Capsule cases Flashcards
A patient with a history of schizophrenia, currently mentally well, is taking the following:
- Risperidone 6mg BD
- Sodium Valproate 1000mg BD
- Citalopram 20mg OD
- Diazepam 5mg BD
He is complaining of a feeling of restlessness, with particularly restless legs, and comes to see you for advice. What is this called?
Akathisia
Give some examples of extrapyramidal side effects (EPSEs).
Akathisia is a very unpleasant sense of restlessness.
Tardive dyskinesia usually manifests as orofacial dyskinesias.
Parkinsonism presents with tremor, rigidity and bradykinesia.
Acute dystonic reaction can present with an oculogyric crisis and torticollis.
List some examples of typical vs atypical antipsychotics.
When is clozapine used in schizophrenia?
Only once other options have been trialled (e.g. olanzapine) and the schizophrenia is treatment resistant
True or False: Diazepam cannot be safely prescribed for more than 10 days due to the risk of addiction.
F
Guidelines state that benzodiazepines should ideally not be prescribed for longer than 2-4 weeks due to addictive potential.
Benzodiazepines are safe and extremely useful if used cautiously in the short-term.
How do you rule out a drug-induced psychosis?
Urine drug screen
Which medications would be appropriate to begin treatment for 1st episode psychosis?
- Fluoxetine 20mg OD
- Diazepam 5mg BD
- Olanzapine 10mg nocte
- Clozapine 200mg BD
- Aripiprazole 10mg OD
- Quetiapine 100mg OD
- Sodium Valproate 500mg BD
Olanzapine and Aripiprazole
These are adequate starting doses of atypical antipsychotics. While quetiapine is an antipsychotic, this dose is likely to be too low for psychosis. Clozapine is not first line.
Patient is given a number of different sedative medications during the admission, including haloperidol. He starts to develop a very painful muscular contraction on the left side of his neck. Which drug will best treat this side effect?
Procyclidine 10mg oral
What dose of lorazepam is initially used in sedation?
1mg PO
Promethazine (sedating antihistamine) is sometimes used 2nd line.
Can Section 5(2) be used to detain someone in A+E?
No, can only be used on a ward.
Which of the following drug lower seizure threshold for ECT?
- Diazepam
- Semi-sodium valproate
- Clozapine
- Zopiclone
- Magnesium
Clozapine - nearly all anti-psychotics and antidepressants will decrease the seizure threshold, making a fit more likely. It is important to take account of any medications when administering ECT, as many psychotropics can have an effect on the seizure threshold.
A patient ppears very low in mood and explains to you that she has become convinced that her insides have rotted away and no longer exist. How would you best describe this symptom?
Nihilistic dilusion - presents in those who are severely depressed
A pt sees a sees a psychiatrist who records the following unprompted speech verbatim: ‘I think I have problems. The history teacher knows all about it. My brother and I went fishing last weekend and we caught two mackerel. This room’s noisy isn’t it. The newsreader had a green shirt on. What time is it? I must see Steve later. Maths is just terrible, I can’t bear it. Sometimes I smoke, yeah’. What is this phenomenon called?
This is a classic example of loosening of association, or Knight’s move thinking, a formal thought disorder observed in psychosis where there are no clear links between successive thoughts.
Neologism is “made up words” and also seen in psychosis. In flight of ideas links are evident from thought to thought despite the topic regularly changing. It is more commonly seen in mania. Running commentary refers to an auditory hallucination common in psychosis.
What are the physical signs of withdrawal symptoms?
Hyperthermic temperature
Pulse rate above 100bpm
Respiration rate above 20bpm
Blood pressure variable, eg, starting off with hypertension in earlier phases of withdrawal followed by hypotension from fluid losses (sweating and hyperventilation)
Dilated pupils as a secondary effect of sympathetic hyperactivity
Palpitations
Musculoskeletal – Tremulous state and dehydration, potentially leading to muscle spasms and rhabdomyolysis
Neurologic – Tremors, increased deep tendon reflexes, ataxia, with or without dyskinesia
True or false: A paradoxical increase in hostility and aggression may be reported by patients taking benzodiazepines.
True - the effects range from talkativeness and excitement to aggressive and antisocial acts.
Adjustment of the dose (up or down) sometimes attenuates the impulses. Increased anxiety and perceptual disorders are other paradoxical effects
True or false: the benzodiadepine withdrawal syndrome should develop within a week of stopping a long acting benzodiazepine.
False - the benzodiazepine withdrawal syndrome may develop at any time up to 3 weeks after stopping a long-acting benzodiazepine, but may occur within a day in the case of a short-acting one
True or false: Benzodiazepines may cause dose-related anterograde amnesia.
True -significantly impairing the ability to learn new information whilst the retrieval of previously learned information remains intact. This effect is exploited when patients undergo uncomfortable procedures because comfort and postoperative amnesia are beneficial.
What are the symptoms of EUPD?
- mood instability,
- impulsivity
- relationship difficulties
manifest since childhood or adolescence
- It is associated with repeated self harm and suicidal tendencies.
- Social functioning and coping with adversity are often significantly impaired.
- Psychiatric co-morbidity is very common and often poses diagnostic difficulties.
What is the first line management of EUPD? What should be avoided?
- Refer to community mental health team (CMHT)
- Risk assessment is particularly important in EUPD. If the patient presents a high risk to them self or others, more urgent referral to psychiatric services is needed.
Drug treatment is generally not recommended unless there are co-morbid conditions requiring medication. Polypharmacy should be avoided.The aim is to reduce unnecessary drug treatment.
List factors which increase risk of completing suicide.
- Men are three times more likely to commit suicide.
- Being divorced,
- living alone ,
- being unemployed,
- belonging to lower social class,
- substance abuse and
- having terminal/chronic illness
puts one at a higher risk of completing suicide.
What are some protective factors against suicide? Which factors are important in prevention?
- Faith in a religion,
- social support and
- no substance abuse are protective factors.
Factors important in prevention are:
- treating the primary mental disorder,
- reducing the patient’s access to means to harm themselves, and
- educating the patient and carers about how/where to seek help in a crisis.