Theme 3 - Modulatory systems in Psychiatry Flashcards
What is the pathway for reward in the brain?
mesocorticolimbic
What is tolerance?
Diminished response to the effects of a given amount of drug following repeated exposures to the drug.
In what brain system does addiction?
Mesolimbic dopaminergic system
What structure releases what substance in addiction?
Dopamine released from nucleus accumbens
What effect does alcohol have on the DAergic system?
disinhibition of ventral tegmental DA neurons
What effect do opiates have of on the DAergic system?
inhibit GABAergic neurons in VTA which disinhibits VTA DA neurons
What effect do psychostimulants have of on the DAergic system?
direct effect on DA neurons in nucleus accumbens
What effect do nicotine have of on the DAergic system?
increases nuclesus accumbens DA directly and indirectly
How does cocaine affect dopamine levels in nucleus accumbens?
Blocks reuptake transporters
How do amphetamines affect dopamine in the nucleus accumbens?
DA transporters run in reverse
What receptors does alcohol affect?
GABAa - agonist
NMDA - anatgonist
What brain structure is linked to the physical dependance upon opiates?
Locus coereolus
What receptors are linked to alcohol dependence?
GABAa - downregulated
NMDA - upregulated
SO when you stop pissing up get excitation symptoms such as tremors, agitation, seizures
6 examples of disorders associated with neurosis?
Anxeity Depressive Obsessive Compulsive Adjustment Somatisation
4 disorders associated with psychosis
Organic
Bipolar
Schizophrenia
Depressive
What is defined as
An illness characterised by a loss of boundaries with reality and loss of insight, with primary features of delusions and hallucinations?
Psychosis
What is the time limit for a psychotic episode?
1 week
What is defined as Belief held firmly but on inadequate grounds, not affected by rational argument or evidence to the contrary, and not shared by someone of similar age, educational, cultural, religious or social background
delusion
What is defined as a perception experienced in the absence of external stimulus?
Hallucination
Schizophrenia is a minimum of 1 of these symptoms
a Thought echo, insertion, withdrawal or broadcast
b Delusion of passivity or delusional perception
(e.g. the toilet flushed and then I knew)
c Running commentary hallucination or 2 voices discussing the patient
d Persistent delusions of other kinds
Schizophrenia it at least 2 of these symptoms for at least one month
e Persistent hallucinations in any modality with accompanying brief delusions
f Breaks in thought resulting in abnormal speech (eg. incoherent, neologisms)
g Catatonic behaviour eg. Excitement, posturing, waxy flexibility, negativism
h Negative symptoms not due to depression or medication
In the absence of an organic disorder
At least 5 causes of organic psychosis
Epilepsy (temporal lobe)
Infections: encephalitis, subacute sclerosing panencephalitis, neurosyphillis, HIV
Cerebral trauma
Cerebrovascular disease
Demyelination: Multiple sclerosis etc
Neurodevelopmental disorders: velocardiofacial syndrome
Endocrine: thyroid disorders (hyper and hypo), Cushing’s syndrome,
Metabolic: hepatic failure, uraemia
Immunological: SLE
Acute drug intoxication: eg. Ketamine, Cannabis, LSD, PCP, Amphetamine,
Toxins eg. lead
Dementias
What are the 2 types of schizophrenia and types of symptoms associated with each?
Acute - positive symptoms
Chronic - negative symptoms
Percentage prognosis of schizophrenia?
20% - complete recovery and off treatment
25% - perisitant symptoms after first episode
+50% - relapsing remitting
At least 5 things that give a good prognosis of schizophrenia
Female Married Family history of affective disorder Good premorbid function Acute onset Life event at onset Early treatment Affective symptoms Good treatment response
At least 5 things for a poor prognosis of schizophrenia
Male Single Family history of schizophrenia Premorbidly schizoid Slow onset Long duration untreated Negative symptoms Obsessions High Expressed Emotion in the family Substance misuse
Two structural changes to brain associated with schizophrenia
Ventricular enlargement
reduced brain volume
What 3 neurophysiological phenomina are associated whith schizophrenia?
Hypofrontality
Hyper-excitable sensory cortex
Abnormal neural oscillations
What are 4 neurocognitive effects associated with schizophrenia?
Lower IQ Attentional deficits (e.g. Stroop Test) Working memory (e.g. Wisconsin Card Sorting Test) Planning and information processing deficits
What are the 4 affective episodes?
Major Depressive Episode
Manic Episode
Hypomanic Episode
Mixed affective episode
give 9 symptoms of depression
Depression of mood Anhedonia Psychomotor retardation Agitation / restlessness Anxiety / preoccupation Diurnal variation of mood Insomnia Feelings of guilt , self-reproach worthlessness Somatic symptoms Hypochondriasis Weight loss Suicidal thoughts
What are the DSM V criteria of a major depressive episode?
5 or more of the following symptoms for 1 week
Depressed mood most of the day, nearly every day
Diminished interest or pleasure
Weight loss / weight gain or appetite decrease / increase
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive or inappropriate guilt
Diminished ability to think or concentrate, or indecisiveness
Recurrent suicidal ideation or a suicide attempt/plan
5 features of atypical depression
Mood reactivity Significant weight gain Hypersomnia leaden paralysis interpersonal rejection sensitivity
3 criteria for manic episode
abnormally and persistently elevated, expansive, or irritable mood
For a period lasting at least one week and present most of the day, nearly every day:
abnormally and persistently increased activity or energy
7 possible symptoms of a manic episode
Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas or racing thoughts
Distractibility
Increase in goal-directed activity or psychomotor agitation
Excessive involvement in high risk activities
2 Differences between a manic and hypomanic episode?
Same symptoms but hypomanic episode is for 4 days rather than 1 week
The episode is not severe enough to cause marked functional impairment or to necessitate hospitalization
What 3 features can be associated with both depression and mania?
Anxiety
Hallucinations/delusions
Catatonia
4 epidemiology features of major depressive disorder
onset 25-35
1 in 5
more females than males
8-19% suicide
Difference between the two types of bipolar disorder
Bipolar Disorder I
At least one manic episode
Bipolar Disorder II
At least one hypomanic episode
At least one major depressive episode
4 epidemiology features of bipolar disorder
15-24 onset
delayed diagnosis
familial aggregation
men and women affected equally BP I
7 typical symptoms of acute stress
Feelings of being numb or dazed Insomnia Restlessness Poor concentration Autonomic arousal Anger/anxiety/depression Withdrawal
2 abnormal response to stress
PTSD
Adjustment disorder
What is the difference between a normal response and an adjustment disorder, how long can the latter last?
Adjustment is out of proportion to stressor
Up to 6 months
6 symptoms of PTSD
Re-experiencing flashbacks/nightmares Numbness/detachment Avoidance Hypervigilance/startle Insomnia Anxiety/depression
What is the average course of PTSD?
Usually immediate onset
Most recover within one year
6 physical symptoms of general anxiety disorder?
sweating palpitations dry mouth epigastric discomfort dizziness trembling
6 psychological symptoms of GAD
Fearful anticipation Irritability Sensitivity to noise Restlessness Poor concentration Worrying thoughts
Aietology of GAD in relation to parenting
Overprotective
Lack of warmth & encouragement
more critical and intrusive
5 Psychological symptoms of panic disorder
fear of losing control dying going mad fainting derealisation
As many physical symptoms of panic disorder as you can think of
Palpitations, tachycardia, sweating, trembling, dyspnoea, choking, chest pain, nausea, ‘butterflies’, urgency, dizziness, faintness, paraesthesia, chills/flushes
What would be 4 differential diagnosis associated with panic disorder?
Endocrine - hypoglycaemia
Respiratory - asthma
Cardio - Arrythmia
Drugs
6 points on aetiology of panic disorders?
Precipitating events in 60-96% of cases
- Separation / loss
- Relationship difficulties
- New responsibilities
Traumatic early life events
- Early parental separation
- Traumatic childhood event – 3 fold increase
- Early sexual abuse (<5 years of age)
Individuals with blood–injection–injury phobias exhibit a biphasic anxiety reaction what is this?
Initial short-lived sympathetic arousal
Followed by parasympathetic arousal
May result in vasovagal syncope
The subjective experience tends to disgust and repulsion rather than pure apprehension
4 aetiology points on phobias
unresolved unconscious conflict
classical conditioning
historically threatened species
observational
In appropriate anxiety in
Situations where the person is observed
Situations where there is potential for criticism
refers to what type of phobia
Social
5 symptoms of social phobia
Anticipatory anxiety
Feeling anxious
Blushing
Trembling (observed writing is a problem)
Relieved by alcohol (potential for abuse)
What brain structure is associated with fear and eliciting a stress a response?
Amygdala
What 2 other structures are excited by the amygdala in a stress response and what do they do?
Hypothalamus - HPA axis
Locus coeruleus - NE
What is the HPA axis?
Hypothalamus - releases CRH
Pituitary - releases ACTH
Adrenal cortex - releases cortisol
If the amygdala excited the HPA axis, what brain structure inhibits it?
Hippocampus
What brain structure is affected by chronic stress and how?
Too much glucocorticoid leads to cell death in hippocampus
Hippocampus cannot feedback to amygdala to limit cortisol production
Give 5 anxiety disorders
OCD Phobias GAD PTSD Panic disorder
