Psychiatry 2 - Mood Disorders and Psychosis Flashcards
(93 cards)
1
Q
What are mood disorders sometimes referred to as?
A
- Affective disorders
2
Q
How might someone with a mood disorder present to a dentist?
A
- This is rare
- Sometimes see oral effects (dysesthesias, facial pain)
- Or can tell from patients general demeanour (especially if you are familiar with them)
3
Q
Can we carry out dental treatment to a patient during depression?
A
- For most patients with depression having dental treatment is not a particular problem however, if any important decisions have to be made for example extracting teeth or changing appearance then this might not be the most appropriate time if it is not clear that the patient is able to make a decision with a positive outlook
4
Q
Explain how mood disorder is a spectrum disorder?
A
- They are a spectrum
- Moods change depending on circumstances
- These circumstances can be from within or can be from our environment
- Start in the middle with normal mood and normal mood can go up or down depending on how you are feeling (the normal mood swing is called Cyclothymia)
- Patients who become depressed will have different severities of depression and most depressive disorders are not psychotic (means the patient has still got contact with the reality of they’re environment - these are neuroses)
- However, at the extremes of depression psychosis can take over - very severely depressed patients can have psychotic views and have a change in their perception of the world
- These depressive disorders can progress for some time or they can alternate with returning to normal mood - in which case the patient would have a recurrent depressive disorder
- An elevated mood goes from elation which is generally feeling pretty good about things - up to hypomania and mania and finally mania with psychosis
- With the extremes of these depressive mood disorders it is possible for the patient to have a change in their perception of reality
- Hypo-mania and mania are excessive forms of well being and they can have associations with particular problems
- A unipolar depressive disorder is where the patient moves usually down towards low mood
- If the patient moves up in mood and then down in mood that is called a bipolar disorder
5
Q
What is Cyclothymia?
A
- Where the patient has a normal mood and their mood can go up or down depending on how they are feeling
6
Q
Name the different changes in mood and what these are?
A
- Normal person has ups and downs
- Slightly more exaggerated versions of nomral is what we term Cyclothymia (this can progress from a temperament which is quite common into a disorder where there are much more pronounced mood swings)
- We then move on to bipolar disorder, Bipolar disorder type II tends to have mostly depression but with periods where the mood will return to normal and perhaps even go slightly higher then normal but never getting as high as mania
- Monopolar mania on the other hand does not have many depressive points but the patient’s mood will go from normal to very high and back again
- Whereas our type 1, or what you might consider our normal bipolar patient will have extreme mood swings from mania (possible including psychosis) to depression (perhaps including psychosis), then returning for a time to a euthymic state
7
Q
Do mood disorders generally affect males or females more and at what ratio?
A
Female : Male
2-3 : 1
8
Q
Mood disorders are a spectrum of diseases. What is the point prevalence of unipolar mood disorders?
A
6% prevalence
9
Q
Mood disorders are a spectrum of diseases. What is the life prevalence of bipolar mood disorders?
A
- Life prevalence of 1.2%
10
Q
What is a Puerperal mood disorder?
A
- Post natal depression
- There are relatively common
- If a patient is prone to post-natal depression after one baby they will be prone to it after each pregnancy
11
Q
What is major depression?
A
- This is where we can move down in towards severe and psychotic depression
- It is a persistent depressive disorder where the patient remains at a low mood - never really returning to normal or to the exceeding depths of depression
12
Q
What are the different common types of depressive disorder? (7)
A
- Major depressive disorder
- Persistent depressive disorder
- Bipolar disorder
- Postpartum depression
- Premenstrual dysphoric disorder
- Seasonal effective disorder
- Atypical depression
13
Q
When a person is depressed what is it important to ask them?
A
- When someone is depressed it is important to ask them if they have thought about suicide - important to detect the people who have thought about it and more importantly to detect those who have thought about it and actually thought about how to carry it out
- By identifying this and providing the right intervention we can make a huge difference
14
Q
What are common symptoms of depression? (10)
A
- Low mood
- Reduced interest & motivation
- Lethargy & tiredness
- Sleep disturbance
- Appetite disturbance
- Poor concentration
- Loss of confidence & self-esteem
- Recurrent thoughts of death & suicide
- Unreasonable self-reproach & guilt
- Any form of anxiety
15
Q
What is bipolar 1?
A
Mania - person who goes from normal to high mood then back again
16
Q
What is bipolar 2?
A
- Cyclothymia & hypomania
- Exaggerated hypothymia and progression onto hypomania and to actually mania with psychosis in some cases and go from there into a depressive state
17
Q
What are the symptoms of mania and hypomania? (5)
A
- Increased productivity & feeling of wellbeing
- Reduced need for sleep
- Gradual reduction in social functioning and occupational functioning
- Increase in reckless behaviour with no fear of the consequences
- Followed by a period of depression regarding their general outlook on life
18
Q
What are 2 forms of elevated mood disorders?
A
- Euphoria and Dysphoria
19
Q
What are the characteristics of a euphoric elevated mood disorder? (9)
A
- Upbeat
- More talkative
- Inflated self-esteem
- Felt everything was possible
- Rapid speech
- Restlessness
- Reckless behaviour
- Excessive energy
- Decreased sleep
20
Q
What are the characteristics of a dysphoric elevated mood disorder? (10)
A
- Irritable
- Agitated
- Aggressive energy
- Restlessness
- Rage
- Rapid speech
- More talkative
- Reckless behaviour
- Excessive energy
- Decreased sleep
21
Q
What is the best mechanism for treatment of mood disorders?
A
- Best mechanism is a combination of treatments
22
Q
What are the different types of treatment we can give for mood disorders? (3)
A
- Psychological
- Drug treatment
- Physical
23
Q
What are the psychological forms of treatment we can give to patients for mood disorders? (2)
A
- Cognitive therapy
- Interpersonal psychotherapies
24
Q
What kinds of drug treatment can we give a patient for a mood disorder? (2)
A
- Antidepressants
- Mood stabilising
25
Why when treating a person with a mood disorder with a drug treatment does the patient need to be on the treatment for 2 years?
- Even if the patient's mood quickly returns to normal
- This is because the normal that they have returned to is because of the medicines and it takes a while before the brain accepts this new equilibrium in biochemistry and accepts it as normal
- Therefore, withdrawing treatment before 2 years is frequently associated with relapse of the patient symptoms
26
What are the different types of physical treatment we can give a patient for a mood disorder? (3)
- Exercise
- Phototherapy
- ECT
27
In a person with a mood disorder what can exercise be really good for?
Exercise is very good for improving mood
28
In a person with a mood disorder what can phototherapy be really good for?
This can be quite helpful in seasonal affective disorder
29
In a person with a mood disorder what can ECT be really good for?
- In some cases, although rarely nowadays electro0convulsive therapy can still be a good way of rapidly changing someone's low mood - this is perhaps more used in post-natal depression than in other forms now
30
Give examples of acute phase antidepressants that can be used for mood disorders? (4)
- Selective Serotonin Reuptake Inhibitor (SSRI)
- Venalfaxine/Mirtazepine
- Tricyclic antidepressants (TCA)
- Monoamine oxidase inhibitor (MAOI)
31
Give examples of mood stabilising drugs that can be used for mood disorders? (4)
- Lithium
- Carbamazepine
- Valporate
- Lamotrigine
32
Info on Drugs
- Anti-depressant medications take the patient from low moods towards normal
- It is possible in some patients that this rise in mood can actually overshoot and the patient can go from low mood up to hypomania
- So drugs used in mood disorders are essentially not always predictable and each individual must be assessed while they are taking this medicine to see how they are managing
- The most common anti-depressants used nowadays are SSRI's
- There are different SSRI's on the market and different ones will suit or be effective in the different patients
- It is sometimes necessary for the patient to try 2 or 3 different SSRI's to find the one that suits them best
- SSRI's can promote anxiety when starting and stopping the drug use and this can be little problem when the patient is depressed but when the person tries to stop the medication later on the associated anxiety often gives them unpleasant withdrawal symptoms and patients sometimes feel that they are addicted to the medicines and can no longer stop them
- In practice with appropriate care and sometimes with the use of benzodiazepines, SSRI's can be stopped successfully
- When an SSRI treatment has not been successful second line antidepressants can be used such as Venalfaxine/Mirtazepine - these are most often started by a psychiatrist rather than a GP
- The older TCA do still have a role to play in some patients but they are much less effective in dealing with depression but are much more effective with dealing with anxiety - for this reason sometimes SSRI's are combined with TCA's and will see these treatments used quite frequently within oral medicine
- A less used anti-depressant nowadays are MAOI's - these drugs have lots of side effects and interactions and are now really only used by psychiatrists where other treatments have failed
- For patients who are more prone to mood cycling, stabilising drugs can be helpful
- Traditionally lithium is the drug that has been used and it has potential interactions and toxicity problems
- More modern drugs that seem to help in the same way include carbamazepine, sodium Valporate and Lamotrigine
33
Always ask the patient why they are taking antidepressants as there are other uses for them other than depression. What are these uses? (4)
- Treating depression
- Treating anxiety disorders including ECD and panic disorders
- Pain relief (particularly the tricyclic anti-depressants and mirtazapine - These drugs will help to boost the noradrenaline levels within the brain and reduce the pain transmission within the CNS
- Helps psychological treatments
- The drugs are sometimes given to promote the learning of new behaviours
34
Give 3 examples of original tricyclic antidepressants?
- Amitriptyline
- Nortriptyline
- Dosulepin
35
Give 2 examples of new TCA's?
- Imipramine
| - Doxepin
36
What are common side effects of Tricyclic Antidepressants? (3)
- Dry mouth
- Sedation
- Weight gain
- There are more side effects with the older types
- They are also dangerous in overdose and this is always an issue when giving them to a patient with depression
37
What do TCA's need to be used with caution with? (2)
- Glaucoma
- Prostatism
- They have the potential to cause problems in patients with these 2 things, causing a rise in eye pressure or blockage in urine outflow - although these problems are not common it is important to consider in patients who have them whether these are the best choice of medicines for them
38
Give examples of SSRI's? (5)
'prozac' type drugs:
- Fluoxetine, Paroxetine, Fluvoxamine
- Citalopram, Sertraline
39
Give examples of side effects of SSRI's? (3)
- Acute anxiety disorders
- Some patients similar to TCA - sedation, dry mouth
- GI upset
40
What is an MAOI?
- Momamine oxidase inhibitor - 5HT & norA
41
Give 3 examples of MAOI's?
- Phenelzine
- Isocarboxazid
- Selegeline
42
MAOI's have a few different interactions. What are these? (2)
Indirect acting sympathomimetic amines (e.g. ephedrine)
- Enhanced vasoconstrictor effect
- Cold and cough remedies
Foodstuffs:
- Tyramine containing, alcohol/low alcohol, bovril/oxo/marmite, cheese, herring, beans
- Therefore these drugs cannot be given unless the patient understands the limitations that they place upon their life
43
Give examples of other drugs used as antidepressants (that are more likely to be given by a psychiatrist than a GP)? (4)
- Venlafaxine (mixed SRI/NRI)
- Mirtazapine (Complex 5HT actions presynaptic alpha2 antagonist)
- Nefazadone (SSRI/5HT blockade)
- Reboxetine (SNRI)
- All of these work in slightly different ways and can be combined in some cases with other antidepressants
44
What drugs can be used in bipolar mood disorder? (5)
- Lithium - mood stabiliser
- Carbamazepine/Lamotrgine/Valporate - mood stabiliser
- Antipsychotic medicines - treating episodes of mania
45
When giving Lithium as a drug for bipolar mood disorder, what should we avoid? (2)
- NSAID's and metronidazole should be avoided
46
Antipsychotic medicines can be used in the treatment of bipolar mood disorder. Give 4 examples of these?
- Aripiprazole
- Olanzapine
- Quetiapine
- Risperidone
- These can be helpful in reducing the episodes of mania
- These are not-antidepressants but they reduce the tendency to mania and to psychosis
47
What are common dental side effects that antidepressant drugs can have? (3)
- Dry mouth - Caries (lithium)
- Sedation
- Facial dyskinesia's (these are uncontrollable facial twitches)
48
Are there any drug interactions we need to be particularly aware about in relation to antidepressant drugs?
- There are no significant drug interactions the dentist needs to be concerned about
- Just be aware of drug metabolism and local anaesthetics
49
Psychoses are perceptual abnormalities. Give 3 examples of these?
- Manic depression
- Schizophrenia
- Korsakoff's psychosis - alcohol induced brain degeneration
50
When can someone with a psychoses be difficult to treat?
- During acute episodes - as they cannot have any insight into the problem that they have
51
What are common drug effects for a person being treated for psychoses? (3)
- Dry mouth
- Drug interactions
- Dyskinesia's - tonic or dystonia (tardive)
52
What is Schizophrenia?
- A thought disorder
| - 'fundamental and characteristic distortions of thinking and perception'
53
What happens in Schizophrenia? (2)
- Various types of delusions - sometimes bizarre (these can be auditory or visual)
- Auditory hallucinations - often threatening or derogatory (there gnaw away at the patient's confidence and they cannot be removed)
- The person will usually behave appropriately for the environment that they find themselves in
- However, their reality is not the same as yours and therefore their behaviour seems irrational
54
What can occur due to Schizophrenia? (2)
- Relapsing and remitting periods of acute psychosis
| - Cumulative, chronic deficits in motivational, affective and social domains
55
Schizophrenia is a multifactorial abnormality of Dopaminergic neurotransmission. What are the possible aetiologies of this condition? (3)
- Genetic susceptibility - multigene
- Environmental - perinatal risk factors
- Drug abuse (cocaine, amphetamine, ecstasy, opiate (cannabis & alcohol))
56
What is the prevalence of Schizophrenia?
1-2%
57
What are the different types of psychological therapy that can be used for Schizophrenia Management? (3)
- CBT
- Cognitive remediation
- Family intervention
58
What are the different types of drug therapy that can be used for Schizophrenia Management? (3)
- Oral or depot IM injections
- Dopamine antagonist drugs
- Atypical antipsychotics
59
What is the problem with oral or depot IM injections as drug therapy for Schizophrenia management?
- Compliance, Frequency of requirement
- Remember that many of the patient's who have Schizophrenia may not have insight into their problem - as far as they are concerned their reality is perfectly normal and they are behaving appropriately - therefore they see no need to take medicine for a condition which they do not seem to have
- For that reason compliance for medication can be poor and for that reason the patients will often have long lasting medicine injections rather than oral tablets
- Once the patient has recovered then oral medication may be appropriate but a single monthly injection of a depo drug can be a good way of helping with compliance in some patients
60
What is the problem with dopamine antagonist drugs as drug therapy for Schizophrenia management?
- Cause 'extrapyramidal' side effects, dry mouth and sedation
- Blocking the effects of the dopamine receptors inside the brain
- They not only block dopamine in the areas of concern but also block dopamine elsewhere in the brain as well
- This is particularly true in the pyramidal systems which are to do with control of movements
- This is the same area of the brain which has dopamine shortages in Parkinson's disease and therefore when dopamine shortages effectively happen because of dopamine blocking drugs, the side effects can be very similar
- The extra pyramidal side effects can be very distressing for the patient
61
Why are atypical antipsychotics preferred nowadays as drug treatment for Schizophrenia management?
- Because they are less likely to cause extrapyramidal side effects
62
What are the 4 different types of antipsychotics?
- Butryrophenones
- Phenothiazines
- Thioxanthenes
- New 'atypical' antipsychotics
63
Give 2 examples of Butryrophenones (antipsychotics)?
- Haloperidol
| - Droperidol
64
Give 4 examples of Phenothiazines (antipsychotics)?
- Chlorpromazine
- Thioridazine
- Prochlorperazine
- Fluphenazine
65
Give 2 examples of Thioxanthenes (antipsychotics)?
- Flupenthixol
| - Zuclopenthixol
66
Why are new antipsychotics described as 'atypical'?
- Because they do not act by being dopamine antagonists and as a consequence do not have as many extra-pyramidal side effects
67
Give 6 examples of new 'atypical' antipsychotics?
- Sulpiride
- Respiridone
- Clozapine
- Quetiapine
- Aripiprazole
- Olanzapine
68
Give examples of extrapyramidal side effects of antipsychotics? (4)
- Akathisia
- Dystonia
- Parkinsonism
- Tardive Dyskinesia
69
What is Akathisia? (2)
- Feelings so restlessness, making it hard to sit down or hold still
- Symptoms include tapping your fingers, rocking and crossing and uncrossing your legs
70
What is Dystonia?
- Muscles involuntarily contract and contort leading to painful positions or movements
- This can affect the muscles of the neck and occasionally the intra-oral muscles such as the tongue
71
What is Parkinsonism? (2)
- The same symptoms as someone with Parkinson's disease, but your symptoms are caused by medications, not by the disease
- May include tremor, slower thought processes, slower movements, rigid muscles, difficulty speaking and facial stiffness
72
What is Tardive Dyskinesia? (2)
- Uncontrollable facial movements such as sucking or chewing, lip smacking, sticking your tongue out or blinking your eyes repeatedly
- Do not go away if medication is stopped
73
How can we treat extrapyramidal symptoms? (3)
- Use an 'atypical' antipsychotic instead
- Beta-adrenergic blockers (non-selective)
- Anticholinergics
74
Give 2 examples of beta-adrenergic blockers?
- Propanolol
| - Metropolol
75
Give 4 examples of anticholinergics and describe how they work?
- Procyclidine
- Benztropine
- Diphenhydramine
- Pramipexole
- To reduce the effect of acetylcholine
- Procyclidine and Benztropine are very frequently used
- Unfortunately, These also have side effects in the mouth of increasing dryness
- So when patient is on a few drugs that all cause dry mouth this patient can be quite severely compromised when it comes to their oral comfort
76
Give 3 examples of eating disorders?
- Anorexia Nervosa
- Bulimia
- Comfort eating
77
What is anorexia nervosa? (2)
- Altered perception of body image
| - Don't eat - oral effects of malnutrition (ulcers, dry mouth, infections, bleeding)
78
What is bulimia? (3)
- Normal weight - binge/vomit
- 'comfort eating' - stress reaction
- dental erosion & oesophageal stricture
79
What is comfort eating?
- Eating disorder used as a coping strategy for anxiety
80
What is the core psychopathology of an eating disorder?
'morbid fear of fatness' and self-perception of being too fat
81
Eating disorders often include restriction of food intake and other behaviours aimed at loosing weight. What are these behaviours? (5)
- Self-induced vomiting
- Excessive exercise
- Use of laxatives, appetite suppressants and diuretics
82
Who are usually affected by eating disorders?
- Characteristically young females
| - But this is not always the case
83
What are some problems with personality disorders? (2)
- Many of them have no effective treatment
- There is difficult knowing how these arise - whether they are genetically coded or whether they are learned behaviours but it would seem from observation that most of them tend to be the way people are
84
What is borderline personality disorder?
- Instability in interpersonal relationships, self image and affects, and marked impulsivity
85
What is antisocial personality disorder?
- Disregard for, and violation of, the rights of others
86
What is Histrionic personality disorder?
- Excessive emotionality and attention seeking
87
What is Narcissistic personality disorder?
- Grandiosity, need for admiration and lack of empathy
88
What is avoidant personality disorder?
- Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation
89
What is dependent personality disorder?
- Submissive and clinging behaviour related to an excessive need to be taken care of
90
What is Shizoid personality disorder?
- Detachment from social relationships and a restricted range of emotional expression
91
What are personality disorders?
- 'chronic peculiarities of character'
- 'maladaptation to life'
- Often 'antisocial' behaviour
92
What is borderline personality disorder?
- Common thing is the black or white thinking
- The patient has great fears and as a consequence this drives their behaviour
- All of the symptoms are disguising the fact that the patient is incredibly anxious and has a great fear - usually of being isolated
93
What are symptoms of borderline personality disorder? (8)
- Deep fear (of getting abandoned or rejected)
- Unstable relationships
- Changes in self-image
- Stress paranoia
- Impulsive behaviour
- Suicidal threats
- Excessive mood swings
- Feelings of solitude
