S12: psychiatry 2

Question 1

Describe the clinical features of depressive disorders

Answer 1

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

Question 2

Compare an adjustment reaction vs depression

Answer 2

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

Question 3

List features of mania

Answer 3

Elated mood
Increased energy 
Pressure of speech
Decreased need for sleep
Normal social inhibitions are lost 
Self esteem is inflated, often grandiose

Question 4

Describe bipolar affective disorders

Answer 4

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

Question 5

List physical differentials for depression

Answer 5

Hypothyroidism
B12 deficiency
Chronic disease
Substance misuse
Hypoactive delirium

Question 6

List physical differentials for mania

Answer 6

Hyperthyroidism 
Delirium
Iatrogenic 
Infection
Head injury
Intoxication

Question 7

Describe the limbic system

Answer 7

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

Question 8

Describe serotonin

Answer 8

Produced in brainstem (raphe nuclei) and distributed to cortex and limbic system
Important for sleep, impulse control, appetite & mood

Question 9

Outline the evidence for decreased serotonin in depression

Answer 9

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

Question 10

Describe noradrenaline

Answer 10

Produced in the locus coeruleus of the brainstem & distributed to cortex and limbic system
Important for: mood, arousal & memory

Question 11

Outline the evidence for decreased levels of noradrenaline in depression

Answer 11

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

Question 12

Describe the treatment of depression

Answer 12

Biological: antidepressants – SSRIs, consider electroconvulsive therapy for severe or refractory cases
Psychological: CBT
Social: help with social stressors such as isolation & financial worries

Question 13

Describe the treatment for acute mania

Answer 13

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

Question 14

Describe the treatment for acute bipolar depression

Answer 14

Biological: use antidepressant with mood stabiliser cover
Psychological: CBT
Social: help with social stressors such as isolation & financial worries

Question 15

Describe the treatment for maintaining stability

Answer 15

Biological: mood stabiliser eg. lithium/valproate with or without antipsychotic
Psychological: education, CBT
Social: consider effects on employment, family support

Question 16

Define psychosis

Answer 16

A set of symptoms, not a diagnosis itself

Presence of hallucinations or delusions

Question 17

Describe hallucinations

Answer 17

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

Question 18

Describe delusions

Answer 18

A fixed, false belief which is unshakeable

Outside of cultural norms

Question 19

Describe the first rank symptoms of schizophrenia

Answer 19

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

Question 20

Outline the positive and negative symptoms in schizophrenia

Answer 20

Positive symptoms – delusions, hallucinations, thought disorder & lack of insight
Negative symptoms – underactivity, low motivation, social withdrawal, emotional flattening & self neglect

Question 21

Describe the evidence for involvement of dopamine in schizophrenia

Answer 21

Drugs that increase dopamine levels induce psychosis

Drugs that antagonise dopamine treat psychosis

Question 22

Describe the treatment of schizophrenia

Answer 22

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

Question 23

Describe side effects of treatment of schizophrenia

Answer 23

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

Question 24

Outline the challenges in treating schizophrenia

Answer 24

Patients lack insight, which can affect compliance

To get around this, medication can be given in different ways (eg. depot injection)

Question 25

List factors associated with good prognosis (schizophrenia)

Answer 25

No family history 
Good premorbid function
Acute onset 
Mood disturbance 
Prompt treatment 
Maintenance of motivation

Question 26

List long term complications of schizophrenia

Answer 26

All cause mortality twice as high as general population 
Shorter life expectancy
Greater suicide risk 
Greater risk of violent death
Substance misuse