Psychiatry Flashcards
What are the ICD-10 ‘3 core symptoms’ of depression?
Low mood
Lack of energy
Anhedonia (lack of enjoyment of activities which the patient formerly enjoyed)
What is the monoamine theory of depression, and what are the 3 main monoamines in the brain?
Theory = depression is due to a reduction in the production/reduced sensitivity to monoamines, which include:
- noradrenaline
- dopamine
- serotonin
What is sertraline?
SSRI
What is fluoxetine?
SSRI
What is citalopram?
SSRI
What is reboxetine?
NARI (noradrenaline reuptake inhibitor)
What are the S/Ex of SSRI’s
GI = N&V, diarrhoea, ulcers CNS = insomnia, fatigue, anxiety, dizzy Other = sexual dysfunction, restlessness
What is amitryptiline?
tricyclic antidepressant (stop serotonin and noradrenaline reuptake)
What is clomipramine?
tricyclic antidepressant (stop serotonin and noradrenaline reuptake)
What are the side effects of tricyclic antidepressants?
Due to HAM antagonism:
Block H1 receptor -> anti-histamine action (sedation and drowsy)
Block Adrenergic receptors -> cause anti-adrenergic effects like dizzyness and postural hypotension)
Block M1 receptor -> antimuscarinic effects (dry mouth, tachycardia, constipated, urinary retention)
What is venlafaxine?
SNRI (serotonin noradrenaline reuptake inhibitors) - better tolerated than TCA’s
What is duloxetine?
SNRI (serotonin noradrenaline reuptake inhibitors) - better tolerated than TCA’s
What is mirtazepine?
NaSSA - noradrenaline specific serotonin antidepressant
What is phenelzine?
MAOI = monoamine oxidase inhibitor (inhibit the action of monoamine-oxidase enzymes which break down serotonin and noradrenaline)
What is tranylcypromine?
MAOI = monoamine oxidase inhibitor (inhibit the action of monoamine-oxidase enzymes which break down serotonin and noradrenaline)
What is the worrying side effect of MAOI’s
TYRAMINE LOAD
Tyramine is a component of our diet and is normally degraded by MAO in the gut, therefore dangerous if inhibited
Describe the ICD-10 criteria for mania
- a persistently elevated mood (above normal)
- mood sustained for 1/week
- 3 or more of the following (with severe interference of daily living)
- > physical restlessness
- > talkative
- > reduced sleep
- > flight of ideas/racing thoughts
- > increased self-esteem
Describe the ICD-10 criteria for hypomania
- a persistently elevated mood (above normal)
- mood sustained for 4 days
- 3 or more of the following (with some interference of daily living)
- > physical restlessness
- > talkative
- > reduced sleep
- > flight of ideas/racing thoughts
- > increased self-esteem
What disorders is lithium used to treat, and how does it work?
Mania
BPAD
Modulates neurotransmitter activation in messenger pathways
What are the S/Ex of lithium treatment?
Teratogenic -> Ebstein anomaly Hypothyroidism Hyperparathyroidism Renal failure Lithium toxicity -> tremor, N&V, dizziness, coma, death
What is Ebstein anomaly?
Teratogenic effects of lithium:
- Dysarhythmias
- ASD
- R heart enlargement
- Tricuspid incompetence
What is sodium valproate used for?
Acute mania
BPAD prophylaxis
Epilepsy
What are the side effects of sodium valproate?
Teratogenic -> neural tube defects
Increased OCP metabolism
What is carbemazipine used for?
Prophylaxis BPAD
Epilepsy
Describe the physical and psychological S/Sx of anxiety
Physical: dizzy, reduced libido, increased autonomic system, chest pain
Psychological: restless, on-edge, AVOIDANCE, fears
Define psychosis
A mental state in which reality is grossly distorted
Describe the 5 parameters of symptoms in psychosis
PANT-P
Perception (illusions and hallucinations)
Abnormal beliefs (delusions/over-valued ideas)
Negative symptoms -> reduced self care, blunting
Thought disorders -> Knight’s move thinking
Psychomotor -> catatonia
Define schizophrenia and the ICD-10 outlines
Type of psychotic disorder
Symptoms should be present for most of the time for 1 month
No set ICD criteria, but should include:
- delusions (bizarre delusions or delusions of control)
- hallucinations
Define delusion
Fixed false belief out-with a persons normal social/cultural/religious background
What is schizoaffective disorder?
Typical schizophrenia, but with mood symptoms (manic or depressive co-existing symptoms)
Describe the dopamine hypothesis of schizophrenia
Schizophrenia is thought to be due to:
- increased dopamine in the mesolimbic pathway (A) -> causes positive symptoms
- decreased dopamine in the mesocortical pathway (B) =-> causes negative symptoms
What is haloperidol/chlorpromazine?
1st gen typical antipsychotics
They block dopamine in the mesolimbic pathway (A)
to reduce positive symptoms
What are the side effects of haloperidol?
Hyperprolactinaemia (galactorrhoea and infertility)
EPSE (extra-pyramidal side effects)
Describe EPSE and why they occur
Due to a deficiency of dopamine, and an XS of acetylcholine
Include:
- parkinsonism = BRTP (bradykinesia, rigidity, tremor, postural instability)
Treated with anticholinergic drugs
What is clozapine and what are its side effects?
2nd gen atypical antipsychotic
- has very few EPSE’s
- can cause agranulocytosis
- SMOKING -> reduces clozapine levels as smoking induces hepatic enzymes which metabolise clozapine faster, therefore cessation of smoking increases clozapine effectiveness!
Which type of anti-hypertensive drug can also cause depression?
Beta-blockers
Define an ego-dystonic thought
A thought which is out-with a persons normal beliefs/values
Define an ego-syntonic thought
A thought which is in-line with a persons normal beliefs/values
What is the first line treatment for OCD
Sertraline
Describe the following thought disorders:
- tangential thinking
- knight’s move thinking
- flight of ideas
Tangential -> patient diverts from initial train of thought
Knight’s move -> thoughts jump between loosely related ideas (seen in schizophrenia)
Flight of ideas -> randomly linked thoughts that may rhyme/have puns (seen in mania)
What are neologisms and idiosyncratic word use?
Part of thought form
Neologisms = patient uses new words
Idiosyncratic word use = using normal words but with inappropriate meaning e.g. the air is allergic
What is palilalia
repeating the last word of a sentence
What is echolalia
like a parrot -> patient repeats words heard around them
Define primary and secondary delusions
Primary - do not occur in response to any previous psychopatholoigcal state
Secondary - delusions occur as consequence of a pre-existing psychopathological state e.g. mood disorder
Describe grandiose delusions
False belief that one is very powerful/important/has magic powers
Describe persecutory delusions
False belief that one is being harmed/threatened/cheated on/victim of conspiracy
Describe delusions of reference
False belief that objects/people/events have personal significance and refer to themself (e.g. that a news story is talking about them)
What are nihilistic delusions?
False belief that oneself/others/the world is going to end
Describe the 3 main delusions of thought control
Thought insertion -> believing that thoughts are being put into one’s head by an external agency
Thought withdrawal -> believing one’s thoughts/ideas are being extracted from their head by external agency
Thought broadcasting -> believing that one’s thoughts are being diffused so that others know what they are thinking
What is an overvalued idea?
Plausible belief that patient becomes preoccupied with to unreasonable extent e.g. believing you will be made CEO of your company
List 5 physical symptoms of anxiety
Chest pain Sweating Tachypnoea Diarrhoea Increase BP Irritability Reduced libido
List 5 psychological symptoms of anxiety
Feeling 'on edge' Restlessness Fear of losing control Difficulty concentrating Detached feelings 'depersonalisation'
Define an obsession
involuntary, recurrent intrusive thoughts which enter the mind against conscious resistance
Define a compulsion
Ritualistic motor acts which cause distress and interfere with ADL
The patient retains insight that their actions are unreasonable and excessive and tries to resist
Define panic attacks and panic disorders
Attack = discrete episode of intense fear accompanied by physical symptoms lasting 10-30mins
Disorder = when attacks come unpredictably without stimuli or situation
List 5 biological symptoms of depression
Early morning wakening Difficulty falling asleep Loss of appetite Weight loss Loss of libido Psychomotor retardation (slow speech, limited facial expression)
List 5 cognitive symptoms of depression
Reduced concentration Reduced memory Guilt Hopelessness Suicide/self-harm
Describe management pillars of depression
Bio - drugs (anti-depressants/psychotics, mood stabilisers)
Psycho - CBT, counselling
Social - help with debt/housing issues, increased socialisation
List 5 biological (physical) symptoms of mania
Decreased need for sleep Increased energy Sexual disinhibition Impaired insight Impaired judgement Impaired concentration
How does hypomania differ from mania?
Hypomania has less severe disruption of work/social situations
What is dysthymia
Chronically depressed mood, onset in early adulthood
May remain throughout life for many years with variable periods of wellness in between
Mood is seldom severe enough to meet the formal depressive episode criteria
What is cyclothymia
Characterised by instability of mood resulting in alternating periods of mild elation and mild depression, but none of these episodes are long/severe enough to classify as hypomanic/depressive episodes
Describe BPAD
A disorder is ‘bipolar’ when a patient suffers from episodes of depressed or elevated mood (which may be punctuated by periods of normal mood), as the mood deviates from normal to wither a depressed or elated pole
When this instability of mood is mild -> cyclothymia
Define psychosis
A mental state in which reality is grossly distorted resulting in symptoms of:
- delusions
- hallucinations
- thought disorder
List 4 differential diagnoses of psychotic symptoms
Schizophrenia
Schizoaffective disorder
Mania with psychotic symptoms
Depression with psychosis
Describe the ICD-10 criteria for schizophrenia
1 or more of:
- thought echo/insertion/withdrawal/broadcast
- delusions of control
- hallucinatory voices
- bizarre delusions (i.e. something that could never happen in real life)
Describe the Stages of Change model which describes how we succeed/fail to make changes
1) Pre-contemplation - no intention of changing
2) Contemplation - aware there is a problem but no commitment to action
3) Preparation - intent on taking action
4) Action - active behaviour modification
5) Maintenance - new behaviour replaces old
6) Relapse - fall back into old patterns of behaviour
Define dependence and its criteria
A syndrome incorporating physiological, psychological and behavioural elements
ICD-10 states 3+ of the following should have been present together at some time in 1 year:
- Desire/compulsion
- issues Controlling substance use behaviour
- Withdrawal state (physically)
- Tolerance
- Neglect in other interests
- Persistence (even though you know it’s harmful)
(Drugs Can Work Together on New People)
Define withdrawal
A substance specific syndrome which occurs on reduction/cessation of the psychoactive substance which has been used repeatedly over long period of time in high doses
Define hazardous vs harmful use
Hazardous -> quantity/pattern of substance use that puts the user at risk of adverse consequences without dependence
Harmful -> quantity/pattern of substance use that causes adverse consequences without dependence
Describe an emergency detention certificate (EDC)
- for pts with a mental disorder/suspected mental disorder
- allows them to be kept in hospital/brought in for assessment
- any FULLY registered doctor can complete
- lasts 72hrs
- not essential, but MHO should consent if possible
- cannot be appealed
- senior psychiatrist can then revoke or convert to STDO
Describe a STDO
Short term detention order
- a Section 22 approved practitioner + MHO must set it
- allows patients with suspected/confirmed mental disorder to be detained in hospital for up to 28 days
- patients have right to appeal
- can be revoked or changed to CTO with appropriate application
Describe a CTO
Compulsory treatment order
- Requires 2 written medical recommendations, one from AMP (approved medical practitioner) and also GP
- Taken to court
- lasts 6 months
Describe the pathophysiology underlying Alzheimer’s disease
B-amyloid proteins deposited in blood vessels and neurotoxic tau proteins accumulate
Name RFx for Alzheimer’s disease
CVD Hyperlipidemia FHx Age Down's syndrome
List 5 symptoms of Alzheimer’s disease
Poor completion of ADL's Mood changes Memory loss Disorientation Nominal dysphasia (unable to recall the names of objects/people)
List RFx for vascular dementia
Hypertension Obesity Hyperlipidaemia Smoking Age
List 5 symptoms of vascular dementia
Poor concentration Disinhibition Previous strokes/TIA's Slow information processing Difficulty problem solving
Describe the pathophysiology of LB dementia
Alpha synuclein protein accumulates -> forms lewy bodies -> these accumulate in the dopaminergic system
Name the common triad of symptoms seen in LB dementia
Hallucinations
Dementia
Parkinsonism (bradykinesia, rigidity, tremor, shuffling gait, postural instability)
(also REM sleep disturbance and cognitive fluctuations)
Describe features of fronto-temporal dementia
Changes in personality and social conduct
Peak onset in 50’s
Compare dementia and delirium in terms of 1. onset, 2. consciousness, 3. course, 4. attention and 5. behaviour
- Delirium = sudden, dementia = gradual
- Delirium = impaired, dementia = normal
- Delirium = short lived, dementia = long
- Delirium = impaired, dementia = normally intact
- Delirium = hypo/hyperactive, dementia = normal
List 5 organic causes of depression
Hypothyroidism Chronic steroid use/Cushing's syndrome Intoxication Anaemia Uraemia
What is serotonin syndrome?
Occurs due to an XS of serotonin in the body
Usually from XS SSRI or use of mix of antidepressant drugs
Triad of symptoms:
- altered mental status (agitated, anxious, restless)
- neuromuscular (tremor, clonus, hyperreflexia, +ve babinski)
- autonomic hyperactivity (HTN)
Describe the components of the SADPERSONS score for assessing suicide risk
Sex (?male) Age (<20, >44) Depressed Previous suicide attempt Ethanol abuse Rational thinking loss (psychosis) Social support lacking Organised suicide plan No spouse (divorced, separated, widowed, single) Sickness (presence of chronic/debilitating illness)
What are the 5 criteria for detaining someone using the mental health act?
- Suspected/confirmed mental disorder
- Treatment available
- Risk to self/others (if no treatment is given)
- Impaired decision making (due to the mental disorder)
- Detention/use of compulsory powers is necessary
What are the classical type of hallucinations in schizophrenia?
Auditory
3rd person
Voices anticipate/echo/broadcast the patients thoughts
What classic hallucinations are found in psychotic depression?
Auditory
2nd person
Derogatory comments made ‘to’ the patient by another voice, which are accepted by the patient as true
Name 5 side effects of TCA’s e.g. amytryptiline
Drowsiness Sedation Dry mouth Constipation Urinary retention Postural hypotension
List 4 side effects of SSRI’s
Dyspepsia
Insomnia
Hyponatremia
Suicidal behaviour
List 3 side effects of ECT
Memory loss (anterograde or retrograde)
Headache
Muscle aches
