S12: psychiatry 2 Flashcards
Describe the clinical features of depressive disorders
Must have had symptoms for at least 2 weeks
Core symptoms: low mood, lack of energy & lack of enjoyment and interest
Depressive thoughts – suicidal ideation
Somatic/biological symptoms – lack of appetite & pain
Might have psychotic symptoms in severe cases
Compare an adjustment reaction vs depression
Adjustment reaction: symptoms develop suddenly after an event, time limited, energy not low, no particular pattern to sleep disturbance & feelings of anger and frustration more typical
Depression: symptoms develop gradually, low energy, sleep disturbance with typical EMW & low self esteem and feelings of guilt and blame are typical
List features of mania
Elated mood Increased energy Pressure of speech Decreased need for sleep Normal social inhibitions are lost Self esteem is inflated, often grandiose
Describe bipolar affective disorders
Can diagnose following two episodes of a mood disorder, one of which must be either mania or hypomania
Fluctuations in mood
Bipolar 1 – episodes of mania or mania & depression
Bipolar 2 – episodes of hypomania or hypomania & depression
List physical differentials for depression
Hypothyroidism B12 deficiency Chronic disease Substance misuse Hypoactive delirium
List physical differentials for mania
Hyperthyroidism Delirium Iatrogenic Infection Head injury Intoxication
Describe the limbic system
Important functions in emotion, memory & motivation
Composed of many brain regions, however the main emotion circuit is known as the Papez circuit:
-various cortical areas send input to the hippocampus which projects to the mammillary bodies via the fornix
-mamillary bodies project to the thalamus & hypothalamus, thalamus projects back to the cortex
-hypothalamus projects down to the pituitary and autonomics mediating some of the somatic effects
-amygdala: can be grouped with hippocampus in terms of its connections
Describe serotonin
Produced in brainstem (raphe nuclei) and distributed to cortex and limbic system
Important for sleep, impulse control, appetite & mood
Outline the evidence for decreased serotonin in depression
Drugs that increase serotonin in the brain treat depression
5HIAA – low in the CSF of patients with depression
Tryptophan – depletion causes depression
NB: not all features of depression are explained by this hypothesis
Describe noradrenaline
Produced in the locus coeruleus of the brainstem & distributed to cortex and limbic system
Important for: mood, arousal & memory
Outline the evidence for decreased levels of noradrenaline in depression
Drugs that increase levels of noradrenaline treat depression
Patients who have recovered, but still have low levels of noradrenaline are at higher risk of relapse
Post-mortem studies suggest lower levels of noradrenaline in the brains of those with depression
Describe the treatment of depression
Biological: antidepressants – SSRIs, consider electroconvulsive therapy for severe or refractory cases
Psychological: CBT
Social: help with social stressors such as isolation & financial worries
Describe the treatment for acute mania
Biological: antipsychotics, mood stabilisers (eg. lithium)
Psychological: unlikely to be helpful in acute phase, helpful to educate patients regarding recognising triggers & signs of relapse
Social: patients need to be kept safe, important to think about implications of mania such as finances etc
Describe the treatment for acute bipolar depression
Biological: use antidepressant with mood stabiliser cover
Psychological: CBT
Social: help with social stressors such as isolation & financial worries
Describe the treatment for maintaining stability
Biological: mood stabiliser eg. lithium/valproate with or without antipsychotic
Psychological: education, CBT
Social: consider effects on employment, family support
Define psychosis
A set of symptoms, not a diagnosis itself
Presence of hallucinations or delusions
Describe hallucinations
A perception without an accompanying stimulus
In any sensory modality
Visual hallucinations are frequently caused by organic pathologies
Hypnogogic – experienced when going to sleep
Hypnopompic – experienced upon waking
Describe delusions
A fixed, false belief which is unshakeable
Outside of cultural norms
Describe the first rank symptoms of schizophrenia
Auditory hallucinations – thought echo, running commentary & third person
Passivity experiences – belief that an action/feeling is caused by external force
Thought withdrawal, broadcast or insertion
Delusional perceptions – attribution of a new meaning to a normally perceived object
Somatic hallucinations
Outline the positive and negative symptoms in schizophrenia
Positive symptoms – delusions, hallucinations, thought disorder & lack of insight
Negative symptoms – underactivity, low motivation, social withdrawal, emotional flattening & self neglect
Describe the evidence for involvement of dopamine in schizophrenia
Drugs that increase dopamine levels induce psychosis
Drugs that antagonise dopamine treat psychosis
Describe the treatment of schizophrenia
Typical antipsychotics – block D2 receptors throughout the CNS, antipsychotic actions from inhibition of mesolimbic & mesocortical pathways, side effects come from blocking other pathways
Atypical antipsychotics – lower affinity for D2 receptors than typicals, hence milder side effects; also block 5HT2 receptors
Describe side effects of treatment of schizophrenia
Can affect movement due to involvement of nigrostriatal pathways
However untreated patients can also develop hypokinetic movement disorders (catatonia) – might be caused by involvement of GABA
Increased prolactin levels: amenorrhea, galactorrhoea, decreased fertility, decreased libido, osteoporosis
Outline the challenges in treating schizophrenia
Patients lack insight, which can affect compliance
To get around this, medication can be given in different ways (eg. depot injection)
List factors associated with good prognosis (schizophrenia)
No family history Good premorbid function Acute onset Mood disturbance Prompt treatment Maintenance of motivation
List long term complications of schizophrenia
All cause mortality twice as high as general population Shorter life expectancy Greater suicide risk Greater risk of violent death Substance misuse
