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Medicine MBBS year 2 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

what is an adjustment disorder?

A

Distress and emotional disturbance(anxiety,outbursts) arising in the period of adaptation to a significant life change or stressful event e.g divorce, illness

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2
Q

what is an organic delusional disorder?

A

Persistent or recurrent delusions dominating the clinical picture. May be accompanied by hallucinations.

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3
Q

What part of the brain is more prone to post-stroke psychosis?

A

right hemisphere

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4
Q

Give examples of physical illness causing mental illness

A

Thyrotoxicosis -) anxiety, mania
Thyroid deficiency-) depression, dementia
Cushings disease -) depression
Infections -) psychosis
Cancer -) depression
Parkinson’s disease -) depression, anxiety, dementia

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5
Q

factors affecting timely diagnosis of mental health disorders.

A

Illness behavior, Stigma, Lack of resources, Diagnostic overshadowing

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6
Q

what is delirium? what are the features?

A

Altering levels of consciousness
Sudden onset fluctuating confusion and inattention
Disorganized thinking, hallucinations, disturbance in sleep wake cycle, cognitive dysfunction, agitation

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7
Q

state 4 causes of delirium

A
  1. CNS disease
  2. infection
  3. trauma
  4. substance abuse/withdrawal
  5. metabolic/electrolyte disturbances
  6. hemorrhage
  7. urinary/fecal retention
  8. Medication like anticholinergics
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8
Q

3 types of stigma?

A

Intrapersonal, Interpersonal, Structural

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9
Q

positive symptoms of psychosis?

A

Hallucinations

Delusions

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10
Q

negative symptoms of psychosis?

A
  1. Alogia (poverty of speech), anhedonia
  2. avolition/apathy - poor self care, lack of motivation
  3. Affective flattening
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11
Q

disorganization symptoms of psychosis?

A

Bizarre behaviour, Thought disorder

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12
Q

how do you take a psychiatric history?

A
  1. history of presenting complaint
  2. past psychiatric history
  3. background history (Family, personal, social which includes forensic)
  4. past medical history and medicines
  5. corroborative history (needs consent)
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13
Q

How do you conduct a mental state examination?

A
  1. Appearance and behaviour - neglect, weight loss, facial expression, posture, movements, social behaviour
  2. Speech - quantity, rate, volume, spontaneity:latency
  3. Mood - subjective, objective (predominant mood, constancy, congruity)
  4. Thoughts - stream, content, form (flight of ideas, loosening of association, preservation)
  5. Perceptions - illusions, hallucinations, distortions
  6. cognition
  7. Insight
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14
Q

cognitive impairments associated with schizophrenia?

A

memory, educational attainments

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15
Q

psychosis is often preceded by_____

A

prodromal symptoms

= changes in social behaviour like social withdrawal, impairments in functioning.

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16
Q

state 4 causes of psychosis

A
  1. schizophrenia
  2. depression
  3. bipolar disorder
  4. delirium
  5. Alcohol withdrawal
  6. drug intoxication
  7. epilepsy
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17
Q

What neurotransmitter increase is associated with psychosis?

A

dopamine.

elevated in striatum

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18
Q

Which antipsychotic drug is a partial agonist? (Most are antagonists)

A

Aripiprazole

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19
Q

What are the EP side effects of antidopaminergic antipsychotics?

A

ADAPT!

  1. Acute Dystonia - muscle spasm, stiffness, oculogyric crisis
  2. Akathisia - restlessness
  3. Parkinsonism - bradykinesia/slow shuffling gait, tremor in hands, rigidity, lack of arm swing in gait
  4. Tardive dyskinesia - chorea, especially orofacial. repeated oral/ facial/ buccal/ lingual movements
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20
Q

how do you manage extrapyramidal side effects of antipsychotics?

A
  1. use more atypical antipsychotics

2. use anticholinergic medications -e.g benztropine - blocks M1 receptors and unfreezes muscles

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21
Q

other than extrapyramidal, state at least 4 other side effects of antipsychotics?

A 
hematological 
metabolic
cardiac
hyperprolactinemia 
antimuscarinic - dry mouth, constipation
antihsitamine - sedation 
alpha-1-blockade - orthostatic hypertension
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22
Q

what are the hematological side effects of antipsychotics?

A

agranulocytosis, neutopenia

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23
Q

what are the metabolic side effects of antipsychotics?

A

weight gain, increased appetite, diabetes, dyslipidemia

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24
Q

what are the cardiac side effects of antipsychotics?

A

dysrhythmia - long QTc - lead to torsades de point

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25
Q

state 4 mood disorders

A

bipolar
MDD
Dysthymic
cyclothymic

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26
Q

criteria for MDD diagnosis?

A

Occurrence of 2 weeks or more of Depressed mood AND the presence of 4 of 8 out of the following: DIGS SPACE (5 in total)

Diminished Interest or anhedonia 
Guilt or feelings of worthlessness 
Sleep disturbances 
Suicidal Ideation
Psychomotor agitation or retardation
 Appetite alterations 
Concentration decreases 
 Energy is low

also no manic or hypomanic symptoms

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27
Q

state 3 subtypes of MDD

A
  1. Depression with Atypical features
  2. Depression with melancholic features
  3. Depression with psychotic features (hallucinations or delusions only in the context of a depressive episode)
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28
Q

Describe features of depression with atypical features.

A
  • mood reactivity
  • hypersomnia
  • hyperphagia
  • leaden paralysis
  • long standing interpersonal rejection
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29
Q

Describe features of depression with melancholic features

A
  • no mood reactivity
  • anhedonia
  • psychomotor retardation
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30
Q

How to diagnose a manic episode?

A

Euphoric or irritable mood, with increased energy/activity for a minimum of 1 week with MARKED functional impairment/HOSPITALISATION with 3 or more of “DIGFAST” manic criteria:

Distractibility
Impulsive behaviour (such as sexual impulsivity or spending sprees)
Grandiosity
Flight of ideas or racing thoughts
Increased goal-directed Activities or psychomotor Agitation
Decreased need for Sleep with increased energy
Talkativeness or pressured speech

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31
Q

When do you get diagnosed with hypomanic episode?

A

Manic symptoms for at least 4 days, without notable functional impairment/psychotic features (psychotic features can be present in manic episodes)

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32
Q

Type 1 biopolar disorder requires?

A

At least 1 manic episode

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33
Q

Type 2 bipolar disorder requires?

A

not history of manic episodes

A hypomanic episode + one major depressive episode

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34
Q

state 3 reasons why you do not use antidepressants to treat bipolar disorder

A
  1. trigger manic or hypomanic episodes
  2. increase frequency of mood episodes
  3. ineffective in treating bipolar
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35
Q

what is a cyclothymic disorder?

A

Milder form of bipolar disorder - fluctuating between mild depressive and hypomanic symptoms

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36
Q

If manic symptoms occur for less than 4 days, or if other specific thresholds are not met for manic or hypomanic episodes, this is known as……

A

unspecified bipolar disorder

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37
Q

bipolar patients usually present with a _____ episode first. symptoms 47% of the time are _____.

A

depressive

depressive

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38
Q

state 4 information processing problems associated with MDD

A
  1. attention bias
  2. memory bias
  3. perceptual bias - increased recognition of negative faces over positive
  4. Facial expression processing - enhanced amygdala response to negative faces
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39
Q

state 3 pieces of evidence for attention bias in MDD

A
  1. fMRI shows sustained amygdala response to negative stimuli
  2. fMRI shows lateral inferior frontal cortex associated with the impaired ability to divert attention from task-irrelevant negative information
  3. fMRI shows perigenual anterior cingulate cortex (ACC) in prefrontal cortex activated - appears to mediate negative attentional biases
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40
Q

how do patients respond neurologically to antidepressants?

A

Early decreased brain (including amygdala) response to fear

Baseline ACC activity

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41
Q

what is the origin of serotonin in brain?

A

Serotonergic neurons project from raphe nuclei in midbrain

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42
Q

what are the monoamine neurottansmitters?

A

serotonin
NE
Dopamine

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43
Q

state 4 indirect evidence for 5-HT hypofunction in depression

A
  1. antidepressant medication has been shown to increase serotonin levels in brain
  2. 5-HT depletion by the antihypertensive drug reserpine could cause depression.
  3. Depleted serotonin in brain stem of patients who had committed suicide.
  4. Monoamine oxidase A enzyme which breaks down serotonin is increased in MDD
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44
Q

Describe how you would quantify dopamine receptors

A
  1. PET - use RACLOPRIDE which binds to dopamine receptors
  2. give AMPHTAMINE challenge - releases dopamine which binds and displaces tracer
  3. calculate the difference in binding of tracer before and after challenge = quantity of dopamine released

*same method for serotonin except use of 5-HT2A agonist PET tracer instead of raclopride.

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45
Q

what are the 3 core symptoms of depression?

A

Depressed mood, low energy, anhedonia

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46
Q

what are the 3 biological symptoms of depression?

A

Sleep disturbances, appetite changes, low libido

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47
Q

what distinguishes Bipolar disorder (BPAD) from BPD (differential)

A
  • BPD has poor self image, fear of abandonment, feelings of emptiness
  • bipolar is heritable, has grandiosity
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48
Q

what distinguishes BPAD from schizophrenia (differential)

A
  • chronic hallucinations/delusion in schizophrenia vs episodic in BPAD
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49
Q

What distinguishes BPAD from ADD (differential)

A
  • BPAD is heritable, has depressive episodes, amphetamines worsen mania
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50
Q

what are the similarities between BPAD and ADD?

A
  • impaired concentration, executive function and short term memory
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51
Q

state a differential for bipolar disorder

A

depression

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52
Q

state some iatrogenic causes of depression

A

systemic conditions - SLE, HIV, CANCER
endocrine conditions - e.g. hypo and hyperthyroidism
deficiencies - B12 and folic acid
neurological conditions - multiple sclerosis, alzhiemers, parkinson
medication - beta blockers, steroids, anticholinergics, antibiotics, etc

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53
Q

vascular depression is associated with ____

A

white matter hyperintensities

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54
Q

what are the cluster B personality disorders?

A

Antisocial - Bad

Borderline - Borderline - unstable mood and interpersonal relationships. Fear of abandonment, suicidality, impulsivity (spending sprees, sex withh strangers)

Histrionic - FlamBoyant - wild stories, hand gestures, provocative dressing

Narcissistic - best

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55
Q

what are the cluster A personality disorders?

A

Paranoid - Accusatory

Schizoid - Aloof - Voluntary social withdrawal, limited emotional expression

Schizotypal - Awkward - odd beliefs or magical thinking, extreme discomfort in social interactions

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56
Q

what are the cluster C personality disorders?

A

Avoidant - cowardly

Obsessive compulsive personality disorder - obsessive compulsive

Dependent - clingy

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57
Q

You can remember personality disorders as….

A

Cluster A = weird
Cluster B = wild
Cluster C = worried

58
Q

why do people abuse drugs?

A
  • positive reinforcement
  • negative reinforcement
  • other (fit in, curious)
59
Q

describe the pathway to drug dependency

A

experimental -> hazardous -> harmful -> addiction/dependence

60
Q

What is the criteria for drug dependency?

A
  • you must meet at least 3 of these within the last 12 months:
  1. A strong desire or sense of compulsion to take the drug
  2. Difficulty in controlling Onset, termination or levels of use
  3. A psychological withdrawal state when substance use has been stopped - e.g. anxiety when not using
  4. Evidence of tolerance - need to take more to get the same effect
  5. Progressive neglect of other interests
  6. Persistent use despite clear harmful effects on body
61
Q

state 2 behavioural disorders

A

internet gaming and gambling

62
Q

state 3 elements involved in addiction

A
  1. social and environmental factors
  2. personal factors - genetics, personality
  3. drug factors - preparation
63
Q

what are the acute effects of alcohol on the brain?

A

enhances activity of GABA-A/GABA-benzodiazepine system - decreased anxiety and sedation
Blocks excitatory system - blocks Glutamate NDMA receptor - impaired memory/alcoholic blackouts

64
Q

what are the chronic effects of alcohol on the brain?

A

Tolerance - upregulation of excitatory system, reduced functioning of inhibitory system.

In the absence of alcohol, - imbalance with more excitation ->increase in Ca2+ is toxic, leading to hyperexcitability/seizures and cell death/atrophy

65
Q

how do you treat alcohol withdrawal?

A

benzodiazepines to boost GABA function

Acamprosate to help remain abstinent – reduces NMDA function

66
Q

Which neurotransmitter pathway is implicated in drug addiction and positive reinforcement

A

Dopaminergic pathway - the pleasure-reward-motivation pathway

67
Q

Rewards such as food and sex ____ levels of dopamine in the brain

A

increase

68
Q

addiction is a reward ____ state

A

deficient

69
Q

how do cocaine and amphetamine increase levels of dopamine?

A

block dopamine re-uptake transporter

amphetamine also enhances release of dopamine from presynaptic vesicles

70
Q

effect of Alcohol, opiates, nicotine on dopaminergic system

A

increase dopamine neuron firing in VTA

71
Q

describe the course of dopaminergic neurons in the brain

A

Dopaminergic projections from brainstem and ventral tegmental area into ventral striatum and frontal cortex

72
Q

what factor affects liking stimulants?

A

The lower levels of D2 receptors you have, the more likely you are to like it

73
Q

What makes adolescents more vulnerable to drug use?

A

Reward deficiency - stunted brain activation in striatum

74
Q

state the 3 features of addiction and the regions of the brain involved

A
  1. positive reinforcement -> DOPAMINERGIC MESOLIMBIC SYSTEM (reduced dopamine and mu opioid function)
  2. negative reinforcement -> AMYGDALA AND BRAINSTEM ( “stress system” activated and increase in activity of kappa opioid, noradrenaline, CRF)
  3. preoccupation/impulsivity -> fronto-striatal connections with reduced frontal ‘control’ of striatal activity. move from ventral to dorsal striatum as dependence develops. less inhibition of craving by hippocampus
75
Q

when do you administer naloxone?

When do you administer naltrexone?

A

Both opioid ANTAGONISTs to block heroin use

  • naloxone is used in an emergency treatment of an overdose
  • naltrexone is used for long term opioid dependence and to modulate reward system in alcoholism
76
Q

sertraline, fluoxetine and citalopram are all examples of ?

A

SSRIs (type of antidepresant)

77
Q

what are some side effects of SSRIs?

A

GI effects (nausea, diarrhea), SEXUAL DYSFUNCTION, anxiety, insomnia

78
Q

venlaxafine is an example of an?

A

SNRI

79
Q

mechanism of SNRIs

A

Inhibits 5HT and NE reuptake

80
Q

state some side effects of SNRIs

A

GI effects, sexual dysfunction, anxiety, insomnia, HYPERTENSION

81
Q

Describe the mechanism, drug target and side effect of Mirtazapine.

A
  • Atypical antidepressant
  • Antagonises central presynaptic alpha-2-adrenergic receptors, which causes an increased release of serotonin and norepinephrine.
  • Antagonises central 5HT2 receptors,

side effects:
H1 receptor antagonist - SEDATION
5-HT3 receptor antagonist - antiemetic effect

82
Q

both citalopram and a medication called _______ prolong the QT interval and increase the likelihood of torsades de pointes. Instead of citalopram, give another SSRI called _______.

A
  1. erythromycin

2. sertraline

83
Q

as you increase the SSRI dose, the reduction in depression eventually plateaus. how do you explain this?

A

All serotonin reuptake transporters have been blocked - maxed out

84
Q

give three reasons why a patient is weaned off SSRIs before starting a new antidepressant

A
  1. prevent withdrawal effects
  2. prevent serotonin syndrome
  3. prevent relapse or drug interactions
85
Q

in a patient with depression presenting with difficulty sleeping ____ is a good antidepressant option

A

Mirtazapine - causes sedation and will help the patient in getting to sleep due to its antihistaminergic effect

86
Q

in a patient with depression and high blood pressure ____ medication should be avoided

A

venlafaxine as it will worsen his hypertension as NE mediates the sympathetic nervous system effect on the heart

87
Q

Mirtazapine has the highest affinity for ____ receptor and lowest for ____ receptor. r

A 
highest = histamine H1
lowest = 5HT3
88
Q

how do you work out alcohol units?

A

% strength x ml /1000 = units

89
Q

how do you classify harmful use of drugs?

A
  1. Must be a pattern of substance use that causes damage to physical or mental health
  2. Adverse social consequences
  3. It is a stage before dependence and does not fulfill the requirement for dependence
90
Q

opiate withdrawal symptoms

A

Tachycardia, Sweating, Restlessness, Dilated pupils, Bone aches, Runny nose, GI upset, Tremor, Yawning, Anxiety/Irritability, Gooseflesh skin

91
Q

how do you take a history in Addiction?

A
  1. Presenting Complaint
  2. history of PC
  3. Substance misuse history - length of current use, last used, amount+/- variability , method, total length of used, withdrawals, previous treatment, overdoses, triggers to use, motivation to change
  4. Family history - mental illness, addiction disorders
  5. Psychiatric comorbidity - depression, anxiety, bipolar, ask about trauma including neglect and abuse, screen for developmental disorders like ADHD
  6. Social history - money, accommodation, employment, relationships, safeguarding concerns, forensic history
92
Q

state major causes of morbidity and mortality associated with substance abuse

A 
overdose
road traffic accident
suicide 
Cirrhosis 
endocarditis
hiv
93
Q

seizures, delirium tremens, alcohol psychosis, haematemesis, and melaena may all be present in

A

alcohol addiction

94
Q

during a physical examination, what may you observe in a patient with alcohol addiction?

A 
jaundice
anaemia
clubbing
oedema 
ascites 
lymphadenopathy
DVT
cyanosis
95
Q

what investigations are carried out if alcohol addiction is suspected?

A

ultrasound
Bloods- LFT, GGT, lipids, U&E, amylase
Breathalyser
Urine Drug Screen

96
Q

during a physical examination, what may you observe in a patient with opiate addiction?

A 
collapsed veins/track marks 
endocarditis
skin abscesses
hepatitis/HIV
pneumonia
97
Q

what investigations are carried out if opiate addiction is suspected?

A

bloods - LFT, U&E GGT, Glucose
breathalyser
urine drug screen
sexual health screening

98
Q

state an alcohol assessment screening tool

A
  1. CAGE

2. Audit

99
Q

describe what happens during alcohol withdrawal

A

Initially withdrawal symptoms, then hallucinations, then seizures then delirium tremens which represents a medical emergency
More dangerous than opiods withdrawal.

100
Q

what do opioids do?

A

ANALGESIC, create a sense of euphoria

opiates = natural version

101
Q

what happens during an opioid overdose?

A

TINY PUPILS, cold and clammy, blue lips and nails

Slow or no breathing, not moving and can’t be woken, choking gurgling or snoring sounds

102
Q

give an example of a semi-synthetic opioid

A

heroin

103
Q

give 2 examples of opIATES

A

morphine, codeine.

104
Q

naltrexone, nalmefene, disulfiram (antabuse), and acomprosate are all used in ______ abstinence/alcohol withdrawal

A

alcohol

105
Q

benzodiazepines like ____ are used in detox regimens for alcohol intoxication.

A

chlordiazepoxide

106
Q

methadone and buprenorphine are used for ______ abstinence. They are both …… ……..

A 
opioid
Opioid agonists (buprenorphine is partial)
107
Q

_____ is a degenerative disease with cognitive and behavioural impairment.

A

dementia

108
Q

Describe the pathophysiology of Alzheimer’s disease

A

Beta amyloid plaques
NFTs - consist of phosphorylated tau proteins
loss of neurons and synapses

areas like cortex and hippocampus affected

109
Q

in the development of alzheimers, chromsome 19 codes for ____

A

apolipoprotein E4.

110
Q

in the development of alzheimers, chromsome 21 codes for ____

A

amyloid precursor protein (APP)

down syndrome patients have increased alzheimers risk

111
Q

in the development of alzheimers, chromsome 14 codes for ____

A

presenilin 1 (implicated in B-amyloid peptide).

112
Q

in the development of alzheimers, chromsome 1 codes for ____

A

presenilin 1 (implicated in B-amyloid peptide).

113
Q

what is the cholinergic hypothesis?

A

alzheimer’s lead to degeneration of cholinergic nuclei in the basal forebrain. This results in reduced acetylcholine (ACh).

114
Q

medications for alzheimers?

A

FIRST LINE = Acetylcholinesterase inhibitors - Donepezil

NMDA receptor antagonists - Memantine

115
Q

what are the 3 stages of alzheimers disease called?

A

early disease
progressive disease
advanced disease

116
Q

name some key features of early stage dementia

A 
absent mindedness
difficulty recalling names and words
difficulty learning new info  
disorientation in familiar surroundings 
reduced social engagement
117
Q

name some key features of progressive dementia

A 
marked memory impairment!
emergence of psychotic phenomena 
mood swings 
decline in ADLs 
reduced vocabulary
118
Q

name some key features of advanced AD

A

loss of bladder and bowel control
monosyllabic speech
reduced mobility
behavioural disturbances

119
Q

what psychiatric symptoms are often seen in AD?

A

delusions
hallucinations - auditory and or visual
depression

120
Q

what behavioural disturbances are seen in AD?

A

aggression, explosive temper, wandering, sexual disinhibition, incontinence, excessive eating and searching behaviour

121
Q

MMSE is used to measure ____ _____ in a screen for ______

A

cognitive impairment

dementia

122
Q

state 2 differentials for a dementia diagnosis.

A

delirium

depression

123
Q

what things can help differentiate delirium from dementia

A
  • delirium is reversible, acute onset, altered levels of consciousness, and has psychomotor changes
124
Q

state 3 tests to rule out reversible causes of dementia

A

blood tests:

  • B12 and folate - vitamin deficiency dementia
  • urea and creatinine - renal failure, dialysis dementia
  • FBC, ESR, CRP - anaemia, vasculitis
  • T4 and TSH - hypothyroidism
  • biochemical screen - hypercalcaemia or hypocalcaemia
  • glucose
  • clotting and albumin - liver function
  • Perform midstream urine test of delirium
  • imaging - MRI
125
Q

drugs that act by blocking ion channels are often used to treat _____

A

epilepsy

126
Q

where are auto-receptors found?

what is their function?

A

on presynaptic neuron

usually inhibitory. inhibit calcium influx and AP

127
Q

____ and ____ are fast acting neurotransmitters

A

glutamate and GABA

128
Q

first line treatment for anxiety includes?

A

CBT, SSRIs, SNRIs

129
Q

serotonin post-synaptic ______ receptor is an ____ receptor. enhancing serotonin stimulates this receptor, leading to a reduction in ____________

A

5HT1A
inhibitory
anxiety and depression

130
Q

which postsynaptic serotonin receptor is the main site of action of psychedelic drugs?

A

5HT2A

131
Q

second line treatment for anxiety includes?

A

benzodiazepines (GABA enhancer)

132
Q

mechanism of acamprosate?

A

NMDA antagonist - used in alcoholism

133
Q

An excess of _____ is implicated in nightmares. Treatment requires _____

A

noradrenaline

prazosin - blocker

134
Q

clomipramine, imipramine, and amitriptyline are examples of ____ ?

A

TCAs

135
Q

advantage of partial agonist drugs?

A

improved safety, especially in overdose

136
Q

what is the difference between an antagonist and an inverse agonist

A

antagonist - blocks - no effect

inverse agonist - blocks and produces the opposite effect

137
Q

Site on a receptor where normal neurotransmitter works on is known as the _____

A

orthosteric site

138
Q

Sites on a receptor where drugs work on that the normal neurotransmitter does not is known as the ____

A

allosteric site

139
Q

Benzodiazepines, barbiturates, alcohol, neurosteroids all act on allosteric site of _____ receptor

A

GABA

enhance GABA effects - sedation, sleep, reduce anxiety, anti-epilepsy

140
Q

the GABAa receptor is made up of ____ proteins and conducts ____ ions, inhibiting neurons.

A

5 - 2 alpha, 2 beta, 1 gamma

chloride

Medicine MBBS year 2 (11 decks)

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