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Psychiatry Flashcards

0
Q

How do we diagnose psychiatric conditions?

A

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

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1
Q

What is one of the main problems with psychiatric treatment?

A

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

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2
Q

What is insomnia?

A 
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
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3
Q

What causes insomnia?

A

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

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4
Q

What is the aim of treatment for insomnia?

A

Identify cause
Eliminate cause which contributes to problem
Avoid chronic drug use

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5
Q

What treatment is there for insomnia?

A

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

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6
Q

What things are examine in sleep hygiene, what can be improved?

A 
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.
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7
Q

What is CBT?

A

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

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8
Q

What are hypnotics?

A

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.

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9
Q

How do benzodiazines work in regards to insomnia?

A

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.

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10
Q

What side effects are expected in benzodiazepines?

A

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.

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11
Q

What are the pharmokinetics of diazapines?

A

High lipid solubility

Metabolised in liver, caution if liver problems.

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12
Q

What would indicate which benzo to use?

A

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

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13
Q

What are z-drugs?

A

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.

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14
Q

What treatments other than z drugs of benzodiazines can be used to help insomnia?

A

Melatonin can help correct circadian rhythms

Antidepressants can help if this is the cause of insomnia

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15
Q

What is anxiety?

A

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.

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16
Q

What is generalised anxiety disorder?

A

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

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17
Q

What is panic disorder?

A

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

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18
Q

What are phobic disorders?

A

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.

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19
Q

What is the first type of intervention that should be taken with low level psychological problems and phobias?

A

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.

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20
Q

What drugs can be used for the treatment of GAD?

A

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.

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21
Q

What drugs and treatment can be used for panic disorder?

A

Relaxation techniques
Behavioural
CBT
Antidepressants - SSRI sertraline is liscenced, tricyclics imipramine and clomimpramine.

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22
Q

What drugs can be used for anxiety?

A

Beta blockers can help with symptoms.

Benzodiazepines for short term use

23
Q

What is the function of benzodiazepines in anxiety?

A

Benzodiazepines have a very quick affect, good for severe anxiety.
They have a specific binding site on the GABAa receptor.

The GABA receptor is a ligand gated ion channel, chloride ions specifically. There are two GABA binding sites, and both need to be bound for the channel to be open.There are five subunits in total, and the joining of different subunits creat the binding sites, and one of these is where benzodiazepines can bind.
When benzodiazepines bind to the channel, this does not itself cause opening. However, it does cause conformational changes that increase the affinity of GABA for its receptor, and when both GABA and a benzodiazepine are bound to the channel, the channel is open more frequently. GABA also increases the affinity for benzodiazepine.

This type of action is positive allosteric modulation.

When the channel is open, chloride follows the concentration gradient and move into the cell, causing hyper polarisation, and making the cell less excitable.

24
What ar the effects if benzodiazepines are withdrawn?
The receptor is left desensitised so that GABA has less effect. Produces anxiety insomnia, depression, convulsions, tension. This will continue until the drugs are replaced, or until the receptors read apt which takes 2-3 weeks. Withdrawl should be done slowly, diazepam choice of drug. Reductions fortnightly, can take up to a year to withdraw completely.
25
What affect will a negative allosteric modulator have on the GABA receptor?
It will have the opposite effect to benzo binding, so when GABA is bound the channel will be closed. This induces anxiety and panic. It can be used to reverse the effect of benzo binding.
26
What are the core symptoms of depression?
``` Sustained Depression of mood Unresponsive Lack of enjoyment Lack of interest and appetite Sleep disturbance Fatigue Indecisiveness Feelings of worthlessness Increase thoughts of suits aide and death Reduced libido Aggression in men ```
27
How is depression diagnosed?
Presentation of core symptoms for at least two weeks, and this must be a change from normal. Symptoms are not due to drugs/alcohol misuse, medication, or bereavement - deal with issue, bereavement is often now treated If it's causing a significant distress or impairment of social, occupational or general function in the world.
28
How is severity of depression categorised?
Mild depression is normally 4/5 core symptoms with minor impairment Moderate is 5+ with variable impairment Severe is 5+ with significant impairment Different therapeutic interventions.
29
What is the recommended treatment for SAD?
Light therapy | Fluoxetine
30
Does depression happen spontaneously?
No, it is normally a continued worsening of mood until it passes the threshold for symptoms, at which it becomes apparent, but this does not mean it has suddenly started.
31
What is dysthymia?
A mild chronic depression witch lasts two years or more and is maintained. Normally low level but sustained rather than improving.
32
How long does depression last and what are the chances of incidence?
10% of people will have some form of depression Women are twice as likely to suffer from depression Most common in late 20s A normal episode lasts between 3-8 months 20% of patients will have depression lasting more than two years 50% recur acne High risk of suicide in severe depression
33
What can be th causes of depression?
``` Genetic history of mania, depression, alcoholism and some ethnicities Life events Unemployment Unstable relationships Other severe illnesses IE cancer Post Natum Old age ```
34
What is the current main hypothesis as to what th neurological cause of depression is?
Reduction in Monoamine metabolites in CNS ( serotonin,noradrenaline,dopamine) In post Mortem patients there is a reduction in these neurotransmitter receptors in the brain
35
What are the problems with managing depression?
Lack of interest means less inclined to seek help Lack of time with Drs to get to issue Many cases are undetected Treatment comes second to other illness High risk of misdiagnosis or unnoticed depression
36
What are the treatments avalible for depression?
Antidepressants Psychotherapy Prophylaxis can be used as well as treatment For patients who do not respond to above, there are more serious options Electro convulsive therapy Neurosurgery Trans cranial magnetic stimulation
37
What is psychotherapy for depression?
Psychological techniques have similar success rates as antidepressants in non psychotic depression Not enough avalibility CBT recommended for use in conjunction with medication for most effective treatment Psychotherapy can be used prophylactically
38
Which families of drugs can be used in the treatment of depression?
SSRI selective serotonin re take inhibitors SNRI serotonin and noradrenaline re uptake inhibitors Monoamine oxidase inhibitors MAOI Reversible inhibitors of MAO-A RIMA Noradrenergic and selective serotonergic action NaSSA Noradrenaline re uptake inhibitor NARI Noradrenergic and dopaminergic re uptake inhibitor NDRI Tryptophan
39
How affective are antidepressants and how long do they take to work?
40-70% patients respond to antidepressants 10-20% respond to placebo Takes 2-6 weeks for effect to be apparent Compliance is a problem if patient is not informed of this Initial dose may be too low It can take a while to find th drug that works best for an individual patient. Most common = drugs that work for most patients.
40
How do MAOI work?
Monoamines are metabolised by MAO. By using MAOI we reduce th breakdown of these monoamines, which increase the avalibility of these neurotransmitter.
41
What is the action of a fe families of antidepressants?
TCA block the uptake of DA NA an 5-HT SSRI block re uptake of 5-HT MAOI block Monoamine oxidises from breaking down DA, NA and 5-HT
42
Why does it take time to increase mood in antidepressants if there is an immediate increase of neurotransmitters?
It is believed that there must also be a change in receptor sensitivity and or density as well as an increase of transmitters. This takes longer to alter so there is a slow onset of improvement.
43
What can affect choice of which antidepressant to prescribe?
Best evidence for that drug at the time All have unwanted side effects, aim to treat while limiting these What has been tried before Which side effects were felt before Risk of overdose, care in patients with suicide risk
44
What are the guidelines for which drug to prescribe first in depression?
Normally start with a generic SSRI. Side effects include GI bleeding and nausea. If taking NSAID consider gastroprotection esp if older If on other medication for chronic illness, citalopram and sertraline are less likely to cause interactions Paroxetine associated with discontinuation symptoms more frequently.
45
Which antidepressant drugs are associate with problems of toxicity/ suicide?
Tricyclics | Venlafaxine
46
What problems are associatd with prescribing antidepressants other than SSRIs?
Increase likelihood of stopping treatment due to side effects Dose may need to be increased gradually. More specific contra indication More age related problems
47
What is the only antidepressant that is suitable for use in under 18s?
Fluoxetine
48
How do SSRIs affect hepatic p450 enzymes?
They inhibit them, so altered metabolism of other drugs
49
What are the withdrawl side effects associated with SSRIs?
``` Dizziness and vertigo Headache Nausea Nervousness and insomnia Star after two days last up to ten days Slow reduction of dose reduces risk ```
50
What side effects to TCA have?
They have muscarinic antagonism at m1 so cause dry mouth,constipation They also have adrenergic antagonist at a1 so also cause drowsiness,tachycardia,hypotension Weigh gain
51
What is bipolar affective disorder?
Change of moods, period of mania and period of depression Mania include large burst of energy, rapid thought, hyperactivity, aggressiveness. Episode last 3-7 days with thre or more characteristic symptoms.
52
What is the first line treatment for bipolar?
Lithium salts Antipsychotics Sometimes used with benzo to calm Anticonvulsants are 2nd line. Antidepressants not recommended as can induce mania.
53
What symptoms define schizophrenia?
``` Delusions Hallucinations Disorganised speech Disorganised behaviour Agitation Poor report Social wothdrawl Continuous for 1-6 months ```
54
In schizophrenia, what are positive and negative symptoms?
Not good and bad. Positive means causing more than normal, ie hallucination, positive because more hallucinations present. Negative means less than normal, ie poor rapport, less able to converse than normal.
55
What are some things that people with schizophrenia might believe are happening?
People inserting thoughts into their head People taking thoughts out of their head Your thoughts being broadcast to everyone
56
What are possible causes of schizophrenia?
``` Dopamine over activity Serotonin over activity Adrenerigc over activity Glutamate under activity Gaba under activity ```

CPT 1 (12 decks)

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