Psychiatry Flashcards
Affective disorders
= disorders of mood, depression and mania (bipolar)
+ dysthymia, rapid cycling, SAD, post-partum depression
Depression diagnostic criteria
Need 2/3 core features:
- Depressed mood, present most of the time, every day, unchanged by circumstances, for over two weeks
- Anhedonia (loss of interest in pleasurable activities)
- Reduced energy/fatigue
And 2+ typical features:
+ physiological
- Loss of appetite
- Sleep disturbance (classically early morning waking)
- Change in activity – high or low (agitation or psychomotor retardation)
- Loss of libido
+ cognitive
- Reduced concentration/indecisiveness
- Loss of self esteem and inappropriate guilt
- Thinking about death/suicide/self harm
Differentiate from normal sadness, adjustment disorder, grief reaction, physical causes, dementia.
Always screen for risk to self/others/from others, and screen for psychosis (hallucinations or delusions)
Epidemiology and risk factors for depression
- 1 in 10 men, 1 in 4 women lifetime prevalence, 3rd most common GP presentation
- Mean age onset 27
- Comorbid with anxiety, chronic physical illness and substance abuse
- Episodic, typically lasting 6 months (recurrence likely if onset young or in elderly)
- Genetic heritability
- Neurological – low monoamine neurotransmitters (5HT/tryptophan, DA, NA), high cortisol (HPA axis change, linked with chronic inflammation) – lots of brain systems involved
- Cognitive schema (negative beliefs)
- Environment – relationship with parents, life events, poverty/inequality (uncontrollable stress)
- Personality – obsessive compulsive, histrionic, anankastic
- Physical – chronic pain, hypothyroid, MS, Parkinson’s, stroke, Cushings
- Medications – antihypertensives, steroids, sedatives (benzodiazepines), chemotherapy agents, antipsychotics
Treatment for depression
1st if mild: Psychological therapies - CBT, interpersonal, psychodynamic, mindfulness based, family therapy. Suggest social/life changes.
Then if psychological unsuccessful, or straight away if mild-moderate depression:
SSRI - escitalopram, fluoxetine, sertraline, citalopram, paroxetine. If one unsuccessful, trial another SSRI before moving on.
Then SNRI - venlafaxine (risk of HTN and discontinuation syndrome), duloxetine
OR atypical - mirtazipine (sedation, weight gain but maybe advantageous effects in severe depression. Also anti-emetic, so drug of choice if chemo. Can be combined with other drugs!)
Then monoamine oxidase inhibitors - phenelzine (rare, risk of ‘cheese reaction’, only last line)
Try augmenting agents lithium / atypical antipsychotics
Electroconvulsive therapy - safe and effective - good for severe depression and rapid short-term improvement if life-threatening condition (the elderly)
NEVER tricyclics (amitriptyline, clomipramine) as lethal in overdose and many side effects, though very effective. Used in IBS, migraine, sleep.
SSRI advice
- increases 5HT, first line for depression
- few side effects (except loss of libido common), very safe in overdose
- advise to take for 6-12 months (no evidence for being on it for many years)
- takes 2-6 weeks to start to show effect
- can be early suicide risk as no antidepressant effect but also 1/10 get ‘jittery’ so treat with 1 week diazepam
- GI side effects common early especially, but important to reinforce that side effects mean the drug is working to increase placebo effects (most people say side effects don’t persist long term)
- need higher doses for anxiety/OCD
- serotonin syndrome risk if combining any except mirtazapine
- none are addictive
Escitalopram, fluoxetine (not always well tolerated), sertraline (GI upset), citalopram (sedating, heart problems), paroxetine (never really, suicide risk? not for <18s)
Psychotic depression
If severe depression + delusions or hallucinations, not explained by schizophrenia or schizoaffective disorder
- often delusions of guilt, worthlessness, bodily disease, impending disaster, nihilistic
- derisive or condemnatory auditory hallucinations
- depressive stupor
Bipolar disorder
= mania and depression
- 1% lifetime prevalence worldwide, M=F, mean age onset 21
- average episode 4 months mania, 6 months depression (once one episode of mania, = bipolar disorder. Bipolar II disorder is with hypomania)
- Mania = pervasive elated/expansive/irritable mood for at least a week (or until hospital admission). Must come with impaired social and occupational functional. \+ three of - increased activity/restlessness - talkativeness - flight of ideas - loss of inhibitions - decreased sleep - grandiosity - distractibility - impulsive behaviour (spending etc) - increased sexual energy
- can come with psychosis (mood congruent, affective psychosis) – typically grandiose, self-referential, erotic, persecutory
- strong genetic component
- related to life events and environment, seasonal effect (episodes of mania tend to have triggers, eg lack of sleep)
- can be from organic causes – hyperthyroid, steroids, stimulants (amphetamines), brain injury, stimulants, antidepressants
Treatment for mania
ALWAYS needs hospitalisation!
Biological
- antipsychotics - olanzapine, risperidone, quetiapine, haloperidol
- benzodiazepines (not more than 2-4 weeks, but short term useful) - diazepam
- mood stabilisers - lithium, sodium valproate (very teratogenic, young woman must be on long acting contraceptive eg IUD), lamotrigine, carbamazepine
STOP ANTIDEPRESSANT
Psychosocial
- psycho-education – eg sleep education, understanding triggers
- self-help/support groups
- healthy lifestyle
- CBT/IPT for depression
- relapse prevention
(maybe give SSRI for depression, but needs to go with eg quetiapine, valproate, lithium)
Differentials for mania
Endocrine – hyperthyroid, Cushing’s
Autoimmune – SLE
Infectious – HIV, neurosyphilis
Neurological – brain tumour, head injury, epilepsy
Medication induced – steroids, antidepressants
Schizoaffective disorders
Cyclothymia (less extreme fluctuations)
Puerperal disorders – eg puerperal psychosis
HYPOMANIA = as with mania, same key features (>3, lasting 4 days+), but less severe with no disruption to life, no delusions or hallucinations
Anxiety disorders
(often co-morbid)
- generalised anxiety disorder
- panic disorder
- social anxiety disorder
- post-traumatic stress disorder
- specific phobia
- obsessive compulse disorder
Ask by SEDATED: Symptoms – somatic, cognition, depersonalisation, derealisation Episodic or continuous Drink and drugs Avoidance and escape Timing and triggers Effect on life Depression
Panic disorder
- baseline anxiety cumulatively increases with recurrent panic attacks, then start phobic avoidance
- physical and psychological effects
Management
• CBT
• SSRI
• If 2 interventions fail, refer to mental health services
Post-traumatic stress disorder
Triad:
- avoidance
- hyperarousal
- ‘re-experiencing’ symptoms
- one life-threatening event, and then experience flashbacks to that event
- EMDR most effective treatment, as well as CBT, hypnotherapy, SSRI paroxetine or TCAs
Phobia
- persistent inappropriate fear of external event, leading to reassurance
- starts in childhood, but usually are mild, incapacity depends on likelihood of encountering
- eg agoraphobia, social phobia, specific phobia
Treatment
- graded in vivo exposure 75% improvement
- paroxetine effective in resistant cases
Obsessive compulsive disorder
= subjective compulsion despite conscious resistance
- ruminations (sex, death, accidents, violence, contamination), rituals (repetitive, time-consuming, distressing) and compulsions eg washing, checking, counting, touching, hoarding, repeating (compulsions must produce temporary relief or do not meet the criteria)
- don’t need both obsessions and compulsions, need to have either present on most days over a period of at least two weeks
- check that these intrusive thoughts are not coming as voices in the head (psychosis)
- screen comorbidity – psychosis, depression, other anxiety disorder, substance misuse, anankastic personality traits
Treat with high dose SSRIs
Management of anxiety
Psychoeducation
- explain fight or flight response as natural
- discuss coping techniques and how they may not be helpful long-term (eg reassurance seeking and avoidance)
Self-help
- sleep hygiene, minimise caffeine, relaxation techniques, exercise etc
- address alcohol or substance misuse problems
Psychological therapy
- CBT, maybe including graded exposure work, or exposure and response prevention
- EMDR for PTSD
Psychotropic medication
- SSRI first line, useful in combination with psychological work (warn of risk of increased anxiety in first few days)
- benzodiazepine may be useful initial therapy if acute crisis (generally should be avoided due to risk of tolerance and addiction, and reinforces the message that the patient can’t cope without)
Substance misuse
Dependence = strong desire/compulsion to take substance, difficulty controlling use, physical withdrawal state, tolerance, progressive neglect of other interests, persistence with substance despite detrimental effects
Experimental -> recreational -> misuse -> dependence
- addiction related to genetics, personality type, life circumstance
- treatment aims to reduce use, and reduce risk - only comes through cognitive change!
Effects of alcohol
- potentiating GABA-R – so calm, relaxation, sleepiness
- inhibiting NMDA-R – so less arousal, learning, memory
- > anxiolytic, relaxing sedation, slurred speech, ataxia, memory loss
- if acute alcohol intoxication – more GABA
- if no alcohol or chronic alcohol – imbalance of GABA glutamate balance
Alcohol withdrawal
- sudden lack of GABA, excess glutamate
- > tremor, anxiety, hallucinations, seizures
- calcium ion flux -> hyper-excitability, cell death
- Simple withdrawal <12 hours
- tremor
- nausea and vomiting
- anxiety, irritability, depression
- raised bp, pulse, temperature
- insomnia - Withdrawal seizures 7-48 hours
- Delirium tremens 48-72 hours (need ICU treatment) – in 10%, high risk to life
- fluctuating consciousness, confusion
- severe agitation
- autonomic symptoms – tachycardia, hypertension, sweating, hyperthermia
- hallucinations (persecutory auditory, small moving animals visual (lilliputions)) and delusions - Wernicke’s encephalopathy – thiamine deficiency
- neurological symptoms caused by lesions of CNS after depletion of B vitamin reserves (chronic gastritis and malnutrition)
- triad of symptoms – ophthalmoplegia, ataxia, confusion (triad in 10%)
- need pabrinex! Low risk treatment, always a good idea to give if unsure - Korsakoff syndrome
- anterograde (and retrograde) memory loss
- confabulation (filling gaps in memory, no insight – not lying!)
- hallucinations
Treatment of alcohol addiction
Brief interventions/stabilisation - harm reduction
Detoxification - inpatient or community (90%)
Relapse prevention - mostly psychosocial
Medication for acute alcohol withdrawal
- benzodiazepine (fixed dose reducing regimen over 8-10 days, or symptom triggered therapy) -chlordiazepoxide usually
- acamprosate (neuroprotective)
- vitamins - pabrinex (IM/IV, contains thiamine, folate and pyridoxine) + oral thiamine + vitamin B
For maintenance of abstinence
- disulfiram – makes alcohol taste disgusting/makes you throws up
Opioid overdose vs withdrawal
Includes heroin, morphine, methadone, dihydrocodeine (DF118), codeine, dextropropoxyphene, buprenorphine
Overdose: pinpoint pupils, euphoria, ‘gouched out’ (drooping eyelids, nodding head, lip movements), itching, nausea, bradycardia, drowsiness, respiratory depression
- treat with naloxone (repeat doses as shorter half life)
Withdrawal (non-fatal): aching muscles and joints, dilated pupils, shivering, goosebumps, insomnia, sneezing, nausea and diarrhoea, restlessness
Substitute prescribing for opiods
Methadone – long acting, overdose risk (better high so street value)
Buprenorphine – partial agonist
(Dihydrocodeine – short acting, weak, bad substitute
Diamorphine – well liked, short acting, street value)
Pros - harm reduction (injecting, sex work, crime), stabilisation (away from street, able to work), no need to score (allows time for therapy), maintain in treatment
Cons - diversion (selling methadone), costs, change in relationship (power balance, ?honesty), reduced incentive to stop?
+ symptom prescribing for withdrawal
o Benzodiazepines
o Anti-sickness/diarrhoea
Medically unexplained symptoms
= persistent physical symptoms for which adequate medical examination has not revealed a condition that adequately explains the symptoms
+ positive evidence/strong assumption that symptoms are linked to psychological factors
(real symptoms, and real pain and worry causing distress)
- need to exclude organic disease first, then stop investigating/overmedicating, explain diagnosis reassure and support, offer CBT and consider antidepressant
MUS syndromes include:
(pain, functional disturbance, or exhaustion)
- Rheumatology – fibromyalgia, chronic fatigue
- Cardiology – palpitations, non-cardiac chest pain
- ENT – globus hystericus, tinnitus
- Gastroenterology – IBS, non-ulcer dyspepsia
- Orthopaedics – lower back pain, regional pain syndromes
- Obs + gynae – pelvic pain, dyspareunia
- Neurology – functional seizures/non-epileptic attack disorders (NEAD), facial pain, headaches, vertigo/dizziness
Two MUS syndromes
Conversion disorder
- Rapid, specific
- Clear psychosocial precipitants
- Eg bilateral leg paralysis the day before an exam
- Usually respond to appropriate treatment
Somatisation disorder
- Multiple MUS in different body systems
- Common, disabling
- 10x more common in females
- Difficult to treat
Conscious/intentional MUS
Factitious disorder (Munchausen’s)
- unconscious motivation, but intentionally causing physical symptoms, or making up psychiatric symptoms in order to become unwell and seek help - to elicit care for yourself and meeting unmet needs
- very high risk for iatrogenic harm
- tends to stem from lack of care in lives previously
- important to diagnose, but poor prognosis as often unwilling to accept therapy, and hard to avoid complete breakdown of therapeutic relationship
- can be Munchausen’s by proxy
- may need criminal justice route to stop accessing services (or remove child if by proxy)
Malingering
- conscious motivation and understanding
- feigning symptoms – often for money (insurance claims) or drugs (opioids)
Development of schizophrenia
= disorder of perception, thought, cognition and behaviour
- 0.5-1% prevalence, in all countries/cultures, peak onset 15-25 in men, 25-35 in women (M=F)
- genetic susceptibility + early environmental events (maternal infection, low birth weight, prematurity) -> neuromotor delay and social anxiety
- then social factors (low SES, urban areas, recent immigration, ACEs) + DRUG MISUSE -> schizophrenia
- premorbid period (subtle motor, linguistic and social dysfunction)
- prodromal months-years (functional decline, odd ideas, eccentric interests, changes in affects, unusual speech, bizarre perceptual experiences)
+ positive and negative symptoms
Symptoms of schizophrenia
Positive (periodic)
- delusions, hallucinations, thought disorder, bizarre behaviour
Negative
- flattening of affect and volition, amotivation, anhedonia, attentional impairment
Diagnosis (ICD10)
- symptoms lasting at least one month
- at least one of: (Schneider’s 1st rank symptoms)
1. Thought disorder – thought echo/insertion/withdrawal, or broadcasting
2. Delusions of control/passivity phenomena
3. Auditory hallucinations giving running commentary or discussing patient between themselves (3rd person), or voices from a body part
4. Delusional perception that is culturally inappropriate and impossible - or at least two of:
• Persistent hallucinations accompanied by delusions without clear affective content, or accompanied by persistent over-valued ideas
• Neologisms, breaks or interpolations in train of thought -> incoherence or irrelevant speech
• Catatonic behaviour
• ‘negative’ symptoms
(CANNOT diagnose if manic or depressive episodes, organic brain disease, alcohol or drug-related)
Schizophrenia prognosis
- high risk suicide in early years
- commonly relapsing episodes of positive symptoms with negative symptoms persisting
- average 10yr reduction in life span
Improved if:
- sudden, short duration illness, affective symptoms, paranoid subtype, good response to treatment
- older age at onset, female, not single, good premorbid state, no illicit drug use, good compliance
Management of schizophrenia
Biological:
Antipsychotics (for +ve and -ve symptoms, cognitive performance and behaviour). 1st line atypical, then different atypical, then clozapine.
- typical antipsychotics - extrapyramidal side effects as D2 antagonists - haloperidol rarely, or as a depot trifluperazine or zuclopenthixol
- atypical new generation antipsychotics - D2 and 5HT2 antagonists - more metabolic side effects eg weight gain, T2DM, HTN, stroke, heart attack
So from the most atypical (most metabolic - good for parkinson’s or LBD)…
- clozapine (BEWARE AGRANULOCYTOSIS, WEEKLY BLOODS) - very effective but needs motivation for bloods and no smoking, if treatment resistance
- quetiapine
- olanzipine
- aripriprazole (safest for QT syndrome, fewest metabolic side effects)
- risperidone (sexual dysfunction)
+ adjunctive anti-depressants, mood stabilisers, tranquilizers
- in extreme resistance or life threatening situations – ECT
Psychological
- integrated care plan, person-centred, occupational therapy, CBT, psychoeducation, + warn high risk relapse if medication stopped in 1-2 years
Social
- family work, art therapy
Rehabilitation and recovery
- social skills training, monitor physical health
Extrapyramidal side effects
From D2 antagonists (typical antipsychotics)
- acute muscle dystonia within hours
- parkinsonism within weeks, akathisia (internal and physical feeling of restlessness) within weeks
- tardive dyskinesia (involuntary repetitive movement, often lip smacking) within months-years
