Psychiatry Flashcards
TCAs 9 SEs
Anticholinergic Cardiotoxicity (QT, Arrythmia, QRS elongation) Weight gain Sexual dysfunction Serotonin syndrome Exanthema Sedation Reduced seizure threshold Insomnia SUICIDE
SSRI 5 SEs
GIT Sexual dysfunction Weight gain Insomnia SUICIDE
Atypical antidepressants and their indication
Bupropion less weight gain less sexual dysfunction (NDRI) Mirtazapin without sexual dysfunction (A2 block) Venlafaxin without sedation (SNRI)
Dual effect of antidepressants
Acute: Sedating also in healthy
Chronic: Mood altering only in sick
KI of SSRI
Acute manic phase
Combination with MAO inhibs bc Serotonine Syndrome
KI of TCA
Acute delirium
Cardiac disease
MAO Inhibit
Groups of TCA and their special effects
Imipramin-Type: only affects mood
Amitryptiline-Type: psychomotor sedative
Desipramin-Type: psychomotor activating
SSRI Names (4)
Citalopram
Escitalopram
Sertralin
Fluvoxamin
History of psychiatry overview (9 Stations)
1) Ancient times:
Egyptians (oldest documentation 1500BC and King Saul (Depressive, Bipolar, Suicide)
2) Hippocrates:
MDs bc of dysbalance of bodily fluids (sanguinous, melancholic, phlegmatic, choleric); treatment by sweating, laxatives, venipuncture
3) Roman empire:
Soranus recommended to permanently friendly supervise mentally ill
4) Middle ages:
Malleus Maleficarum; Witch hunts; Exorcism
“Demonological interpretation of MD”
5) Renaissance:
Return to humanism; MDs as diseases;
1st psychiatric revolution by Johann Weyer 1550 ==> No blame for affected, they should be examined properly
6) Enlightment:
Rationalism, Logic, Humanism
2nd psychiatric revolution by Phillipe Pinel 1800 ==> No restraint system in two prison that became mental institutions
7) 1800 - 1900:
Acceptance of psychiatry as medical field
Foundation of mental insitutes esp. at edge of towns
Sigmund Freud 1900: Psychoanalysis, Theory of Unconscious
8) WW2
Euthanasia and Sterilization of mentally ill
Aktion T4: kill mental inmates to save ressoucres
9) from 1950
3rd psychiatric revolution with psychopharmaca, social approaches (bc of american wars ==> PTSD), community psychiatry (outpatient care, self help groups etc.)
Vascular dementia types
Cortical - several small infarcts (slow onset) or one large (quick onset)
Subcortical/Binswanger - Gait problems, Incontinence, milder dementia than in cortical
Symptoms/associations of vascular dementia (4)
Emotional liability
Delirium
Personality unchanged typically
Hypertension/Atherosklerose
Alzheimer types (2)
Early onset <65 - quick progression, personality changes, sudden onset, loss of cortical functions (aphasia, apraxia, alexia, agraphia)
Late onset >65 - slow onset, slow progression, personanlity changes, mainly memory and cognitive impairment
Etiopathogenese Alzheimer (5)
APP ==> beta-amyloid extracellular plaques
Cytoskeleton ==> tau protein intracellular neurofribrillary tangles
Both lead to inflammation
Atrophy esp. Hippocampus and Temporallappen
Loss of Cholinergic neurons
Diagnostic of Alzheimer
Dementia Slow progression Non explicable by other stuff NO specific neurological signs (as opposed to vascular dementia) MRT for brain atrophy CSF examination
Therapy Alzheimer
1) Cognitive (only slowing down)
- ACh-Esterase inhibitors (Rivastigmine, Galantamine, Donepezil)
- Nootropics/Antioxidants (Vit E und Gingko)
- NMDA Blockers (Memantine)
- NSAIDs (ASS)
2) Non-cognitive
- Psychoses (Neuroleptics 2nd gen. Risperidon, Clonazapine)
- Antidepressants (SSRIs)
- Hypnotics (BZ-like, Clomethiazole)
3) Psychotherapy
- Skill/Task oriented training
- Alzheimer communities esp. good for family
Therapy Vascular Dementia
- Treat HTN
- Statins
- Anticoagulants
- Antidiabetic (Metformin)
Dementias except Alzheimers (10) (5 Names, 3 Infections, 2 other) and metabolic dementias
1) Creutzfeld-Jakob (Prion disease, pyramidal and extrapyramidal symptoms)
2) Huntington (AD, Middle age, mainly basal ganglia, Strong genetic component, Choriform movements)
3) M. Wilson (Copper metabolism disorder)
4) Parkinson (Lewy Bodies, Parkinson symptoms, dementia is late stage)
5) Picks Disease (Frontotemporal dementia, Middle Age, Behavioural symptoms [Euhporia, Blunt emotionally, coarse social interactions] similar to syphilis, Pick bodies/Tau protein)
6) Syphilis (3rd stage 15y after infection, Treponema is found in CSF, [Malariatherapy), Generalized Paralysis of the Insane = Tabes Dorsalis, Behavioural changes similar to Picks disease, Delusions, Neurological signs like Argyl-Robinson-Pupils, Meningitis); Pathogenesis: Atheritis
7) HIV (Late stage by inflammation caused by infected microglia etc.)
8) Neuroboreliosis
9) CO Poisoning (Suicide, Industrial)
10) Normal pressure hydrocephalus
Metabolic: Hyponatremia, Anemia, Intoxications, Hormonal disturbances esp, hypothyroidism, Korsakoff/Wernicke, Uremia, Hepatic encephalopathy
Classifications of Dementias (2)
1) Degree of dementia
-Mild - Can look after oneself but forgetful and hard to
learn new stuff
-Moderate - Memory declines, severe handicaps
-Severe - Completly dependent, disoriented, only
fragmented memory
2) Types of dementia
- Primary atrophic dementia (Alzheimer, Huntington, Parkinson, Pick)
- Secondary (Vascular, Prion, Infectious, Injury, Tumor, Drugs, Metabolic)
Mental disorders caused by alcohol (11)
1) Acute intoxication (Desinhibition, poor concentration/cognition,
2) Alcohol pathological intoxication (Sudden change of conciousness with aggressive behaviour with even low amounts of alcohol)
3) Dependence (deterioration of social life, behavioural changes)
4) Withdrawl (Tremor, anxiety, seizure)
5) Delirium tremens (Delirium in evening in heavy drinkers esp. during withdrawl)
6) Alcohol hallucinoses (Severe anxiety, voices etc.)
7) Pathological jealousy (Delusion)
8) Korsakov psychosis (Severe disorder of recent memory, confabulations, no insight, bad prognosis)
9) Wernicke encephalopathy (Acute life threatening condition caused by B1 deficieny typically in heavy drinkers)
10) Alcoholic dementia (esp. personality changes)
11) Suicidal behaviour
Treatment of alcoholism
In withdrawl - BZ, Clomethiazole
For abstinence - Naltrexon (opioid) for primary stop of drinking and Acamprosat (NMDA Antagonists) for maintenance of abstinence
Psychotherapy with anonymous alcoholics
Anxiety vs Fear Def
Fear: Spec object of fear, disappears if threat is gone
Anxiety: no spec object
Typical comorbidity of anxiety
Depression (Mixed depression-anxiety disorder)
Untreated anxiety leads to depression
Phobic anxiety disorder subtypes
Agoraphobia (Fear of leaving home basically)
Social phobia (Fear of scrutiny of other people)
Specific phobias
Phobic anxiety disorder description and symptoms
External situation/stimulus causes increased stress levels
Leads to avoidance of situations
Symptoms: Palpitations, Fear of dying
Panic Disorder description and symptoms
No specific trigger, sudden extreme pain lasting max. 20 minutes
Somatic symptoms that may be similar to heart attack or choking etc. leading to frequent visit of emergency services
General anxiety disorder description and symptoms
More than 6 months lasting anxiety with no specific trigger
Etiology of phobias
Conditioned
Genetic/Neurobiology including psychoactive substance abuse
Early trauma
Therapy of anxiety disorders
Psychotherapy: Cognitive behavioural therapy Pharmacotherapy: BZ for acute attacks only bc dependence Beta blockers Antihistaminics SSRIs (first line)
Graphs of Phobic Anxiety Disorder, Panic disorder and generalized anxiety disorder
1st: Trigger ==> Plateau until out of situation
2nd: Randomly extreme and short panic
3rd: COntinous increased stress
OCD definition, obsession vs compulsion
Impulses or thoughts repeatedly enter patients mind in stereotyping form
Obsession: Intrusive thought/image/urge that often feels alien/inappropiate/violent/suicidal
Compulsion: Repetetive stereotypical action that decreases stress/obsession
Obsession vs schizophrenia
Obsession are recognized by patient as his own thoughts and know that they are inappropriate
Examples of compulsions
Repetetive hand washing
RItualistic checking
Typical comorbidity of OCD
Depression
OCD onset?
Early teens or 20s
OCD etiology
Neurobiological stuff
Psychodynamic
Genetic
Behavioural
OCD Specific types
Trichotillomania (hair pulling disorder typical after trauma in puberty)
OCD Therapy
Psychotherapy: Cog-Behave-Therapy
Pharmatherapy: SSRI
Family therapy to teach family how to work with disease
Acute stress reaction def
PTSD def
Adjustment disorder def
Acute stress reaction: Directly after event severly increased emotions (esp. anger and sadness), often with inital incomprehension of situation and strong autonomic response (Ger: Nervenzusammenbruch)
PTSD: Delayed reaction to catastrophic event with flashbacks, emotional numbing and hyperarousal (irritability), 6m after event
Adjustment disorder: Bad adjustment to new life situation (strong predisposing/genetic elements) leading to depression, feeling of maladjustment, anxiety; not longer than 6 months
Acute stress reaction therapy
Talking and BZs
PTSD symptoms
Insomnia Anxiety Social withdrawl Flashbacks Hypervigility Suicide
PTSD Comorbidities
Panic disorders, Depression, Alcoholism
PTSD Therapy
Psychotherapy: Cog-Beh-Therapy
Pharmacotherapy: SSRIs, BZs, Betablocker, Antipsychotics
Something about virtual reality
Adjustment disorder therapy
Psychotherapy
Def. conciousness
Awareness of self and surrounding
Conciousness disorders
Qualitative:
Delirium: Altered relation to reality (illusions, hallucinations, mood disorders (aggressive), often amnesia after recovery (complete or incomplete)
Obnubilation: abrupt start and end, complete amnesia, Patient is disoriented, acting aimlessly, sometimes agressive (Schlafwandellike)
Transitory delirium/Dissociative disorder: High stress situation leads to pathological affect (e.g. wife kills husband in affect)
Quantitative: Reduced vigility/alertness
Somnolence: Slowed thinking (also when ill or before sleep)
Sopor: Motionless patient, can be awakened, reacts to painful stimuli and with 1-2 words then falls asleep
Coma: No reaction to any stimuli, pathological reflexes present
Causes of delirium
Drugs, Serious illness, high fever, Delirium tremens, withdrawl, post-op, nighttime etc.
Causes of obnubilation
Temporal epilepsy, metabolic states like hypoglycemia, rarely in drunkness
Disturbances and definition of perception
Perception is process of becoming aware
Pseudoillusions: Distorted perception of objects which may occur because of reduced sensory stimulation (perception of a tree as human in darkness), might be physiological
Illusion: Pathological, difference to pseudillusion is insight, Typical in qualitative disturbances of consciousness, Misinterpretation of actual existing stimulus
Hallucination: Perception without any stimulus, might be elementary (flashes, whistles) or complex (voices, seeing people), may be auditory, visual, olfactory, gustatory, tactile etc.,
Pseudohallucination: Patient has insight, knows what he perceives is unreal
Inadequate hallucinations: Perception via inadequate organs e.g. hearing with a tooth
Disorders of thinking
Qualitative: = Psychosis
Delusions: A judgement held firmly on inadequate grounds (e.g. FBI is controlling my brain) with absence of insight
Quantitativen:
1) Pressure of thought - abundance of ideas typical in manic syndrome
2) Povery of thought - lack of ideas and thoughts typical in depression
3) Flight of ideas - Thoughts move quickly between topics, one train of thought isnt finished
4) Perservation - =Obsession (inappropriate pesistent repetition of same ideas) typical in OCD (if combined with compulsions)
5) Loosening of associations - Incoherent, unstructured thinking typical for schizophrenia
Subtypes of delusions
1) Paranoid d.: D. of jealousy, Control, possesion of thought typical in schizophrenia, paranoia, psychosis
2) Megalomanic d.: D. power, worth, noble status, supernatural skills typical in GPI and organic disorders
3) Micromanic d.: D. of worthlessness, guilt, nihilism typical in depression
How to differentiate between Alzheimer’s and vascular?
Hachinsky score
0-18 points, >5 is multi Infarct dementia
Includes abrupt onset, typical neurological symptoms ans history of CV disease
Pseudodementia?
Dementia caused by depression
Rapid progression, sudden onset, insight present
Definition of dementia
Decrease of memory and cognitive function from a previously higher level (as opposed to retardation)
Parkinson symptoms
Rigidity, tremor, depression, subcortical dementia, hallucinations, urinary problems, insomnia
Difference between psychosis and schizophrenia?
Psychosis is hallucinations/delusions only
Schizophrenia causes positive (hallucinations/delusions) and negative (loss of volition/motivation, loss of awareness of socially acceptable behaviour, flattened mood, poverty of thought) symptoms.
Diagnosis of schizophrenia?
Two main groups of symptoms; for diagnosis:
1 from group 1 or
2 from group 2
+ At least 1 months duration
Group 1 of schizophrenia symptoms include (3)
1) Delusions esp. paranoid
2) Hallucination of voices either imperative or commenting on patients behaviour
3) Insertion of thoughts into patients brain
Group 2 of schizophrenia symptoms include (3)
1) Persistent hallucinations of any modality
2) Incoherent train of thoughts
3) Catatonic behaviour
4) Negative symptoms
5) Significant change in personal behaviour
Whats catatonic behaviour?
Psychomotor activity mainly found in schizophrenia; two subtypes
1) Stuporous catatonia is characterised by immobility during which people may hold rigid poses (stupor), an inability to speak (mutism), as well as waxy flexibility, in which they maintain positions after being placed in them by someone else.
2) Excited catatonia is characterised by bizarre, non-goal directed hyperactivity and impulsiveness.
Schizophrenia subtypes (6)
1) Paranoid s. - Mainly delusions and hallucinations
2) Hebephrenic s. - Disorganized thinking and blunted, inappropriate emotions
3) Catatonic schizophrenia - Catatonic behaviour
4) Post-s. depression - Some residula schizophrenic symptoms but depression is main problem
5) Residual schizophrenia - Prominent negative symptoms, less positive symptoms
6) Simple schizophrenia - Basically only negative symptoms
DD of Schizophrenia (6)
1) Toxic psychosis
2) Psychosis due to another condition (Head injury, infection, fever, endocrine, metabolic etc.)
3) Acute schizophrenic disorder (<6m)
4) Delusional disorder (without hallucinations and neg. symptoms)
5) Dementia
6) Delirium
Etiology of schizophrenia (3)
1) Dopaminergic overactivity (as opposed to loss in parkinson; too high L-Dopa can lead to choroid movements)
2) Neurodevelopmental disorder: Obstetric complications and structural abnormalities of the brain
3) Disconnection theory: Fronto-temporal and fronto-temporal connection is impaired
Epidemiology of schizophreni (Incidence, Mortality, Cause of death, Comorbidities)
Incidence 1%
Mortality: Life expectancy is decreased by 20%, main cause of death is suicide
Comorbidities: Substance abuse
Phases of psychotic diseases in general and schizophrenia specifically
1) Acute psychotic episode: First episode or relapse of schizophrenia with strong psychotic symptoms, aim of treatment is to abolish psychotic symptoms and keep patient safe, typically neuroleptics
2) Maintenance phase: Prophylaxis of acute episode, rehabilitation and maximization of function, in schizophrenia acute attacks can often not be prevented even with adequate medication
Definition of schizoaffective disorder
Features of schizophrenia and affective disorders (manic or depressive, often cycling) in approx. equal parts
Schizophrenic and affective symptoms must be present at the same time!
Positive symptoms of schizophrenia
Qualitatively different from normal function:
Delusions, Hallucinations, Schizophrenic thought disorder
Negative symptoms of schizophrenia
Impairment of normal function including:
lack of drive, apathy, anhedonia, flattening of affect, blunting of affect, alogia
Whats schizophrenic thought and schizophrenic speech disorder?
Thought: Loosening of associations, Derailment, Thought blocking
Speech: Changes in speech like loss of associations, neologisms
Mood vs affect
Affect: Brief strong emotional response
Mood: subjective long lasting disposition to have correct affect in correct situation
Disorders of emotions (5)
1) Pathological affect - Strong affect with change of consciousness
2) Pathological mood - characterized by its origin (has a reason or not) duration (long), intensity (strong); two poles: manic and depressive
3) Blunted affect/emotions - in schizophrenia
4) Emotional lability - rapis changes of mood, normal in children, path in dementia
5) Phobia
6) Anhedonia - inability to feel pleasure
Structure of memory and subtypes
Sensory stores - Can hold information for 0,5s to allow processing
Short-term/Working memory - 15-20s while info is used by cognitive processes; then either deleted or put into long term memory
Long-term memory - basically as long as wanted
Executive and semantic memory
Disorders of memory and associated disorders
1) Dementia
2) Amnesia - Retrograde, congrade and anterograde; partial and complete
3) Confabulations - Filling of memories with usually wrong stories or answering with false contents typically with loss of insight and euphoria; typical in alzheimer and korsakoff
4) Pseudologia phantastica - Normal in childhood; making up fantastic events
5) Aprosexia - attention disorder leading to bad memory
6) Mental retardation - Leads to bad memory
