Psychiatry - conditions Flashcards
What is a mood disorder?
Marked disruptions in emotions - severe lows (depression)/ highs (mania)
What two sets of diagnostic criteria are frequently used for psychiatric conditions?
- ICD-10/11
- DSM-5 (shitty American version)
What are the three core symptoms of depression?
- Low mood
- Anhedonia (lack of interest)
- Anergia (lack of energy)
What are some other symptoms of depression (6)?
- Weight change
- Sleep changes
- Reduced libido
- Worthlessness/ guilt
- Decreased concentration
- Thoughts of self harm
What sleep change is typical of depression?
Early morning wakening (typically 2-3 hours early) - although sleeping more/ less overall are both common
What 3 criteria should be fulfilled for a diagnosis of depression?
- Impair daily function + cause distress
- Symptoms most days for more than 2 weeks
- Not due to substance use or grief
What are some risk factors for depression (8)?
- Chronic pain
- Post partum
- Hypothyroid
- Trauma + abuse
- Bereavement (although this itself is not depression)
- Divorce
- Stress
- Female
What group of people are a higher suicide risk when depressed?
Male
What are two theories that could lead to or worsen depression/ other psychiatric disorders?
- Stress-vulnerability model = positive outcome more likely if stress minimised
- Monoamine hypothesis = deficiency of catecholamines (e.g. norepinephrine) –> depression
How is depression initially assessed (3)?
- Psychiatric: history, MSE, risk assessment
- Bloods: FBC, U&E, LFTs, TFTs, Ca2+, B12/folate, glucose, CRP/ESR
- Questionaries
What questionnaire is commonly used for depression?
PHQ-9
What scores are suggestive of different levels of depression in the PHQ-9?
Out of 27:
* <10 = mild
* 10-19 = moderate
* >19 = severe
What symptom can occur alongside severe depression?
Psychosis
What is psychosis?
Symptoms that occur when the mind has difficulty determining what is real and what is not
What are some symptoms of psychosis (3)?
- Hallucinations
- Delusions
- Disorganised speech/thought
What is a delusion?
A false belief based in incorrect inference about reality
How is mild depression managed?
Psychotherapy - guided self help, CBT, group exercises/ mindfulness
Only give antidepressant if requested
How is more severe depression treated?
- Offer antidepressant (SSRI/ SNRI)
- Psychotherapy (less group activities than mild depression)
What PHQ-9 score should antidepressants be offered as first line?
16 or more
under 16 should only be given if requested
When should initial follow up appointments be arranged for depression after starting antidepressants?
2 weeks
Who should be seen sooner than 2 weeks after starting antidepressants?
- 18-25 year olds
- High risk of suicide
How soon should antidepressants begin to have a clinical effect?
Within 4-6 weeks
What should be done after 4-6 weeks of treatment if there has been no improvement?
- Re-evaluate + manage risk factors for depression
- Check compliance with medication
- Consider differential diagnoses
How long after symptoms resolve should an antidepressant be taken for?
6 months
How frequently should those on long term antidepressants be seen?
Every 6 months
What treatment can be offered for extremely severe, life threatening depression?
ECT
What are the pharmacological options and order typically given for depression (6)?
- SSRI
- SNRI
- TCA/ mirtazapine
- MAOIs
Treatment resistant depression: lithium, antipsychotics, lamotigene, etc…
When should a patient with depression be referred?
Treatment resistant depression/ very severe depression
Other than depression what are some other affective disorders (mood disorders) (5)?
- Bipolar disorder
- Dysthmia
- Postnatal depression
- Seasonal affective disorder
- Premenstrual dysphoric disorder (PMDD)
What is dysthymia?
Persistent (2-5 years) sub-threshold depressive symptoms
What is postnatal depression?
Depression within first year of giving birth
What severe symptoms can occur alongside postnatal depression?
Psychosis (postpartum psychosis)
What is the “baby blues”?
Depression that resolves within 2 weeks of giving birth
How is postnatal depression medically managed when mother is breastfeeding?
Sertraline/ paroxetine
low levels pass into breast milk
What is seasonal affective disorder (SAD)?
Depression usually during autumn/ winter with remission between
What is a specific treatment for SAD?
Light therapy
What is adjustment disorder?
Negative reaction to stress involving negative thoughts, strong emotions and changes in behaviour.
May occur with depressive symptoms
How long does adjustment disorder last?
Less than 6 months
What are some key differential diagnoses for low mood (4)?
- Affective disorders (e.g. depression, bipolar, SAD…)
- Hypothyroidism
- Bereavement
- Cancer/ terminal illness
What is bipolar disorder?
The presence of both depressive and (hypo)manic episodes
What is mania?
Abnormally elevated mood lasting for more than 1 week resulting in impairment in social and occupational functioning. Psychotic symptoms often present
What is hypomania?
Elevated mood lasting for more than 4 days that does not significantly impact on the persons functioning
What are the types of bipolar disorder (3)?
- Type 1 = mania + depression
- Type 2 = hypomania + depression
- Cyclothymia = hypomania + mild depression
What criteria are needed for a diagnosis of each of the bipolar disorders?
- Type 1 = manic episode, don’t need depressive episode
- Type 2 = hypomanic AND depressive
- Cyclothymia = hypomania and subclinical depression (much faster alternating)
What are some symptoms of a manic episode (8)?
- Elevated mood
- Increased activity
- Grandiose ideas
- Decreased need for sleep
- Easily distracted
- Psychotic symptoms
- Pressure of speech, flight of ideas
- Changing appearance + overspending money
The lack of what features would point toward a hypomanic episode (3)?
- Grandiosity
- Psychosis
- Lack of insight (so would have some insight)
What can precipitate a manic episode (3)?
- Positive life events
- Getting up early
- Drugs/ alcohol
What are some risk factors for bipolar (4)?
- Family history (first degree)
- Trauma/ abuse
- Stress
- Substance abuse
What might be considered a typical person at risk of developing bipolar?
Female < 30 with family history of bipolar
What activities pose a risk to those in a manic episode (3)?
- Reckless behaviour/ aggression
- Sexual promiscuosity
- Lack of self care for physical illnesses
What are some organic causes of bipolar disorder (3)?
- Endocrine e.g. hyperthyroidism
- Neurological - MS, CVA, epilepsy, tumour
- Drugs - steroids, antidepressants
How is bipolar diagnosed (2)?
- Clinical diagnosis
- Bloods, imaging and other Ix used to rule out organic causes
How should bipolar be immediately managed (2)?
- Manic episode = urgent referral
- Hypomanic episode = routine referral
What is rapid cycling bipolar disorder?
Having 4 or more manic episodes in 1 year
What is the medication pathway to treat a manic episode (3)?
- Antipsychotic (haloperidol, risperidone, quetiapine, olanzapine)
- Offer second antipsychotic
- Add sodium valproate/ lithium
What should be stopped during a manic episode?
Antidepressants - tapered and stopped
How is a depressive episode in bipolar managed with medication (3)?
- Antipsychotics
- Olanzapine + fluoxetine
- Lamotrigine
What is the medication pathway for the long term management of bipolar?
- Lithium
- Sodium valproate
- Olanzapine
How should lithium be monitored when started for bipolar disorder?
Concentration measured 12 hours after dose weekly until stable, then every 3 months
What non pharmacological options are there for those with bipolar disorder?
- Education about bipolar and early warning signs (with involvement of family)
CBT can be used - not particularly effective
What are some differential diagnoses for bipolar disorder (3)?
- Unipolar depression
- Schizophrenia
- Emotionally unstable personality disorder (EUPD/BPD)
What is schizophrenia?
An acute mental health state resulting in psychosis (delusions and hallucinations) and dissociation from reality
What are 3 types of delusion?
- Grandeur = belief of inflated self importance (e.g. that they are the queen)
- Paranoid
- Somatic = believe they have a terrible illness
What are some risk factors for schizophrenia (6)?
- Family history (1st degree) = biggest factor
- 16-30 years
- Previous illicit drug user
- Trauma + abuse
- Traumatic birth
- Emigrating
What broad groups are the symptoms of schizophrenia divided into (3)?
- Positive symptoms
- Negative symptoms
- Cognitive impairment
What is a positive symptom in schizophrenia?
Those present in people during a psychotic episode
What is a negative symptom in schizophrenia?
Deficits of normal emotional responses
What are some examples of positive symptoms in schizophrenia?
- Delusions
- Hallucinations
- Thought disorders
- Disorganised speech/ behaviour
What types of hallucinations are common in schizophrenia?
Auditory (however talking to the voices is rare)
visual and olfactory hallucinations are rarer in schizophrenia
What types of disorganised speech sometimes occur in schizophrenia (6)?
- Word salad - completely mixed up sentence
- Neologism - made up word
- Flight of thought - jumps from one idea to another with associations
- Knights move thinking - jump from ideas with no associations
- Pressure of speech - fast talking
- Circumstantiality - take ages to get to the point
What type of thought disorders occur in schizophrenia (3)?
- Insertion - thoughts put in mind
- Withdrawal - thoughts taken from mind
- Broadcasting - thoughts told against will
What negative symptoms can be present in those with schizophrenia (5)?
- Alogia - impoverished level of thinking (poverty of speech)
- Blunting of affect (emotionless)
- Anhedonia - loss of pleasure
- Apathy - lack of enthusiasm
- Slowness of thought and movement
What other symptoms can be present in those with schizophrenia (5)?
- Depression
- Anxiety
- Agitation
- Withdrawal
- Self harm
What are Schniders first rank symptoms for schizophrenia (more historical criteria) (4)?
- Auditory hallucinations
- Broadcasting, insertion, withdrawal of thoughts
- Control (passivity) - others controlling actions + thoughts
- Delusional perceptions
What are some differential diagnoses for psychosis (4)?
- Psychological disorders
- Delirium tremens
- Drugs e.g. cannabis
- Organic disorder e.g. epilepsy
What psychological disorders cause psychosis (4)?
- Schizophrenia
- Bipolar disorder
- Brief psychotic disorder
- Delusional disorder
How long should a brief psychotic disorder last?
less than 1 month, often with a precipitating factor
What is delusional disorder?
Similar to schizophrenia but without significant hallucinations, though disorders or mood disorders
How is schizophrenia investigated (4)?
- FBC + LFTs
- Drug screening
- EEG - for epilepsy
- CT/ MRI - enlarged lateral ventricles
How long should symptoms of schizophrenia be going on for before a diagnosis is made?
28 days
What is important to tell people with a diagnosis of schizophrenia?
Can’t drive until well for 3 months
What is indicative of a poor prognosis for schizophrenia (4)?
- Slower onset
- Family history
- Abuse history
- Negative symptoms
What is late onset schizophrenia?
After age 45
What is the prognosis for later onset schizophrenia?
Better prognosis
What risks are associated with those with schizophrenia (3)?
- Self neglect - exacerbate physical health conditions
- Risk to others
- Suicide - thoughts/ auditory hallucinations
How is schizophrenia managed pharmacologically?
- Trial 2 atypical antipsychotics (risperidone, olanzapine, aripiprazole, quetiapine)
- if no effect … clozapine
What non pharmacological treatments are offered to those with schizophrenia (3)?
- CBT
- Early warning signs education
- Family therapy (they can recognise the signs)
What is schizoaffective disorder?
Schizophrenia + mood disorder (e.g. depression/ bipolar)
What “state” do some people with schizophrenia sometimes end up in?
Catatonia
What is catatonia?
Ceases in movements/ speech, sometimes with abnormal movements
Other than schizophrenia what is catatonia associated with (2)?
- Major depressive disorder
- Mania/ bipolar disorder
What is the most common anxiety disorder affecting 15% of people?
Specific phobias
How could a specific phobia be defined?
Irrational fear of particular thing/ situation
What is a symptom of specific phobias (2)?
- Avoidance behaviours
- Catastrophising
What are some examples of specific phobias (2)?
- Agoraphobia = fear of public places
- Social phobia = fear of social situations
How is a specific phobia treated (2)?
- Exposure responce prevention
- Consider SSRIs
What is the second most common anxiety disorder?
PTSD
What is PTSD?
Onset of symptoms such as flashbacks more than 1 month after a particularly traumatic event
What is ‘PTSD’ that does not continue 1 month past the traumatic event known as?
Acute stress reaction
What are the 3 main symptoms of PTSD?
- Flashbacks/ nightmares to event
- Avoidance behaviour of things that remind them of the event
- Hypervigilance - exaggerated responce to stimuli
What is the first line treatment for PTSD?
Trauma focused CBT + exposure therapy
What is the gold standard treatment for chronic PTSD?
Eye movement desensitisation and reprocessing (EMDR)
What is a pharmacological treatment for PTSD?
SSRI or venlafaxine
Other than PTSD and phobias, what are some other anxiety disorders (3)?
- Panic disorder
- GAD
- OCD
What 3 features are suggested in models that result in the development of panic/ anxiety disorders?
- Stress
- Loss of control
- Genetics
What are some risk factors for the development of anxiety/ panic disorders (6)?
- Genetics
- Stimulant drugs
- Palpitations
- Hyperthyroid
- Trauma/ abuse
- Stress
How many panic attacks are required for a diagnosis of panic disorder?
4 or more within 1 month
usually last 10-30 min
Who is typically affected by panic disorder?
Female (20-30 years old)
What are 8 symptoms of a panic attack?
- SoB
- Chest pain
- Lightheaded/ dizzy
- Palpitations
- Shaking
- Sweating
- Parasthesia
- Fear of dying
