29.04 - the day of the Gnarklebark Flashcards
When can clozapine be used in schizophrenia?
Only after 2 different antipsychotics have been tried
treatment resistant
Risks with clozapine
Neutropenia and fatal agranulocytosis
Side effects of Clozapine
Sedation!
Weight Gain!
Hypersalivation Raised triglycerides Cardiomyopathy DM Lowers seizure threshold
How is clozapine treatment started
Dose needs titrating.
Check FBC weekly for 18 weeks. THen 2 weekly for a year. Then 4 weekly.
BP, pulse and weight, Temp is also checked YEARLY (physical health). Ask about smoking and alcohol
Safety netting about high fever, chills, bone aches
Side effects of 1st generation antipsychotics
EXTRAPYRAMIDAL: Rigidity Bradykinesia Dystonias Akathisia Tardive dyskinesia
Neuroleptic Malignant syndrome
Describe neuroleptic malignant syndrome
Life threatening
Fever
Altered consciousness
Muscle rigidity
Autonomic dysfunction
Side effects of 2nd generation antipsychotics
Fewer extrapyramidal SE
Metabolic effects: Increase appetite Weight gain DM Sedation Hypotension Dry mouth Constipation
TCAs side effects (Amitryptiline)
Sedation
Weight gain
Dizziness
Hypotension
NOT TERATOGENIC, HOWEVER (used in pregnancy)
Antidepressants in pregnancy
Fluoxetine most commonly prescribed
Amitryptiline is also fine, but high OD risk
NO PAROXETINE!! or SNRIs (venlafaxine, dulexitine) or MAOIs or Mirtazapine
How long are SSRIs used for?
At least 4 wks, to say that treatment has failed.
Continue for 6 months following symptom resolution
Withdrawal symptoms of SSRIs
Anxiety
Dizziness
Sleep disturbance
Nausea
Antidepressants in Breastfeeding
Imiparime and Nortriptyline are prefered
Paroxetine or Sertraline can be used
How is lithium started?
Weight and BP measured annually
Give contraception and folic acid advise.
Check levels weekly and titrate up. Once optimum dose, check every 3 months.
U and E and TFTs every 6 months
SE of lithium
GI upset Fine tremor Polyuria Polydipsia Metallic taste Weight gain Oedema
Toxic symptoms of lithium
Diarrhoea Course tremor Ataxia Dysarthria Nystagmus Confusion Convulsions
AKI
Which is the only mood stabiliser that can be used in pregancy
Lithium
NOT in breastfeeding
still teratogenic, but less than carbamazepine or sodium valproate
which mood stabiliser may be used in breastfeeding
lamotrigine in low dose
Common symptoms of social phobia
Blushing or shaking
Fear of vomiting
Urgency or fear of micturition
Marked feature of being the focus of attention, embarrassment or humiliation.
Restricted to fearful situations.
AVOIDANCE
Questions To distinguish OCD from schizophrenia
Thoughts are acknowledged as excessive/unreasonable
NOT due to thought insertion
Compulsions originate in the mind of the patientand are not imposed by outside persons or influences
Medications for anxiety
All anti-depressants are anxiolytics (brief increase initially)
Beta blockers for autonomic symptoms: HR, sweating etc
Lorazepam has a short half-life
Diazepam has a long
<4 weeks due to addictive nature
What is an acute stress reaction
<1month after stressful even
For >3 days Anxiety Depression Numbness Detachment Derealisation Insomnia Restlessness Anger
Alcohol/drug abuse?
Management of acute stress reaction
Reduce emotional response: talk to friends/family/professionals
Encourage recall to debrief
Teach coping skills
Anxiolytics only used if severe anxiety
Hypnotics if sleep distubrance
What is adjustment disorder
Psychological reaction to new circumstances
Within 3 months
Proportionate
Anxiety/depression
Irritable
Dramatic?
Aggressive?
Sometimes autonomic arousal
Social functioning is impaired
Usually lasts couple of months
Management of Adjustment disorder
Support groups to accept change
Prevent avoidance and denial
Encourage problem solving
Encourage talk/express feelings
Consider therapy
3 core symptoms of PTSD
Hyperarousal: persistent anxiety, irritability, insomnia, poor concentration
Re-experiencing: flashbacks
Avoidance: numbness, loss of interest in activities, avoiding reminders
These symptoms persist beyond 6 MONTHS after event
Substance abuse and guilt common
Can also occur years later, if reactivation
Management of PTSD
Psychoeducation
Trauma focused CBT
Eye movement desensitisation and Reprocessing (EMDR)
Antidepressants (SSRIs)
Social: family support/education
Reintegration
Avoid alcohol
Characteritics of borderline EUPD
Chronic empty feeling Abandonment fears Relationships are unstable and intense Suicide attempts and self-harm Occasional psychotic features (pseudohallucinations)
Impulsive EUPD
Lacks impusle control Outbursts of violence Sensitivity to being criticised Emotional instability Inability to plan ahead Thoughtless of consequence
Management of EUPD
Dialectical behavioral therapy
Group therapies
Admit if danger to self
Help from seniors
Mood stabilisers or antidepressants may be helpful.
Antipsyhcotics for agitation
Types of alcohol misuse
Acute intoxication
Harmful use
Dependence syndrome
Withdrawal
Core features of dependence syndrome
Primacy (obtaining drug becomes most important)
Continued use despite negative consequences (eg. loss of family, money)
Loss of control of consumption (early morning start)
Narrowing of repertoire (same drug in same setting with same people)
Rapid reinstatement of dependent use after abstinence
Tolerance and withdrawal
how does mild alcohol withdrawal present?
4-12 hours after last drink
Coarse tremor Sweating Tachycardia Nausea Vomiting Agitation Insomnia
Intense cravings
Lasts 2-5 days
Transient hallucinations are possible
Describe severe alcohol withdrawal
Peaks at 4-6 days
Acute confusion Amnesia Psychomotor agitation Psychosis Delirium tremens
Seizures:
5-15% of cases
Occur 6-48hrs after last drink
What is delirium tremens
Medical emergency
Occurs 1-7 days post drink in 5%
Disoriented to time, place and person
Recent amnesia Hallucinations and delusions Severe psychomotor agitation Fever Autonomic disturbance and electrolyte imbalance
40% mortality if left untreated
Management of delirium tremens (alcohol withdrawal)
Benzodiazepines for symptomatic relief (Chlordiazepoxide)
Nutritional and vitamin supplementation (Thiamine and B vitamins for WErnicke’s)
Close monitoring
Admit if:
past hx of complicated withdrawal, current psychiatric symptoms, severe malnutrition, severe biochemical abnormalities
What is Wernicke’s encephalopathy
Neuronal degeneration 2° to thiamine deficiency
- acute confusional state
- Ophthalmoplegia, nystagmus
- Ataxic gait
Complete triad only in 10%.
Confusion in 80%
Tx IV Pabrinex (B1 replacement)
If left untreated, 80% progress to Korsakoff’s
Korsakoff syndrome
Usually due to thiamine deficiency
Can be chronic
anterograde amnesia with some retrograde amnesia
Confabulation (describe false memories)
Apathy
KEEP ON THIAMINE and MULTIVITs for 2 yrs!
Management strategies for alcohol misuse
Disulfiram (alcohol deterrent. Irreversibly inhibits ADH. Build of ADH causes flushing, headache, tachycardia and vomiting)
Motivational interviewing
CBT
Assertiveness training (learning to say no)
AA
Social support
Biological management of opiate detox
Methadone (symptomatic tx)
Lofexidine (reduces symptoms)
Anti-emetics
Postnatal pinks
First 48hrs
Temporary excitement, mild overactive with insomnia
Self-resolves
Postnatal blues
50-80% Day 3-10 Tearfulness Emotional lability Anxiety Lasts 48hrs and self-resolves
Postnatal depression
Peak onset 2-4 weeks
50% risk of recurrence if previous severe depression or postnatal depression
What is used to screen for postnatal depression
Edinburgh scale!
When does postpartum psychosis present
50% present by day 7
Almost all by day 90
50% risk with bipolar or previous psychosis
Criteria for delirium
Clouding of consciousness
Disturbed cognition
1 of:
variable activity levels, increased reaction time, altered speecn of flow
+1 of: insomnia, daytime drowsiness, nocturnal worsening of symptoms, disturbing dreams
Which drug can be used for rapid sedation in a patient with acute behavioral disturbance? (patient becomes aggressive/agitated or psychotic)
Lorazepam (quick onset)
Anti-psychotics: olanzapine or haloperidol
What is acute dystonia
Reversible extrapyramidal side effects that occur due to anti-psychotics
Muscle spasm occurring aywhere in the body. Can be lifethreatening if it affects laryngeal muscles!! IT is a psychiatric emergency
Most common with haloperidol (in 10%)
30% Neck twisting 17% Tongue, 15% Jaw, 6% Oculogyric crisis (neck arched and eye rolled back)
Management of acute dystonia
Anticholinergics (Procyclidine 5-10mg)
When is lithium clearance reduced?
It is only renally excreted
Renal impairment
Sodium depletion
Can be with diuretics, NSAIDs and ACEI
Symptoms of lithium toxicity
Early: Tremor Anorexia N/V/D Dehydration and lethargy
Late: Restlessness Muscle fasciculations Myoclonic jerk Hypertonicity
Ataxia, dysarthria, confusion, hypotension, arrhythmias
Treatment of lithium toxicity
Stop lithium!
Hydrate
May require haemodialysis
What is neuroleptic Malignant syndrome
Fever
Diaphoresis
Rigidity
Confusion and fluctuating consciousness
Autonomic instability: tachycardia, salivatin and incontinence
SLOW onset! Days-weeks
Management of neurpleptic malignant syndrome
withdraw antipsychotics!!
Hydrate
Consider benzos for sedation or bromocriptine
What is serotonin syndrome
Usually when swithcing an antidepressant or combining
Or when mixing with Triptans for migraines or illicit substances
Various symptoms come on within a few hours: Restlessness/Agitation/confusion Hyperthermia GI upset Mydriasis Myoclonus Rigidity Tremors/convulsions Ataxia
Can be fatal if left untreated
Management of serotonin syndrome
Stop serotonergic meds
Rehydrate
Benzos for severe agitation
Consider gastric lavage if OD
