Quick revision Flashcards
Depression as a symptom?
an emotion within the range of normal experience
Depression as a syndrome?
a constellation of symptoms and signs
Depression as a recurrent illness?
“recurrent depressive disorder”
What are the three core symptoms of depression?
The three core symptoms are:
1) Low Mood
2) Anhedonia = A complete inability to feel pleasure
3) Low Energy
What are the other symptoms outside of the three core symptoms (Low Mood, Anhedonia, Low Energy) of depression?
> Poor appetite
> Poor sleep
> Poor concentration
> Reduced libido
> Tearfulness
> Negative thoughts
> Suicidal thoughts
….. this list is not exhaustive
What is psychosis?
a mental disorder characterized by symptoms such as delusions or hallucinations, that indicate impaired contact with reality
What are delusions?
Usually negative or guilty in nature
e.g. “My body is rotting”, “I have committed a great crime and am being punished”
What are hallucinations?
Usually Auditory
Second Person (talking directly to the patient) e.g. A voice telling them they are 'worthless', that they smell bad or criticising what they are wearing
Can also be:
> Visual (e.g. spiders)
> Tactile (e.g. feeling things crawling on their skin)
> Olfactory (e.g. smelling rotting flesh)
> Gustatory (e.g. bad taste in mouth
What medical history would you want to know about in depression?
> Thyroid disorders (hypothyroidism can mimic depression)
> Chronic illness/pain
What psychiatric history would you want to know about in depression?
Admissions, suicide attempts
What family history would you want to know about in depression?
Psychiatric disorders, suicide
What personal history would you want to know about in depression?
Adverse experiences which may have effected their ways of thinking
…and their current situation
Which medications would you want to know about in depression?
Prescribed drugs such as beta-blockers can cause depression
What social history would you want to know about in depression?
Current social or financial difficulties
Use of alcohol/drugs
Within depression what features can be seen on the mental state examination - appearance?
Poor self-care, Reduced range of facial expressions
Within depression what features can be seen on the mental state examination - speech?
Slow, Quiet, Monotonous
Within depression what features can be seen on the mental state examination - mood and affect?
Subjectively and Objectively depressed mood
Reduced range and intensity of affects
Within depression what features can be seen on the mental state examination - thought?
Form = Thoughts may be slowed
Content:
1) Negative, guilty or suicidal thoughts
2) Depressive delusions if psychotic
Within depression what features can be seen on the mental state examination - perceptions?
Possible auditory hallucinations if psychotic
Reduced Eye Contact
Within depression what features can be seen on the mental state examination - cognition?
Not usually impaired
Within depression what features can be seen on the mental state examination - insight?
Usually present
Within depression what features can be seen on the mental state examination - behaviour?
Psychomotor retardation or agitation
Reduced Eye Contact
Treatment options in depression?
1) Biological:
- Antidepressants
- Electro-convulsive therapy
2) Psychological:
- Cognitive Behavioural Therapy (CBT)
- Interpersonal Psychotherapy (IPT)
3) Social:
- No specific treatments but modification of lifestyle factors may be helpful
Treatment options in depression - Biological?
Biological:
- Antidepressants - Electro-convulsive therapy
Treatment options in depression - Psychological?
- Cognitive Behavioural Therapy (CBT)
- Interpersonal Psychotherapy (IPT)
Treatment options in depression - Social?
No specific treatments but modification of lifestyle factors may be helpful
How long should antidepressants be used for in depression?
6-12 months in normal circumstances
Can be continued for long-term use in the case of chronic depression or in a prophylaxis nature
Complications of depression?
> Suicide
> Psychosis
> Social and Occupational dysfunction:
- Unemployment or problems at work - Family and relationship problems - Socially isolation
What is deliberate self harm?
Is self-mutilation or self-poisoning, which a person carries out in order to relieve (or attempt to relieve) distressing emotional states
What is self-mutilation?
Is usually by cutting
Can be burning with flame or caustic substances
What is self-poisoning?
Is usually by overdoses of pharmaceutical agents e.g. Paracetamol
What is parasuicide?
An attempted suicide
What are the most common group of individuals to be affected by an eating disorder?
> Women - around 10 times as common
> Younger age groups - 15-40 years
> Western cultures
> Groups where a thin physique is highly-prized
e.g. modelling, ballet
What are the main two types of eating disorders?
Anorexia Nervosa
Bulimia Nervosa
What are the four features of anorexia nervosa?
1) The patient has a dread of being overweight and imposes a low target weight (Often a disturbance of perception)
2) The patient restricts their food intake, and uses other methods to reduce weight e.g. vomitting, diuretics, laxatives, excessive exercise
3) BMI <17.5 (at least 15% less than expected)
4) Sex hormone failure:
> Amenorrhea in women
> Impotence and loss of libido in men
> Failure of development of secondary sexual characteristics if the onset is prepubertal
What is often associated with elevated or irritable mood (mania)?
Increased energy & activity
Elevated mood
Increased talkativeness & sociability
Inflated self-esteem & grandiosity
Decreased need for sleep
Poor concentration & distractibility
Increased libido
Overspending
Reckless behaviour
Racing thoughts
No longer working
Relationship difficulties
Within mania what may be seen with speech?
Speech can show flight of ideas, thoughts jumping from topic-to-topic
Within mania what may be seen with delusions?
Usually grandiose delusions
e.g. “I am king of Scotland”, “I can control the weather”
Within mania what may be seen with hallucinations?
Usually 2nd person auditory hallucinations
What psychotic symptoms may be seen in mania?
1) Speech can show flight of ideas, thoughts jumping from topic-to-topic
2) Delusions - usually grandiose e.g. “I am king of Scotland”, “I can control the weather”
3) Hallucinations - usually 2nd person auditory
What medical treatment options are there for acute mania within bipolar disorder?
1) Benzodiazepines/sedation (Short term)
= calm patient down and re-instate normal sleep pattern
2) Antipsychotics (haloperidol, olanzapine, quetiapine, risperidone)
= have sedative and mood-stabilising properties, as well as reducing any psychotic symptoms
3) Consider stopping any antidepressants as these can induce or worsen mania
4) Mood stabilisers = Lithium, anticonvulsants
What is bipolar affective disorder?
This disorder is characterised by repeated episodes of mania and depression:
- at least two episodes of mania (or) - one episode of mania and one episode of depression
Characteristically, recovery is usually complete between episodes
Patients who suffer only from repeated episodes of mania are rare, and they are classified as having bipolar disorder
What medical treatments may be used in bipolar disorder?
1) Mood stabilisers = lithium and anticonvulsants (sodium valproate/valproic acid, lamotrigine and carbamazepine)
2) Antipsychotics, even if not psychotic
3) Antidepressants may be appropriate so long as they have not induced mania for the patient in the past!
4) Consider benzodiazepine and/or night sedation within acute mania, hypomania or mixed affective disorder
Often multiple medications are used
What medical treatment options are there for depression within bipolar disorder?
Antidepressants should be coprescribed with an antimanic agent (Benzodiazepine, antipsychotic or mood stabiliser)
1st line = Quetiapine or a combination of fluoxetine and olanzapine
2nd line = Lamotrigine alone can be given
3rd line = Consider a mood stabiliser (Lithium or anticonvulsant e.g. valproic acid)
4th line a combination of all three above
What is used as a prophylaxis within bipolar disorder?
1st line = Lithium although stopping can induce a manic episode. Bloods should be monitored regularly
If someone is unable to tolerate lithium olanzapine or quetiapine can be considered
2nd line = Addition of Valproate/Valproic acid (Remember can cause neural tube defects)
3rd line = Lamotrigine or Carbamazepine
Outside of medical treatments what other options are there for treatment within bipolar disorder?
Psychological therapy can be used within a depressive episode but not manic:
- Cognitive behavioural therapy
- Interpersonal therapy
- Behavioural couples therapy
Electroconvulsive therapy may be used in severe episodes of mania or depression although it can precipitate a manic episode
What are the symptoms of Bulimia nervosa?
> Episodes of binge eating
- very large quantities of foods consumed in a short period with a feeling of a loss of control
> General preoccupation with eating
> Attempts to compensate for weight gain by restricting food intake between binges
- Self-induced vomiting, diuretics, laxatives, appetite suppressants, or excessive exercise
> A fear of being overweight
In terms of weight was are the differences between anorexic and bulimic patients?
Anorexic patients are always underweight
Bulimic patients can be underweight, normal weight, or even overweight
What are the complications of anorexia or bulimia?
These are mostly due to malnutrition or vomiting - some can be lethal.
> Lanugo hair - fine, downy hair seen in malnourished patients
> Russell’s sign - calluses or knuckles on the back of hand or knuckles due to repeated self-induced vomiting
> Erosion of tooth enamel and other dental signs associated with vomiting
> Loss of secondary sexual characteristics - malnutrition
> Vitamin deficiency states, peripheral neuropathy - malnutrition
> Electrolyte imbalances - due to malnutrition or vomiting
> Hypotension, bradycardia
> Suicide and self-harm are more common
> Death is due to complications e.g. malnutrition, electrolyte imbalance, ruptured oesophagus, cardiac failure
How is anorexia nervosa treated?
1) Psychoeducation about nutrition and weight
2) Psychotherapy (CBT orientated), preferably with familial involvement.
3) Medications = Multivitamins if low BMI, consider an SSRI in depressive or comorbid patients
4) High physical risk requires safe referring with specialist advice
How is bulimia nervosa treated?
1) Psychoeducation about nutrition and weight
2) Self help manuals and self help groups in mild cases; in more severe psychotherapy (CBT) is advised
3) In comorbid or depressed patients a SSRI may be consider
Due to purging electrolyte should be monitored closely
Which biological factor does OCD, self-harm and eating disorder have in common?
Serotonin neurotransmitter dysfunction
Within an acute stage what is schizophrenia characterised by?
By hallucinations and delusions relating to disruption of ego-boundary
Within a chronic stage what is schizophrenia characterised by?
By deficits of affect, motivation and thinking
What is psychosis?
Psychosis is characterized by the presence of one or more of
- Thought-form disorder
- Delusions
- Hallucinations
Psychotic symptoms within schizophrenia?
The psychotic symptoms in schizophrenia
> are usually bizarre thoughts and experiences
> are often related to a breakdown in the boundary between a patient’s internal personal experience and external reality (ego-boundary)
In schizophrenia, the psychotic symptoms are referred to as
“positive symptoms”
In schizophrenia what are positive symptoms?
The psychotic symptoms:
- Thought-form disorder
- Delusions
- Hallucinations
Which specific types of auditory hallucinations are often experienced in schizophrenia?
> Hearing their thoughts being repeated aloud
> 3rd person auditory hallucinations- a running commentary on their actions, or voices arguing about them
Which specific types of delusions are often experienced in schizophrenia?
Delusions about thought alienation:
> Thought withdrawal - their thoughts are being taken from their head by some external force or person
> Thought insertion - that thoughts are being inserted into their heads by some external force or person
> Thought broadcasting - that their thoughts are being read and broadcast to others
Which specific types of delusions are often experienced in schizophrenia - thought withdrawal?
Thought withdrawal - their thoughts are being taken from their head by some external force or person
Which specific types of delusions are often experienced in schizophrenia - thought insertion?
Thought insertion - that thoughts are being inserted into their heads by some external force or person
Which specific types of delusions are often experienced in schizophrenia - thought broadcasting?
Thought broadcasting - that their thoughts are being read and broadcast to others
What is passivity phenomena within schizophrenia?
Delusions that their thoughts, feelings, or impulses are driven by some external force or person
What is somatic passivity within schizophrenia?
A delusion that some external force is causing physical sensations (which may be hallucinations) in their body
What is Delusional perceptions within schizophrenia?
A delusion which arises because of a completely unrelated happening in external reality e.g. “Three letters, which is the number of the Holy Trinity, came through my letter box, and then I realized I was the son of God”
Non-psychotic symptoms within schizophrenia?
Mood disturbance
Unusual behaviour
Negative symptoms within schizophrenia?
These include:
> Apathy and lack of motivation
> Poverty of speech (and lack of thoughts)
> “Blunted” or incongruous affect (and lack of emotions)
> Social withdrawal
> Occupational decline
Cognitive symptoms within schizophrenia?
e.g. poor executive function (reduced decision-making ability) and poor abstract reasoning
The deficits are subtle and are usually not evident on basic clinical tests of cognition such as the Mini-Mental State Examination.
Alternative diagnosis in psychosis?
- Schizophrenia
- Psychotic mania or depression
- Delirium
- Drug induced psychosis or intoxication
- Medication e.g. steroids
- Cerebral causes e.g. tumour, infection, infarction, epilepsy
- Endocrine disease e.g. thyroid, chronic hypoglycaemia, Cushing’s, Addison’s
- Systemic illness such as anaemia, carcinoma, or sarcoid
Treatment within schizophrenia - Acute phase?
Antipsychotic medication
Sedatives
Treatment within schizophrenia - long-term treatment?
Antipsychotic medication
Support in the community e.g. housing, employment, support worker
Rehabilitation in dedicated facilities
Psychotherapies are not useful - there is minimal evidence for the effectiveness of CBT, and psychodynamic psychotherapy is unhelpful
Schneider’s first rank symptoms within schizophrenia?
1) Specific auditory hallucinations:
- Hearing their thoughts being repeated aloud
- 3rd person auditory hallucinations = A running commentary of their acton, or voices arguing about them
2) Delusions about shout alienation :
- Thought withdrawal
- Thought insertion
- Thought broadcasting
3) Passivity phenomena
4) Somatic passivity
5) Delusion perception
Other symptoms:
> Psychotic (“positive”) symptoms
- Persecutory or grandiose delusions
- Other bizarre delusions
- Disorders of thought forme.g. “loosening of associations”
> Non-psychotic symptoms
- Mood disturbance
- Unusual behaviour
Which drug has the biggest impact on social harm and how?
Heroin misuse causes much more social harm than misuse of other illicit drugs (such as cannabis, cocaine or MDMA)
- blood-borne transmission of disease
- acquisitive crime (sometimes violent)
- prostitution
When does substance use become harmful?
Harmful Use is…
A pattern of substance use that is causing damage to physical or mental health…
where use has persisted for at least 1 month or has occurred repeatedly within a 12 month period
What is considered dependance syndrome within substance misuse?
Dependence syndrome - 3 or more of the following features occur together for at least 1 month, or repeatedly over 12 month period:
1) Compulsion - strong desire to take the substance
2) Difficulties controlling use
3) Continued use despite harmful consequences
4) Salience - higher priority given to substance use than to other activities and obligations
5) Tolerance
6) Withdrawals when substance is reduced/stopped
What is tolerance?
a drug’s early effects are later achievable only by higher doses
What is withdrawal state?
a group of symptoms of variable severity occurring on absolute or relative withdrawal of a psychoactive substance, after persistent use of that substance
Safe limits of alcohol use?
Men = 21 units per week
or not regularly consuming more than 4 units/day
Women = 14 units per week
or 2 units/day for women
What does 1 unit of alcohol equate to?
10mls ethanol = half pint beer = 1 single measure of spirits = 1 glass of sherry = 1 glass of wine
Screening test in substance use?
Screening tests :FAST, CAGE
Details: - What? - How much? - How often? - Features of dependence? - Complications (such as liver failure)?
Background history which should be asked within substance use?
1) Family history -genetic factors, environment
2) Past history
- Previous alcohol/drug use
- Age started, when use became heavy
3) Physical health (harm from alcohol/other drugs)
4) Any social or psychiatric problems due to substances?
Complications of alcohol misuse?
1) Physical
2) Psychiatric
3) Social
Complications of alcohol misuse - Physical?
> Accidental injury, violence, sexual dysfunction
> Gastrointestinal (liver disease, gastritis, peptic ulcer, GI bleeding, pancreatitis)
> Cardiovascular (hypertension, heart disease, stroke)
> Cancer (mouth, oesophagus, liver)
> Neurological (fits, confusional states, head injury, Wernicke/Korsakoff’s)
Complications of alcohol misuse - Psychiatric?
> Deliberate self harm
> Anxiety states
> Depression
> Morbid jealousy
> Alcoholic hallucinosis
Complications of alcohol misuse - Social?
> Employment & financial difficulties
> Marital & family problems
> Criminal convictions
Treatment for alcohol misuse - non medical?
> Alcohol counselling & psychological input
> Referral for help with social/occupational issues
> Encourage use of community supports
e.g. AA
> In-patient detoxification
Treatment for alcohol misuse - medical?
1) Thiamine - To prevent Wernicke’s/Korsakoffs
2) Acamprosate or naltrexone for alcohol craving
3) Disulfiram (Antabuse) makes you feel very sick if you drink alcohol
4) During detoxification benzodiazepines may be required
Treatment for Opiate Dependence?
> Counselling & psychological input
> Referral for help with social/occupational issues
> Encourage use of community supports
> In-patient or residential treatment
> Methadone:
- Gradual reduction
- Maintain same dose (harm reduction)
Which medications can be used to help reduce alcohol cravings?
Acamprosate or naltrexone
What is the role of disulfiram in alcohol mis-use?
Disulfiram post-detox, which causes an unpleasant and potentially dangerous reaction if alcohol is consumed, acting as a ‘deterrent’
