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Flashcards in Conditions Deck (150):

Name the 3 core symptoms of depression?

Low mood, anhedonia (loss of pleasure in activities) and anergia (loss of energy)


How would you describe the low mood?

Constant, diurnal variation (worse in morning, better at night)


Name 8 other (non-core) symptoms of depression?

Lack of libido, lack of sleep, lack of appetite, weight loss, lack of concentration, feelings of hopelessness for future, feelings of guilt, loss of confidence


How do you describe the sleep pattern in depression?

Early morning wakening (waking up 3/4 hours before alarm) and not getting back to sleep. Or initial insomnia


How would you diagnose mild depression?

2 out of 3 core symptoms. and 2-3 other symptoms. Very mild impact on functioning


How would you diagnose moderate depression?

2 out of 3 core symptoms and 4 other symptoms. Marked impact on functioning


How would you diagnose severe depression?

3 out of 3 core symptoms and 5 other symptoms. Severe impact on functioning.


What are important negatives to rule out before diagnosing depression?

Bipolar?- any episodes of elated mood etc. Drug/alcohol induced? Psychosis?- any hallucinations etc


Name 5 risk factors for depression

Unemployed, chronic physical illness, genetic, childhood trauma eg. abuse/loss of parental care, personality- anxious, obsessional, low self esteem


Name 5 risk factors for depression?

Unemployed, chronic physical illness, genetic, childhood trauma eg. abuse/loss of parental care, personality- anxious, obsessional, low self esteem


What is the cause of depression?

Decreased serotonin function (& GABA, dopamine, noradrenaline)


What is the first line treatment of depression (& mild depression)?

CBT, self help, group therapy, IAPT


What is the 2nd line treatment of depression (& moderate depression)?

psychological therapies AND antidepressants


What is the first line anti-depressant used? and why? and give 3 examples

SSRIs eg. citalopram, sertraline, fluoxetine. They are first line because they are the safest in an overdose.


What is the mechanism of action of SSRIs?

They stop the re-uptake of serotonin by inhibiting the re-uptake pumps leaving more free serotonin in the synapse


Name 4 side effects of SSRIs?

sexual dysfunction, weight loss, D&V, hyponatraemia


What is the main thing to tell patients before starting them on anti-depressants?

That they will feel worse initially before they get better


What are the 2nd line anti-depressants used? (2) and give examples

Mirtazipine, SNRIs - venlafaxine, duloxetine


How does mirtazipine work?

It's a NASSA (noradrenergic and specific serotonergic antidepressant). Antagonist to adrenergic and serotonergic receptors to increase it's neurotransmission (adrenergic receptors are inhibitory)


How long does it generally take anti-depressants to work?

Around 4 weeks.


How do SNRIs work?

Selective noradrenaline reuptake inhibitors- Inhibit the re-uptake pumps and noradrenaline transporter increasing the amount of free noradrenaline in the synapse


Name 3 side effects of mirtazipine.

Drowsiness, weight gain, dry mouth


Name 3 side effects of SNRIs

Sexual dysfunction, nausea, insomnia


Name 3 TCAs

Amitryptilline, nortryptilline, clomipramine


How do TCAs work?

Block both serotonin and noradrenaline pumps to increase the amount of free serotonin and noradrenaline. But also blocks muscarinic and cholinergic receptors


Name 4 side effects of TCAs?

Constipation, dry mouth, blurred vision, urinary retention 'can't shit, can't spit, can't see, can't pee'


Name 2 MAOIs

Rasagiline, phenelzine


How do MAOIs work?

Block the monoamine oxidase enzyme to stop the breakdown of monoamines - higher levels of serotonin and noradrenaline in the synapse


Why are MAOIs potentially dangerous?

Tyramine is a monoamine present in many things and is a potent vasoconstrictor. It is not broken down due to MAOIs so can cause hypertensive crisis.


What are 3 side effects of MAOIs?

Constipation, headache, postural hypotension


Why are MAOIs not used as much anymore?

Lots of dietary restrictions - couldn't eat foods with tyramine in eg. beer, white wine, cheese, smoked meat/fish


What is the leading cause of maternal death post partum?



What is discontinuation syndrome?

Symptoms that occur when antidepressants are stopped abruptly or the dose is decreased too quickly


What symptoms do you get in discontinuation syndrome?

GI disturbances, flu like symptoms, anxiety, sweating, dizziness, electric shocks down spine and neck


What 2 drugs are the main culprits of discontinuation syndrome and why?

Venlafaxine and paroxetine- they have the shortest half lives so are excreted from the body very quickly


When are patients deemed to be treatment refractory on anti-depressants?

When 2 or more anti-depressants haven't worked


How do you treat treatment refractory depressed patients

Combine anti-depressants, Mood stabiliser- lithium, anti-psychotics, Vortioxetine (serotonin modulator), ECT


When is ECT indicated?

For severe depression- when medication hasn't worked and it is becoming potentially life threatening


What is the mechanism of action of ECT?

Unknown. Think maybe it increases release of neurotransmitters or enhances response of post-synaptic receptors to neurotransmitters


Name 6 side effects of ECT

Memory loss, confusion, drowsiness, headache, nausea , aching muscles, loss of concentration in longer term


Define 'bipolar disorder'

A disorder characterised by 2 or more episodes of alternating mood - either elated with increased energy (mania) or low mood with decreased energy (depression)


Define Bipolar I disorder

Mania and depression (sometimes only mania)


Define Bipolar II disorder

More episodes of depression and only hypomania


Give 7 symptoms of mania

'DIGFAST': distractibility, indiscretion (impaired judgement and reduced social inhibitors), grandiose delusions (can be psychotic sx= diagnostic of mania), flight of ideas, activity increase, sleep deficit/increased sexual activity, talkative (pressure of speech)


What is the difference between mania and hypomania?

Hypomanic symptoms last 4+ days, manic sx last over a week. Hypomania only partially affects functioning, mania fully affects the patient's functioning and life


What is cyclothymia?

Disorder similar to bipolar but they have milder symptoms so switch between episodes of mild depression and hypomania


What is the gold standard treatment of Bipolar? (medication)

Lithium. Works best on mania and works to reduces relapses


How does Lithium work?

Mechanism of action is unknown. Thought to inhibit cAMP production (which inhibits monoamines), overall increasing monoamines


Why is it important to monitor drugs and diet etc while on lithium?

Anything that causes the body to lose sodium and water can be damaging because lithium already causes water loss and can lead to toxicity eg. Diuretics, NSAIDs, ACEi low salt diet,


Name 6 side effects of Lithium

LITHIUM: diabetes insipidus, fine tremor, hydration - increased thirst and polyuria, increased GI disturbances, underactive thyroid (hypothyroidism), metallic taste in mouth


What 3 aspects need careful monitoring when on Lithium?and when are they checked?

Lithium levels- every week until the dose is stable, on every dose change and 3 monthly once stable. Thyroid function at the start and every 6 months. Renal function at the start and every 6 months


What is the biggest risk while on lithium?

Lithium toxicity


What level does lithium have to be to be toxic?

>1.5 mmol/L


Name 4 causes of lithium toxicity

Overdose, sudden dehydration, diarrhoea and vomiting,, new drugs/interactions eg. NSAIDS, diuretics, ACEi, change in salt level in diets


Name 6 symptoms of lithium toxicity

Coarse tremor, diarrhoea, vomiting, myoclonic jerks, seizures, confusion


Between what ages is the commonest onset of schizophrenia?

15-35 years old


What is the cause of schizophrenia?

Overactivation of dopamine receptors leading to excessive dopamine production


Name 3 risk factors of schizophrenia?

Birth injury - such as infant hypoxia or viral infections in pregnancy, substance misuse especially cannabis, childhood/family dysfunction


What is the definition of schizophrenia?

A disorder characterised by a distortion in thinking and loss of contact with reality.


Name the first rank symptoms of schizophrenia?

3rd person auditory hallucinations 'running commentary', delusional perceptions (delusions of reverence), passivity phenomena, thought alienation- thought insertion, thought withdrawal, thought broadcast


What is the definition of delusional perceptions?

A true perception to which a patient has attributed a false meaning eg. patient will see the traffic light turn green and believe the government is after them


What is the definition of passivity phenomena?

The belief that external agents are controlling the patient's thoughts and movements.


What is the definition of thought insertion?

Patient's believe that thoughts are being put into their head by external agents


What is the definition of thought withdrawal?

Patients' believe that thoughts are being taken out of their head by external agents


What is the definition of thought broadcast?

Patients believe that everyone around them can hear what they are thinking


Name 5 secondary symptoms of schizophrenia?

Delusions. 2nd person auditory hallucinations, hallucinations in any other modality eg. tactile, visual. Negative symptoms- apathy, blunted emotional responses, social isolation, poverty of speech, self-neglect. Catatonic behaviour- either motor rigidity or severe excitement.


How do you diagnose schizophrenia?

Need 1 first rank symptom lasting 1 month or more


What investigations would you do when a patient presents with a mental illness?

FBC- WCC, U&Es, CRP/ESR, glucose, urine drug screen, LFTs, TFTs. CT/MRI brain- exclude structural causes. ECG.


What examinations would you do when a patient presents with a mental illness?

Cardiac exam- listened to heart sounds, respiratory exam- any infection? normal breath sounds. Neurological exam- any neurological sx from any disorders? Abdominal- any masses? Urological- UTI eg


How do typical anti-psychotics work?

They antagonise dopamine 2 receptors so artificially decrease the amount of dopamine in the brain


Name 4 typical/first generation anti-psychotics?

Haloperidol, chlorpromazine, sulpiride, prochlorperazine


Name 6 atypical/2nd generation anti-psychotics?

Clozapine, Amisulpiride, Quetiapine, Olanzipine, Risperidone, Aripriprazole


How do atypical anti-psychotics work? And why are they more advantageous?

They block dopamine 2 and serotonin (5HT) receptors which reduce the number of EPSEs


When is clozapine used?

For treatment resistant schizophrenia.


When are patients declared treatment resistant and requiring clozapine?

When 3 antipsychotics have been tried and failed


What is the biggest risk to the patient when on clozapine?

Agranulocytosis so need mandatory monitoring of FBC monthly


Name 3 other side effects of clozapine (other than agranulocytosis)

Constipation, myocarditis, hyper salivation


What are the side effects of first gen/typical anti-psychotics? (4)

ESPEs - acute dystonic reaction, tardive dyskinesia, Parkinsonism, akathisia


What are the symptoms of acute dystonic reaction? (3)

Sustained involuntary muscular contractions affecting any part of body eg. Muscle spasm, ocular gyrate crisis (eyes rolled up), acute torticollis (twisted neck)


How do you treat acute dystonic reaction?

ABCDE. Treat with fluids and IV anticholinergics- procyclidine (blocks Ach so stops parasympathetic impulse causing s/m contraction)


What are the symptoms of tardive dyskinesia? (3)

Tongue protrusion, lip smacking, grimacing


How do you treat tardive dyskinesia?

Stop the anti-psychotic.


What are the symptoms of Parkinsonism (4)

Bradykinesia, resting tremor, rigidity, shuffling gait


How do you treat the symptoms of Parkinsonism?

Change the anti-psychotic/reduce dose, anticholinergic- procyclidine


What are the symptoms of akathisia?

'inner restlessness', pacing, agitation


How do you treat akathisia?

Change anti-psychotic/ reduce dose to lowest possible, may need propranolol


What are the side effects of atypical/2nd generation antipsychotics (9)

They are more anticholinergic side effects - dry mouth, constipation, blurred vision, urinary retention, palpitations, weight gain, diabetes, erectile dysfunction, HYPERPROLACTINAEMIA


What are 2 emergency side effects of antipsychotics?

Long QT syndrome, neuroleptic malignant syndrome


Name 7 things that need regularly monitoring while on antipsychotics

Bloods- FBC, U&E, Lipids, HbA1c, LFTs. ECG- long QT, prolactin, BP, weight, efficacy and adherence, side effects


What psychological treatment is used in schizophrenia?

CBT, family therapy, substance misuse clinic (if needed), social- housing, occupation


What is schizoaffective disorder?

Condition which has symptoms of a mood disorder and psychotic symptoms at the same time with the same intensity


How do you treat schizoaffective disorder?

With antipsychotics and a mood stabiliser


What is the triad of symptoms in serotonin syndrome?

Autonomic hyperactivity- tachycardia, sweating. neuromuscular abnormality- hyperreflexia, clonus, tremor. Mental state change- confusion, anxiety, agitation


What is the cause of serotonin syndrome?

Excessive stimulation of serotonin receptors. Can be due to normal drug dose, overdose, drug interactions


What drugs cause serotonin syndrome?

Antidepressants- SSRIs, TCA. analgesics- tramadol, pethidine. Recreational- amphetamine, cocaine. Anti-emetics


What investigations would you do in someone presenting with symptoms of serotonin syndrome?

Toxicology screen to find cause. Diagnosis is clinical.


How do you treat serotonin syndrome?

If mild- supportive tx: IV fluids and benzodiazepines for agitation. If severe- ITU for ventilatory support and sedation


What is the cause of neuroleptic malignant syndrome?

Greatly reduced function and amount of dopamine. Side effect of anti-psychotics.


What are the symptoms of neuroleptic malignant syndrome?

Fever, muscle rigidity- dyspnoea, dysphagia, difficulty walking, altered mental state- confusion, agitation, autonomic dysfunction- pallor, tachycardia, sweating


What is the main sign found on investigation in neuroleptic malignant syndrome

Very raised creatinine kinase


What is the treatment of neuroleptic malignant syndrome?

Supportive- IV fluids, cooling blankets for fever, Benzos for agitation. Dopaminergic drugs eg. bromocriptine.


What is the definition of personality disorder?

Prevailing, chronic, abnormal disturbances in personality and behaviour


Name 4 characteristics of a paranoid PD?

Suspicious of others, holds grudges, distrusting, preoccupied with conspiratorial explanations


Name 4 characteristics of a schizoid PD?

Emotionally cold- withdrawn from others and can't show emotion. Socially isolated- no interest in others. Prefer to be in a fantasy world. Excessive introspection.


Name 4 characteristics of a dissocial PD?

Aggressive, callous unconcern for other people, lack of guilt for what they've done, criminal activity is common


Name 4 characteristics of borderline (emotionally unstable) PD?

Unpredictable mood and affect- prone to outbursts of emotion, unclear sense of self/aims, unstable/intense relationship. Pseudohallucinations. Self harm/suicide attempts.


Name 4 characteristics of borderline (impulsive) PD?

Impulsive behaviour- acts without thought for consequences, unpredictable mood and affect- prone to outbursts. Inability to control anger- lash out. Tendency to conflict with others.


Name 4 characteristics of a histrionic PD?

Over-dramatise with exaggerated expression of emotions self-centred, seeks attention and excitement, manipulative behaviour, easily hurt feelings


Name 4 characteristics of anankastic PD?

(Obsessive compulsive) Worries and doubts, perfectionist, repeated checking and preoccupation with details, rigidity and stubbornness


Name 4 characteristics of an anxious PD?

Feelings of tension/anxiousness, fear of rejection- wants to be liked, insecure, tendency to avoid everyday situations by exaggerating dangers of it.


Name 4 characteristics of a dependent PD?

Reliance on other people, clingy and submissive to wishes of others, fear of abandonment, feels helpless and incompetent (especially when not in relationship)


What are 5 risk factors/causes of developing PD?

Growing up : Abuse (physical, sexual, verbal), neglect, trauma eg. death of parent, unstable family life- parent is alcoholic/ mental health issues, being bullied


What is the main treatment of PD? and how does it work?

DBT- dialectical behavioural therapy. Emphasis on developing coping skills to improve affective stability and impulse control and on reducing self-harm behaviours


Are medications useful in PD?

Useful in symptom management eg. aggression- short term benzodiazepines, mood stabilisers- antipsychotics, antidepressants if comorbid depression


What is the definition of anxiety disorder?

Excessive anxiety (feeling fearful, worried and tense) constantly, across different situations and lasting >6 months


What are 7 symptoms of anxiety?

Insomnia, feeling fearful, worried and tense in all situations, irritability, poor concentration, Sweating, nausea, hyperventilation, dependence on 1 person, avoidance


What are 3 causes of anxiety?

Stress at work/home eg. lots of work/relationship troubles, genetics, stressful events- lost job, moving house etc


What is the first line treatment of anxiety?

Symptom control. Regular exercise, mediation. Psychological therapies.


Name 3 psychological therapies that can be used in the treatment of anxiety?

CBT with relaxation. Progressive relaxation training- teaches deep breathing and relaxing muscles. Behavioural therapy- with exposure to anxiety provoking stimuli


Name the first line medication given for anxiety?

SSRIs- eg. sertraline or benzodiazepines eg. diazepam (but only in short term bursts)


What other medications (not first line) given for anxiety?

Pregabalin. 2nd line- SNRI/TCA. Beta blockers can be used to treat physical symptoms of anxiety eg. sweating ,palpitations, tremor.


Define panic disorder

Acute onset of intense panic and anxiety symptoms that don't usually last longer than 20 minutes


Name 6 physical symptoms that occur in panic disorder?

Palpitations, tachypnoea, chest pain, dry mouth, choking, dizziness


Name 5 psychological symptoms that occur in panic disorder?

Feeling of impending doom, fear of dying ,fear of losing control, depersonalisation (thoughts/feelings don't belong to them), derealisation (altered perception that world isnt real)


Define OCD.

Obsessive compulsive disorder. Patient will have obsessive thoughts and do compulsive acts and will try to be resisted by patient initially.


What are obsessions?

Stereotyped, purposeless words or thoughts eg. if dont wash hands 40 times a day ,she will get a severe infection


What are compulsions?

Sensless repeated rituals eg. repeated hand washing


Name 3 characteristics about the obsessions

Irrational (recognised by pt), repetitive and intrusive


What are the 3 most common compulsions?

Checking things repeatedly, counting and washing


How do you diagnose OCD?

Obsessions/compulsions on most days for at least 2 weeks and interfering with life - usually by wasting time


What is the pathophysiology behind OCD?

Abnormalities in orbitofrontal cortex and caudate nucleus


What are 5 causes of OCD?

Genetics, developmental factors- abuse, neglect, bullying. Stress eg. pregnancy. Personality characteristics- obsessive type. Neurological conditions- frontotemporal dementia/ tumour


Which psychiatric patients are at risk of OCD? (4)

Depression, anxiety ,substance misuse, eating disorders


What is first line treatment for OCD?

CBT- exposure and response prevention. Expose them to the trigger.


What is the medication treatment for OCD?

First line- SSRI eg. fluoxetine. or Clomipramine - TCA


What is the definition of a phobia?

Anxiety that is experienced only/predominantly in situations that aren't dangerous


When does a phobia become a phobic disorder?

When it begins to significantly impair function


Name 4 symptoms of phobia

Palpitations, feeling faint, losing control, fear of dying


What is agoraphobia?

Fear of big areas eg. crowds, supermarkets, travel, events away from home. They fear something bad will happen so tend to avoid this.


What are social phobias? What are 3 symptoms?

Triggered by certain situations eg. small dinner party. Worried about judgement from other people. Sx= blushing, hand tremor, nausea


What is a simple phobia?

Phobia is triggered by certain situations only eg. spiders, clowns, heights, small spaces


What is the main treatment for a phobia?

Exposure therapy


What is the definition of acute stress reaction?

It's a transient condition that develops as a response to exceptional physical/ mental stress that usually lasts hours-days.


What are the symptoms of acute stress reaction?

Immediate dissociation- disorientated, loss of attention, decreased consciousness. Followed by mixed emotions -anger, anxiety, confusion


What is the treatment for acute stress reaction?

TRICK QUESTION! Sx usually resolve without intervention


What is PTSD?

Post traumatic stress disorder. It develops after an exceptionally stressful, life threatening or catastrophic event.


Name 7 symptoms of PTSD.

Flashbacks in day time and nightmares replaying the past trauma, hypervigiliance, insomnia, paranoia, detachment from others, anhedonia, poor concentration, suicidal thoughts


What is the pathophysiology of PTSD?

Failure to inhibit amygdala which is responsible for fear and decreased amygdala threshold for fearful stimuli


What is the first line treatment for PTSD?

Trauma focused CBT. Eye movement desensitisation and reprocessing (uses rhythmic eye movements to decrease anxiety associated with traumatic events), Anxiety management, relaxation/de-stress techniques.


What medications can be given for PTSD?

SSRI- fluoxetine! Mirtazipine. Benzos can be given for sleep and irritability- short term.