Psychiatry Flashcards
Depressive disorder
Affective mood disorder characterised by persistent:
* Low mood
* Loss of pleasure (anhedonia)
* Lack of energy
Accompanied by emotional, cognitive and biological symptoms
Cause of depression
Multifactorial
Use bio-psychosocial model
* Genetic predisposition
* Early adverse life experiences
* Biological vulnerability
* Personality/temperament
* Biological alterations in brain functioning
* Traumatic or adverse life events
* Social circumstances
* Alcohol/substance misuse
* Physical illness
What is the monoamine theory
Deficiency of functioning monoamines (noradrenaline, serotonin and dopamine) causes depression
Biological risk factors for depression
- Older
- Female
- Family history
- Postnatal period
- Physical comorbidities - dementia, brain injury, hypothyroidism, congestive cardiac failure, chronic pain syndromes
- Medications - corticosteroids
Psychological risk factors for depression
- Beck’s triad - negative thoughts about self, world and future
- PMH of depression
- Other mental health diagnoses, e.g. dementia
- Alcohol and substance misuse
- Anxious, impulsive and obsessive personality
- Stressful life events
- Poor coping strategies
Social risk factors for depression
- Divorce or separation
- Lack of social support
- Childhood abuse
- Unemployment
- Poverty
- Homelessness
- Lack of parental care
- Parental alcoholism
3 core symptoms of depression
- Anhedonia
- Low mood for at least 2 weeks, present most of the day, nearly every day
- Lack of energy
Biological symptoms of depression
- Diurnal mood variation (mood worse in morning)
- Early morning wakening
- Insomnia or hypersomnia
- Loss of libido
- Psychomotor retardation (slow speech and movement) or agitation
- Weight loss and loss of appetite
Cognitive symptoms of depression
- Lack of concentration
- Feelings of worthlessness
- Excessive guilt
- Suicidal ideation
Common hallucinations in those with depression with psychosis
- Auditory - defamatory or accusatory voices, cries for help or screaming
- Olfactory - bad smells (rotting food, faeces, decomposing flesh)
- Visual - tormentors, demons, the devil, dead bodies, torture
Common delusions in those with depression with psychosis
- Hypochondriacal
- Guilt over presumed misdeeds
- Poverty
- Personal inadequacy
- Responsibility for world events (accidents, natural disasters, war), deserving of punishment, nihilistic
Symptoms of atypical depression
- Depressed mood but reactive
- Hypersomnia (sleeping > 10 hours / day, at least 3 days / week for at least 3 months)
- Hyperphagia (weight gain > 3kg in 3 months)
- Leaden paralysis (heaviness in limbs, 1 hour / day, 3 days / week for at least 3 months)
- Oversensitivity of perceived rejection
How is depression diagnosed?
Clinically
* Mild depression: 2 core symptoms + 2 other symptoms
* Moderate depression: 2 core symptoms + 3-4 other symptoms
* Severe depression: core symptoms + 4 or more other symptoms
* Severe depression with psychosis: core symptoms + 4 or more other symptoms + psychosis
Diagnostic questionnaires for depression
Patient health questionnaire 9 (PHQ9)
HADS
Beck’s depression inventory
Investigations to rule out differential diagnoses of depression
- FBC (anaemia)
- TFT (hypothyroidism)
- U&E
- LFT
- Calcium
- Glucose (DM)
- Cortisol
- B12 and folate
- Syphilis serology
- MRI/CT head
Differential diagnoses of depression
- Psychiatric - bereavement, PTSD, bipolar affective disorder, anxiety disorders, eating disorders, schizophrenia, personality disorders
- Neurological - dementia, Parkinson’s, stroke, head injury
- Endocrine - hypothyroidism, menopause, Cushing’s
- Metabolic - hypoglycaemia, hypercalcaemia
- Anaemia
- Infections - syphilis, HIV encephalopathy
- SLE
- Sleep apnoea
- Medications - antihypertensivse, corticosteroids, sedatives
- Substance misuse - alcohol, benzodiazepines, opioids
Management of mild depression
- Assess suicide risk
- Watchful waiting and reassess in 2 weeks time
- Consider antidepressants
- Psychoeducation, self-help based on CBT principles, computerised CBT and structured group physical activity programmes
When are antidepressants given for mild depression?
- Depression has lasted a long time (over 2 years)
- Past history of moderate-severe depression
- Failure of other interventions
- Depression complicated care of other physical health problems
Management of moderate/severe depression
- Assess suicide risk
- Antidepressant - SSRI, tricylic, SNRI, MAOI
- If severe: psychiatric referral +/- hospital admission
- Consider ECT
- CBT, interpersonal therapy, behavioural activation, counselling and psychodynamic therapy
- Social support groups
When is ECT indicated for depression?
Severe depression and:
* Life-threatening
* Rapid response required
* Psychotic features
* Severe psychomotor retardation or stupor
* Failure of other treatments
Psychological managements of depression
- Psychoeducation
- CBT (self-help, computerised)
- Group physical activity programmes
- Interpersonal therapy
- Behavioural activation
- Counselling
- Psychodynamic therapy
Management of depression with psychosis
- Antidepressant and antipsychotic
- ECT
Management of treatment resistant depression
- Review diagnosis
- Check their compliance
- Continue monotherapy at maximum tolerable dose
- Change antidepressant
- Augment antidepressant with an antipsychotic or mood stabiliser (lithium)
- Combine antidepressants from different classes
- ECT
- Possibility of psychosurgery
Reasons to admit someone with depression to hospital
- Serious risk of suicide
- Significant self-neglect
- Severe depressive symptoms
- Severe psychotic symptoms
- Lack or breakdown of social support
- Initiation of ECT
- Treatment-resistant depression
- A need to address comorbid conditions
When starting antidepressants
- First review within 2 weeks (or 1 week if aged 18-25 or particular concern for risk of suicide)
- Regular monitoring
Serotonin syndrome
Occurs within minutes of taking antidepressants
* Cognitive: headache, agitation, hypomania, confusion, hallucinations, coma
* Autonomic: shivering, sweating, hyperthermia, hypertension, tachycardia, diaphoresis, diarrhoea
* Somatic: myoclonus (muscle twitching), hyperreflexia, tremor, rigidity
Discontinuation syndrome
Antidepressant dose reduced too quickly
* GI symptoms
* Headache
* Anxiety
* Dizziness
* Paraesthesia
* Electric shock sensations in the head, neck and spine
* Tinnitus
* Insomnia
* Flu-like symptoms: fatigue, sweating, chills
* Hypomania
* Restlessness
Which antidepressants are most likely to cause discontinuation syndrome and why?
Venlafaxine and paroxetine
Short half-lives
6 SSRIs
- Sertraline
- Citalopram
- Escitalopram
- Paroxetine
- Fluoxetine
- Fluvoxamine
Main side effect of antidepressants
GI disturbance - nausea, diarrhoea, bloating
Why is SSRI first line for depression?
- Safer in overdose
- Less sedating and fewer antimuscarinic and cardiotoxic effects than TCAs
Which antidepressant is safesty post-MI?
Sertraline
Which is the preferred antidepressant for under 18s?
Fluoxetine
Cons of SSRIs
- Hyponatraemia
- GI bleeding (avoid in those on blood thinning medications)
2 SNRI
- Venlafaxine
- Duloxetine
4 tricylic and related antidepressants
- Lofepramide
- Clomipramine
- Imipramine hydrochloride
- Amitriptyline
Can’t pee, can’t see, can’t spit, can’t shit
Side effects of tricylic antidepressants
- Antimuscarinic: urinary retention, blurred vision, dry mouth, constipation
- CV: arrhythmias, postural hypotension, syncope
- Mania
Reasons to give amitriptyline for depression
Sedative compounds can help agitated and anxious patients
Safer in pregnancy (as are SSRIs)
Cons of tricyclic antidepressants
- Toxic in overdose
- Antimuscarinic side effects
Contraindications to tricyclic antidepressants
- CV: recent MI, arrhythmias
- Mania
- Severe liver disease
- Agranulocytosis
4 MAOIs
- Trancylcypromine
- Phenelzine
- Isocarboxazid
- Moclobemide
Interactions with MAOIs
- Tyramine-rich food (cheese, pickled herring, Bovril, marmite, red wine) > hypertensive crisis
- Drugs (insulin, opiates, SSRIs, TCAs, antiepileptics)
What reasons may mirtazapine be given for depression?
Help with insomnia and weight gain
What is cyclothymia?
Mood fluctuations over 2 years with episodes of elation and depression
What is dysthymia?
2 years of depressive symptoms that don’t meet the criteria for depressive disorder
Difference between mood and affect
Mood: sustained, experienced, emotional state over a period of time
Affect: transient flow of emotion in response to a particular stimulus
What are objective descriptions of mood?
Dysthymic (low)
Euthymic (normal)
Elated (elevated
What is an affective disorder?
Mood disorder
When a disturbance of mood is severe enough to cause impairment in ADLs
Any condition characterised by distorted, excessive or inappropraite moods or emotions for a sustained period of time
What is the difference between a primary and secondary mood disorder?
Primary: does not result from another medical or psychiatric condition
Secondary: results from aother medical or psychiatric condition
Name 2 unipolar primary mood disorders
- Depressive disorder
- Dysthymia
Name 2 bipolar mood disorders
- Bipolar affective disorder
- Cyclothymia
What physical disorders can cause a secondary mood disorder?
- Anaemia
- Hypothyroidism
- Malignancy
- Cushing’s
- Addison’s
- MS
- Parkinsonism
What are the 3 categories of causes of secondary mood disorders?
- Physical disorder
- Psychiatric disorder
- Drug-induced
What psychiatric disorders can cause secondary mood disorders?
- Schizophrenia
- Alcoholism
- Dementia
- Personality disorder
What drugs can cause secondary mood disorders?
- Interferon-alpha
- Corticosteroids
- Digoxin
- Antiepileptic drugs
- Beta blockers
- Antidepressants
Define bulimia nervosa
Eating disorder characterised by repeated episodes of uncontrolled binge eating followed by compensatory weight loss behaviours and overvalued ideas regarding ideal body shape/weight
2 types of bulimia nervosa
- Purging: self-induced vomiting and other ways of expelling food, e.g. laxatives, diuretics, thyroid extract and enemas
- Non-purging: excessive exercise or fasting after binging
What is binge eating?
Excessive eating in a short period of time
Cycle of bulimia nervosa
Sense of compulsion to eat
Binge eating
Fear of fatness
Compensatory weight loss behaviours
Compensatory behaviours in bulimia nervosa
- Self-induced vomiting
- Drugs
- Exercising excessively
- Starvation
What drugs may someone with bulimia nervosa use as a compensatory behaviour?
- Laxatives
- Diuretics
- Appetite suppressants
- Amphetamines
- Thyroxine
- Enemas
Symptoms and signs of self-induced vomiting
- Erosion of teeth
- Swollen salivary glands
- Mouth ulcers
- Gastro-oesophageal reflux
- Mallory-Weiss tears
- Russel’s sign
- Cardiac arrhythmias
- Renal failure
- Muscle weakness
- Tetany
What is Russell’s sign?
Calluses on knuckles where they have been scraped across teeth
How might someone’s relationship with food be if they have bulimia nervosa?
- Compulsion to eat
- Binging (overeating at least 2 times a week over 3 months)
- Eat rapidly, in secret and to the point of physical discomfort
- Feel guilty, disgusted, low, regret or shame after binging
Weight of someone with bulimia nervosa
Often normal body weight
Fluctuates
How may someone with bulimia nervosa see themselves?
- Self-perception of being too fat
- Low self-esteem
Signs of dehydration
- Low BP
- Dry mucous membranes
- Increased CRT
- Decreased skin turgor
- Sunken eyes
Associated psychiatric disorders with bulimia nervosa
- Depressive disorder
- Alcohol misuse
- Perfectionism
- Deliberate self-harm
Screening questionnaire for eating disorders
SCOFF (2 or more)
* S - do you make yourself sick because you feel uncomfortably full?
* C - do you worry you have lost control over how much you eat?
* O - have you recently lost more than one stone (6.35kg) in a 3 month period?
* F - do you believe yourself to be fat when others say you are too thin?
* F - would you say food dominates your life?
What is binge eating disorder?
Binge eating without compensatory behaviours after episodes
What do you need to assess risk of in someone with bulimia/anorexia nervosa?
Suicide
Which patients with bulimia nervosa should receive inpatient treatment?
Those at risk of:
* Suicide
* Severe electrolyte imbalances
* Refeeding syndrome
Medication for bulimia nervosa
High-dose (60mg) fluoxetine (SSRI)
Advice to give someone who makes themselves vomit
- Avoid highly acidic food and drink
- Avoid brushing teeth immediately after vomiting
- Rinse with non-acid mouthwash after vomiting
- Give advice on importance of regular dental review
Psychological interventions for someone with bulimia nervosa
- Psychoeducation about nutrition
- Bulimia-nervosa-focused guided self-help programme
- Eating-disorder-focused CBT (CBT-ED)
- Interpersonal therapy
- Bulimia-nervosa-focused family therapy
- Cognitive analytic therapy
Techniques to avoid binging
- Eat in company
- Distractions
- Small regular meals
What to monitor in someone with bulimia nervosa
- BMI
- Electrolytes
- ECG
What might someone with bulimia nervosa’s ECG look like?
- Arrhythmias
- Increased P wave
- Prolonged PR interval
- ST depression
- Flattened or inverted T wave
- Prominent U wave after T wave
Cause of refeeding syndrome
During prolonged starvation (more than 5 days), intracellular potassium, phosphate and magnesium decreases due to decreased cell metabolism (to conserve energy) and movement of electrolytes from inside the cell to the blood to maintain normal serum levels.
During refeeding, carbohydrate intake causes an increase in insulin, which drives glucose, potassium, phosphate and magnesium into cells. The sodium/potassium ATP pump actively pumps potassium into the cell and sodium out into the blood.
Insulin also causes increased sodium reabsorption in the kidneys.
Overall effects of refeeding syndrome
- Hypomagnesaemia
- Hypokalaemia
- Hypophosphataemia
- Fluid overload
How can refeeding syndrome be fatal?
Arrhythmia
Management of refeeding syndrome
- Slowly reintroduce food with limited calories
- Magnesium, potassium, phosphate and glucose monitoring
- Fluid balance monitoring
- ECG monitoring in severe cases
- Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine
What is anorexia nervosa?
Eating disorder characterised by deliberate weight loss, an intense fear of fatness and distorted body image
Demographic most likly to have bulimia/anorexia nervosa
Female
Adolescent and young adult
Transgender
Physical factors associated with bulimia nervosa
- Early onset of puberty
- T1DM
- Childhood obesity
Family factors linked to bulimia nervosa
- FH of eating disorders and other mental health disorders
- Parental obesity
- Parents with high expectations
- Family dieting
- Criticism regarding body weight/shape
Mental health disorders associated with bulimia nervosa
- Depressive disorder
- Anxiety
- Deliberate self-harm
- Substance misuse
- ADHD
- Emotionally unstable personality disorder
- Perfectionism or obsessional personality
What professions can predispose to bulimia/anorexia nervosa?
- Actors
- Dancers
- Models
- Athletes
What childhood trauma can increase risk of bulimia nervosa?
- Bullying
- Physical or sexual abuse
Family history risk factors for anorexia nervosa
- Female sibling with anorexia nervosa
- Eating disorder
- Depression
- Substance misuse
Perpetuating factors for anorexia nervosa
- Body dysmorphia
- Starvation (neuroendocrine change that perpetuates anorexia)
- Personality
- Other mental health disorders
- Low self-esteem
- Family problems
- Criticism regarding body weight/shape or eating behaviour
- Family dieting
- Profession
- Cultural pressure to be thin
Mental health diagnoses associated with anorexia nervosa
- Perfectionism or obsessional/anankastic personality
- Emotionally unstable personality disorder
- Depressive disorder
- Anxiety
- Deliberate self-harm
What family issues are associated with anorexia nervosa?
- Family problems
- Family dieting
- Criticism regarding body weight/shape or eating habits
Where can pressures to be thinner come from?
- Parents
- Peers
- Society (Western society)
- Social media
FEEDD
Presentation of anorexia nervosa
The following for 3 months and in the absence of recurrent episodes of binge eating
* Fear of weight gain and fatness
* Endocrine disturbances > amenorrhoea, loss of sexual interest and potency
* Emaciated (BMI < 17.5)
* Deliberate weight loss - decreased food intake, increased exercise or purging
* Distorted body image
Physical signs of anorexia nervosa
- Fatigue
- Hypothermia
- Bradycardia
- Hypotension
- Arrhythmias
- Peripheral oedema
- Dry skin
- Brittle nails
- Headache
- Lanugo hair
- Constipation
- Weak
- Slow
What test can be used to assess muscle wasting in anorexia nervosa?
Sit up, squat and stand test
Tests for complications of anorexia nervosa
- U&E
- FBC
- TFT
- LFT
- Lipids
- Cortisol
- Sex hormones
- Glucose
- Amylase
- VBG
- ECG
- DEXA scan
Electrolyte abnormalities in anorexia nervosa
Decreased
* Potassium
* Phosphate
* Magnesium
* Chloride
How are urea and creatinine affected in dehydration?
Increased
Thyroid, cortisol, sex hormones, growth hormone
How may hormones be affected in anorexia nervosa?
Low thyroid
High cortisol
High growth hormone
Low sex hormones
How may lipids be affected in anorexia nervosa?
High cholesterol
What causes peripheral oedema in anorexia nervosa?
Low albumin
Why do a FBC for anorexia nervosa?
- Anaemia
- Thrombocytopenia
- Leukopenia
Glucose test in anorexia nervosa
Low
What may a VBG show in someone with anorexia nervosa?
Metabolic acidosis if vomiting/laxatives
What may an ECG show in someone with anorexia nervosa?
Arrhythmias (sinus bradycardia, prolonged QT)
What may a DEXA scan show in someone with anorexia nervosa?
Low bone mineral density (osteoporosis)
Weight gain in anorexia nervosa
- Set a goal between the ideal body weight and their ideal weight
- Provide a balanced diet, aiming at 0.5-1 kg/week
- Eliminate purging
Which anorexia nervosa patients require inpatient care?
- ECG changes
- Severe electrolyte abnormalities
- Very low BMI (< 14) or rapid weight loss
- Dehydration
- Organ failure
- Suicide risk
Psychological therapies for anorexia nervosa
- Psychoeducation about nutrition
- Self-help resources
- CBT
- Cognitive analytic therapy
- Interpersonal psychotherapy
- Family therapy
Complications of anorexia nervosa
- Impaired glucose tolerance
- Hormonal imbalance
- ECG abnormalities and arrhythmias
- Cardiac failure
- GI: enlarged salivary glands, pancreatitis, constipation, peptic ulcers, hepatitis
- Renal failure
- Proximal myopathy
- Osteoporosis
- Neurological: seizures, peripheral neuropathy, autonomic dysfunction
- Haematological: iron deficiency anaemia, thrombocytopenia, leucopenia
- Infections
- Suicide
Which psychiatric condition has the highest mortality rate?
Anorexia nervosa
Poor prognostic factors for anorexia nervosa
- Long initial illness
- Severe weight loss
- Older age at onset
- Binging and purging
- Personality disorders
- Difficulties in relationships
Prognosis for anorexia nervosa
25% recover
50% yoyo
25% die
What is somatic symptom disorder?
Symptoms suggestive of a physical disorder, but in the absence of physiological illness
Cause of somatic symptom disorder
Biopsychosocial model
Biological risk factors for somatic symptom disorder
- Female
- < 30
- Chronic ill health as a child
- Overuse/dependence on prescribed medications, e.g. sedatives and analgesics
Psychological risk factors for somatic symptom disorder
- Childhood abuse
- Other psychiatric conditions: anxiety, mood or personality disorders, PTSD
- Physical or sexual abuse
- Distress
- Sick role provides relief from stress or unachievable interpersonal expectations
Social risk factors for somatic symptom disorder
- Social stressors: caring for someone, relationship issues, work
- Sick role provides attention, care from others and sometimes financial awards
Clinical manifestations of somatic symptom disorder
- Prolonged history of multiple physical symptoms, often occurring in different systems, that cannot be explained by any detectable physical disorder
- Belief that they have a serious illness
- Repeated medical consultations and requesting investigations
- Do not accept reassurance from doctors
Clinical manifestation of somatisation disorder
- At least 2 years of physical symptoms that cannot be explained by physical disorder
- Preoccupation with symptoms causing them to seek repeated medical consultations and requesting investigations
- Continuous refused to accept reassurance from doctors that there is no physical cause for their symptoms
- 6 or more symptoms
Clinical manifestation of hypochondriacal disorder
- Misinterprets normal bodily sensations, which leads them to think they have a serious physical condition
- Repeatedly requesting investigations
- Reassurance from doctors rarely lasts long or refuse to accept
- Dysmorphobia, where they are preoccupied by barely noticeable or imagined defects in their physical appearance
Clinical manifestation of somatoform autonomic dysfunction
- Autonomic arousal causes physical symptoms, e.g. palpitations, tremor, sweating, dry mouth, flushing, hyperventilation
- Attribute to physical disorder when there is no evidence of physical disease
Clinical manifestation of persistent somatoform pain disorder
- At least 6 months of severe pain that cannot be explained by a physical disorder
- Usually due to psychosocial stressors and emotional difficulties
Investigations for somatic symptom disorder
- FBC
- U&E
- LFT
- CRP
- TFT
- GI: AXR, stool culture, OGD, colonoscopy, laparoscopy
- CV: ECG, 24h tape, echo, angiogram
- GU: urine dipstick, MSU, cystoscopy
- MRI
- Neuro: EEG, NCS, LP
What is dissociative (conversion) disorder?
Ever since I lost my job, I’ve been feeling so unwell
What is factitious disorder?
I want to go to the hospital to be looked after
What is malingering?
If I go to the hospital, I may receive compensation
Management of somatic symptom disorder
Biological: treat mood (SSRI) and sleep (amitriptyline) disorders, appropriate analgesia only taken when necessary
Psychological: psychoeducation, CBT
Social: exercise, pleasurable activities, involve family
Complications of somatic symptom disorder
Family, marital and/or occupational problems
