Depression and Anxiety Flashcards
(173 cards)
1
Q
Define inequality.
A
• Inequality = lack of equality, fairness or evenness
2
Q
Describe the term health inequalities.
A
• Health inequalities = systematic, avoidable and unfair differences in health outcomes observed between populations, social groups or gradients across population ranked by social position
3
Q
List 3 key areas of the Black Report.
A
Artefact explanations
Natural/Social Selection
Materialist explanations
Cultural/Behavioural Explanations
4
Q
Give two socioeconomic ranking systems.
A
- NS-SEC
• 1-9 (9 is full-timer students): Descending ‘importance’
• 1: Higher managerial administrative/Professional Occupations
• 2: Lower managerial administrative/Professional Occupations
• 7: Routine occupations: Cleaners, Refuse collectors - SIMD
• Area measure using: income, employment, education, health, access to services, crime and housing
• SIMD1-5
5
Q
Name two examples of people who have changed the face of Public Health. Give the example to accompany the individual.
A
Ada Salter (Improvements in landscape of Bermondsey)
Aneurin Bevan (NHS 1948)
6
Q
Outline 3 waves of Public Health.
A
• Cultural: Culture for health
• Social: Social determinants**
• Clinical: Lifestyle-related diseases
• Biomedical: ABX/vaccines/interventions
• Structural: Clean water/Sewers/Drainage and policy/systemic/organisational
-> Structural Competence: Identification of inadequacies within a healthcare system
7
Q
Give 3 benefits of Medicating for Psychiatric illness.
A
- Quickly prescribed
- Available
- Measurable effects
8
Q
Give 3 negatives of Medicating for Psychiatric illness.
A
- Cost
- Side-effects
- Withdrawal effects
- Disenfranchised patients (‘by-stander’)
9
Q
List 3 non-pharmacological approaches to the management of Psychiatric illness.
A
- Physical Exercise
- Bibliotherapy (reading books)
- Self-support groups
- Counselling
- Psychotherapy: CBT/Mindfulness
10
Q
Describe CBT.
A
Type of psychotherapy focusing on behaviours, thoughts and feelings and teaching coping skills for dealing with different problems – focus on behavioural therapy. Combination of cognitive therapy and behavioural therapy.
11
Q
Outline the Cognitive Triangle
A
• Cognitive Triangle: Behaviour, Feelings and Thought
- Behave ≈ thoughts about something ≈ feelings about something
- E.g. Fail exam ≈ knew I wasn’t good at something ≈ feel hopeless + dreadful
- Core Beliefs (about self): Yourself, others and future (all interlinked)
12
Q
List 3 of the thought distortions.
A
Mnemonic: SAM-MOP
Self-Abstraction: Conclusion from one
Arbitrary interference: Conclusions with no evidence
Minimisation: Downplay achievements
Magnification: Overplay worries
Overgeneralisation: Sweeping generalisations
Personalisation: Self-blame
13
Q
Give the 2 psychiatric conditions for which CBT is NICE recommended.
LIst 3 others.
A
- Anxiety/Panic Attacks***
- Depression***
- Bipolar
- Eating problems
- OCD
- Phobias
- PTSD
- Psychosis
- Schizophrenia
14
Q
List 5 potential issues with the provision and conduction of CBT.
A
- Staff: Who, What, Why, Personal Specification
- Training and Accreditation: Quality maintained and training provision
- Position in NHS service: Public vs Private provision
- Medical training required: No, but useful even in other practices
- Abuse and neglect:
- Supervision
- Relapse rates
- Tailoring of interventions
- Manualised or flexible
- Group or individual
- Booster sessions
- Internet
15
Q
What is mindfulness?
A
Type of psychotherapy using mindfulness (awareness of thoughts, feelings and actions hindering daily life) to promote good mental, physical and social healthy. Can often be couples with other therapies – CBT, ACT etc.
16
Q
Outline the MOA of MOAi.
A
• Inhibit MAO enzymes ≈ reduce breakdown of NE/serotonin and dopamine ≈ increase levels of serotonin/dopamine/NE
17
Q
Which of the following is an MOAi?
A. Sertraline
B. Fluoxetine
C. Nortryptaline
D. Selegiline
A
D. Selegiline
18
Q
Which of the following is an MOAi?
A. Sertraline
B. Duloxetine
C. Venlofaxine
D. Phenelzine
A
D. Phenelzine
19
Q
Which of the following is an MOAi?
A. Sertraline
B. Tranylcypromine
C. Venlofaxine
D. Duloxetine
A
B. Tranylcypromine
20
Q
List a MAOi.
A
- Phenelzine
- Selegiline
- Tranylcypromine
21
Q
List 3 side effects of MAOi.
A
- Weakness
- Headache
- Weight gain
- Dizziness
- Fatigue
- Impotence
22
Q
Give the main prescribing points of an Rx of a MAOi.
A
- Not used with SSRI/TCA + Opioids (morphine/tramadol) –> increase serotonin to high levels = Confusion, hypertension, tremor, coma and death i.e. neuroleptic malignant syndrome
- 14 days washout before starting other antidepressants
- High-tyramine foods (cheese/venison/meats/alcohol/green vegetables) –> hypertensive crisis
23
Q
Which of the following is a RIMA?
A. Sertraline
B. Tranylcypromine
C. Selegeline
D. Moclobemide
A
D. Moclobemide
24
Q
Name a RIMA.
A
Moclobemide
25
How does a RIMA work?
• Reversible inhibition of MAO type A reduce breakdown of NE/serotonin and dopamine ≈ increase levels of serotonin/dopamine/NE
26
List 3 side effects of a RIMA.
* Weakness
* Headaches
* Dizziness
* Fatigue
* Weight gain
* Impotence
27
Outline the main prescribing points for a RIMA.
* Reduced effect of tyramine (alcohol/meat – venison/green vegetables/cheese)
* Short acting thus 7 days prior to change to another antidepressant
28
Which of the following is a TCA?
A. Sertraline
B. Amitryptiline
C. Selegeline
D. Moclobemide
B. Amitryptiline
29
Which of the following is a TCA?
A. Sertraline
B. Fluoxetine
C. Nortryptiline
D. Moclobemide
C. Nortryptiline
30
Which of the following is a TCA?
A. Sertraline
B. Fluoxetine
C. Imipramine
D. Moclobemide
C. Imipramine
31
Which of the following is a TCA?
A. Sertraline
B. Fluoxetine
C. Clomipramine
D. Moclobemide
C. Clomipramine
32
Which of the following is a TCA?
A. Duloxetine
B. Diazepam
C. Lofepramine
D. Moclobemide
C. Lofepramine
33
Outline the MOA of TCAs
• Inhibit re-uptake of NE and Serotonin via blocking transporters (5-HT re-uptake transporter/ NE re-uptake transporter/ mAChR) responsible for re-uptake and block action of ACh (anti-cholinergic) ≈ increase [NA] + [Serotonin] in synapses
34
List 3 uses for TCAs.
* Depression
* Anxiety
* OCD
* Chronic pain
* Neuralgia
* IBS
* Nocturnal enuresis
* PTSD
35
Give 5 side effects of Amitriptyline.
* Blurred vision
* Dry mouth
* Constipation
* Bronchodilation
* Reduced bronchial secretions
* Urinary retention
* Weight gain/loss
* Hypotension
* Rash
* Hives
* Tachycardia
36
Which of the following should you be cautious of when prescribing amitriptyline?
A. A healthy individual
B. A patient with IBD
C. A patient with anxiety in low dose to prevent OD
D. A patient with CVD
D. A patient with CVD
• Caution with CVD due to arrhythmias
37
Which of the following should you be cautious of when prescribing amitriptyline?
A. A healthy individual
B. A patient with IBD
C. A patient with severe depression who has attempted suicide recently
D. A patient with compensated liver failure
C. A patient with severe depression who has attempted suicide recently
• Check amount prescribed in pt with suicidal ideation --> suicide risk
38
What is the mechanism of action of SSRIs?
• Bind to Serotonin re-uptake transporter ≈ reduce reuptake ≈ increase [Serotonin]
- > Weak affinity for NE and DA transporters thus fewer side-effects
- > 5-HT (serotonin) receptors in peripheral and central nervous systems with both excitatory and inhibitory neurotransmission mediating release of numerous NTs: GABA/Dopamine/Epinephrine/Norepinephrine/Acetylcholine
- > Influence: Aggression/Anxiety/Cognition/Learning Memory/Mood and Sleep
39
List 3 SSRIs.
* Citalopram
* Escitalopram
* Paroxetine
* Sertraline
* Fluoxetine
40
Which of the following SSRIs is most likely to precipitate LQTS?
A. Sertraline
B. Escitalopram
C. Citalopram
D. Fluoxetine
C. Citalopram
41
Which of the following SSRIs is most likely to precipitate sleep difficulties?
A. Sertraline
B. Escitalopram
C. Citalopram
D. Fluoxetine
D. Fluoxetine
42
List 5 side effects of SSRIs.
```
• Nausea
• Rash
• Muscle aches
• Insomnia*** -> Sleep difficulties (Fluoxetine)
• Aggression
• Anxiety
• Cognition
• Learning memory
• Mood
• Sleep
• Sweating
• Epilepsy
No driving for 12 months (be weary)
```
* Reduced libido
* Sexual dysfunction
• LQTS (Citalopram)
• Haemorrhage
• GI bleed risk increased
-> Raynaud’s Disease off license and Systemic Sclerosis ≈ improve blood flow
• Overdose
• Suicide
-> Do not prescribe for u18s unless Consultant Supervision
43
What is the MOA of an SNRI?
• Serotonin Norepinephrine Reuptake Inhibitor (SNRI) -> Bind Serotonin and Norepinephrine Re-Uptake Transporters -> increase [Serotonin] + [Norepinephrine]
44
Which of the following is an SNRI?
A. Sertraline
B. Duloxetine
C. Citalopram
D. Fluoxetine
B. Duloxetine
45
Which of the following is an SNRI?
A. Sertraline
B. Venlafaxine
C. Citalopram
D. Fluoxetine
B. Venlafaxine
46
Which SNRI is indicated for social phobia?
A. Sertraline
B. Venlafaxine
C. Duloxetine
D. Fluoxetine
B. Venlafaxine
47
Which SNRI is indicated for stress urinary incontinence?
A. Sertraline
B. Venlafaxine
C. Duloxetine
D. Fluoxetine
C. Duloxetine
48
Which SNRI is indicated for neuropathic pain?
A. Sertraline
B. Venlafaxine
C. Duloxetine
D. Fluoxetine
C. Duloxetine
49
Which SNRI is indicated for panic?
A. Sertraline
B. Venlafaxine
C. Duloxetine
D. Fluoxetine
B. Venlafaxine
50
List 5 side effects of SNRIs.
* Nausea
* Headaches
* Insomnia
* Hypersomnia/Drowsiness
* Dizziness
```
Low % of Anticholinergic effects
• Dry mouth
• Sweating
• Blurred vision
• Constipation
```
51
What is the main prescribing point for a patient on SNRIs?
• Metabolised in liver --> desvenlafaxine (CP206 isoenzyme)
52
Name a Tetracyclic antidepressant.
• Mirtazapine
53
Which of the following is tetracyclic antidepressant?
A. Sertraline
B. Mirtazapine
C. Duloxetine
D. Fluoxetine
B. Mirtazapine
54
Outline the MOA of a Tetracyclic Antidepressant.
• Presynaptic alpha-2 adrenoceptor antagonist ≈ increase [NE] + [5-HT]
55
List 3 side effects of Tetracyclic Antidepressants.
Orexigenic
Weight gain
Drowsiness
Stimulant
56
Which is most likely to occur at a 15mg dose of Mirtazapine?
A. Tachycardia
B. Insomnia
C. Somnolence
D. Loss of libido
C. Somnolence
57
Which is most likely to occur at a 30mg dose of Mirtazapine?
A. Bradycardia
B. Insomnia
C. Somnolence
D. Loss of libido
B. Insomnia
58
Outline the main prescribing points for Tetracyclic antidepressants.
* 15mg: sedative thus take at night
| * 30mg: stimulant thus take in morning
59
Which drug is most likely to precipitate LQTS?
A. Sertraline
B. Citalopram
C. Mirtazapine
D. Duloxetine
B. Citalopram
60
Which of the following user groups is most likely to experience LQTS when prescribed Citalopram?
A. Males
B. Young people
C. Elderly
D. SE Asian
C. Elderly
61
Which of the following user groups is most likely to experience LQTS when prescribed Amitriptyline?
A. Males
B. Young people
C. Women
D. SE Asian
C. Women
62
Which of the following user groups is most likely to experience LQTS when prescribed Amitriptyline?
A. Males
B. Young people
C. Previous history of CVD
D. SE Asian
C. Previous history of CVD
63
What is tolerance best described as?
A. Induces reward thus required
B. Has adverse effects when stopping
C. Reduced effect with time
D. Acceptance of change
C. Reduced effect with time
64
What is withdrawal best described as?
A. Induces reward thus required
B. Has adverse effects when stopping
C. Reduced effect with time
D. Acceptance of change
B. Has adverse effects when stopping
65
What is dependence best described as?
A. Induces reward thus required
B. Has adverse effects when stopping
C. Reduced effect with time
D. Acceptance of change
A. Induces reward thus required
66
Outline the MOA of benzodiazepines.
Bind BZD binding site on pentameric GABA (GABRA1-3/GABRB1-2) ≈ Cl- ion influx ≈ hyperpolarisation
67
Binding to which of the following receptor subunits will induce somnolence?
A. GABAa2
B. GABAa1
C. GABAb1
D. GABAb2
B. GABAa1
68
Binding to which of the following receptor subunits will induce anxiolytic effects?
A. GABAa2
B. GABAa1
C. GABAb1
D. GABAb2
A. GABAa2
69
Binding to which of the following receptor subunits will induce anxiolytic effects?
A. GABAa3
B. GABAa1
C. GABAb1
D. GABAb2
A. GABAa3
70
List 3 examples of benzodiazepines.
* Diazepam
* Lorazepam
* Loprazolam
* Nitrazepam
* Temazepam
71
Which of the following benzodiazepines have the fasted speed of onset?
A. Chlordiazepoxide
B. Diazepam
C. Lorazepam
D. Temazepam
B. Diazepam
72
Which of the following benzodiazepines have the slowest speed of onset?
A. Chlordiazepoxide
B. Diazepam
C. Lorazepam
D. Temazepam
A. Chlordiazepoxide
73
Which of the following benzodiazepines have the slowest speed of onset?
A. Chlordiazepoxide
B. Zaleplon
C. Lorazepam
D. Temazepam
B. Zaleplon
74
What are the uses of benzodiazepines?
* Anxiolytics
* Insomnia (sleep assistance)
* Acute alcohol withdrawal
* Enable uncomfortable diagnostic and therapeutic procedures
* Anticonvulsant
75
Outline the pharmacokinetics of Benzodiazepines.
• Lipophilic -> Absorbed well orally (1/2-2 hours) -> Protein bound (95%) -> Hepatic metabolism (CP450) -> Active metabolites (high T1/2) -> Excreted as glucuronide conjugate -> Renal excretion
76
List the side effects of Benzodiazepines.
• Tolerance: Sedative >>> Anxiolytic/Anticonvulsant via desensitization of inhibitory GABA receptors + sensitization of excitatory NMDA receptors
- GABA desensitized
- NMDA sesnitised
• Dependence: Elicits rewarding feeling suggestive of physical or physiological dependence
• Withdrawal effects
Anxiety/sleep disturbance/ mood changes/ stiffness/ muscle aches/ convulsions)
77
List 3 Z drugs.
- Zopiclone
- Zolpidem
- Zaleplon
78
What are the uses of Z-drugs?
* Anxiolytics
* Insomnia (sleep assistance)
* Acute alcohol withdrawal
* Enable uncomfortable diagnostic and therapeutic procedures
* Anticonvulsant
79
Outline the MOA of Z-drugs.
• Binds GABAa receptor (GABA-A1-2) ≈ Cl- influx ≈ hyperpolarize ≈ reduced AP chance
80
Outline the major pharmacodynamic effects of Z-drugs.
* Anxiolytic (a2 + a3 of GABA)
* Hypnotic (a1 GABA)
* Reduced muscle tone
* Anterograde amnesia
* Anticonvulsant effect
81
Which of the following is a Z-drug?
A. Chlordiazepoxide
B. Zaleplon
C. Lorazepam
D. Temazepam
B. Zaleplon
82
Which of the following is a Z-drug?
A. Chlordiazepoxide
B. Zopiclone
C. Lorazepam
D. Temazepam
B. Zopiclone
83
Which of the following is a Z-drug?
A. Chlordiazepoxide
B. Zolpidem
C. Lorazepam
D. Temazepam
B. Zolpidem
84
During tolerance to drugs, which of the following happens?
A. NMDA desensitised, GABA sensitised
B. GABA desensitised, NMDA sensitised
C. Kainate desensitised, AMPA sensitised
D. AMPA desensitised, Kainate sensitised
B. GABA desensitised, NMDA sensitised
85
Which Questionnaire system can be used to assess someone's Alcohol Dependence?
A. RAGE
B. CAGE
C. SAGE
D. BEIGE
B. CAGE
CAGE:
• Cut Down?
• Annoyed by people criticizing drinking?
• Guilty?
• Eye-opener – drinking in the morning/loosen nerves?
86
List 5 symptoms of Acute Alcohol Withdrawal.
* Insomnia
* Anxiety
* Restlessness/Agitation
* Tremor
* Nausea
* Vomiting
* Sweating
* Palpitations
* Hallucinations auditory/visual/tactile
* Seizures
87
What is the management for a patient with acute alcohol withdrawal?
* ABCDE
* Sleep hygiene
* Chlordiazepoxide
88
What is depression?
Depressive orders (MHD), characterized by persistent low mood, anhedonia, neurovegetative disturbance, reduced energy and varying levels of social and biological dysfunction.
89
Mrs. Jones, a 43 year old single mother presents with persistent low mood. She says she has gained 10kg, taking her up to 80kg. She is constantly tired due to poor sleep. Additionally, she recently got a promotion at work however did not feel any enjoyment. She has had thoughts of killing herself but says her children and religion keep her going however she remains pessimistic about the future and her friends.
i) What condition and category does she have?
ii) What is the criteria for this category of disease?
iii) What factors contribute towards Mrs. Jones' placing into this category?
iv) What are her protective factors against suicide?
v) What investigations might you conduct?
vi) What management would you suggest?
i) Severe depression
ii) Major Depressive Disorder: ≥ 5 Sx --> Mild to Severe for 2+ weeks
iii)
- Persistent low mood
- Anhedonia
- Significant weight gain
- Poor sleep
- Suicidal ideation
- Fatigue
- Negative cognitive triad
iv)
- Family
- Religion
- Dependants
v)
• Clinical Diagnosis: DSM-5 Diagnostic Criteria
• Patient Health Questionnaire-2 (PHQ-2): Positive result screens for depression in primary care
* Metabolic Panel: Normal
* FBC: Normal – rule out causes of fatigue e.g. anaemia
* HbA1c
* TFTs: Normal – rule out causes of fatigue e.g. hypothyroidism
* Serum Cortisol: Normal – rule out Cushing’s Disease
* Cobalamin (B12)/Folate (B9): Normal – rule out macrocytic anaemia/paraesthesia/numbness and impaired memory; Normal
* Syphilis Serology
vi)
• Hospital Referral
• SSRI: Citalopram (20mg PO OD); Escitalopram (10mg PO OD)
+
• Benzodiazepine: Lorazepam/Clonazepam/Trazodone
OR
• ECT
+
• SSRI: Citalopram (20mg PO OD); Escitalopram (10mg PO OD)
90
Mr. Taku, a 43 year old single father presents with persistent low mood. He says he has gained 10kg, taking him up to 100kg. He is constantly tired. Additionally, you notice fresh cut marks on his thighs and arms but he says he fell. He has been feeling this way for the last 3 years but didn't want to trouble the doctor.
i) What condition and category does he have?
ii) What is the criteria for this category of disease?
iii) What factors contribute towards Mr. Taku placing into this category?
iv) What are his risk factors for suicide?
v) What investigations might you conduct?
vi) What management would you suggest?
i) Persistent Depressive Disorder
≥ 2 years of ¾ dysthymic symptoms for more days than not
ii) ≥ 2 years of 3/4 dysthymic symptoms for more days than not
iii)
- Persistent low mood
- Significant weight gain
- Fatigue
- Weight gain
- Lasting more than 2 years
iv)
- Male
- Self-harm
- Financial? (single-parent)
v)
• Clinical Diagnosis: DSM-5 Diagnostic Criteria
• Patient Health Questionnaire-2 (PHQ-2): Positive result screens for depression in primary care
* Metabolic Panel: Normal
* FBC: Normal – rule out causes of fatigue e.g. anaemia
* HbA1c
* TFTs: Normal – rule out causes of fatigue e.g. hypothyroidism
* Serum Cortisol: Normal – rule out Cushing’s Disease
* Cobalamin (B12)/Folate (B9): Normal – rule out macrocytic anaemia/paraesthesia/numbness and impaired memory; Normal
* Syphilis Serology
vi)
• SSRI: Citalopram (20mg PO OD); Escitalopram (10mg PO OD); Fluoxetine (20mg PO OD); Sertraline (50mg PO OD); Mirtazapine (15mg PO OD)
+
• Psychotherapy: CBT/Mindfulness
91
What is anxiety?
Generalised anxiety disorder (GAD) is ≥ 6 months of excessive worry about disproportionate everyday issues + 3/6 of the DSM-5 criteria.
92
List 5 risk factors for anxiety.
* FHx
* Female
* Increased stress
* PMHx trauma/emotional trauma
* Comorbid depression
* Substance abuse/dependence
* Other anxiety disorders
93
List the signs and symptoms of anxiety.
* Excessive worry ≥ 6 months
* Poor concentration
* Restlessness
* Irritability
* Sleep disturbance
* Muscle tension
* Fatigue
* Headache
* Sweating
* Dizziness
* GI Symptoms: Nausea/Vomiting/Increased urinary urge/Tenesmus
* Rash
* Muscle aches
* SOB
* Trembling
* Exaggerated startle response
94
List the DSM-5 criteria for anxiety
≥ 6 months of excessive worry AND 3/6 PRISM-F
* Nervousness/Restlessness
* Fatigued
* Poor concentration
* Irritability
* Muscle tension
* Sleep disturbance
95
Mr. Tripp presents with a fast heart rate. O/E there is nothing remarkable. During his social history, you identify he has been consumed by worry for the last 7 months. He has noticed his eczema exacerbated and his rash has appeared in other places. He also notes that he has been restless and irritable, during the day but increasing prior to the evening, disturbing his sleep.
i) What is your differential?
ii) What criteria contribute towards your DDx?
iii) What investigations might you conduct?
iv) What management would you suggest?
i) Generalised Anxiety Disorder
ii) ≥ 6 months + 3/6 DSM-5 criteria
- Irritable
- Restless
- Sleep disturbance
- Tachycardia
- Rash
iii) • Clinical Diagnosis
• TFTs: Normal
--> (if Sx suggestive of Thyroid disease: Weight loss/Exopthalmos/Goitre/PMHx)
• Urine drug screen: Negative
• ECG: Normal sinus rhythm
--> If suggestive of cardiac cause: PMHx/FHx/RFs
• 240hour urine for vanillylmandelic and metanephrines: Normal
--> If severe HTN or Tachycardia, rule out Phaeochromocytoma
iv)
• Lifestyle: Reduce caffeine/Reduce alcohol/Sleep hygiene/Exercise/Self-help
• Psychotherapy: CBT/ Mindfulness
• SSRI/SNRI/Antidepressant: Escitalopram/Duloxetine/Venlafaxine/Sertraline/Fluoxetine/ Mirtazapine
- Consider withdrawal
- Consider SE profile: Nausea/Diarrhea/Insomnia/Sexual dysfunction/Suicidal behavior
• TCA/Gabapentin/Pregabalin: Imipramine/Pregabalin
• Melatonin
96
Mr. Chipotle presents with a fast heart rate. O/E there is nothing remarkable. During his social history, you identify he has been consumed by worry for the last 7 months. This worry is predominantly present in public places, around his friends or wider social circle. He has noticed his eczema exacerbated and his rash has appeared in other places. He also notes that he has been restless and irritable, during the day but increasing prior to the evening, disturbing his sleep.
i) What is your differential?
ii) What criteria contribute towards your DDx?
iii) What investigations might you conduct?
iv) What management would you suggest?
i) GAD + Social Anxiety
ii) ≥ 6 months + 3/6 DSM-5 criteria
- Happens in public/social
- Irritable
- Restless
- Sleep disturbance
- Tachycardia
- Rash
iii) • Clinical Diagnosis
• TFTs: Normal
--> (if Sx suggestive of Thyroid disease: Weight loss/Exopthalmos/Goitre/PMHx)
• Urine drug screen: Negative
• ECG: Normal sinus rhythm
--> If suggestive of cardiac cause: PMHx/FHx/RFs
• 240hour urine for vanillylmandelic and metanephrines: Normal
--> If severe HTN or Tachycardia, rule out Phaeochromocytoma
iv)
• Lifestyle: Reduce caffeine/Reduce alcohol/Sleep hygiene/Exercise/Self-help
• Psychotherapy: CBT/ Mindfulness
• SSRI/SNRI/Antidepressant: Escitalopram/Duloxetine/Venlafaxine/Sertraline/Fluoxetine/ Mirtazapine
- Consider withdrawal
- Consider SE profile: Nausea/Diarrhea/Insomnia/Sexual dysfunction/Suicidal behavior
• TCA/Gabapentin/Pregabalin: Imipramine/Pregabalin
• Melatonin
97
What is the most common age of onset for generalised anxiety disorder?
A. Age 11 to early adulthood?
B. Age 35 to 55?
C. Over age 65?
D. Any age after a significant life stressor
A. Age 11 to early adulthood?
98
A 72 year old widowed woman with osteoarthritis and chronic obstructive pulmonary disease says she is finding life a huge struggle. Everything is a worry and an effort. She cannot face people, is not keeping up with the housework, has lost interest in and stopped watching the TV programmes she used to enjoy, and cannot concentrate on anything. She feels tired all the time and is sleeping poorly. She has always worried about things (paying bills, deciding what to cook, her children and grandchildren, what the neighbours might think), but always previously coped. Now she feels unable to cope and feels like she is sinking, at times becoming uncontrollably tearful.
What is the likely diagnosis?
A. Major depressive disorder
B. Generalised anxiety disorder
C. Social anxiety disorder
D. Generalised anxiety disorder and major depressive disorder
E. Social anxiety disorder and major depressive disorder
D. Generalised anxiety disorder and major depressive disorder
99
A 25 year old single man describes being beset by worries. He describes worries that he is going to harm someone by some violent action, which is completely against his principles. He doesn’t have any sharp knives in his house and avoids being near small children as he considers them more vulnerable to a possible attack by him. You ask him about other worries and he describes feeling anxious around people he doesn't know, worried that he will shake and show he is anxious around them. As a result he does not speak up at meetings at work.
A. Generalised anxiety disorder and obsessive compulsive disorder
B. Generalised anxiety disorder and social anxiety disorder
C. Social anxiety disorder and obsessive compulsive disorder
D. Generalised anxiety disorder, social anxiety disorder, and obsessive compulsive disorder
C. Social anxiety disorder and obsessive compulsive disorder
100
In patients who have comorbid generalised anxiety disorder and depression, which should be treated first as the primary disorder?
A. Treat the generalised anxiety disorder first
B. Treat the depression first
C. Treat first whichever is the more troublesome to the patient
D. Treat both equally
C. Treat first whichever is the more troublesome to the patient
101
You have diagnosed a 35 year old woman working in a high pressure executive role with moderate generalised anxiety disorder, comorbid with mild social anxiety disorder. She identifies the generalised anxiety disorder as most troublesome for her, and you have agreed that this should be the focus of treatment. She has not previously had any treatment for generalised anxiety disorder.
What first line treatment would you recommend?
A. A self help “low intensity” psychological intervention
B. Cognitive behavioural therapy (CBT)
C. Cognitive behavioural therapy (CBT)
D. Medication for generalised anxiety disorder
E. Cognitive behavioural therapy (CBT) or medication for generalised anxiety disorder
B. Cognitive behavioural therapy (CBT)
102
You review the 35 year old woman with moderate generalised anxiety disorder and mild comorbid social anxiety disorder after she has completed a self help online treatment, supported by telephone and email by a psychological wellbeing practitioner. She reports that she has found this useful, but that there has been minimal improvement in her generalised anxiety disorder symptoms.
What further treatment for generalised anxiety disorder would you recommend?
A. An alternative self help “low intensity” psychological intervention
B. Cognitive behavioural therapy (CBT)
C. Medication for generalised anxiety disorder
D. Choice of cognitive behavioural therapy (CBT) or medication for generalised anxiety disorder
D. Choice of cognitive behavioural therapy (CBT) or medication for generalised anxiety disorder
103
Your 35 year old patient, who did not improve following a self help treatment, chooses medication over CBT, as she feels unable to take time away from her high pressured executive job to attend CBT
What medication for her generalised anxiety disorder should you recommend?
A. A benzodiapine
B. A selective serotonin reuptake inhibitor (SSRI)
C. A serotonin noradrenaline reuptake inhibitor (SNRI)
D. Pregabalin
B. A selective serotonin reuptake inhibitor (SSRI)
104
You start your patient on escitalopram 20 mg once a day. After two days she returns to the surgery and tells you she feels more anxious than before
What should you do next?
A. Increase the dose of escitalopram
B. Stop the escitalopram and refer for CBT
C. Stop the escitalopram and try a different medication for generalised anxiety disorder
D. Reduce to 10mg escitalopram and emphasise it may take 2-3 weeks to have a beneficial effect
D. Reduce to 10mg escitalopram and emphasise it may take 2-3 weeks to have a beneficial effect
105
Your patient tolerates the escitalopram after titration. After eight weeks at 20 mg, she still reports no improvement in her generalised anxiety disorder symptoms. She feels increasingly desperate as she is finding her generalised anxiety disorder symptoms are beginning to interfere with the demands of her job, and colleagues have been commenting on this.
What should you now recommend?
A. Continuing on escitalopram
B. Trying an alternative medication (another SSRI or an SNRI)
C. Referral for cognitive behavioural therapy (CBT)
D. Choosing either an alternative medication or CBT
D. Choosing either an alternative medication or CBT
106
Which one of the following medications should NOT be offered in primary care for patients with generalised anxiety disorder?
A. Benzodiazepines
B. Beta blockers
C. Low dose antipsychotics
D. Pregabalin
C. Low dose antipsychotics
107
Which of the following is one of the two required criteria required for a diagnosis of major depression?
A. Significant weight loss when not dieting, weight gain or decrease, or increase in appetite nearly every day
B. Insomnia or hypersomnia nearly every day
C. Psychomotor agitation or retardation nearly every day
D. Diminished interest or pleasure in all or almost all activities most of the day, nearly every day
E. Fatigue or loss of energy nearly every day
D. Diminished interest or pleasure in all or almost all activities most of the day, nearly every day
108
According to the majority of studies, what is the relationship between physical activity and depression?
A. There is a positive relationship
B. There is an inverse relationship
C. There is no relationship
B. There is an inverse relationship
109
Which of the following is not a screening tool for depression?
A. PHQ-9
B. GAD-7
C. PHQ-2
D. Edinburgh post-natal depression scale
B. GAD-7
110
Which of the following is not a risk factor for depression?
A. Having a family history
B. Being male
C. Taking corticosteroids
D. Age over 65
B. Being male
111
Which of the following is NOT an SSRI?
A. Paroxetine
B. Fluoxetine
C. Venlafaxine
D. Citalopram
C. Venlafaxine
112
After the resolution of symptoms of a first episode major depression, medication should be continued for at least:
A. 3 months
B. 2 years
C. 1 year
D. 6 months
D. 6 months
113
A PHQ-9 score of 4 signifies:
A. Mild depression
B. Severe depression
C. No depression
D. Moderate depression
C. No depression
114
A 24 year old man has been suffering depressive symptoms for over 2 months. In spite of being on fluoxetine for a week he feels worse. He feels suicidal, and is hearing voices telling him to hang himself. He has written a note for his girlfriend explaining why he decided to kill himself. He has been drinking heavily. He does not want to go to hospital. Do you -
A. Increase his dose of fluoxetine?
B. Change to a different antidepressant?
C. Arrange a compulsory admission?
D. Prescribe an antipsychotic medication?
C. Arrange a compulsory admission?
115
What is Panic Disorder?
Recurrent panic attacks over 1 month associated to worry which leads to behavioural change
116
Define a panic attack
discrete period with sudden onset of intense apprehension, fearfulness and marked autonomic arousal ± impending doom (angor animi)
117
What two types of Panic Disorder are there?
Panic disorder with Agoraphobia
Panic disorder without Agoraphobia
118
Give 5 Sx for Panic Disorder
* Rapid onset
* Discrete time period
* Worry/Fear/Apprehension
* Behavioural avoidance: External + Internal situations
* Nausea and vomiting
* Dizziness
* SOB
* Tachycardia
* Palpitations/Pounding heart
* Tremulous
* Sweating
* Hyperventilation/SOB/Choking
* Chills/Hot flushes
* Muscle shaking
119
Give the Clinical Assessment tool used for patients with Panic Disorder.
PRIME-MD Screen: Positive if ≥ 4/11 Yes
120
Give the Tx for Panic Disorder
• Supportive: Reassurance/CBT
±
• SSRIs/SNRIs: Sertraline/Paroxetine/Fluoxetine/ Citalopram/ Venlafaxine
121
What is Agoraphobia?
Fear of a place/setting from which escape may be difficult
122
Give 5 Sx or S of Agoraphobia
* Rapid onset
* Discrete time period
* Worry/Fear/Apprehension regarding a place
* Behavioural avoidance: External + Internal situations
* Nausea and vomiting
* Dizziness
* SOB
* Tachycardia
* Palpitations/Pounding heart
* Tremulous
* Sweating
* Hyperventilation/SOB/Choking
* Chills/Hot flushes
* Muscle shaking
123
Give the Tx for Agoraphobia
• Supportive: Education + Monitoring/ CBT + Exposure therapy
+ (Concurrent vasovagal syncope)
• Applied tension: Tensing and releasing large muscle groups to increase BP and promote circulation
± (Frequent Sx interfering in Life)
• Benzodiazepines: Diazepam/Lorazepam/Clonazepam/Alprazolam
124
What is specific phobia?
Specific intense fear of specific objects or situations that are triggered upon exposure to phobic stimuli resulting in fear avoiding behaviour of phobic cues
125
What is agoraphobia?
• Agoraphobia = places/settings
126
What is a social phobia?
• Social = Social situations/Performance in social settings
127
What is acrophobia?
• Acrophobia = Heights
128
What is aerophobia?
• Aerophobia = Flying
129
What is Astraphobia?
• Astraphobia = Thunder/Lightning
130
What is arachnophobia?
• Arachnophobia = Spiders
131
What is claustrophobia?
• Claustrophobia = confined spaces/places
132
What is auto phobia?
• Autophobia = Alone
133
What is homophobia?
• Hemophobia = Blood
134
What is ophidiopobia?
• Ophidiophobia = Snakes
135
Give 5 Sx or S for phobias?
* Rapid onset
* Discrete time period
* Worry/Fear/Apprehension regarding a place
* Behavioural avoidance: External + Internal situations
* Nausea and vomiting
* Dizziness
* SOB
* Tachycardia
* Palpitations/Pounding heart
* Tremulous
* Sweating
* Hyperventilation/SOB/Choking
* Chills/Hot flushes
* Muscle shaking
136
Give the Tx for Phobias
• Supportive: Education + Monitoring/ CBT + Exposure therapy
+ (Concurrent vasovagal syncope)
• Applied tension: Tensing and releasing large muscle groups to increase BP and promote circulation
± (Frequent Sx interfering in Life)
• Benzodiazepines: Diazepam/Lorazepam/Clonazepam/Alprazolam
137
What is OCD?
Anxiety disorder characterised by obsessions, unwanted excessive or impulsive desires, compulsions, repetitive mental acts and behaviours to reduce obsessions and emotional distress, which causes significant distress and impairment on daily functioning.
138
What is the difference between obsessions and compulsions?
Obsession = Unwanted excessive or impulsive desires and thoughts which are seen as irrational or unwanted
Compulsions = Repetitive behaviours which aim to neutralise obsessions and emotional distress
139
Give the Tx for OCD
• CBT
±
SSRIs: Fluoxetine/Paroxetine/Sertraline/Clomipramine
140
What is PTSD?
Anxiety disorder characterised a traumatic event(s) causing 1-month of symptoms of intense fear, helplessness or horror, intrusive recollection of event, acting as if the event were occurring, distress from exposure to event cues, avoidance of trauma-associated stimuli and persistent increased arousal which wasn’t present prior to traumatic event.
141
Outline the process of PTSD
```
Traumatic event
Re-experience
Avoidance
Unable to function Sx
Month (at least)
Arousal
```
142
Give 5 Sx and S of PTSD
• Exposure to traumatic event
• Intrusion Sx: Re-experiencing in vivid ways -> Flashbacks; Intrusive images; Intrusive thoughts; Sensory impressions; Dreams/Nightmares; Emotional and physiological reactivity to internal and external cues
• Avoidance Sx: Effortful avoidance of trauma cues -> Push memories out; Avoid news; avoid events; avoid settings
May ruminate excessively about questions to prevent coming to terms with event
• Hyperarousal: Hypervigilance; Exaggerated startle response; irritability; angry outbursts; self-destructive; reckless behaviours; poor concentration; sleep problems
Must impair function
• Negative cognition and mood: Asocial behaviours; Distorted beliefs; Ideas of blame; Anhedonia; Poor trauma-related memory (events of trauma)
• Depression (Anhedonia + Persistent low mood + Anergia…)
• Anxiety (Intense fear + ∆ Behaviours + Systemic symptoms)
• Substance misuse: Alcohol/Drugs
143
A patient experiences PTSD Sx for 2 months, wha tis your Tx
• Supportive: Monitoring
144
A patient experiences PTSD Sx for 4 months, wha tis your Tx
```
• Supportive: Monitoring
+ (≥ 3 months Sx)
• CBT- Trauma focused (TFCBT)
±
• SSRIs: Paroxetine/Fluoxetine/Sertraline/Venlafaxine
```
145
What is Generalised Anxiety Disorder?
Anxiety disorder typified by ≥ 6 months of excessive fear/worry about disproportionate everyday issues + 3/6 of the DSM-5 criteria
146
What are the Sx and S of GAD?
* Poor concentration
* Restlessness
* Irritability
* Muscle tension
* Easily fatigues
* Sleep Disturbance
147
Outline the Tx for GAD
• Lifestyle: Reduce caffeine/Reduce alcohol/Sleep hygiene/Exercise/Self-help
• Psychotherapy: CBT/ Mindfulness
±
• SSRI/SNRI/Antidepressant: Escitalopram/Duloxetine/Venlafaxine/Sertraline/Fluoxetine/ Mirtazapine
- Consider withdrawal
- Consider SE profile: Nausea/Diarrhea/Insomnia/Sexual dysfunction/Suicidal behavior
±
• TCA/Gabapentin/Pregabalin: Imipramine/Pregabalin
± (Sleep difficulties)
• Melatonin
148
What is a Psychosis?
Umbrella term for a disorder whereby patient loses contact with external reality, associated with abnormal functioning of frontal and temporal lobes and disorganised thoughts and actions
149
Outline the possible causes of a Psychosis
- 1º (Caused by MHDs) Schizophrenia/ BPD/ Schizoaffective Disorder/ Persistent Delusional Disorders/ Schizophreniform Psychosis
- 2º (Other factors): Drug/Toxin exposure/Recreational drugs/Organophosphates/ Trauma/ Delirium/ Brain tumour/ SOL/ Steroids (high dose)/ Lead/ Mercury/ Cannabis/ Mushrooms/ LSD/ Infection/ Delirium/ Vitamin Deficiency (B12/ B1/ B3)/ Endocrine disorders/ Metabolic disorders/ Chromosomal Disorders (PWS/Klinefelter’s)
150
What is Schizophrenia?
1 Positive Sx and 1 Negative Sx for 1 month with continuous problem over > 6 months
151
Give the Sx of Schizophrenia?
```
Tangentiality/ Thought processing
Hallucinations (auditory/visual)
Reduced reality (Delusions)/Repetition of words (Verbigeration)
Emotional control: Incongruous effect?
Arousal
Disorganised/ Catatonic Behaviour
```
```
Loss of volition/social settings/ Pleasure
Emotional flatness (Affective Blunting)
Speech reduced (Alogia)
Slowness in thought (cognitive deficit)/Somatisation (physical Sx – expressed in body)
```
152
Give the Tx for Schizophrenia
• Anti-psychotic medication: Aripiprazole
+
• Psychological Interventions: Family/CBT/Social-skills training
153
What type of Antipsychotic would you give for Positive Sx in Schizophrenia?
FGA
154
What type of Antipsychotic would you give for both Positive and Negative Sx in Schizophrenia?
SGA
155
What is the difference between Schizoaffective Disorder and Schizophrenia?
Schizoaffective Disorder ≠ Schizophrenia as the symptoms may be transient and episodic, fluctuating and simultaneously prominent cf Schizophrenia, the Sx are present throughout (e.g. Paranoia, Delusions and Hallucinations)
156
What is Schizoaffective Disorder?
Mental health illness characterised by schizophrenia symptoms concurrent with affective symptoms lasting for ≥ 1 months - which may be present in the absence of schizophrenia symptoms at times.
157
What is the difference between schizotypical disorder and schizophrenia?
Schizotypal Disorder ≠ Schizophrenia as Schizotypal Disorder have insight into illness and awareness that experiences are false cf delusions in Schizophrenia
158
What is a brief psychotic disorder?
MHD characterised by co-occurrence of: delusions, hallucinations, disorganised speech, catatonic/disorganised behaviour or negative symptoms (anhedonia/affective flattening/avolition/cognitive deficit or alogia) occurring for between one day and one month.
159
Give the Tx for Brief Psychotic Disorder?
• Aripiprazole (10-15mg PO OD)/Risperidone (1mg PO BD)/ Quetiapine (25mg PO BD)
+ (adjunct)
• Lorazepam: 1-2mg IM per 8 hours
160
What is Persistent Delusional Disorder?
Umbrella term for mental health disorders typified by persistent, often life-long, delusions which have an insidious onset usually in later adult life. The conditions may be stratified as Eponymous or Non-Eponymous e.g. Capgras Syndrome or Paranoia.
161
What is a Mood Disorder?
Umbrella term for Mental Health Diseases (MHD) typified by a distortion in mood (affect) which impacts on lifestyle and activities. Can be categorised into Unipolar Mood Disorders (Depression/ Dysthymia/ Substance-induced Mood Disorder) or Bipolar Mood Disorders (Bipolar Disorder/Cyclothymia).
162
What is Depression?
Depressive orders (MHD), characterized by persistent low mood, anhedonia, neurovegetative disturbance, reduced energy and varying levels of social and biological dysfunction.
163
What are the categories of Depression?
- Major Depressive Disorder: ≥ 5 Sx -> Mild to Severe for 2+ weeks
- Minor Depression: 2-4 Sx for 2+ weeks
- Persistent Depressive Disorder (Dysthymic Disorder): ≥ 2 years of ¾ dysthymic symptoms for more days than not
164
Give 5 RFs for Depression
* Chronic Health Conditions
* History of Depression/MHD
* Medication – Glucocorticoids
* Female gender
* Older age
* Recent childbirth – post-partum depression
* Pychosocial issues
* Genetic factors
* History of childhood abuse
* History of Head Trauma
165
Give 5 Sx or S of Depression
• Persistent Low Mood
• Anhedonia (marked loss of interest/pleasure)
• Anergia
+
• Tearfulness
• Irritability
• Poor concentration
• Anxiety (Physical + Mental components)
• Slowed thought (cognitive impairment/decline) ‘Depressive pseudodementia’
• Thought blocking
• Reduced speech
• Reduced tone of voice
• Thought content (negative cognitive triad): Self-blame (self)/ Negativism (world)/ Pessimism (future)
• Suicidal ideatio
• Sleep disturbance: insomnia/hypersomnia
• Weight gain
• Psychomotor agitation/retardation (restlessness)
• Fatigue
166
What assessment tool can be used to diagnose depression?
* Clinical Diagnosis: DSM-5 Diagnostic Criteria
| * Patient Health Questionnaire-2 (PHQ-2): Positive result screens for depression in primary care
167
Give the Tx for Depression
* SSRI: Citalopram (20mg PO OD); Escitalopram (10mg PO OD); Fluoxetine (20mg PO OD); Sertraline (50mg PO OD); Mirtazapine (15mg PO OD)
* Psychotherapy: CBT/Mindfulness
168
What is Dysthymia?
Mood disorder that is a form of Unipolar Depression, featuring the same symptoms however the duration is for more than 2 years, with symptoms present for more days (4/7) than they are absent. Dysthymia is less acute and less severe than Major Depressive Disorder
169
What is Bipolar Disorder?
Bipolar mood with 1≤ manic episodes over 1 week followed by hypomanic ≥ 4 days or MDD
170
What is the Sx and S of Bipolar Disorder?
* Major depressive disorders
* Episodes of mania (mania Sx) -> Bipolar I = 1+ manic/mixed episodes
* Episodes of hypomania (1 or more hypomania episodes) -> Bipolar II = 1 or more hypomania episodes
* Grandiosity
* Decreased need for sleep
* More talkative
* Flight of ideas
* Increase in goal-directed activity
* Risk-taking behaviours: buying sprees/sexual indiscretions/foolish business investments
* No underlying medical cause
171
What is the Difference between Bipolar I Disorder and Bipolar II Disorder?
Bipolar I = 1 manic/mixed episode
Bipolar II = 1 hypomanic
172
What is the difference between Mania and Hypomania?
Intensity and Severity (1 week vs several days)
173
What Cyclothymia?
Cyclothymia (Chronic, fluctuating course of mood disturbance – numerous periods of hypomania and depressive episodes)
