Year 3: Psychiatry Flashcards
Depression, BPAD, Schizophrenia, Detention Orders, Anxiety, PTSD, OCD, ADHD, ASD, LD, Personality Disorders, Eating Disorders, Addiction
Depression is due to
Decreased Serotonin (5-HT)
But also due to decreased Dopamine
What 3 dopamine pathways are affected in depression
Nigrostriatal
Mesolimbic
Anterior Cingulate
Hence side effects like anhedonia etc
3 core symptoms of Depression
- Persistent low mood (2 weeks+)
- Anhedonia
- Decreased energy, increased fatigue
F32 Criteria
(Severity of Depression)
- Mild: 1/3 core features
- Moderate: 2/3 core features + 3 additional symptoms
- Severe: 3/3 core features + 5 additional symptoms
Depression immediately becomes BPAD when
there are any manic symptoms
First line treatment for depression
Escitalopram (SSRI)
An SSRI that is to be used in pregnancy, cardio patients and anxiety patients
Sertraline (SSRI)
“As you are certain that it’s okay in pregnancy etc”
Anti-depressant that increases weight gain (appetite) and is good for sleep
Mirtazipine (Tetracycline)
Anti-depressant used for resistant depression
- Tried many drugs and they don’t work
Venlafaxine (SNRI)
Side effect of Citalopram (SSRI)
Can cause long QT syndrome
An anti-depressant with little side effects
Can be used in kids
Fluoxetine (SSRI)
Why are tricyclic anti-depressants bad in patients with suicidal risk
They are cardiotoxic, and so are easy to overdose on
Contraindications of Monoamine Oxidase Inhibitors
A tyramine rich diet
- Cheese
- Red wine
- Cured/processed meats
- Sauces and gravy
Why are tyramine rich food avoided in MAOIs
Can cause a hypertensive crisis
Contraindications with SSRIs
NSAIDs
Elderly (can cause hyponatraemia)
What is seen in Direct Self Harm?
Decreased activity in the pre-frontal cortex
Hallucinations seen in Psychotic Depression
Second person hallucinations
“You are fucking crazy son, kill yourself”
DSM-V Criteria for BPAD
(Subtypes of Bipolar Affective Disorder)
Type 1: More manic than depressed
Type 2: More depressed than manic
Type 3: Hypomanic due to chronic use of antidepressants
Examples of Type 1 BPAD
The “classic Bipolar person”
- Have a manic episode lasting 1 week+
- Has been depressed in the past
- Flight of ideas, grandiosity, increased activity etc
- On an absolute high
High 15% of the time
Examples of Type 2 BPAD
Most common form of BPAD
- Hypomania lasting 4 days
- Has been depressed in the past
- Reckless behaviour (spending money rashly)
- Increased libido
High 5% of the time
ICD-10 Criteria for BPAD shows
The severity of Bipolar Affective Disorder
ICD-10 Criteria for a hypomanic episode
Increased mood sustained for 4 consecutive days
Need 3/6 symptoms
ICD-10 Criteria for a manic episode
Increased mood sustained for 1 week
3/9 Symptoms
Symptoms are a bit more mental
If a BPAD patient is manic and on an antidepressant then
Take them off the antidepressant
1st line drug for BPAD
Lithium carbonate
To stabilise long term mood
If a patient is on lithium you should
- 12-hour monitoring when first started
- U&Es - as nephrotoxic
- TFTs- as thyrotoxic
Main rule for 2nd line prescribing in BPAD
- If you prescribe an antidepressant then you must also prescribe an antimanic drug
- If you prescribe an antimanic drug you must also prescribe an antidepressant drug
If BPAD patient is mainly manic what is the 2nd line drug combination
Sodium valproate (antiepileptic) and fluoxetine (SSRI)
If BPAD patient is mainly depressed what is the 2nd line drug combination
Lamotrigine (antiepileptic) and fluoxetine (SSRI)
1st line for acute mania management
Olanzapine (atypical antipsychotic)
2nd line for acute mania management
Quetiapine (atypical antipsychotic)
Has a sedative effect
Risk factor for schizophrenia
Cannabis use
Pathophysiological changes in schizophrenia
- Reduction in grey matter
- Enlarged ventricles
Neurochemical changes in schizophrenia
Increase in dopamine
3 first rank symptoms of schizophrenia
- Delusions
- 3rd party hallucinations
- Thought interference
Patients often have a lack of insight
ICD-10 Criteria states that you need
- 1/3 first rank symptoms
- 2/4 additional symptoms
- blunting of emotion, catatonic behaviour etc
Bad prognosis of schizophrenia
Quick onset
Good prognosis of schizophrenia
If patient is depressive
Atypical Antipsychotics work on
Serotonin and dopamine
Typical Antipsychotics work on
Dopamine
Name some Atypical antipsychotics
- Risperidone
- Quetiapine
- Clozapine
- Aripiprazole
Name some typical antipsychotics
- Chlorpromazine
- Haloperidol
First line drug for schizophrenia
Risperidone
Which antipsychotic class has the least side effects
Atypicals
Side effects of atypical antipsychotics
Metabolic syndrome
- HTN
- Hyperglycaemia
- Hypercholesterolaemia
- Increased body fat around the waist
Side effects of typical antipsychotics
Extrapyramidal symptoms
- Acute dystonia (muscle contraction/spasm)
- Akathisia (motor restlessness)
- Bradykinesia (slow movement)
- Tremor
- Tardive Dyskinesia (irregular jerky movements)
Basically, you give them Parkinson’s due to blocking dopamine
Side effect of Clozapine (atypical antipsychotic)
Agranulocytosis
(decreased WCC)
What is good about aripiprazole (atypical antipsychotic)
It has the least side effects
Patient can’t move their neck
Acute neck dystonia due to haloperidol
Risk factor for puerperal psychosis
BPAD
Mum gave birth a few weeks ago and is batshit crazy, killing baby
Puerperal psychosis
Management for puerperal psychosis
Admission to specialised unit
Olfactory hallucination is usually due to
epilepsy / stroke
Auditory hallucination is usually due to
Psychosis
2nd person: Depressive psychosis
“You are useless”
3rd person: Schizophrenia
“He wants to kill her”
Visual hallucination is usually due to
An organic cause:
- Lewy Body Dementia
- Delirium
- Eye problems
Tactile hallucinations are usually due to
- Schizophrenia: Skin stretched across their head
- Parkinsonism, Ekbom’s syndrome and alcohol and cocaine use: Bugs underneath/ on skin
Gustatory (taste) hallucinations are usually due to
Epilepsy
Haptic hallucinations (inside of body/organs) are usually due to
Mood disorders
“My insides are dying”
What is the Common Law
If a psychiatric patient is going absolutely fucking mental then sedate them to fuck
Drugs used in common law
1st line: Lorazepam
- If patient is know to be on antipsychotics then add on haloperidol
Give orally if possible
If not, then give IM, if that doesn’t work wait 30mins and go IM again
The 5 pillars you need to detain someone
- Danger to themselves or others
- There must be treatment available that works
- Patient can’t make their own decisions
- No other alternative
- Confirmed mental health problem (THAT IS NOT ALCOHOL/DRUG RELATED)
Emergency Detention Order
72 hours
Section 36
Who do you need to consent to emergency detention
No one to begin with
ACT FIRST THINK LATER
MHO is required to consent while detainment is happening
Short Term Detention Order
28 days
Section 44
Who do you need to consent to a short term detention order
MHO before detention begins
Compulsory Detention Order
6 months
Who do you need to give consent to a compulsory detention order
Goes to court: Tribunal
Application is needed: MHO and 2 medical reports
Do not detain
Alcoholics or drug users
4 types of thought interference
- Insertion: “There are thoughts being put in my head”
- Withdrawal: “They are extracting my thoughts from my head”
- Broadcasting: “Everyone knows what I’m thinking”
- Blocking: “I get halfway through thinking and then my thoughts vanish”
What to say in an OCSE to someone that is clearly nuts
“I think that there is evidence to suggest that you are actually unwell, and I think that for your own wellbeing you need to receive treatment, even if that means you need to be in a hospital, although I recognise that you don’t agree with this”
Biggest comorbidity in general anxiety disorder (GAD)
Depression
Criteria for GAD
- Must feel anxious and have associated symptoms most days for 6 months
- Loss of function/ affects daily life
- Not controllable
- Irrational
Short term treatment for GAD
BZD (e.g. Diazepam)
Long term treatment for GAD
Sertraline
“Because you’re certain that it works”