Psychiatry Flashcards
What are the core symptoms of depression?
- Low mood → varies little day-to-day, unresponsive to circumstances
- Anhedonia → reduced/little interest in most activities that were formally enjoyable
- Anergia → lack of energy, increased fatigability on minimal exertion.
What are the biological (somatic) symptoms of depression?
- Early morning wakening
- Insomnia
- Depression worse during morning → diurnal mood changes
- Loss of appetite with weight loss
- Reduced libido
- Cognitive
For a diagnosis to be made of depression, what factors (ie, not just the symptoms) must be present?
- Symptoms must be present for >2 weeks
- Symptoms are not attributable to other organic or substance causes → eg, normal bereavement
- Symptoms impair daily function & cause significant distress
What are the first line antidepressants? What are their common side effects & contraindications?
SSRIs - Sertraline, fluoxetine citalopram
- Common side effects → GI disturbance, loss of appetite, insomnia, sweating, increased risk of suicide. Initially for first couple of weeks, then generally improves.
- Contraindications → mania, poorly controlled epilepsy, long QTc for citalopram
What antidepressant is first line in patients struggling with eating & sleep? What are the side effects & contraindications?
Mirtazapine
- Side effects → increased appetite, weight gain, sedation, headache
- Contraindications → mania, < 18 years old
How is moderate generalised anxiety disorder managed (or mild which has failed to respond to 1st line treatments)?
- SSRIs → initially increase anxiety & agitation but will then improve
- SNRI second line → venlafaxine
- Propranolol → often used to treat the physical symptoms of anxiety, but is only short acting & does not help with the underlying anxiety.
- Benzodiazepines → stimulate GABA receptors which has a relaxing effect on the brain. However prolonged used can lead to tolerance & dependence.
How are phobias managed?
- CBT
- Exposure therapy
- SSRIs → particularly for agoraphobia & social phobia
- Benzodiazepine if appropriate → eg, before a flight or going to the dentist.
What effect does alcohol have on the brain?
- Alcohol is a depressant → stimulates GABA receptors which have a relaxing effect on the brain.
- Alcohol also inhibits glutamate receptors, causing a further relaxing effect on the electrical activity of the brain. Glutamate is an excitatory neurotransmitter.
- Long-term use results in the GABA system becoming down-regulated & the glutamate system becoming up-regulated to balance the effects of alcohol.
- If the patient stops drinking at this point, they will experience unpleasant & dangerous withdrawal symptoms.
What is the criteria for someone to be diagnosed with substance dependence?
In order to diagnose someone with substance dependence, they must have 3 or more of the following criteria present in the past year:
- Strong desire or compulsion to take the substance
- Difficulty in controlling substance-taking behaviour → onset, termination, levels of use
- Persistence despite awareness of physical or mental harm
- Priority given to the substance, with neglect of other interests & activities due to time spent acquiring & taking the substance, and recovering from its effects.
- Increased tolerance → where increased quantities of the substance are required to produce the same effect originally produced by lower amounts.
- Physiological withdrawal state when substance use has reduced or ceased → or continued use to relieve/avoid symptoms
What symptoms can develop during alcohol withdrawal?
- 6-12 hours → tremor, sweating, headache, craving, anxiety/agitation, nausea & vomiting
- 12-24 hours → hallucinations (visual, auditory, or tactile)
- 24-48hrs → seizures
- 1-7 days → delirium tremens (most common after 48hrs)
What is delirium tremens & how does it present?
- = a life-threatening condition characterised by a rapid onset of confusion often precipitated by alcohol withdrawal.
- Present 1-7 days after alcohol cessation (48hrs average)
- Presentation of DTs:
- Acute confusion
- Severe agitation
- Delusions & hallucinations
- Tremor
- Ataxia
- Autonomic arousal → heavy sweating, tachycardia, hypertension, fever
What are the symptoms of Wenicke’s Encephalopathy?
Wernicke encephalopathy tetrad → acute confusion, ataxia, nystagmus, opthalmoplegia
What 2 questionnaires are used to assess a person’s dependence on alcohol?
CAGE/AUDIT questionnaire
What is asked during a CAGE questionnaire?
C- do you ever think you should Cut down?
A - do you get Annoyed at others commenting on your drinking
G - do you ever feel Guilty about drinking
E - Eye opener, do you ever drink in the morning to help your hangover or nerves?
When is assisted alcohol withdrawal required?
If the patient is drinking >15 units per day or those scoring >20 on the AUDIT questionnaire
What is CIWA used for?
It is used to score the patient on their withdrawal symptoms & guide whether medical treatment is required.
When is inpatient alcohol withdrawal recommended?
severe dependence, history of withdrawal seizures/DTs, unsupportive home environment, failed community detox.
What drugs are given during alcohol withdrawals?
- Benzodiazepine
- Have a similar effect on the brain to alcohol, so prevents acute withdrawals.
- Given for a couple of weeks before gradually reducing
- Chlordiazepoxide.
- IM/IV thiamine (pabrinex)
- Helps prevent Wernicke’s encephalopathy
- Followed by long-term oral thiamine.
How is delirium tremens managed?
- Medication → control symptoms & reduce risk of seizures
- Benzodiazepines are first line → oral lorazepam
- Antipsychotics as adjuncts for severe disturbance or psychotic features
- IM/IV thiamine
What medications can be given following alcohol detoxification to support someone in their abstinence?
-
Acamprosate
- Increases GABA & decreases excitatory glutamate → reduces cravings
- Generally well tolerated
-
Naltrexone
- Opiate blocker that makes alcohol less enjoyable & less rewarding
-
Disulfiram
- Inhibits the breakdown of acetaldehyde from alcohol, causing accumulation & therefore unpleasant symptoms → flushing, sweating, headache, nausea & vomiting.
- They must avoid all contact with alcohol whilst taking this
What medications can be given for those who are opioid dependent?
- Methadone → binds to opioid receptors
- Buprenorphine → binds to opioids receptors
- Naltrexone → helps prevent relapse
When is activated charcoal given to someone if they have overdosed on drugs?
If they present within an hour of overdose, charcoal can reduce the absorption of various drugs - eg, aspirin, SSRIs, benzodiazepines
What drug is given for a paracetamol overdose?
Acetylcysteine
What drug is given for a benzodiazepine overdose?
Flumazenil
What drug is given for a cocaine overdose?
Diazepam
What drug is given for a methanol (solvents, fuels) or antifreeze overdose?
Fomepizole or ethanol
