Psychiatry Flashcards
How do we diagnose psychiatric conditions?
Personal and family history very important
Mental state exam - difficult if depression as not always want to answer, easier to tell in extreme forms, harder to see milder forms.
Observation of behaviours,speech cognitive function
Anxiety,self harm, depression.
Circumstantial - IE bereavement
What is one of the main problems with psychiatric treatment?
Large social stigma
Only 30% of people with psychiatric problems recive treatment, the large proportion of patients don’t even have their problems as acknowledged.
Long waiting period
What is insomnia?
Difficulties falling asleep Difficulties staying asleep Poor quality of sleep Early morning wakening Increases with age Higher incidence in women than men Most cases clinically insignificant as it passes itself in a few days
What causes insomnia?
There are several causes of insomnia.
Self limiting - travel, shift work,jet lag
Psychological - depression, anxiety, OCD, grief, mania
Physical/chemical - drugs use/withdrawl, alcoholism,pain,tinnitus
It is an imblalance of arousal sleep system
What is the aim of treatment for insomnia?
Identify cause
Eliminate cause which contributes to problem
Avoid chronic drug use
What treatment is there for insomnia?
Improve sleep hygiene, examine sleep pattern and see if this can be improved.
CBT - examine behaviour and try to retrain the body a good sleep patter. Best first line treatment but not enough avalibility, long waiting times for appointment.
Hypnotic drugs
What things are examine in sleep hygiene, what can be improved?
Avoiding naps Have a set routine Do not use sleep room for other purposes Avoid stimulants like caffeine nicotine Avoid alcohol Don't go to bed if not sleepy, this can cause more stress when unable to sleep, makes sleep later harder.
What is CBT?
Cognitive behavioural therapy.
Analyse thoughts, behaviours, beliefs about sleep, reeducate, retrain brain to be in a healthier place, understanding how to deal with problems that can be changed, and help to manage problems which cannot.
Very effective, however low availability
What are hypnotics?
Drugs that can be used to aid sleep.
Investigate cause of sleep problems, so that after course of drugs sleep should be returned to normal.
Short term use of two to four weeks recommended, chronic insomnia should be treated with CBT but not always possible.
How do benzodiazines work in regards to insomnia?
Sedating medication that can be used to aid sleep. Increase duration of sleep, reduce anxiety that can be causing insomnia.
It binds to a specific binding site on GABAa receptor, which increases the receptor affinity for GABA. As GABA is a inhibitory pathway, this enhances its effects.
What side effects are expected in benzodiazepines?
Hangover effect, left over drowsiness, confusion
Alcohol and other CNS depressant used with them causing increased sedation and respiratory depression
In elderly linked to increased risks of falls and confusion
Tolerance is a problem with this type of drug so reduced impact.
Drug taking becomes compulsive, addiction.
What are the pharmokinetics of diazapines?
High lipid solubility
Metabolised in liver, caution if liver problems.
What would indicate which benzo to use?
Duration - can affect driving and lingering drowsiness, so shorter half lives of 8-12 hours better verses longer nitrazepam of 16-40.
Diazepam for anxiety related insomnia
Active metabolites in temazepam
What are z-drugs?
They act at the benzodiazepine binding site on the GABA a receptor, but have a shorter half lives as they are modified.
Zolpidem is best for inducing sleep as it has v short half life 1.5 to 4
Zopiclone better for maintaining sleep with 3.5-6.5
Reduced hangover effects
Because they work at benzo binding site they need GABA present to work.
What treatments other than z drugs of benzodiazines can be used to help insomnia?
Melatonin can help correct circadian rhythms
Antidepressants can help if this is the cause of insomnia
What is anxiety?
A normal phenomenon in responce to stress, can be beneficial at appropriate levels, can improve performance, problems occur when levels are disproportionate/persistent.
Unpleasant emotion state, can cause physical symptoms
Many types of anxiety disorders.
Greater in women’s than men.
What is generalised anxiety disorder?
Generalised persistent anxiety, apprehension, hypervigilance, disturbed sleep, tense.
Increased autonomic drive, increase in adrenaline and associated symptoms.
Caused by stress, some cases are genetically driven, previous experiences, childhood problems
Higher in women than men
What is panic disorder?
Rather than being background persistent anxiety, this is short unpredictable episode of high level fear IE fear of dying, loss of control.
Panic attacks if occurs once or twice
If reccuring it is panic disorder.
Hyper aware, high adrenalin, sympathetic system activated.
Fight or flight with no real stimulus, irrational, sometimes a build up followed by a tipping point
What are phobic disorders?
Different types of phobias, social phobias, agoraphobia, specific phobias.
This is when the phobias get in the way of normal life, inhibiting normal function, irrational stress caused by triggers.
Not a useful responce if the fear starts getting in the way, affecting How you deal with life.
What is the first type of intervention that should be taken with low level psychological problems and phobias?
Initially non drug help, group work, individual self help, low level guidance by a trained professional. Signposting important.
If this does not work, CBT by trained practitioner or applied relaxation delivered by a professional. Problems with avalibility.
What drugs can be used for the treatment of GAD?
If CBT doesn’t work or is not avalible, SSRIs (selective serotonin re uptake inhibitors) or SNRIs (selective noradrenaline re uptake inhibitors) can be used. Sertraline is an example but is not liscenced for this use uk.
SSRIs have serious side effects, including withdrawl(paroxetine and venlafaxine). Venlafaxine also has suicide risk and toxicity.
Pregabalin can be tried to increase GABA if SSRIs not tolerated.
Benzodiazepines short term only.
What drugs and treatment can be used for panic disorder?
Relaxation techniques
Behavioural
CBT
Antidepressants - SSRI sertraline is liscenced, tricyclics imipramine and clomimpramine.
