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.
What is the first line treatment for schizophrenia?
Atypical (2nd generation) antipsychotic other than clozapine
- Olanzapine
- Respiridone
- Amisulpride
- Quetiapine
What is the second line treatment for schizophrenia?
Typical (1st generation) antipsychotic
- Chlorpromazine
- Haloperidol
What can be used if there is poor compliance to medication in schizophrenia?
Depot injections
- long-acting antipsychotic injected into muscle
- provides sustained release (1-4 weeks)
What is common in those taking typical (1st generation) antipsychotics?
Extra-pyramidal side effects (in 705)
Acute dystonia - painful spastic contractions, usually neck, eyes, trunk
Parkinsonism - tremor, rigidity, bradykinesia
Akathisia - restlessness in lower limbs
Tardive dyskinesia - continuous slow writhing movements + sudden involuntary movements usually oral-lingual area
What is a major side effect of clozapine?
Agranulocytosis in 1% - must monitor leucocyte count
What is the definition of alcohol dependency?
A craving, tolerance and preoccupation with alcohol and continued drinking despite harmful consequences
Why does suddenly removing alcohol lead to CNS hyper-excitability?
In addiction there is upregulation of glutamate (powerful excitatory neurotransmitter) to compensate for alcohol’s depressive effects on CNS
What does alcohol interfere with in the GI tract?
Thiamine (vitamin B1) absorption
What is thiamine responsible for?
Thiamine is required for the functioning of enzymes involved in carbohydrate metabolism and synthesis of neurotransmitters
What are the 7 clinical features of alcohol dependency?
- Tolerance
- Narrowing of repetoire
- Compulsive drinking
- Withdrawal symptoms
- Drinking to alleviate withdrawal symptoms
- Continued drinking despite harm i.e. inability to stop
- Saliency - preocupation with drinking
What are common withdrawal symptoms in chronic heavy drinkers?
Anxiety Tremor Sweating Vomiting Tachycardia Sleep disturbance
What severe symptoms can present in acute alcohol withdrawal?
Grand mal seizures
Delirium tremens - altered mental state, hallucinations, delusions, severe agitation, seizures
What CNS conditions can develop from acute alcohol withdrawal?
Wernicke’s encephalopathy = triad of ophthalmaplegia (paralysis of eye muscles), ataxia, confusion
Korsakoff’s psychosis = persistent + dense cognitive impairment - loss of old memories and failure to make new memories
What is the CAGE questionnaire for alcoholism?
- Do you ever feel you should CUT DOWN your drinking?
- Do you ever feel ANGRY/ANNOYED when people comment on your drinking?
- Do you ever feel GUILTY as a consequence of drinking?
- Have you ever had an EYE OPENER - do you need a drink in the morning to get going?
What questions can you ask to assess tolerance i.e. biological dependence?
If you stop drinking, what happens?
Do you get the shakes / feel sick?
Do you have to drink more than you used to for the same effect?
What questions can you ask to assess compulsion i.e. psychological dependence?
If you stop drinking do you get angry / feel down?
Do you feel a need to drink?
What 3 medications are used in the management of alcohol dependency?
- Disulfaram = antabuse = acetylaldehyde dehydrogenase inhibitor
- Acamprosate = calcium acetyl-homotaurinate - it reduces cravings
- Naltrexone = opioid receptor blocker - affects pleasure of drinking
What medications are used in the management of acute alcohol withdrawal?
Benzodiazepines (specifically chlordiazepoxide-depends on alcohol consumption)
Pabrinex = vitamin B complex injection
- in withdrawal: 100mg PO TDS for 1 month
- in Wernicke’s: (i+ii)x2 ampoules IV BD for 3-7 days
- in Korsakoff’s: oral replacement for 2 years
What score is used to assess severity of acute alcohol withdrawal?
CIWA score (Clinical Institutes Withdrawal Assessment) - it is measured based on common signs and symptoms e.g. hypertension, seizures, insomnia, hallucinations, nausea -calculate when giving chlordiazapoxide
What LFTs are raised in alcohol abuse?
GGT = best indicator
Triglycerides
What changes would be seen in FBC in alcohol abuse?
High MCV - due to direct toxicity on bone marrow (it is reversible after a few months of abstinence) or folate/B12 deficiency
Low platelets
How many units a week is considered moderate/hazardous/harmful drinking for men and women?
Men
Moderate: <21
Hazardous: 21-50
Harmful: 50+
Women
Moderate: <14
Hazardous: 14-35
Harmful: 35+
What is addiction mediated by?
The midbrain dopamine system and nucleus accumbens (craving centre)
What are the withdrawal symptoms from opioids?
Intense craving Restlessness + insomnia Muscle pains Tachycardia Piloerection Abdominal cramps Vomiting Diarrhoea
When do the withdrawal symptoms from opioids begin, peak and subside?
begin 8-12 hours after last dose
peak at 36-72 hours
subside over 7-10 days
what is the treatment for opioid overdose?
IV naloxone - short acting opioid antagonist
What drug can help detoxify and prevent relapse in opioid addiction?
Naltrexone - long acting opioid antagonist
What treatment is given in symptomatic opioid withdrawal?
Lofexidine - alpha-adrenergic agonist
Loperamide
Metoclopramide
Ibuprofen
What substitutes can be given in opioid addiction?
Methadone - long acting synthetic opioid (24hr half life so good for daily dosing)
Buprenorphine - partial opioid agonist, less euphoria than methadone
How do benzodiazepines work?
They enhance GABA transmission
GABA is the main inhibitory neurotransmitter in the brain
How quickly does addiction develop to benzodiazepines?
After 3-6 weeks of regular use
What is given in benzodiazepine overdose?
Flumenazil - BDZ receptor antagonist
What symptom is very common in withdrawal from crack cocaine?
Formication - feeling of insects under skin
How do tricyclic antidepressants work?
Inhibit neuronal reuptake of serotonin and noradrenaline from synaptic cleft which increases their availability for neurotransmission
they also block other receptors e.g. histamine, muscarinic, alpha-adrenergic, dopamine
What can occur if excess SSRIs, tricyclics or monoamine oxidase inhibitors are taken?
Serotonin syndrome
Triad of:
1) Autonomic hyperactivity - hypertension, hyperthermia
2) Altered mental state
3) Neuromuscular excitation
What is a biochemical side effect of SSRIs?
Hyponatraemia
What is normally done as the confusion screen?
B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism
Glucose: hypoglycaemia can commonly cause confusion
Bone Profile (Calcium): hypercalcaemia can cause confusion
