B6W2 PBL

Case 1

100

What are the 4 pharmacological antidepressant therapies? 

•Tricyclic antidepressant

•Selective serotonin reuptake inhibitors (SSRIs)

•Monoamine Oxidase Inhibitors (MAOIs)

•Serotonin Noradrenaline reuptake inhibitors (SNRIs)

200

Describe the 10 symptoms of depression:

*hint:use the acronym DEPRESSION to help you

D = Depressed Mood

E = Energy Loss/fatigue

P = Pleasure Lost (Anhedonia)

R = Retardation or Agitation

E = Eating Changed (Appetite /Weight)

S = Sleep Changed

S = Suicidal Thoughts (or Future bleak)

I = I’m A Failure (Loss Of Confidence/Self Esteem)

0 = Only Me To Blame (Guilt)

N = No Concentration (Not able to function)

300

What is the theory behind why antidepressants take 2 weeks to work?

•One Theory is that initially the increased 5HT in synapses is cancelled out by auto-receptors reducing 5HT release and more reuptake  of the extra 5HT in the synapses

•But after a couple of weeks, the auto-receptors desensitise and the blocked reuptake transporters get internalised

•So eventually there really is increased 5HT in the synapses

400

Describe the monoamine theory of depression

Depression is a result of a deficiency in brain monoamine neurotransmitters –Noradrenaline, Serotonin, Dopamine

Serotonin: influences mood, emotional behaviour and sleep

Noradrenaline: influences sleep, wakefulness, attention, feeding behaviour

Dopamine: influences motivation, reward

500

what are the arguments for AND against the monoamine theory of depression?

FOR

•Antidepressants increase the availability of monoamines at synapses

•Reserpine which depletes monoamine transmission causes depression (stops monoamines getting into vesicles)

•People with depression can have lower levels of monoamine precursors/metabolites in their CSF or blood

AGAINST

•Neurotransmitter effects of antidepressants are immediate but they take 2+ weeks to work on symptoms

•Cocaine and amphetamine mimic NA and 5-HT but do not act as antidepressants

•Inprindole is an antidepressant which does not effect NA or 5-HT reuptake (5-HT2 antagonist)

Case 1

100

What is CBT and how is it tailored for depression?

a major evidence-based treatment of choice for many mental disorders eg phobias, anxiety, depression, OCD, physical health

•It’s C + B + T…….

•Cognitive = Challenge unhelpful and extreme ways of thinking eg using thought records

•Behavioural = behavioural activation, inc. activity scheduling + goal setting eg using an activity diary

•Therapy = a talking (or should that be a ‘doing’?) treatment – also includes generic skills (empathy, listening, therapeutic relationship)

200

Which pathways does dopamine use and what do they do?

1. Nigrostriatal –initiation and control of movement
2. Mesolimbic –reward, reinforcement
3. Mesocortical –cognition, planning, motivation
4. Tubero-infundibular” (hypothalamus to pituitary) -inhibits the release of prolactin hormone from the pituitary gland

300

How many symptoms of depression must the patient present with and for how long?

The number of symptoms: 4 = mild depression, 5 or 6 = moderate, 7+= severe depression.

Patient must present with symptoms for a least two week, most days within that period.

Take into account a not just the number of symptoms about the individual’s ability to function in everyday life.

400

Explain the cognitive model of depression *5 parts*

Early experience - criticised and ignored for mistakes as child 

Core beliefs - thinks they are an unloveable person 

Unhelpful assumption - if they are not good all of the time, people will not love them

Trigger - criticised by partner 

Negative thoughts - thinks partner does not love them!

500

Outline the components of the mental state examination (8 categories)

Appearance 

Behaviour

Speech

Mood and Affect

Thought

Perception 

Cognition

Insight and Judgement

Use the mnemonic ASEPTIC 

A=appearance & behaviour 

S= speech 

E = emotion (mood and affect)

P = perception 

T = thought (content and process)

I = insight & judgement 

C = cognition

Case 2

100

List the symptoms of anxiety

Cognitive symptoms: fear of losing control; fear of physical injury or death; fear of "going crazy"; fear of negative evaluation by others; frightening thoughts, mental images, or memories; perception of unreality or detachment; poor concentration, confusion, distractible; narrowing of attention, hypervigilance for threat; poor memory; and difficulty speaking.

Physiological symptoms: increased heart rate, palpitations; shortness of breath, rapid breathing; chest pain or pressure; choking sensation; dizzy, light-headed; sweaty, hot flashes, chills; nausea, upset stomach, diarrhea; trembling, shaking; tingling or numbness in arms and legs; weakness, unsteadiness, faintness; tense muscles, rigidity; and dry mouth.

Behavioural symptoms: avoidance of threat cues or situations; escape, flight; pursuit of safety, reassurance; restlessness, agitation, pacing; hyperventilation; freezing, motionless; and difficulty speaking.

Affective symptoms: nervous, tense, wound up; frightened, fearful, terrified; edgy, jumpy, jittery; and impatient, frustrated.

200

Name 4 causes of anxiety

Trauma

Genetic predisposition

Brain chemistry

Social circumstances/influence

Life experiences

300

How do benzodiazepines work?

GABA: Main inhibitory neurotransmitter in the brain

• Benzodiazepines are agonists

• They bind to a regulatory site on the GABAa- receptor to enhance the inhibitory effect of GABA

• Increases the influx of negatively charged chloride ions (Cl-) into the neuron, causing hyperpolarisation and inhibiting action potentials

• By inference, causes suppression of brain circuits in stress response (In the limbic system)

400

What is the function of the Amygdala, Hippocampus, prefrontal cortex and anterior cingulate cortex?

1. Hippocampus: The hippocampus is a brain region involved in memory and spatial navigation. It is also involved in the regulation of the stress response and is thought to play a role in the development of anxiety disorders. The hippocampus may be smaller in people with anxiety disorders, and chronic stress can lead to damage and dysfunction in this region.
2. Prefrontal cortex: The prefrontal cortex is the part of the brain responsible for executive functions, such as decision-making, planning, and impulse control. It is involved in regulating the amygdala and the stress response, and dysfunction in this region can contribute to anxiety symptoms.
3. Anterior cingulate cortex: The anterior cingulate cortex is a brain region involved in regulating emotions and cognitive control. It is activated in response to perceived threats and may play a role in the development of anxiety disorders.

500

what is the definition of classical conditioning with examples?

Classical conditioning: a learning process where a previously neutral stimulus becomes associated with another stimulus by repeated pairing 

Example: 

classical (Pavlov dogs)

neoclassical (taste aversion eg food poisoning)

Case 2

100

what are 3 types of treatment for anxiety?

Education:

Relaxation techniques 

Advice on sleep

Cognitive behavioural therapy (CBT):

Teaches us how to feel better by changing the way we feel think and behave = change behaviour (graded exposure) and change thinking (eg anxiety is unpleasant but not dangerous).

Pharmacological treatment:

SSRIs – sertraline 

Benzodiazepines – diazepam

Beta-blockers – propranolol 

200

How does the GABA receptor link to anxiety?

• GABA is considered an inhibitory neurotransmitter because it blocks, or inhibits, certain brain signals and decreases activity in your nervous system.
• When GABA attaches to a protein in your brain known as a GABA receptor, it produces a calming effect. This can help with feelings of anxiety, stress, and fear
• Released by inhibitory neurones throughout the CNS
• Once stimulated, GABA receptors allow a flux of Chloride ions across the post-synaptic membrane. 
• This hyperpolarises (stabilises) the neurone

300

Draw the panic cycle 

see notes 

400

What are 5 associated behaviours of anxiety and which ones do CBT target?

1. Pacing room, wringing of hands, sighing
2. Attempts at coping (caffeine, smoking, alcohol, illegal or prescribed drugs)
3. Avoiding fear-provoking situations
4. Safety behaviours (eg in agoraphobia only go out with friend, carry mobile)
5. Asking for reassurance (visiting GP, somatic complaints, checking body)

Cognitive behavioural therapy involves dropping 3, 4 and 5 to manage and treat anxiety. 

500

what is the definition of operant conditioning with examples?

Operant conditioning: the alteration of behaviour by reward or punishment ie certain responses are learned because they affect (operate on) the environment 

Example:

positive reinforcement (praise)

negative reinforcement (picking up crying baby, punishment-smacking, extinction-time out)

Pharmacology

100

what is the drug class of citalopram?

 selective serotonin reuptake inhibitors (SSRIs)

200

what are the indications of lithium?

• mania (feeling highly excited, overactive or distracted)
• hypo-mania (similar to mania, but less severe)
• regular periods of depression, where treatment with other medicines has not worked
• bipolar disorder, where your mood changes between feeling very high (mania) and very low (depression)

300

what is the drug class of venlafaxine?

 serotonin and noradrenaline reuptake inhibitors

400

what is the mechanism of action of amitriptyline?

• The serotonin is stored within vesicles, which then fuse with the membrane and the serotonin is released into the synaptic cleft.
• Upon release serotonin is then taken back up into the cell, to stop transmission of the signal.  
• The Tricyclic inhibitors block this reuptake. 
• This blockage of the reuptake allows the neurotransmitter to have an elongated effect.

500

what is a contraindication of buspirone?

epilepsy