety?
Fear of impending doom Restlessness Exaggerated startle response Concentration difficulties Irritability Insomnia Night terrors Derealisation
What is the pharmacological treatment for generalised anxiety disorder?
Buspirone - anxiolytic medication; effects take 2-4 weeks
Anti-depressants e.g. SSRIs
Non cardiac selective beta-blockers for symptom control
Benzodiazepines
What is bipolar disorder?
Normal mood is interspersed with depressive and manic episodes
What is the mean age of onset of bipolar disorder?
21 years
if age onset > 51 years it is likely to have organic cause
What are the different types of bipolar disorder?
Bipolar I - 1+ manic episode with/without 1+ depressive episodes
Bipolar II - 1+ depressive episodes with at least 1 manic/hypomanic episode
How long do manic/depressive episodes last in bipolar disorder?
Manic - last 1 week (average is 4 months)
Hypomanic - last 4 days
Depressive - last 2 weeks (average 6 months)
What is a mixed episode in bipolar disorder?
Contain both manic/hypomanic and depressive symptoms in an single episode
Lasts at least 2 weeks
E.g.:
- Depression + overactivity/pressured speech
- Mania + reduced energy/libido
What can precipitate or exacerbate mania in bipolar disorder?
Drugs such as cocaine or amphetamines
What are some presenting symptoms of mania?
o Mood elevated out of keeping with circumstances o Increased energy = overactivity o Pressure of speech o Decreased need for sleep o Normal social inhibitions lost o Inattention o Inflated self esteem o Over-optimistic ideas o Perceptual disorders - appreciation of colours or textures o Reckless spending o May be irritable or suspicious
What condition presents with milder symptoms than bipolar disorder?
Cyclothymia
What drugs are used to stabilise mood?
Lithium
Sodium valproate - less effective than lithium but quicker onset and better tolerated
Lamotrigine - more effective against depressive than manic relapses
Carbamazepine - 3rd line; used in treatment-resistant; requires lots of blood monitoring
What are the positive/negative symptoms in schizophrenia?
Positive:
- hallucinations (mostly auditory)
- delusions
- thought disorder
Negative:
- lack of motivation = avolition
- poverty of speech = alogia
- blunt affect
- anhedonia
- no relationship desires = asociality
What are Schneider’s First Rank Symptoms?
Auditory hallucinations - 3rd person
Delusions of control - thought insertion, withdrawal, broadcast, echo
Delusion of passivity - affect, sensations and impulses are under external agent’s control
Delusional perception - patient attributes abnormal significance to normal perceptions
These symptoms help to distinguish schizophrenia from other psychotic disorders
What are the different types of schizophrenia?
Paranoid
- stable
- paranoid delusions
- hallucinations
Hebephrenic
- prominent affective changes
- fragmentary delusions and hallucinations
- irresponsible and unpredictable behaviour
- incoherent speech
Catatonic
- psychomotor disturbance
- posturing
- mutism
- staring
- rigidity
How would schizophrenia present in a mental state exam?
A+B - May be normal, social awkwardness, smiling inappropriately,
withdrawal. Arousal (e.g. aggression) is less common.
Speech - May be difficult to follow in acutely ill, poverty of speech, neologisms.
Mood - Changes are common, blunting/indifference, depression and euphoria,
incongruous = not in keeping with the trigger.
Thought form - Difficult to follow, concrete ideas, loosening of associations, thought
block (stop mid-sentence)
Thought content - Delusions are common, often persecutory and sometimes grandiose,
delusions of reference / control / passivity.
Perceptions - Mostly auditory hallucinations.
Insight - Variable
Cognitive function - Reduced, may not be oriented.
