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
2
Q
what is an organic delusional disorder?
A
Persistent or recurrent delusions dominating the clinical picture. May be accompanied by hallucinations.
3
Q
What part of the brain is more prone to post-stroke psychosis?
A
right hemisphere
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
5
Q
factors affecting timely diagnosis of mental health disorders.
A
Illness behavior, Stigma, Lack of resources, Diagnostic overshadowing
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
7
Q
state 4 causes of delirium
A
- CNS disease
- infection
- trauma
- substance abuse/withdrawal
- metabolic/electrolyte disturbances
- hemorrhage
- urinary/fecal retention
- Medication like anticholinergics
8
Q
3 types of stigma?
A
Intrapersonal, Interpersonal, Structural
9
Q
positive symptoms of psychosis?
A
Hallucinations
Delusions
10
Q
negative symptoms of psychosis?
A
- Alogia (poverty of speech), anhedonia
- avolition/apathy - poor self care, lack of motivation
- Affective flattening
11
Q
disorganization symptoms of psychosis?
A
Bizarre behaviour, Thought disorder
12
Q
how do you take a psychiatric history?
A
- history of presenting complaint
- past psychiatric history
- background history (Family, personal, social which includes forensic)
- past medical history and medicines
- corroborative history (needs consent)
13
Q
How do you conduct a mental state examination?
A
- Appearance and behaviour - neglect, weight loss, facial expression, posture, movements, social behaviour
- Speech - quantity, rate, volume, spontaneity:latency
- Mood - subjective, objective (predominant mood, constancy, congruity)
- Thoughts - stream, content, form (flight of ideas, loosening of association, preservation)
- Perceptions - illusions, hallucinations, distortions
- cognition
- Insight
14
Q
cognitive impairments associated with schizophrenia?
A
memory, educational attainments
15
Q
psychosis is often preceded by_____
A
prodromal symptoms
= changes in social behaviour like social withdrawal, impairments in functioning.
16
Q
state 4 causes of psychosis
A
- schizophrenia
- depression
- bipolar disorder
- delirium
- Alcohol withdrawal
- drug intoxication
- epilepsy
17
Q
What neurotransmitter increase is associated with psychosis?
A
dopamine.
elevated in striatum
18
Q
Which antipsychotic drug is a partial agonist? (Most are antagonists)
A
Aripiprazole
19
Q
What are the EP side effects of antidopaminergic antipsychotics?
A
ADAPT!
- Acute Dystonia - muscle spasm, stiffness, oculogyric crisis
- Akathisia - restlessness
- Parkinsonism - bradykinesia/slow shuffling gait, tremor in hands, rigidity, lack of arm swing in gait
- Tardive dyskinesia - chorea, especially orofacial. repeated oral/ facial/ buccal/ lingual movements
20
Q
how do you manage extrapyramidal side effects of antipsychotics?
A
- use more atypical antipsychotics
2. use anticholinergic medications -e.g benztropine - blocks M1 receptors and unfreezes muscles
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
22
Q
what are the hematological side effects of antipsychotics?
A
agranulocytosis, neutopenia
23
Q
what are the metabolic side effects of antipsychotics?
A
weight gain, increased appetite, diabetes, dyslipidemia
24
Q
what are the cardiac side effects of antipsychotics?
A
dysrhythmia - long QTc - lead to torsades de point
25
state 4 mood disorders
bipolar
MDD
Dysthymic
cyclothymic
26
criteria for MDD diagnosis?
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
27
state 3 subtypes of MDD
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)
28
Describe features of depression with atypical features.
- mood reactivity
- hypersomnia
- hyperphagia
- leaden paralysis
- long standing interpersonal rejection
29
Describe features of depression with melancholic features
- no mood reactivity
- anhedonia
- psychomotor retardation
30
How to diagnose a manic episode?
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
31
When do you get diagnosed with hypomanic episode?
Manic symptoms for at least 4 days, without notable functional impairment/psychotic features (psychotic features can be present in manic episodes)
32
Type 1 biopolar disorder requires?
At least 1 manic episode
33
Type 2 bipolar disorder requires?
not history of manic episodes
| A hypomanic episode + one major depressive episode
34
state 3 reasons why you do not use antidepressants to treat bipolar disorder
1. trigger manic or hypomanic episodes
2. increase frequency of mood episodes
3. ineffective in treating bipolar
35
what is a cyclothymic disorder?
Milder form of bipolar disorder - fluctuating between mild depressive and hypomanic symptoms
36
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......
unspecified bipolar disorder
37
bipolar patients usually present with a _____ episode first. symptoms 47% of the time are _____.
depressive
| depressive
38
state 4 information processing problems associated with MDD
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
39
state 3 pieces of evidence for attention bias in MDD
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
40
how do patients respond neurologically to antidepressants?
Early decreased brain (including amygdala) response to fear
| Baseline ACC activity
41
what is the origin of serotonin in brain?
Serotonergic neurons project from raphe nuclei in midbrain
42
what are the monoamine neurottansmitters?
serotonin
NE
Dopamine
43
state 4 indirect evidence for 5-HT hypofunction in depression
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
44
Describe how you would quantify dopamine receptors
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.
45
what are the 3 core symptoms of depression?
Depressed mood, low energy, anhedonia
46
what are the 3 biological symptoms of depression?
Sleep disturbances, appetite changes, low libido
47
what distinguishes Bipolar disorder (BPAD) from BPD (differential)
- BPD has poor self image, fear of abandonment, feelings of emptiness
- bipolar is heritable, has grandiosity
48
what distinguishes BPAD from schizophrenia (differential)
- chronic hallucinations/delusion in schizophrenia vs episodic in BPAD
49
What distinguishes BPAD from ADD (differential)
- BPAD is heritable, has depressive episodes, amphetamines worsen mania
50
what are the similarities between BPAD and ADD?
- impaired concentration, executive function and short term memory
51
state a differential for bipolar disorder
depression
52
state some iatrogenic causes of depression
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
53
vascular depression is associated with ____
white matter hyperintensities
54
what are the cluster B personality disorders?
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
55
what are the cluster A personality disorders?
Paranoid - Accusatory
Schizoid - Aloof - Voluntary social withdrawal, limited emotional expression
Schizotypal - Awkward - odd beliefs or magical thinking, extreme discomfort in social interactions
56
what are the cluster C personality disorders?
Avoidant - cowardly
Obsessive compulsive personality disorder - obsessive compulsive
Dependent - clingy
57
You can remember personality disorders as....
Cluster A = weird
Cluster B = wild
Cluster C = worried
58
why do people abuse drugs?
- positive reinforcement
- negative reinforcement
- other (fit in, curious)
59
describe the pathway to drug dependency
experimental -> hazardous -> harmful -> addiction/dependence
60
What is the criteria for drug dependency?
- 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
state 2 behavioural disorders
internet gaming and gambling
62
state 3 elements involved in addiction
1. social and environmental factors
2. personal factors - genetics, personality
3. drug factors - preparation
63
what are the acute effects of alcohol on the brain?
enhances activity of GABA-A/GABA-benzodiazepine system - decreased anxiety and sedation
Blocks excitatory system - blocks Glutamate NDMA receptor - impaired memory/alcoholic blackouts
64
what are the chronic effects of alcohol on the brain?
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
how do you treat alcohol withdrawal?
benzodiazepines to boost GABA function
| Acamprosate to help remain abstinent – reduces NMDA function
66
Which neurotransmitter pathway is implicated in drug addiction and positive reinforcement
Dopaminergic pathway - the pleasure-reward-motivation pathway
67
Rewards such as food and sex ____ levels of dopamine in the brain
increase
68
addiction is a reward ____ state
deficient
69
how do cocaine and amphetamine increase levels of dopamine?
block dopamine re-uptake transporter
| amphetamine also enhances release of dopamine from presynaptic vesicles
70
effect of Alcohol, opiates, nicotine on dopaminergic system
increase dopamine neuron firing in VTA
71
describe the course of dopaminergic neurons in the brain
Dopaminergic projections from brainstem and ventral tegmental area into ventral striatum and frontal cortex
72
what factor affects liking stimulants?
The lower levels of D2 receptors you have, the more likely you are to like it
73
What makes adolescents more vulnerable to drug use?
Reward deficiency - stunted brain activation in striatum
74
state the 3 features of addiction and the regions of the brain involved
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
when do you administer naloxone?
When do you administer naltrexone?
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
sertraline, fluoxetine and citalopram are all examples of ?
SSRIs (type of antidepresant)
77
what are some side effects of SSRIs?
GI effects (nausea, diarrhea), SEXUAL DYSFUNCTION, anxiety, insomnia
78
venlaxafine is an example of an?
SNRI
79
mechanism of SNRIs
Inhibits 5HT and NE reuptake
80
state some side effects of SNRIs
GI effects, sexual dysfunction, anxiety, insomnia, HYPERTENSION
81
Describe the mechanism, drug target and side effect of Mirtazapine.
- 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
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 _______.
1. erythromycin
| 2. sertraline
83
as you increase the SSRI dose, the reduction in depression eventually plateaus. how do you explain this?
All serotonin reuptake transporters have been blocked - maxed out
84
give three reasons why a patient is weaned off SSRIs before starting a new antidepressant
1. prevent withdrawal effects
2. prevent serotonin syndrome
3. prevent relapse or drug interactions
85
in a patient with depression presenting with difficulty sleeping ____ is a good antidepressant option
Mirtazapine - causes sedation and will help the patient in getting to sleep due to its antihistaminergic effect
86
in a patient with depression and high blood pressure ____ medication should be avoided
venlafaxine as it will worsen his hypertension as NE mediates the sympathetic nervous system effect on the heart
87
Mirtazapine has the highest affinity for ____ receptor and lowest for ____ receptor. r
```
highest = histamine H1
lowest = 5HT3
```
88
how do you work out alcohol units?
% strength x ml /1000 = units
89
how do you classify harmful use of drugs?
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
opiate withdrawal symptoms
Tachycardia, Sweating, Restlessness, Dilated pupils, Bone aches, Runny nose, GI upset, Tremor, Yawning, Anxiety/Irritability, Gooseflesh skin
91
how do you take a history in Addiction?
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
state major causes of morbidity and mortality associated with substance abuse
```
overdose
road traffic accident
suicide
Cirrhosis
endocarditis
hiv
```
93
seizures, delirium tremens, alcohol psychosis, haematemesis, and melaena may all be present in
alcohol addiction
94
during a physical examination, what may you observe in a patient with alcohol addiction?
```
jaundice
anaemia
clubbing
oedema
ascites
lymphadenopathy
DVT
cyanosis
```
95
what investigations are carried out if alcohol addiction is suspected?
ultrasound
Bloods- LFT, GGT, lipids, U&E, amylase
Breathalyser
Urine Drug Screen
96
during a physical examination, what may you observe in a patient with opiate addiction?
```
collapsed veins/track marks
endocarditis
skin abscesses
hepatitis/HIV
pneumonia
```
97
what investigations are carried out if opiate addiction is suspected?
bloods - LFT, U&E GGT, Glucose
breathalyser
urine drug screen
sexual health screening
98
state an alcohol assessment screening tool
1. CAGE
| 2. Audit
99
describe what happens during alcohol withdrawal
Initially withdrawal symptoms, then hallucinations, then seizures then delirium tremens which represents a medical emergency
More dangerous than opiods withdrawal.
100
what do opioids do?
ANALGESIC, create a sense of euphoria
| opiates = natural version
101
what happens during an opioid overdose?
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
give an example of a semi-synthetic opioid
heroin
103
give 2 examples of opIATES
morphine, codeine.
104
naltrexone, nalmefene, disulfiram (antabuse), and acomprosate are all used in ______ abstinence/alcohol withdrawal
alcohol
105
benzodiazepines like ____ are used in detox regimens for alcohol intoxication.
chlordiazepoxide
106
methadone and buprenorphine are used for ______ abstinence. They are both ...... ........
```
opioid
Opioid agonists (buprenorphine is partial)
```
107
_____ is a degenerative disease with cognitive and behavioural impairment.
dementia
108
Describe the pathophysiology of Alzheimer's disease
Beta amyloid plaques
NFTs - consist of phosphorylated tau proteins
loss of neurons and synapses
areas like cortex and hippocampus affected
109
in the development of alzheimers, chromsome 19 codes for ____
apolipoprotein E4.
110
in the development of alzheimers, chromsome 21 codes for ____
amyloid precursor protein (APP)
| down syndrome patients have increased alzheimers risk
111
in the development of alzheimers, chromsome 14 codes for ____
presenilin 1 (implicated in B-amyloid peptide).
112
in the development of alzheimers, chromsome 1 codes for ____
presenilin 1 (implicated in B-amyloid peptide).
113
what is the cholinergic hypothesis?
alzheimer's lead to degeneration of cholinergic nuclei in the basal forebrain. This results in reduced acetylcholine (ACh).
114
medications for alzheimers?
FIRST LINE = Acetylcholinesterase inhibitors - Donepezil
| NMDA receptor antagonists - Memantine
115
what are the 3 stages of alzheimers disease called?
early disease
progressive disease
advanced disease
116
name some key features of early stage dementia
```
absent mindedness
difficulty recalling names and words
difficulty learning new info
disorientation in familiar surroundings
reduced social engagement
```
117
name some key features of progressive dementia
```
marked memory impairment!
emergence of psychotic phenomena
mood swings
decline in ADLs
reduced vocabulary
```
118
name some key features of advanced AD
loss of bladder and bowel control
monosyllabic speech
reduced mobility
behavioural disturbances
119
what psychiatric symptoms are often seen in AD?
delusions
hallucinations - auditory and or visual
depression
120
what behavioural disturbances are seen in AD?
aggression, explosive temper, wandering, sexual disinhibition, incontinence, excessive eating and searching behaviour
121
MMSE is used to measure ____ _____ in a screen for ______
cognitive impairment
| dementia
122
state 2 differentials for a dementia diagnosis.
delirium
| depression
123
what things can help differentiate delirium from dementia
- delirium is reversible, acute onset, altered levels of consciousness, and has psychomotor changes
124
state 3 tests to rule out reversible causes of dementia
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
drugs that act by blocking ion channels are often used to treat _____
epilepsy
126
where are auto-receptors found?
| what is their function?
on presynaptic neuron
| usually inhibitory. inhibit calcium influx and AP
127
____ and ____ are fast acting neurotransmitters
glutamate and GABA
128
first line treatment for anxiety includes?
CBT, SSRIs, SNRIs
129
serotonin post-synaptic ______ receptor is an ____ receptor. enhancing serotonin stimulates this receptor, leading to a reduction in ____________
5HT1A
inhibitory
anxiety and depression
130
which postsynaptic serotonin receptor is the main site of action of psychedelic drugs?
5HT2A
131
second line treatment for anxiety includes?
benzodiazepines (GABA enhancer)
132
mechanism of acamprosate?
NMDA antagonist - used in alcoholism
133
An excess of _____ is implicated in nightmares. Treatment requires _____
noradrenaline
| prazosin - blocker
134
clomipramine, imipramine, and amitriptyline are examples of ____ ?
TCAs
135
advantage of partial agonist drugs?
improved safety, especially in overdose
136
what is the difference between an antagonist and an inverse agonist
antagonist - blocks - no effect
| inverse agonist - blocks and produces the opposite effect
137
Site on a receptor where normal neurotransmitter works on is known as the _____
orthosteric site
138
Sites on a receptor where drugs work on that the normal neurotransmitter does not is known as the ____
allosteric site
139
Benzodiazepines, barbiturates, alcohol, neurosteroids all act on allosteric site of _____ receptor
GABA
| enhance GABA effects - sedation, sleep, reduce anxiety, anti-epilepsy
140
the GABAa receptor is made up of ____ proteins and conducts ____ ions, inhibiting neurons.
5 - 2 alpha, 2 beta, 1 gamma
| chloride
