Psychiatry Flashcards
Affective/Mood Disorders
Disorders of mental status and function where altered mood is a core feature
- Depression
- Mania
- Bipolar disorder
Primary problem or secondary to other disorder (e.g. cancer, dementia, drug misuse, medical Tx - steroids)
Affective disorder features
- Persistence of symptoms (>2 weeks)
- Pervasiveness of symptoms
- Degree of impairment
- Presence of specific symptoms
Depression
Mental state characterised by:
- Low mood
- Loss of interest/enjoyment
- Neurovegetative disturbance
- Reduced energy causing social/occupational dysfunction
Depression Aetiology
Genetic-environment interaction
- F > M
- Stressors: unemployment, financial, relationships
Medical causes
- Traumatic brain injury
- Post-natal
- TH abnormalities
- Chronic conditions: cancer, stroke, diabetes, heart disease, arthritis, MS
- Delirium
IC-10 Depression
- Criteria
- Severity
> 2 weeks
No mania
No psychoactive substance or organic mental disorder
General criteria:
- Depressed mood (abnormal)
- Loss of interest/pleasure
- Decreased energy or increased fatigue
Additional criteria
- Loss of confidence
- Guilt
- Thoughts of suicide
- Decreased concentration
- Agitation/retardation
- Sleep disturbance
- Change in appetite
Mild: total 4
Moderate: total 6
Severe (automatic severe if psychosis): total 8
Somatic syndrome
Cluster of depressive syndromes
- Anhedonia
- Lack of emotion
- Waking 2 hours early
- Worse in morning
- Psychomotor changes
- Marked loss of appetite/weight
- Marked loss of libido
Depression measurement tools
- SCID
- SCAN
- HDRS
- BDI-II
- HADS
- PHQ-9
Depression management
Antidepressants (continue for further 6 months after successful)
- SSRIs
- TCAs
- Monoamine oxidase inhibitors
Psychological treatments:
- CBT
- Interpersonal therapy
- Psychotherapy
- Family therapy
Physical treatments:
- Electrocompulsive therapy (ECT)
- Psychosurgery
- DBC
- VNS
Mania
Pathological mental state that causes unreasonable euphoria, very intense moods, hyperactivity and delusions
Mania features
- Grandiose ideas
- Disinhibition
- Loss of judgement
- Elated
IC-10 Hypomania
- No psychosis
- Mild elevation of mood for several days
- Increased energy
- Marked feeling of wellbeing
- Increased sociability, talkativeness and overfamiliarity
- Increased libido
- Decreased sleep
- Irritability
- Reduced concentration
- Creativity
- Mild overspending
IC-10 Mania
Elevated hypomania symptoms
- With or without psychosis
- Severe enough to disrupt ordinary work and social activities
Mania measurement tools
Admission - safety
SCID, SCAN, YMRS (young mania rating scale)
Mania management
Antipsychotics
- Olanzapine
- Risperidone
- Quetiapine
Mood stabilisers
- Sodium valproate
- Lamotrigine
- Carbamazepine
Lithium
Benzodiazepines
ECT
Bipolar disorder
Repeated (2+) episodes of depression AND mania
- Genetic link (young)
Cognitive Behavioural Therapy (CBT)
Focuses on how our thoughts relate to our feelings and behaviours
- Identify, assess and change
- Challenge unrealistic/unhelpful thoughts
Behavioural Activation
Focuses on avoided activities (depression)
- Activity scheduling
Interpersonal Therapy
Focuses on interpersonal events
- Link depressive symptoms with IP event
- Goal -> reduce symptoms and improve IP function
Motivational Interviewing
Promotes behaviour change in wide range of health care settings
- More effective than advice giving/commanding
- Indication: unmotivated patient
- Prochaska and DiClemente stages of change: pre-contemplation, contemplation, planning/determination, action, maintenance
Phobic anxiety disorders
Stress response in a particular circumstance
- +/- anticipatory anxiety
- Agoraphobia (leaving home)
- Social phobia
- Specific/isolated phobia (spiders, germs)
Anxiety disorders symptoms
Psychological arousal:
- Nervousness
- Fearful anticipation
- Irritability
Autonomic arousal:
- Palpitations
- Sweating
- Blushing (social)
Muscle tension:
- Tremor
- Headache
Hyperventilation, SOB
Sleep disturbance
Panic attack
Phobic anxiety disorder management
- Education and advice
- CBT
- Antidepressants: SSRIs
Generalised anxiety disorder (GAD)
Stress response which occurs persistently (several months)
- Not confined to situation/object
- Aetiology: stressor acting on predisposed personality (genetic and environmental factors)
Generalised anxiety disorder (GAD) Management
- Counselling
- Relaxation training
- Antidepressants
- CBT
Obsessive Compulsive Disorder (OCD)
Recurrent obsessions
- Thoughts: unpleasant, distressing, not willed
- Acts: not helpful, seen to prevent harm to self/others
- Anxiety worsens with incompletion of tasks
Genetic: SHT receptor genes
OCD Management
- Education and explanation
- Antidepressants: SSRIs, TCAs
- CBT
- Psychosurgery
Post-Traumatic Stress Disorder (PTSD)
Delayed reaction to a stressor of exceptional severity
- E.g. combat, assault, disaster, or witness to above
Vulnerability factors:
- Mood disorder
- Previous trauma
- Lack of social support
- Female
Susceptibility partly genetic
Post-Traumatic Stress Disorder (PTSD) Features
- Hyperarousal
- Persistent anxiety
- Irritability
- Insomnia
- Poor concentration - Re-experiencing phenomena
- Intense, intrusive images - Avoidance of reminders
- Emotional blunting
- Anhedonia
- Cue avoidance
- Recall difficulties
- Diminishes interests
Post-Traumatic Stress Disorder (PTSD) Management
Screened (1/12 after)
Trauma-focused CBT
Eye Movement Desensitisation and Reprocessing (EMDR)
Medication: antidepressants (SSRIs, TCAs)
Legal Aspects
Mental Health (Care and Treatment) (Scotland) Act 2003 - Power to provide compulsory care for people with mental disorder (detention)
Adults with Incapacity (Scotland) Act 2000
Criminal Procedure (Scotland) Act 1995
Detention criteria and duration
MH(C&T)(S)A2003
For any mental disorder with significant impairment of decision-making or risk to health and treatment is available.
- Emergency - up to 72 hours
- Short-term - up to 28 days
- Compulsory Tx order - up to 6 months
- Nurses - up to 3 hours
Criminal Procedure (Scotland) Act 1995
Unfitness for trial
Diminished responsibility
- Acquitted of offence if unable to appreciate nature of conduct due to mental disorder
- Murder -> culpable homicide
Forensic sections
- Assessment Order
- Treatment Order
- Compulsion Order
- Restriction Order
Selective Serotonin Reuptake Inhibitors (SSRIs)
- Antidepressant
Fluoxetine
- Block presynaptic serotonin reuptake
- Side effects: GI upset, sexual dysfunction, anxiety, insomnia, fatigue, dizziness
- Activation syndrome (agitation)
- Discontinuation syndrome (flu-like)
Serotonin/Noradrenaline Reuptake Inhibitors (SNRIs)
- Antidepressant
Duloxetine
- Dual (serotonin and noradrenaline) reuptake inhibitor
Like TCA’s but less side effects.
Good for neuropathic pain
Side effects: increase DBP, nausea, QT prolongation, sexual dysfunction, discontinuation syndrome
Tricyclic antidepressants
Amitriptyline
- Dual reuptake inhibitor
Side effects: antihistaminic, anticholinergic, antiadrenergic, QT prolongation, OD
Monoamine Oxidase Inhibitors
- Antidepressant
Bind irreversibly to monoamine oxidase
- Prevent amine inactivation and increase synaptic levels of noradrenaline, dopamine, serotonin
- Good for resistant depression
- Side effects: hypotension, weight gain, dry mouth, sedation, sexual dysfunction, sleep disturbance
- Hypertensive crisis
- Serotonin syndrome
Lithium
- Mood stabilisers
Testing and monitoring (3 months):
- U&E
- TSH
- Pregnancy test
- Serum: 0.6-1.2 (toxicity)
Side effects: GI, thyroid, renal, hair loss, acne, neurological
Valproic acid (Depakote)
- Mood stabilisers (anticonvulsant)
Another form of sodium valproate
- Test (LFTs, FBC) and monitor
- Side effects: thrombocytopenia, platelet dysfunction + similar to lithium
Carbamazepine (Tegretol)
- Mood stabilisers (anticonvulsant)
- Test (LFTs, FBC, ECG) and monitor
- Side effects: rash, drug interactions, GI, neurological (sedation, dizziness, ataxia, confusion), AV conduction delays
Lamotrigene (Lamictal)
- Mood stabilisers (anticonvulsant)
- Test (LFTs) and monitor
- Side effects: rash, drug interactions, GI, neurological
Anxiolytics
Indications: anxiety, substance-related, insomnias
Buspirone
Benzodiazepines
Typical antipsychotics
D2 dopamine receptor antagonists
- Haloperidol
- Loxapine
- Fluphenazine
Atypical antipsychotics
Serotonin-dopamine 2 antagonists
- Affect ^ in 4 dopamine pathways
- Risperidone - extrapyramidal symptoms
- Olanzapine
- Quetiapine
- Aripiprazole
- Clozapine
Check bloods - fasting lipids and BG, LFTs, FBC
Harmful alcohol use
Pattern of use causing damage to physical or mental health
- Use >1 month or repeatedly over 12 months
Alcohol dependence syndrome
3 or more for >1 month or over 12 months
- Craving
- Difficulty controlling
- Increased tolerance
- Psychological withdrawal
- Persistence despite harm
Alcohol withdrawal symptoms
- Tremor
- Weakness
- N+V
- Anxiety
- Seizures
- Confusion
- Agitation
- Insomnia
- Death
Delirium Tremens
- Profound, fluctuating confusion
- Disorientation, impaired consciousness
- Memory impairment
- Psychosis
- Tremor
- Agitation
- Sleeplessness
- Autonomic over-activity
Complications of alcohol misuse
Physical
- Alcoholic fatty liver, acute alcohol hepatitis
- Accident
- Cancer
- Seizures
- Thiamine deficiency
Mental
- Mood disorder
- Sleep disruption
- Alcoholic hallucinosis
- Suicidal behaviour
- Aggression
Relationships
Employment
Financial
Legal
Alcoholism screening tools
CAGE (2 or >)
- Cut down
- Annoyed (criticised)
- Guilty
- Eye-opener
AUDIT
FAST
PAT
Alcoholism Investigations
- LFTs: GGT elevated
- FBC: MCV elevated (macrocytosis)
- Nutrient status
- Imaging: cortical atrophy, ventricular enlargement
- EEG
Alcoholism Management
Education
- Psychological: CBT, BA, group therapy
- Social work
- Community support: ADA
- Medication: thiamine supplementation, benzos, Antabuse (deterrent), anti-craving
Wernicke’s encephalopathy
Acute thiamine (B1) deficiency
- Acute confusion
- Ataxia
- Ophthalmoplegia
- Nystagmus
Management: supplementation (parenteral, oral)
Korsakoff’s psychosis/
Acute amnesic syndrome
Thiamine deficiency
- Marked impairment of anterograde memory (learning)
- Disorientation
- Cognitive impairment
- Personality change, apathy, loss of initiative
Management: supplementation
Physical aspect of addiction
- Tolerance mechanisms
Reduced responsiveness to a drug caused by previous administration of many types of drugs. Develop dependence to prevent withdrawal symptoms.
Dispositional (less drug reaches active site)
- Decreased absorption/ metabolism (-> active) rate
- Increased metabolism (-> inactive)/excretion
Pharmacodynamic (drug has less action at active site)
- Down-regulation of receptors
- Reduced signalling of receptors
- Other compensatory mechanism
Psychological aspect of addiction
- Reward pathway
Some drugs utilise reward pathway and increase dopamine levels
- May be a genetic variation for strength of reward centre
Cocaine
- Effects
- Side effects
- Withdrawal symptoms
Monoamine reuptake inhibitor
- Increases dopamine, serotonin and noradrenaline
Smoked, injected, snorted
- Stimulant, euphoriant
- Anaesthetic
- Hypersensitive, alert, energy
- Confidence, impaired judgement
- Decreased appetite, tiredness
- Anger (cocaethylene)
Side effects:
- Damage to nose/airways
- Seizures, stroke, confusion, paranoid psychosis
- Respiratory failure
- Cardiac arrhythmia, MI, hypertension
Withdrawal:
- Depression
- Irritability, agitation
- Craving
- Hyperphagia/somnia
Amphetamine (speed)
Snorted, Swallowed, Injected
- Stimulant
- Similar to cocaine
Heroin
Opioid agonist
Snorted, Smoked, Injected.
- Analgesia
- Emotional analgesia
- Pin-point pupils, pruritis, sweating
- Decreased libido, menstrual irregularities
- Reduced cough reflex
Side effects:
- N+V
- Headache
- Phlebitis (vein)
- Endocarditis
- Injection injuries and BBVs
- Anorexia
- Constipation
- OD: respiratory depression
Withdrawal:
- Craving
- Insomnia, yawning
- Muscle pain, cramps
- Increased secretions (salivary, nasal, lacrimal)
- Dilated pupils
- Piloerection
Naxolone
Opiate antagonist
Methadone
Heroin substitute (longer half-life)
- Decriminalises drug use
- Normalise life
- Reduces IV misuse
Opiates
- Heroin (dihydrocodeine)
- Methadone
- Benzos
- Codeine
- Morphine
Schizophrenia
Severe mental illness affecting thinking, emotion and behaviour
ICD-10: 1 for > 1 month - Alienation of thought: echo, insertion, withdrawal, broadcasting - Delusions - Hallucinatory voices
Or 2 of
- Hallucinations
- Breaks in train of thought
- Catatonic behaviour - excitement -> stupor
- Negative symptoms
Schizophrenia symptoms
Positive
- Hallucinations
- 5 senses
- Clarity of true perception
- No external stimulus
- Located in external space - Delusional beliefs
- Grandiose
- Paranoid
- Hypochondriacal
- Self-referential - Disordered thinking
Negative - worse prognosis
- Apathy
- Lack of interest
- Lack of emotions - blunting, incongruity
Schizophrenia aetiology
Unknown
Likely to be combination of physical, genetic, psychological and environmental factors
Schizophrenia differential diagnosis
- Delirium
- Acute organic brain
- Depressive/manic episode (severe)
- Schizoaffective disorder
Schizophrenia management
- Education
- Antipsychotic medication
- CBT
- Family therapy
Personality disorder
Rigid/unhealthy patterns of thinking, functioning (emotions) and behaving.
- Interaction of genes and environment
Cluster A personality disorders
Odd, eccentric thinking/behaviour
- Paranoid
- Schizoid
- Schizotypal
Cluster B personality disorders
Dramatic, overly emotional/ unpredictable thinking + behaviour
- Borderline
- Antisocial
- Histrionic
- Narcissistic
Borderline Personality Disorder
- Unstable and intense relationships - fear of being alone, distress when strained
- Impulsive/risky behaviour
- Unstable/fragile self-image
- Problems controlling emotion
- Ongoing feelings of emptiness
Management
- Mentalization-Based Treatment (MBT)
- Dialectical Behaviour Therapy (DBT)
Antisocial Personality Disorder
- Persistent criminal conduct and remorselessness
- Difficulty with empathic concerns
- Antisocial behaviours
- Difficulty controlling impulse/anger
Management
- CBT
Cluster C personality disorders
Anxious, fearful thinking + behaviour
- Avoidant
- Dependent
- Obsessive compulsive
Personality Disorder management
- Group psychotherapy
- Community mental health team
- Medication: antidepressants, mood stabilisers, antipsychotics, anti-anxiety
Psychiatric disorders in child
- Aetiology
- Genetics
- Intra-uterine and perinatal factors - Biological processes
- White matter connectivity
- Grey matter gyrification - Life experiences (environmental factors)
- Psychological: toxic stress, attachment
- Social: emotion and empathy sharing
