General Adult Psychiatry Flashcards
DIS
Diagnostic Interview Schedule
1981 Robins
Structured diagnostic interview designed for use by lay interviewers
ECA programme
NIMH
Epidemiological Catchment Area Programme
CIDI
WHO Composite International Diagnostic Interview
Version of DIS that used ICD criteria
NCS
National Comorbidity Survey
First to use the CIDI. 1990-2.
8000 respondents
Reinterviewed between 2000-1 - called NCS-R
Found substantially higher prevalence results than the ECA
Most prevalent anxiety disorder was specific phobia.
Findings of ECA and NCS
Number of people with MH problems far outweighed resources available
Did not comment on severity therefore likely overstated demand
WMH-CIDI
Revised version of CIDI
Assesses severity and other aspects such as risk factors, socio-demographics and treatments
ECA study
Selected neighbourhoods in 5 US communities
1980-5
Each site - 3000 community residents and 500 residents in institutions were sampled (20,000 total)
2 interviews over a year using the DIS
DIS diagnosis of schizophrenia not congruent with psych classifications
ECA study - lifetime prevalences
Any disorder 32.3% Substance misuse disorder 16.4 Anxiety disorder 14.6 Affective disorder 8.3 Schizophrenia and schizophreniform 1.5 Somatization disorder 0.1
ECA study - anxiety disorder prevalence (1 month)
Phobia 12.5% Generalised anxiety and depression 8.5 OCD 2.5 Panic 1.6 Anxiety disorder were twice as common in women as they were in men
National Psychiatric morbidity survey 2000
1993-4
Conducted by OPCS (Office for Population Census and Surveys) using CIS (clinical Interview Schedule)
16-64 living in UK
10,000 interviews
Repeated in 2000 and upper age limit increased to 74
National Psychiatric Morbidity Survey - Findings
1 in 6 people in Britain have a neurotic disorder
• The most common neurotic/anxiety disorder was mixed anxiety and depression (88 cases per 1000), generalised anxiety was the next most common (44 cases per 1000)
• 5 per 1000 have a psychotic disorder
• Older people report less neurotic symptoms
• Prevalence rates were higher in women than men for all neurotics disorders except
panic (equal)
National Psychiatric Morbidity Survey - Findings (2)
44 per 1000 were classed as having a personality disorder, the prevalence being
slightly higher in men
• The most common personality disorder was anankastic (obsessive compulsive
personality disorder) (twice as common as all the others)
• The prevalence of alcohol dependence in the overall population was 74 per 1000
• 10% of people reported using illicit drugs in the year prior to interview, cannabis was
the most commonly used
World Mental Health Survey Initiative
Surveys in 28 countries
5000 interviews per country
Sample size >154,000
Interviews face to face by lay interviewers (trained)
Use the WMH-CIDI
The US has the highest prevalence of any disorder
Anxiety d most common followed by mood disorder
Male:Female ratios
Reading disorder 3-4:1 ASD 4-5:1 Asperger's 5:1 Tourette's 2-5:1 ADHD children 2:1 ADHD adults 1.6:1 Major depression 1:2 BPAD1 1:1 Panic with agoraphobia 1:3 Panic without agoraphobia 1:2 GAD 1:2 OCS 1:1 Specific phobia 1:2 Conversion disorder 1:2-10 Anorexia 1:9 Bulimia 1:9 BOD 1:3
Bipolar disorder - epidemiology
lifetime prevalence 0.3-1.5%
6/12 month prevalence - same
mean age of onset - 17 (community), 21 (hospital studies)
Gender M=F
Comorbidity - substance misuse and anxiety disorder
Major depression - epidemiology
lifetime prevalence 4-30%
6/12 month prevalence - same
mean age of onset - 27
Gender M:F 1:2
Comorbidity - substance misuse and anxiety disorder
Most prevalent in 18-44 group
People born since 1945 in industrialised countries have higher lifetime risk and earlier age of onset
Higher rates in women become apparent at puberty
Higher rates in unemployed, divorced, lower socio-economic class, urban areas
Major Depression - genetics
Twin studies - risk in 1st degree relatives is about 3 fold
MZ concordance rate = 45%
DZ concordance rate = 20% Heritability = 37%
Polygenic inheritance
GWAS have yet to report any convincingly replicated loci in depression
Monamine theory of depression
suggests that allelic variation in genes coding for monoamine synthesis or metabolism or specific receptors may contribute to the risk of mood disorders
Serotonin transporter gene
a particular allele has been shown to increase the risk of a subsequent episode of major depression when exposed to childhood adversity (Caspi et al, 2003)
Sociotropy
A strong need for approval
a/w increased risk of depression after adverse life events
Neuroticism
Measured by EPQ
Predisposes to major depression
Parental deprivation and depression
Death of parent in childhood - does not increase risk
Parental separation - increases risk, particularly divorce - due to discord and diminished care
Relationship with parents and depression
Physical and seual abuse clear risk factors
Non-caring and overprotective parenting styles are a risk (non-melancholic depression)
Depression - precipitating factors
Recent life events - 6 fold excess of adverse life events in months before onset
Poor social support
Physical illness - source of stress but can also have organic mood disorder e.g. HIV, endocrine, brain disease
Psychoanalytic theories - Freud
Mourning and melancholia
Loss of an ‘object’
Psychoanalytic theories - Melanie Klein
Weaning represents a major symbolic loss for the infant
Leads to attempt at reparation and concern for others
Failure in this can result in depressive reactions in the face of future losses
Psychoanalytic theories - John Bowlby
Insecure attachment can increase the risk of depression
Cognitive theories - Beck
Cognitive distortions such as arbitrary inference, selective abstraction, overgeneralization and personalisation lead to persistence of negative automatic thoughts.
Believes that dysfunctional beliefs (schemas) precede and predispose to depression.
The monoamine hypothesis
depressive disorder is due to abnormality in a monoamine neurotransmitter at one or more brain sites
noradrenaline and dopamine are catecholamines
5-HT function
Plasma tryptophan levels are decreased in untreated depressed patients
Shown in CSF studies (impulsive suicide attempts), neuroendocrine tests (blunted 5-HT neuroendocrine responses), imaging studies (decreased brain 5-HT1a receptor binding (PET) and decreased brain 5-HT re-uptake sites (SPECT and PET))
Noradrenaline function
Increased brain noradrenaline elevates growth hormone. GH response is blunted in depressed patients
Catecholamine synthesis can be reduced with AMPT. AMPT leads to depressive relapse in those with a personal h/o depression
Dopamine function
CSF levels of HVA are consistently low in depressed patients
AMPT leads to clinical relapse
Amino acid neurotransmitters
Decreased levels of glutamate in the anterior brain regions in depressed patients
Endocrine abnormalities
50% of patients with Cushing’s syndrome suffer from major depression
Addison’s disease, hypothyroidism and hyperparathyroidism also associated
HPA axis
Plasma cortisol secretion is increased throughout the 24h cycle in 50% of those with mod-sev depression
A/w enlargement of the adrenal gland
Increased cortisol response to ACTH challenge
Thyroid function
levels of free T3 may be decreased
1/4 of depressed patients have a blunted TSH response to TRH (also in alcoholism and panic disorder)
Organic causes of depression
Medications
Riserpine Interferon alpha Beta blockers Levodopa Digoxin Anabolic steroids H2 blockers Oral Contraceptives
Organic causes of depression
Drug abuse
Alcohol
Amphetamine
Cocaine
Hypnotics
Organic causes of depression
Metabolic
Hyperthyroidism Hypothyroidism Cushings Addisons Hypercalaemia (can be caused by Li or thiazide diuretics) Hyponatraemia DM
Organic causes of depression
Nutritional
Pellagra
Vit B12 def
Organic causes of depression
Neurological
Stroke MS Brain tumour PD Huntington's Epilepsy Syphilis Subdural haematoma
Organic causes of depression
Haematological
Anaemia
Leukaemia
Organic causes of depression
Other
Infection
Carcinoma
Revealed depression
Depressive symptoms present during acute psychotic episode but only become apparent as the positive symptoms resolve.
Post-schizophrenic depression
Has met criteria for schizophrenia in last 12m
Some schizophrenic sx still present but not dominating
Depressive sx fulfill the criteria for a depressive episode and present for at least 2 weeks
Depression - clinical features
Core features
Low mood
anhedonia
anergia
lack of interest
Depression - clinical features
Negative cognitions
Worthlessness
Hopelessness
Helplessness
Guilt
Depression - clinical features
Biological symptoms
Diminished sleep/insomnia Reduced appetite/weight loss Diurnal mood variation Psychomotor agitation/retardation Fatigue Reduced libido Constipation Anhedonia
Depression - clinical features
Other features
Suicidal ideation Poor concentration Self-neglect Isolative behaviour Anxiety/obsessional sx Somatic complaints Irritability Depressive stupor
Atypical depression
Klein and Davis’ description 1969
Low mood with mood reactivity and reversal of features normally seen in depression
Hypersomnia, hyperphagia, weight gain and libidinal increases
Tend to respond best to MAOIs
Response to TCAs is poor, SSRIs in the middle
Not in ICD-10
Psychotic depression
Psychotic symptoms indicate severe depression and usually mood congruent around themes of worthlessness, guilt
Persecutory delusions also seen
Cotard delusion
Delusional belief that they are already dead, do not exist, are putrefying or have lost their blood or internal organs
Dysthymia
Low-grade depressive symptoms for at least 2 years (1 year in adolescence)
Often early onset
Lifetime prevelance 3.6% (3-6%) (US)
Dysthymia (DSM criteria)
depressed mood for most of the day, for more days than not, as well as at least two of the following diagnostic symptoms: • poor appetite or overeating • insomnia or hypersomnia • low energy or fatigue • low self esteem • poor concentration or difficulty making decisions - hopelessness - normal mood for no more than 2 months - no episodes of major depression
Postnatal depression
Risk is 10%
Increased to 25% if there is a hx of depression
Increased to 50% if there is a hx of postpartum depression
Mod-sev depression = 3-5%
Risk is not influenced by obstetric factors (e.g. length of labour) or social class
Depression - treatment
First line - SSRI
Antidepressants are not 1st line for mild depression
Continue for at least 6 months after remission
If antidepressants are stopped immediately then 50% of patients experience a relapse within 3-6 months.
Continue for at least 2 years in pts with 2 prior episodes of depression
4 step approach
Depression - antidepressants
First SSRI Then another SSRI or newer gen hen venlafaxine, TCA or MAOI Augment with: Lithium, antipsychotics or another antidepressant (mirtazapine)
Refractory depression
Definition and treatment
2 successive failed attempts at treatment despite good compliance and adequate doses
Add lithium ECT Add T3 Combined fluoxetine and olanzapine Add quetiapine to SSRI or SNRI Add risperidone Add aripiprazole Bupropion and SSRI SSRI and venlafaxine, mirtazapine, or mianserin
Combining antidepressants
Irreversible MAOIs such as phenelzine and tranylcypromine are dangerous in combination with SSRIs - risk of serotonin syndrome
St John’s Wort
Effective in mild-mod depression but not recommended due to uncertainty about appropriate doses, variation in nature of preparations and potential serious reactions with other drugs
Can cause serotonin syndrome
Inducer of P450 system - decreases warfarin and ciclosporin, may also effect OCP
STAR*D Study
4 levels of treatment
Level 1 - citalopram for 14 weeks
Level 2 - swap to sertraline, bupropion or venlafaxine or augment with bupropion or buspirone. +/- cognitive psychotherapy
Level 3 - swap to mirtazapine or nortriptyline or adding on lithium or T3
Level 4 - swap to MAOI or ven + mirt
Outcome = remission
STAR*D Study - outcomes
Level 1 - 1/3 achieved remission, +10-15% responded
If levels 1 fails - 1 in 4 responded to switch, 1 in 3 responded to combination
50-85% who have a single episode will go on to have a second and 80-90% will have a third
Factors known to increase the risk of recurrence of depression
Family hx of depression • Recurrent dysthymia • Concurrent non-affective psychiatric illness • Female gender • Long episode duration • Chronic medical illness • Lack of a confiding relationship
Bipolar disorder - prevalence
Bipolar 1 - 1%
Bipolar 2 - 0.4%
Lifetime risk 0.3-1.5%
Peak age of onset 15-19 yrs
Usually begins as depression, 1st manic episode 5yr later
Average length of manic episode is 6 months
Drugs that precipitate mania
Levodopa
Corticosteroids
Anabolic-androgenic steroids
Antidepressants (TCA and MAOi)
Weaker evidence for: Dopaminergic anti-parkinsonian drugs, thyroxine, iproniazid and isoniazid, chloroquine
Gerald Klerman subtypes of bipolar disorder
1981
Bipolar III - cyclothymic disorder
Bipolar IV: Hypomania or mania precipitated by antidepressant drugs
Bipolar V: Depressed patient with a family history of bipolar illness
Bipolar VI: Mania without depression (unipolar mania)
Bipolar depression is different from unipolar…
Episodes are more rapid in onset
Episodes are more frequent
Episodes are shorter
Likely to involve reverse neurovegetative sx such as hyperphagia and hypersomnia
Features suggestive of mania rather than hypomania
Duration Flight of ideas Psychotic sx Loss of social inhibitions DSM - hypomania occurs without any marked social or occupational interference
Rapid cycling BPAD
10-20% of all patients with bipolar disorder
Tends to develop late in the course of the disorder and lasts less than 2 years in 50% of pts
Increased suicide risk
More common in women, earlier age at onset, greater illness burden, higher treatment resistance
More related to external factors such as life events, alcohol abuse, antidepressants and medical disorders rather than genetics
Medical disorders associated with rapid cycling
hypothyroidism Grave's disease SAH Stroke MS Head injury Drugs (propranolol, levodopa, cyproheptadine)
BPAD depression - treatment - NICE
No drug treatment - fluox + olanz or quet. If no response consider lamotrigine on own
On lithium - check level etc. Add fluoxetine with olanz or quet, or lamotrigine if no resp
On valproate: Increase dose to max then add fluox + olanz or quet. If no resp consider lamotrigine.
BPAD depression - treatment - Maudsley
1st choice - quetiapine
2nd choice - lithium or valproate
3rd choice - lamotrigine
3th choice - antidepressant plus mood stabiliser or antipsychotic
BPAD Mania/hypomania - treatment
Stop antidepressant
Antipsychotic - haloperidol, olanzapine, quetiapine or risperidone
Check Li levels if taking
If antipsychotic ineffective try another, if still ineffective add lithium, if this is ineffective or unsuitable consider valproate.
Do not offer lamotrigine
Children and young people 13+ - aripiprazole
Short term benzos
Acceptability of antimanic medication
Cipriani 2011
Best overall were olanzapine, risperidone, quetiapine and quetiapine
Rapid cycling - treatment
Combine lithium and valproate as first line
Second line: lithium monotherapy
Stop antidepressants
Evaluate precipitants
Consider combining mood stabilisers. Quetiapine best choice based on limited evidence
BPAD - long-term management
Lithium as first line, long term
If lithium is ineffective, consider adding valproate
If lithium is poorly tolerated or not suitable, consider valproate or olanzapine instead, or if prev effective during episode, quetiapine
NICE recommend li, olanz, quet, valp
Sodium valproate - s/e
hepatic failure
pancreatitis
suicidal behaviour and ideation
thrombocytopenia
Carbamazepine s/e
marrow suppression
hyponatraemia and SIADH
skin reactions, inc TEN and SJS
suicidal behaviour and ideation
Lamotrigine s/e
skin reactions, TEN, SJS
suicidal behaviour and ideation
blood dyscrasias
Gabapentin s/e
DRESS/multiorgan hypersensitivity
anaphylaxis/angioedema
suicidal behaviour and ideation
Topiramate s/e
acute myopia and secondary angle closure glaucoma
oligohydrosis and hyperthermia
suicidal behaviour and ideation
kidney stones
Other uses of lithium
Aggressive and self mutilating behaviour
Steroid induced psychosis
To raise WCC in people using clozapine
Reduced completed suicide in patients with BPAD
Valproate - side effects
Tiredness Significant weight gain (affects 30-50%) Tremor (25%) Hair loss (5-10%) Teratogenic effects
BPAD Mortality
8% of men and 5% of women hospitalised for BPAD died by suicide
Life expectancy is reduced by 13 years in men and 9 years in women
Schizophrenia - prevalence
1.4-4.6%
Schizophrenia - incidence
0.16 per 1000
Schizophrenia - gender
1:1
Schizophrenia
Increased risk/prevalence with…
winter births (5-15% higher) urbanicity migration and ethnic minorities (AESOP) lower socio-economic class LD (3% vs 1%) Family history Obstetric complications (prenatal nutritional deprivation, prenatal brain injury, prenatal influenza) no difference with race
Selection drift hypothesis
This suggests that people with schizophrenia tend to drift towards the lower class due to their inability to compete for good jobs etc
Schizophrenia and family history
Gottesman (1982)
Lifetime risk of developing schizophrenia
Gen pop 1% First cousin 2 Uncle/aunt 2 Nephew/niece 4 Grandchildren 5 Parents 6 Half sibling 6 Full sibling 9 Children 13 Fraternal twins 17 Off of dual matings 46 Identical twins 48
Schizophrenia and cannabis use
Overall, cannabis use appears to confer a two-fold risk of later schizophrenia or
schizophreniform disorder
People are 4.5 times more likely to be schizophrenic at 26 if they were regular cannabis smokers at 15, compared to 1.65 times for those who did not report
regular use until age 18
Lifetime risk of developing psychosis increased by 40% (odds ratio = 1.41) if a person had ever used cannabis (Moore, 2007)
Age at onset of psychosis for cannabis users was 2.70 years younger than for nonusers (Large, 2011).
Schizophrenia - macroscopic pathological features
Ventricular enlargement
Reduced brain vol (up to 5%)
Reduced left planum temporale gray matter, and reversed planum temporale surface area asymmetry (L larger than R in R-handed person)
Schizophrenia - microscopic findings
Reduction of the size of the dorsolateral prefrontal cortex
Reduction of the size of the hippocampus
AESOP study
Incidence of all psychoses was found to be higher in African-Caribbean (x9) and Black African (x6) populations compared to white british group.
Schizophrenia - Positive sx
Hallucinations
Delusions
Thought disorder
Schizophrenia - negative sx
social withdrawal apathy lack of energy poverty of speech (alogia) flattening of affect anhedonia Amisulpride has the most evidence for treating negative sx
Psychogenic polydipsia
Fluid drinking that greatly surpasses physiological requirements
Results in hyponatraemia - vomiting, agitation, ataxia, seizures, coma
Manage by fluid restriction
PANSS
7 positive symptom items, 7 negative and 16 general psychopathology
Each item scored on 7 point severity scale
Schizophrenia subtypes (ICD-10)
Paranoid Hebephrenic (disorganised) Catatonic Undifferentiated (doesn't conform to any subtype) Post-schizophrenic depression Residual Simple (predominate;y neg sx w/o being preceded by overtly psychotic sx Other Unspecified
Bouffee delirante
Brief short lived psychosis that last less than 3 months
Schizophrenia subtypes (Crow)
Type 1 - positive symptoms - excess of dopamine D2 receptors - respond better to antipsychotics
Type 2 - negative sx - underlying/anatomical abnormality such as ventricular enlargement or cortical atrophy - respond poorly to tx, chronic course, poor outcome
Schizophrenia: DSM-5 vs ICD-10
ICD-10 - sx present for at least 1 month, DSM-V - 6 months with 1 mnth active sx
Less than 1m in ICD - acute and transient psychotic disorder and DSM - brief psychotic disorder. In DSM if between 1-6m then its schizophreniform disorder
DSM requires some impairment of social and occupational dysfunction - not in ICD
Early onset schizophrenia
Affects 1 in 1000 children EOS - 13-18yrs VEOS - before 13yrs Insidious onset More severe premorbid neurodevelopmental abnormalities More frequent terrifying visual hallucinations Constant inappropriate of blunted affect Higher rate of familial psychopathology Minor response to tx Poorer outcome
Antipsychotics in schizophrenia - minimum effective doses
Chlorpromazine 200mg Haloperidol 2mg Sulpride 400mg Amisulpride 400mg Aripiprazole 10mg Olanzapine 5mg Quetiapine 150mg Risperidone 2mg
Antipsychotics in schizophrenia - maximum doses
Clozapine 900mg Haloperidol 20mg Olanzapine 20mg Quetiapine 750mg Risperidone 16mg Aripiprazole 30mg Flupentixol depot 400mg/week Zuclopenthixol 600mg/week Haloperidol depot 300mg 4 weekly
Antipsychotic Adverse Effects
Hypertension (mostly clozapine)
Reduction of the seizure threshold (esp clozapine)(haloperidol, sulpride and trifluperazine are good choices)
Sexual dysfunction (in order: risperidone, haloperidol, olanzapine, quetiapine, aripiprazole)
Weight gain
Antipsychotic weight gain - mechanisms
5-HT2c antagonism
H1 antagonism
Hyperprolactinaemia
Increased serum leptin (leading to desensitisation)
Antipsychotic weight gain - high risk
Clozapine
Olanzapine
Antipsychotic weight gain - medium risk
Chlorpromazine Quetiapine Risperidone Paliperidone Zotepine
Antipsychotic weight gain - low risk
Amisulpride Asenapine Aripiprazole Haloperidol Sulpride Trifluoperazine Ziprasidone
Tardive dyskinesia
Typically affects the face (75%), also limbs (50%) and trunk (25%)
Increasing dose of antipsychotic tends to lessen problem temporarily
Anticholinergics tend to worsen the movements. Believed to be due to postsynaptic D2 receptor hypersensitivity in the nigrostriatal pathway.
Develops over months to years
Risk factors for TD
Advancing age Females- not consistent finding Ethnicity - higher in african americans ?higher in affective disorders First gen antipsychotics Mental retardation Substance abuse
TD - treatment
Withdraw antipsych and switch to atypical e.g. clozapine or quetiapine
Discontinue anticholinergic
Tetrabenzine ( only licensed tx in UK - has depressogenic effects)
Benzos
Vit E (slows deterioration)
Ginkgo biloba
Propranolol
Schizophrenia - physical health monitoring
FBC, U&E, LFT - baseline and yearly lipids - baseline, 3m then yearly weight - baseline, freq for 3m then yearly glucose - baseline, 4-6m then yearly ECG - baseline and after dose change BP - baseline and freq during titration prolactin - baseline, 6m then yearly CPK - baseline, then if NMS suspected TFT - yearly if on quetiapine
Depots
Suggested role in…
Zuclopenthixol decanoate (has slight advantage in terms of efficacy) - aggressive patients
Flupentixol - depressed patients
Haloperidol - prophylaxis of mania
Pipotiazine palmitate - when EPSEs are a problem
Chlorpromazine
1st drug used for psychosis
Photosensitivity reactions
Clozapine
Reduced suicidality 30% would respond by 6wks A further 20% by 3m Additional 10-20% by 6m 30% do not respond (Meltzer 1992) Need level of 350-450ng/ml before a pt is considered resistant
Clozapine resistance - augmentation
Sulpride or amisulpride Lamotrigine Aripiprazole Haloperidol Risperidone Avoid: Pimozide, olanzapine
Clozapine resistance - other options
- Allopurinol + antipsychotic
- Max dose amisulpride
- Max dose aripiprazole
- D-Alanine and D-Serine
- ECT
- High dose olanzapine (usually tried first, if failed then…
- Olanzapine with various combinations
Lithium increases WCC - mechanism
?Stimulation of GM-CSF
?Demargination
No left shift
Clozapine levels (reference range)
350-500ug/L
Catatonia complications
Dehydration
DVT
PE
Pneumonia
Catatonia - treatment
Benzos (1st line)
ECT
Antipsychotics best avoided during acute phase
CATIE
Compared older vx newer antipsychotic meds
Phase 1 compared old and new antipsych
1400 participants
1 of 4 atypicals (OLZ, QTP, RIS, ZIP) or typical (perphenazine)
OLZ slightly better than others but weight gain significant
EPSEs not seen more with older drug
CATIE - Phase 2
Guidance on what to try next
If ineffective - tried clozapine
If intolerable - tried ziprasidone
Clozapine was much more effective than other atypicals
NCEP criteria for metabolic syndrome
• Central obesity: waist circumference 102 cm or 40 inches (male), 88 cm or 36
inches(female)
• Dyslipidaemia: TG 1.7 mmol/L (150 mg/dl)
• Dyslipidaemia: HDL-C < 40 mg/dL (male), < 50 mg/dL (female)
• Blood pressure 130/85 mmHg
• Fasting plasma glucose 6.1 mmol/L (110 mg/dl)
CATIE study - metabolic syndrome
The prevalence of MS at baseline in the CATIE group was 40.9%. By gender this was 51.6% in females and 36% in males. Male patients were twice as likely to have MS than matched controls, and female patients were three times as likely compared to matched controls.
Antipsychotic non-compliance in psychotic patients
25-75% - of these, 90% are intentional Following d/c from hospital non-compliance is: 25% at ten days 50% at one year 75% at 2 years
DAI
Drug Attitude Inventory
Assess’ patient attitude to medication - to predict compliance
Other scales: ROMI, Beliefs about medication questionnaire, MARS
Schizophrenia - course and prognosis
Ram (1992) concluded that over a 2 year period, one-third of patients with schizophrenia showed a benign course, and two-thirds either relapsed or failed to recover.
2-3 fold increased risk of premature death
The risk of dying over the next year for people with schizophrenia is 2.6 times higher than for people without it. (SMR 2.6) - mainly due to CVD
SMR falls with age due to early peak of suicides and gradual rise of population mortality
Agoraphobia
Age at onset: 20s
Gender distribution: F>M
12m prevalence: 1.8%
Specific phobia
Age at onset: childhood
Gender distribution: F>M
12m prevalence: -
Social phobia
Age at onset: late teenage/early 20s
Gender distribution: F=M (more F in comm)
12m prevalence: 2.3%
OCD
Age at onset: 25-35 years
Gender distribution: F>M
12m prevalence: 0.7%
PTSD
Age at onset:
Gender distribution: F>M
12m prevalence: 1.1-2.9%
GAD - Epidemiology
Prevalence (12m) - 4.4%
Rates in women are twice as high as in men
A/w lower household income, unemployment, divorce and separation
GAD - Cognitive Theories
Looming cognitive style - increased attention to potentially threatening stimuli, overstimulation of environmental threat, enhances memory of threatening material
Lack of a sense of control of events and of personal effectiveness
GAD - Personality
Personality traits - neuroticism
Personality disorder - anxious-avoidant
GAD - Neurobiology
- Amygdala and hippocampus implicated
- Noradrenergic neurons that originate in the locus coeruleus have been shown to increase arousal and anxiety
- GABA receptors are inhibitory and reduce anxiety, as fo the associated benzo-binding sites
- Probably a role for corticotropin-releasing hormone
GAD - Diagnosis
6 months with prominent tension, worry and feelings of apprehension about every day events and problems
At least 4 of following (and at least 1 of 1st 4)
(1) Palpitations or pounding heart, or accelerated heart rate
(2) Sweating
(3) Trembling or shaking
(4) Dry mouth (not due to medication or dehydration)
(5) Difficulty breathing
(6) Feeling of choking
(7) Chest pain or discomfort
(8) Nausea or abdominal distress
(9) Feeling dizzy, unsteady, faint or light-headed
(10) Feelings that objects are unreal (derealization), or that one’s self is distant or ‘not
really here’ (depersonalization)
(11) Fear of losing control, going crazy, or passing out
(12) Fear of dying
GAD - Diagnosis (2)
(13) Hot flushes or cold chills
(14) Numbness or tingling sensations
(15) Muscle tension or aches and pains
(16) Restlessness and inability to relax
(17) Feeling keyed up, or on edge, or of mental tension
(18) A sensation of a lump in the throat, or difficulty with swallowing
(19) Exaggerated response to minor surprises or being startled
(20) Difficulty in concentrating, or mind going blank, because of worrying or anxiety
(21) Persistent irritability
(22) Difficulty getting to sleep because of worrying
GAD Management - NICE
Step 1 - mild - education and active monitoring Step 2 - (no response to step 1) - low intensity psychological intervention Step 3 - (no response to step 2 or marked impairment) - high intensity psychological intervention or drug treatment Step 4 (no response to step 3 or marked impairment, comorbidity, risks) - complex drug/psychological treatment, input from MDT, crisis services, day hospital, inpatient care
GAD - Medication - NICE
Benzodiazepines should not be used beyond 2-4wks
1st line - SSRIs (sertraline) - warn of increased risk of suicidal thinking and self-harm if under 30 - weekly follow-up for 1m
If pt cannot tolerate SSRI or SNRI - offer pregabalin
Continue treatment for at least 1 year
Kava
Piper methysticum
Effective in reducing anxiety but a/w hepatotoxicity - not recommended
Specific phobia - epidemiology
Lifetime prevalence: men 7%, women 17%
Age of onset usually childhood
7 years for animals, 8 years for blood
Early twenties for most situational phobias
Specific phobia - Blood-infection-injury type
Bradycardia and hypotension often follow the initial tachycardia that is common to all phobias
Genetic link - may have particularly strong vasovagal reflex
Specific phobia - treatment
Behaviour therapy
Graded exposure
Social phobia - Epidemiology
Lifetime prevalence - 12%
Equally frequent in men and women who seek treatment, but more common in women in the community surveys
Associated with depression and alcoholism
Social phobia - genetics
First-degree relatives of persons with social phobia are about three times more likely to be affected with social phobia
Social phobia - clinical picture
Whereas breathlessness, dizziness, a sense of suffocation, and a fear of dying are common in panic disorder and agoraphobia, the symptoms associated with social phobia usually involve blushing, muscle twitching, and anxiety about scrutiny.
Social phobia - treatment
Meds - antidepressants, anxiolytics, BB
Behaviour therapies - relaxation training and CBT
Agoraphobia - Epidemiology
Prevalence considerably more in women (75%)
Age of onset early or middle 20s, with further peak in mid thirties
Typically starts with a panic attack
Agoraphobia - Classical Conditioning Approach
a noxious stimulus (e.g., a panic attack) that occurs with a neutral stimulus (e.g., a bus ride) can result in the avoidance of the neutral stimulus.
Agoraphobia - situations that provoke anxiety have 3 common themes
Distance from home
Crowding
Confinement
Agoraphobia - treament
Medication - anxiolytics and antidepressants
Behaviour therapy, CBT
Panic disorder - Epidemiology
20 years of age, highest in the 25-44 year age group. Rarely after 65yo
High comorbidity
Association with benign joint laxity (15 fold increase)
Panic disorder - Panicogens
IV infusion of sodium lactate can induce panic
Others: carbon dioxide, bicarbonate, yohimbine, mCPP, flumazenil, cholecystokinin, caffeine
Panic disorder - Cognitive theory
• Thoughts of imminent catastrophe have been identified as triggers of panic attacks
• Patients with panic disorder relative to healthy and patient controls have been shown to be:
⁃ 1. Characterized by strategic and automatic information processing (i.e., memory, attention) biases for physical threat cues;
⁃ 2. More accurate, in some instances, at detecting body sensations;
⁃ 3. More likely to report fear of somatic sensations and beliefs in their harmful
consequences
Suffocation alarm theory of anxiety
States that some people have a hypersensitive central chemoreceptor leading to carbon dioxide sensitivity.
Panic attacks in different disorders
SOB more common in panic attacks is agoraphobia
Blushing more common in social phobia
More dizziness, paraesthesia, shaking, chest pain in panic disorder
Panic disorder - Management
1st line - SSRIs
2nd line - no response after 12 wk - imipramine or clomipramine
Sedating antihistamine, antipsychotics and benzos should not be used
Encourage CBT based self-help
Continue antidepressant for at least 6m after optimal dose reached
OCD - Epidemiology
1-3% of population
Begins in early adulthood, mean age 20yrs (slightly earlier in men)
Very slightly higher prevalence in women
Lifetime prevalence for major depressive disorder is 67%, social phobia 25%
OCD - Personality
Only about 15-35% of patients with OCD have had premorbid obsessional traits
OCD - Psychodynamic theory
Disturbances in normal growth and development related to the anal-sadistic phase of development
Magical thinking - persons believe that merely by thinking about an event in the external world they can cause the event to occur without intermediate physical actions
OCD - Biological causes
Historically associated with Encephalitis Lethargica
Increased glucose metabolism in the caudate nucleus and orbitofrontal cortex
OCD - Neuroimaging
FDG-PET - increased glucose metabolism in the OFC, caudate, thalamus, prefrontal cortex and anterior cingulate
HMPAO-SPECT - increased and decreased blood flow to various brain regions including the OFC, caudate, various areas of the cortex and thalamus
Obsessions
Recurrent intrusive thoughts, images, ruminations or impulses that a person recognises as his own, occurring against his will but he finds it difficult to resist it.
- Most common is contamination, followed by washing
- Obsessional sx occur in 20% of cases of severe depression
Compulsions
Obsessional motor acts.
OCD - Treatment
High dose SSRIs and clomipramine
8-16wks needed for maximal therapeutic benefit
Behaviour therapy (ERP) and CBT
ERP - habituation leads to eventual extinction of the response
Hypochondriasis - Epidemiology
6m prevalence of 4-6%, but may be as high as 15%
M=F
20-30yo most commonly
80% have coexisting anxiety or depressive disorders
Hypochondriasis - Psychodynamic theory
Aggressive and hostile wishes toward others are transferred (through repression and displacement) into physical complaints
Hypochondriasis - common features
Avoidance
Bodily checking
Reassurance seeking
Hypochondriasis - name in DSM V
Illness Anxiety Disorder
Body dysmorphic disorder
Most common area perceived to be affected is the skin, followed by hair, nose, toes and then weight
Classified under hypochondriasis in ICD-10
Psychological therapy (CBT)
Somatoform and Dissociative Disorders - differences in classification
• In DSM-5, somatoform disorders as a category has been replaced by somatic
symptom and related disorders. Somatisation disorder has been eliminated.
• A further confusion relates to the relationship between conversion disorder and
somatoform/dissociative disorders. In ICD-10, conversion is used synonymously with dissociation I.e. ‘Dissociative (conversion) disorders’. In DSM-4 and DSM-5, conversion is a subtype of somatoform/somatic symptom disorder. DSM-5 gives the alternative name of functional neurological symptom disorder.
Briquet’s syndrome (Somatisation disorder) - Epidemiology and Aetiology
Lifetime prevalence 0.2% More common in females (5:1) Onset: childhood to early 30s A/w childhood sexual abuse Increased freq in 1st degree relatives
Briquet’s syndrome (Somatisation disorder) - Presentation
Multiple, recurrent and frequently changing physical sx of at least 2 years duration
If short-lived or less striking sx - undifferentiated somatoform disorder
Somatic symptom disorder
Excessive preoccupation and worry about somatic symptoms
Inversely related to social class (more common in low ed and low income)
More common in women
Sx may or may not be a/w med condition
Sx DO NOT need to be medically unexplained to qualify for diagnosis
Somatoform autonomic dysfunction
- Da Costa’s syndrome
- Cardiac neurosis
- Neurocirculatory asthenia
- Dyspepsia
- Pylorospasm
- Irritable bowel syndrome
- Psychogenic flatulence
- Psychogenic cough
- Hyperventilation
- Psychogenic frequency
- Dysuria
Somatisation disorder - treatment
Communicate the diagnosis
Acknowledge symptom severity and experience of distress as real but emphasise negative investigations and lack of structural abnormality
Reassure patient of continuing care
Attempt to reframe symptoms as emotional
Assess for and treat psychiatric comorbidity
Reduce and stop unnecessary drugs
Dissociative disorders
Complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements.
Only disorders of physical functions normally under voluntary control and loss of sensations are included here. Disorders involving pain and other complex physical sensations mediated by the autonomic nervous system are classified under somatization disorder (F45.0).
Dissociative amnesia
Inability to recall important personal memories, usually of a stressful nature, too extensive for N forgetfulness
Dissociative fugue
Rare. Loss of memory coupled with wandering away from the person’s usual surroundings. Some deny knowledge of personal identity.
DID
Multiple personality disorder in ICD-10
Sudden alternations between 2 patterns of behaviour, each of which is forgotten by the pt when the other is present
PD - Prevalence
Any PD 4.4% Paranoid 0.7 Schizoid 0.8 Schizotypal 0.06 Antisocial 0.6 Borderline 0.7 Avoidant 0.8 Dependent 0.1 Obsessive-compulsive (anankastic) 1.9
PD - Prevalence by population
- Community prevalence –2-3% (according to some studies, up to 10%)
- GP attenders –20%
- Psychiatric outpatients –40%
- Psychiatric inpatients –50%
- Male prisoners – 60%
PD Screening - SAPAS
Interview. 8 areas 2minutes to complete Score between 0 and 8 Yes/no answers to 8 q Score of 3 or more warrants further assessment
PD Screening - FFMRF
Self reported
30 items
rated 1-5 for each item
Based on symptoms rather than diagnosis
PD Screening - IPDE
Interview method, self reported
Semistructured clinical interview
Compatible with ICD-10 and DSM-IV
Includes patient questionnaire and an interview
PD Screening - PDQ-R
Self reported
100 true/false questions
30 mins to complete
Based on DSM-IV criteria
PD Screening - IPDS
Interview method
11 criteria
Takes less than 5 mins
PD Screening - IIP-PD
Self reported
Contains 127 items
Items rated 0-4
PD Classification - ICD-10
- Paranoid, Schizoid
- Dissocial, Emotionally Unstable (Impulsie, borderline), Histrionic
- Anankastic, Anxious (avoidant), Dependent
PD Classification - DSM-V
Cluster A - Paranoid, Schizoid, Schizotypal
Cluster B - Antisocial, Borderline
Cluster C - Obsessive-compulsive, Avoidant, Dependent
PD - Antisocial - male prisoners
47% of male prisoners
Antisocial (dissocial) PD ICD-10
At least 3 of following:
• Callous unconcern for the feelings of others;
• Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations;
• Incapacity to maintain enduring relationships, though having no difficulty in
establishing them;
• Very low tolerance to frustration and a low threshold for discharge of aggression,
including violence;
• Incapacity to experience guilt or to profit from experience, particularly punishment;
• Markedly prone to blame others or to offer plausible rationalizations for the behaviour
that has brought the person into conflict with society.
Antisocial (dissocial) PD DSM-V
Disregard for and violation of the rights of others, occurring since age 15, as indicated by three (or more) of:
⁃ Failure to conform to social norms with respect to lawful behaviours
⁃ Deceitfulness, as indicated by repeated lying or conning of others for personal
profit or pleasure
⁃ Impulsivity or failure to plan ahead
⁃ Irritability and aggressiveness, as indicated by repeated fights or assaults
⁃ Reckless disregard for safety of self or others
⁃ Consistent irresponsibility, as indicated by repeated failure to sustain work or honour financial obligations
⁃ Lack of remorse, as indicated by being indifferent or rationalising having hurt,
mistreated, or stolen from another
Must be evidence of conduct disorder before age 15.
Avoidant PD - clinical features
• Avoidance of occupational activities which involve significant interpersonal contact
due to fears of criticism, or rejection.
• Unwillingness to be involved unless certain of being liked
• Preoccupied with ideas that they are being criticised or rejected in social situations
• Restraint in intimate relationships due to the fear of being ridiculed
• Reluctance to take personal risks doe to fears of embarrassment
• Views self as inept and inferior to others
• Social isolation accompanied by a craving for social contact
Borderline PD - clinical features
• Efforts to avoid real or imagined abandonment
• Unstable interpersonal relationships which alternate between idealization and
devaluation
• Unstable self image
• Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
• Recurrent suicidal behaviour
• Affective instability
• Chronic feelings of emptiness
• Difficulty controlling temper
• Quasi psychotic thoughts
BPD and abuse
• Up to 87% have suffered childhood trauma of some sort,
⁃ 40-71% have been sexually abused
⁃ 25-71% have been physically abused (Winston, 2000).
Dependent PD - DSM-IV
At least 5 of:
• Difficulty making everyday decisions without excessive reassurance from others
• Need for others to assume responsibility for major areas of their life
• Difficulty in expressing disagreement with others due to fears of losing support
• Lack of initiative
• Unrealistic fears of being left to care for themselves
• Urgent search for another relationship as a source of care and support when a close
relationship ends
• Extensive efforts to obtain support from others
• Unrealistic feelings that they cannot care for themselves
Dependent PD - ICD-10
At least 3 of following
• Encouraging or allowing others to make most of one’s important life decisions;
• Subordination of one’s own needs to those of others on whom one is dependent, and undue compliance with their wishes;
• Unwillingness to make even reasonable demands on the people one depends on;
• Feeling uncomfortable or helpless when alone, because of exaggerated fears of
inability to care for oneself;
• Preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself;
• Limited capacity to make everyday decisions without an excessive amount of advice
and reassurance from others.
Histrionic PD
- Inappropriate sexual seductiveness
- Need to be the centre of attention
- Rapidly shifting and shallow expression of emotions
- Suggestibility
- Physical appearance used for attention seeking purposes
- Impressionistic speech lacking detail
- Self dramatization
- Relationships considered to be more intimate than they are
Narcissistic PD
- Grandiose sense of self importance
- Preoccupation with fantasies of unlimited success, power, or beauty
- Sense of entitlement
- Taking advantage of others to achieve own needs
- Lack of empathy
- Excessive need for admiration
- Chronic envy
- Arrogant and haughty attitude
Obsessive-Compulsive PD
DSM-IV Criteria
4 of more of:
• Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
• Demonstrates perfectionism that hampers with completing tasks
• Is extremely dedicated to work and efficiency to the elimination of spare time
activities
• Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
• Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
• Is unwilling to pass on tasks or work with others except if they surrender to exactly
their way of doing things
• Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
Anankastic (Obsessive-Compulsive) PD
ICD-10 Criteria
At least 3 of:
• Feelings of excessive doubt and caution
• Preoccupation with details, rules, lists, order, organization or schedule
• Perfectionism that interferes with task completion
• Excessive conscientiousness, scrupulousness, and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships
• Excessive pedantry and adherence to social conventions
• Rigidity and stubbornness
• Unreasonable insistence by the patient that others submit to exactly his or her way of
doing things, or unreasonable reluctance to allow others to do things
• Intrusion of insistent and unwelcome thoughts or impulses
Paranoid PD
- Hypersensitivity and an unforgiving attitude when insulted
- Unwarranted tendency to questions the loyalty of friends
- Reluctance to confide in others
- Preoccupation with conspirational beliefs and hidden meaning
- Unwarranted tendency to perceive attacks on their character
Schizoid PD
- Indifference to praise and criticism
- Preference for solitary activities
- Lack of interest in sexual interactions
- Lack of desire for companionship
- Emotional coldness
- Few interests
- Few friends or confidants other than family
Schizotypal PD
- Ideas of reference (differ from delusions in that some insight is retained)
- Odd beliefs and magical thinking
- Unusual perceptual disturbances
- Paranoid ideation and suspiciousness
- Odd, eccentric behaviour
- Lack of close friends other than family members
- Inappropriate affect
- Odd speech without being incoherent
Treatment for PD - Meds
- Low dose neuroleptics in cluster B and schizotypal disorders
- Carbamazepine for behavioural dyscontrol in borderline PD
- Lithium for aggressive behaviour
- SSRIs in impulsive behaviour
- MAOIs or imipramine in comorbid atypical depression in histrionic and borderline PD
- Comorbid PD and depression may benefit from ECT (good initial response)
Psychotherapy for BPD
DBT MBT SFT TFP STEPPS CAT (Ryle) Some evidence for IPT Therapeutic communities - milieu therapy
Acute Stress Reaction
• There is an initial stage of a daze, followed by symptoms of disorientation, inattention, and inability to comprehend external stimuli.
• This is then usually followed by a rapidly changing picture of symptoms which might
include flight reactions, panic, autonomic hyperarousal, anger, or despair.
• Symptoms usually diminish within 24-48 hours and should be minimal after 3 days.
PTSD - epidemiology
Female preponderance
Lifetime incidence - 9-15%
Lifetime prevalence - 8% of general population
PTSD - aetiology
- Ambient cortisol levels lower than normal due to chronic adrenal exhaustion from inhibition of the HPA axis by persistent severe anxiety.
- Decreased hippocampal volume
- Amygdala - mediates unconscious memories
- Hippocampus - mediates conscious memories
- Neuroimaging studies - decreased activity in medial prefrontal and anterior cingulate, increased activity in amygdale.
Moderate impact traumas
Precede PTSD in 5-20%
e.g. diagnosis of life threatening illness in self or loved one, sudden death of a loved one, witnessing death
or serious injury of another person, direct involvement in a serious accident and
involvement in fires, floods or small scale natural disaster
High impact traumas
Precede PTSD in >20%
e.g. muggings, threats with a
weapon, serious domestic violence, rape, childhood sexual abuse, war/combat,
kidnap, torture, large-scale or man-made disasters.
PTSD - ICD-10 criteria
• Exposure to a traumatic event which would be likely to cause pervasive distress in
almost anyone.
• The event must be persistently remembered or relived, as evidenced by flashbacks, vivid memories, or nightmares.
• The patient must actively avoid situations which remind them of the event.
Plus 1 of:
• Partial amnesia for part of the event
• Persistent symptoms of psychological arousal such as, poor sleep, poor concentration, hypervigilance, exaggerated startle response, irritability.
Above must occur within 6m of event
PTSD - Treatment - Children and Young people
Do not offer psychological debriefing
- Sx for >1m - individual trauma-focused CBT intervention
- Consider EMDR for children 7-17 with sx >3m with no response to CBT
- Do not offer drug tx
PTSD - Treatment - Adults
- Do not offer psychological debriefing
- 1st line - Individual trauma-focused CBT or EMDR (non-combat related only and if pt prefers) or supported trauma-focussed computerised CBT
- Do not offer drug treatments to prevent PTSD
- Venlafaxine or SSRI (not 1st line)
- Antipsychotics if severe hyperarousal or psychotic sx
EMDR
Francine Shapiro in 1980s
Grief - John Bowlby
- Shock and protest including disbelief (few days)
- Preoccupation - involves yearning and anger (few weeks)
- Disorganisation - includes despair and acceptance of loss (several months)
- Resolution (1-2 years)
Grief - Kubler-Ross 1969
Stage 1 - Denial Stage 2 - Anger Stage 3 - Bargaining Stage 4 - Depression Stage 5 - Acceptance
Abnormal grief - Inhibited
Absence of expected grief sx at any stage
Abnormal grief - Delayed
Avoidance of painful sx within 2 weeks of loss
Abnormal grief - chronic/prolonged
Continued significant grief related sx 6m after loss
Features that distinguish normal grief from depression
Generalised guilt
Thoughts of death (except in relation to the deceased)
Feeling worthless
Psychomotor retardation
Prolonged functional impairment
Hallucinations (except in relation to the deceased)
Dyssomnias
Intrinsic sleep disorder
Extrinsic sleep disorders
Circadian rhythm disorders
Parasomnias
- Arousal disorders - sleepwalking, sleep terrors
- Sleep wake transition disorders - RMD, sleep talking, nocturnal leg cramps
- Parasomnias a/w REM sleep - nightmare, sleep paralysis
Intrinsic sleep disorder
Narcolepsy Psychopsycholical insomnia Idiopathic hypersomnia RLS Periodic Limb Movement disorder OSA
Extrinsic Sleep disorders
Inadequate sleep hygiene
Alcohol dependent Sleep disorder
Circadian Rhythm Disorders
Jet lag syndrome Shift work sleep disorder Irregular sleep wake pattern Delayed sleep phase syndrome Advanced sleep phase disorder
Cataplexy
Sudden loss of bilateral muscle tone provoked by strong emotion
Seen in Narcolepsy
Few sec to few mins
Treat with TCA such as protriptyline or imipramine
Narcolepsy
Commonly begins in 2nd decade
Peak incidence around 14yo
Repeated episodes of sleep of short duration
Modafinil
Enhances wakefulness, attention and vigilance
Not addictive, lacks euphoric effect, does not tend to precipitate psychosis
Used in narcolepsy, OSA, chronic shift work, depression
Periodic Limb Movement Disorder
Repetitive and highly stereotyped limb movements during sleep
A/w partial arousal or awakening
Restless Leg Syndrome
Disagreeable leg sensations that usually occur prior to sleep onset causing irresistible urge to move the legs - partial or complete relief when legs moved
RLS - risk factors
- Older age
- Female sex
- Pregnancy
- Iron deficiency and anemia
- Renal failure
- Hypothyroidism
- Diabetes
- B12 deficiency
Jet leg syndrome
Sx typically last longer following eastward flights
Shift work sleep disorder
Sleep length reduced by 1-4 hours and mainly affects REM and stage 2 sleep
Non 24hr sleep wake syndrome
Chronic steady pattern comprising one to two hour daily delays in sleep onset and wake times
Sleepwalking
During slow-wave sleep - therefore 1st 1/3 of the night or following sleep deprivation
Peak between 4-8yo
Lithium can exacerbate or induce it
Sleep terrors
sudden arousal from slow wave sleep with a piercing
scream or cry, accompanied by autonomic and behavioural manifestations of intense
fear.
May have micturition
Amnesia for episode
Rhythmic Movement Disorder
Stereotyped, repetitive movements
involving large muscles, usually of the head and neck
Sleep starts
sudden, brief contractions of the legs, sometimes also involving the arms
and head, that occur at sleep onset
Nocturnal leg cramps
Painful sensations of muscular tightness or tension, usually in calf
Few seconds up to 30min
One or two episodes nightly several times a week
Nightmares
Usually awaken the sleeper from REM sleep
Long dreamlike feature differentiates it from sleep terrors
Sleep paralysis
Transient paralysis of skeletal muscles which occurs when awakening from sleep or when falling asleep
Hallucinations
Clonazepam may be used
Insomnia - short term
Hypnotic drug e.g. temazepam or z drug only if daytime impairment is severe
Max 2 weeks
Insomnia - long-term
CBT
Meds for up to 4 weeks
If over 55 - melatonin - 3w, if response then cont for 10w
Neurasthenia (F48)
Excessive fatigue following mental or physical effort
Neurasthenia - ICD-10
- Either persistent and distressing complaints of increased fatigue after mental effort, or bodily weakness and exhaustion after minimal effort
- At least two of the following: muscular aches, dizziness, tension headaches, sleep disturbance, inability to relax, irritability, dyspepsia
- Inability to recover through rest, relaxation or enjoyment
- Duration exceeds 6 months
- Does not occur in the presence of organic mental disorders, affective disorders or panic or GAD
Somatisation disorder
- multiple physical SYMPTOMS present for at least 2 years
* patient refuses to accept reassurance or negative test results
Hypochondrial disorder
- persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
- patient again refuses to accept reassurance or negative test results
Conversion disorder
• typically involves loss of motor or sensory function
• the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
• patients may be indifferent to their apparent disorder - la belle indifference - although
this has not been backed up by some studies
Dissociative disorder
- in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
- dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
Munchausen’s syndrome
- also known as factitious disorder
* the intentional production of physical or psychological symptoms
Malingering
• fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
BDD - Epidemiology
• Equal sex incidence
• Less than 1% prevalence but markedly over-represented in some groups (e.g. plastic
surgery - 10% - and dermatology)
• 10% incidence in first-degree family members
BDD - Treatment
- SSRI - fluoxetine 20mg increasing to 60mg
- If ineffective try Clomipramine up to 250mg
- Antipsychotic if delusional features
- Psychological - CBT, with ERP
Premenstrual tension syndrome (ICD-10)
Known as Premenstrual dysphoric disorder in DSM-V
- mood lability, irritability, dysphoria, and anxiety
symptoms that occur repeatedly during the premenstrual phase of the cycle and remit around
the onset of the menses.
Premenstrual tension syndrome - treatment
SSRIs
Gonadotrophin releasing hormone analogues
?Vit B6
?Bright light therapy
For mastalgia - Danazol, evening primrose oil
Progesterone has no effect
Drugs affecting contraception
Carbamazepine
Phenytoin
Topiramate
Valproate and carbamazepine in pregnancy
Increase risk of neural tube defect (1-2% and 0.5-1% resp)
Lithium in pregnancy
Ebstein’s anomaly (relative risk 10-20 times that of control, absolute risk 1:1000)
Benzos in pregnancy
Oral clefts in newborns and floppy baby syndrome
Antipsychotics in pregnancy
Olanzapine is recommended choice
Paroxetine in pregnancy
More commonly a/w neonatal withdrawal, increased risk of cong malformations (particularly heart defects)
Pregnancy
spontaneous abortion 10-20%
Major malformations 2-3% (1 in 40)
Drugs account for 5% of all abnormalities
Antidepressants recommended in pregnancy
Fluoxetine, sertraline, amitriptyline, imipramine
Antidepressants recommended in breastfeeding
Sertraline
Antipsychotics rec in pregnancy
Olanzapine, quetiapine, haloperidol, clozapine, chlorpromazine
Antipsychotics rec in breastfeeding
Olanzapine
Mood stabilisers in pregnancy
Avoid if possible
Mood stabilisers in breastfeeding
Avoid if possible
Valproate if essential
Sedatives in preg
Promethazine (little data)
Benzos (avoid in late preg)
Sedatives in breastfeeding
For anxiety - lorazepam
For insomnia - zolpidem
Baby blues
30-75%
transient mood disturbance characterised by emotional lability, sadness, and tearfulness. This usually clears up by 2 weeks
Onset 3-5 days following birth
Postpartum depression
10-15%
Similar to major depression
Risk increased to 25% with h/o depression and 50% with h/o postpartum depression
3-5% will be mod-sev
Postpartum psychosis
1-2 per 1000
Approx 50% have FH of mood disorder
Usually begins within 1st 2wk following birth (2-14d)
HIV and CD4 count
Most individuals are asymptomatic when their CD4 counts are >500 x 10^6/l. They are at greatest risk when this count falls below 200 x 10^6/l.
Non-nucleoside reverse-transcriptase inhibitors
Efavirenz - can cause psychosis, suicide, mania
Nevirapine
Nucleoside reverse-transcriptase inhibitors
Abacavir
Didanosine
Protease inhibitors
Retinovir
Indinavir
Others (HIV drugs)
Enfuvirtide
Psychosis in HIV
Atypicals
Risperidone widely used
Delirium in HIV
Atypicals and low-dose short acting benzos
Depression in HIV
SSRIs, esp citalopram. Also SNRIs, mirtazapine and bupropion
Bipolar in HIV
Valproate, lamotrigine
Lithium ok but poorly tolerated
Avoid carbamazepine
Atypicals
MS - primary progressive
5-10%
Steady progression no remissions
MS - relapsing-remitting
20-30%
Relapsing-remitting course
MS - secondary progressive
60%
Initially relapsing-remitting but followed by phase of progressive deterioration
Depression in MS
Lifetime prevalence of 25-50%
Somatic sx not good discriminators in MS
SSRIs 1st line
Interferon-beta - start on antidepressant prophylaxis if there is h/o depression
Risk factors for suicide in MS
- Male gender
- Young age at onset of illness
- Current or previous history of depression
- Social isolation
- Substance misuse
Mania in MS
More common
Mood stabilisers recommended in preference to lithium due to tolerance issues
Pathological laughing/crying
uncontrollable laughing and/or crying but
without the associated affect and is a common feature of Multiple sclerosis
Use amitriptyline or fluoxetine 10% in MS
Emotional lability in MS
Amitriptyline and SSRIs recommended
Porphyria - drugs that precipitate
- Barbiturates
- Benzodiazepines
- Sulpiride
- Certain mood stabilizers
Porphyria - symptoms
- Abdominal pain
- Mental state changes
- Constipation
- Vomiting
- Muscle weakness
Post-concussion syndrome - symptoms
- headache
- fatigue
- anxiety/depression
- dizziness
Wilson’s disease - inheritance
Autosomal recessive inheritance
Wilson’s disease - cause
Mutation in Wilson disease protein (ATP7B) gene
Low levels of ceruloplasmin and total serum copper, high levels of copper in liver and brain
Wilson’s disease - presentation
movement disorders such as dystonia, parkinsonian tremor, and rigidity combined with behavioural problems and a degree of dementia is often seen.
Kayser-Fleischer ring is the term given to the brown ring seen around the iris in people with Wilson’s disease.
Suicide - Epidemiology
M:F = 4:1 in western countries, 2:1 in asian countries, higher in women in China. GENERAL 3:1
Average suicide rate = 1 per 10,000 in gen pop
Most common in 40-44 age group
Suicide - most popular methods in desc order
- Hanging/strangulation
- Self-poisoning
- Jumping and multiple injuries (mainly jumping from a height or being struck by a train)
- CO poisoning and drowning (these occur at approximately the same rate)
- Cutting and stabbing
Patient suicides
28% of gen population suicides
10% of patient suicides occurred as inpatients
Suicide is rate is 1 in 1000 (x10 higher than gen pop)
1st 3m after discharge is high risk
Risk factors for completed suicide
⁃ Male ⁃ Elderly age. ⁃ Single, divorced, or widowed ⁃ Living alone ⁃ Poor social support ⁃ Unemployed ⁃ Low socio-economic class ⁃ Previous self harm ⁃ Any mental disorder ⁃ Dependence on substances ⁃ Recent inpatient treatment ⁃ Concurrent physical disorder ⁃ Bereavement in recent past
Suicide - protective factors
- Children in the home
- Sense of responsibility to family
- Pregnancy
- Religiosity
- Life satisfaction
- Reality testing ability
- Positive coping skills
- Positive problem-solving skills
- Positive social support
- Positive therapeutic relationship
Self-harm
Annual prevalence 0.5%
16% of pt repeat within 1yr
3-12 session of psychological intervention for self-harm
Do not offer drug treatment specifically for self-harm
SCOFF questionnaire
• Do you ever make yourself Sick because you feel uncomfortably full?
• Do you ever worry that you have lost Control over how much you eat?
• Have you recently lost more than One stone in a three month period?
• Do you believe yourself to be Fat when others say you are too thin?
• Would you say Food dominates you life?
Score 2 or more indicated AN or bulimia
84.6% sensitivity and 98.6% specificity, NPV 99.3%
AN - DSM-V
• Restriction of energy intake relative to requirements, leading to a significantly low
body weight (generally speaking a BMI < 18.5)
• Intense fear of gaining weight or of becoming fat, or persistent behaviour that
interferes with weight gain, even though at a significantly low weight
• Disturbance in the way in which one’s body weight or shape is experienced,
AN - DSM-V (severity)
- Mild = BMI > 17
- Moderate = BMI 16 – 16.99
- Severe = BMI 15 – 15.99
- Extreme = BMI < 15
AN - cardiac complications
bradycardia, hypotension, arrhythmia, prolonged QT, ventricular tachy, peripheral oedema, sudden death
AN - skeletal complications
osteoporosis
AN - haematologic complication
anaemia, leukopenia, thrombocytopenia
AN - reproductive complications
amenorrhea, low levels of LH and FSH, premature births
AN - metabolic complications
Hypothyroidism, hypothermia, dehydration, hypoglycaemia, hypokalaemia, hypomagnesia, metabolic alkalosis
AN - Gastrointestinal complications
Delayed gastric emptying, constipation, pancreatitis
AN - CNS complications
Cerebral atrophy, depression, cognitive impairment
AN - Dermatological complications
Lanugo, hypercarotanaemia, acrocyanosis, hypertrichiosis
AN - Treatment
CAT, CBT, IPT, focal psychodynamic therapy and family interventions
Aim 0.5-1kg/wk weight gain inpatient, or 0.5kg outpatient
No medication for sole or primary tx for AN but olanzapine can effect weight restoration
MARSIPAN - high risk items for AN
BMI <13 Pulse <40bpm SUSS test <2 Sodium <130mmol/L Potassium <3 mmol/L Serum glucose <3mmol/L QTc >450ms
AN f/u over 29yr period
50% recovered completely
1/3 had partial recovery
20% had chronic eating disorder
5% died
Factors for poor prognosis with anorexia
Patients with a long duration of hospital care Psychiatric co-morbidity Being adopted Growing up in a 1 parent household Having a young mother Lower minimum weight Poor family relationships Failed treatment Late age of onset Social problems
Bulimia Nervosa - Prevalence
Prevalence 2-3% F:M = 10:1 Depression more prominent than in AN Alcohol abuse occurs in 15% 13% have co-morbid BPD
BN - aetiology
Risk factors
?decreased CCK levels
Childhood sexual abuse Male homosexuality Having an occupation that focuses on weight Low self-esteem Female gender
BN - DSM-IV
- Recurrent episodes of binge eating (large amount of food with lack of control)
- Recurrent inappropriate compensatory behaviour in order to prevent weight gain
- Above occur at least twice a week for 3 months
- Self-evaluation is unduly influenced by body shape and weight
- Disturbance does not occur exclusively during episodes of AN
- Can be over or underweight
Ipecac
Produces vomiting within 15-30min
A/w serious cardiac toxicity, including cardiomyopathy and left ventricular dysfunction
Causes elevated serum amylase levels
BN - Physical Complications
- Hypokalemia
- Hypochloremia
- Hyperphosphatemia (note in anorexia a low phosphate level is usually seen)
- Metabolic alkalosis (if induced vomiting is main method)
- Metabolic acidosis (if purging is main method)
- Parotid gland enlargement (sialadenosis)
- Dental erosion
- Gastric and oesophageal rupture
- Seizure
BN - treatment
- 1st line - evidence-based self-help program or/plus antidepressant - SSRI (fluoxetine 60mg OD)
- CBT-BN 16-20 sessions
- IPT but takes 8-12m
BN - Outcome
Standardised Mortality Rate 1.3
BN is preceded by AN in about 25% of cases or AN-like state
Metabolic complications in eating disorders - Electrolytes
- Hypokalemia
- Hypomagnesemia
- Hypocalcemia
- Hypophosphatemia (note in bulimia a high phosphate level is generally seen)
Metabolic complications in eating disorders - Endocrine
- Low estradiol
- Low luteinizing hormone (LH)
- Low follicular stimulating hormone (FSH)
- Low T3 (low T3 syndrome/ sick euthyroid syndrome), TSH and T4 are usually normal
- Hypercortisolism
- Hypoglycemia
- Elevated growth hormone
Metabolic complications in eating disorders - other
- Hypercarotenemia
- Hypercholesterolemia
- Urea and creatinine low
Complications of purging - vomiting
Na high, low or N
K low
Chloride low
pH high
Complications of purging
- laxatives
Na high or N
K low
Chloride high or low
pH high or low
Complications of purging - diuretics
Na low or N
K low
Chloride low
pH high
Transsexualism
Desire to live and be accepted as a member of the opposite sex
Feelings persistent for 2yrs
Dual-role transvestism
Wearing of clothes of the opposite sex in order to enjoy the temporary membership of opposite sex w/o desire for permanent change.
No sexual excitement
Gender identity disorder of childhood
Persistent intense distress about assigned sex, together with desire to be other sex, manifests before puberty.
M>F
Risk factors for QTc prolongation
Long QT prolongation Bradycardia IHD Myocarditis MI LVH Hypokalaemia Hypomagnesia Hypocalcaemia Extreme Extreme physical exertion Stress or shock AN Extremes of age Female gender
Drugs causing prolonged QTc (non-psych)
Ampicillin, Erythromycin
Amiodarone, sotalol
Chloroquine, quinine
Methadone, tamoxifen, amantadine
Priapism
Persistent and painful erection
Caused by alpha blockade, ?also by serotonin
Drugs that cause: trazodone, chlorpromazine
Treatment: Alpha-adrenergic agonists
Drugs that raise ALT
clozapine haloperidol olanzapine quetiapine chlorpromazine mirtazapine moclobemide SSRIs Carbamazepine lamotrigine valproate
Drugs that lower ALT
vigabatrin
Drugs that raise ALP
haloperidol clozapine olanzapine duloxetine sertraline carbamazepine
Drugs that raise AST
clozapine
olanzapine
valproate
methadone
Drugs that lower AST
trifluperazine
Drugs that raise TSH
aripiprazole
carbamazepine
lithium
drugs that lower TSH
moclobemide
Drugs that raise thyroxine
dexamfetamine
moclobemide
Drugs that raise thyroxine
lithium
aripiprazole (rare)
quetiapine (rare)
Sedatives in liver impairment
lorazepam
oxazepam
temazepam
zopiclone
Serotonin syndrome
⁃ neuromuscular abnormalities (myoclonus, and clonus, hyperreflexia, muscular rigidity),
⁃ altered mental state
⁃ autonomic dysfunction.
Onset usually after 1 or 2 doses of the medication
Most frequently due to co-administration of MAOI and SSRI
Mild cases: benzos and fluids
Severe: ITU
NMS
- result of dopamine blockade at the hypothalamus which messes up the thermo-regulatory system and hence results in hyperthermia
- also suggested that the use of antipsychotics (neuroleptics) causes calcium uptake
into muscles resulting in muscle rigidity, then rhabdomyolysis and elevated CPK - Caused by antipsychotics, also antidepressants and lithium
- Onset - within 2w of initial treatment usually
- Management: removal of drug, control of fever, benzos, sometimes ECT, bromocriptine, dantrolene
- Mortality up to 20%
Risk factors for NMS
Younger age Make Physical exhaustion Dehydration or electrolyte imbalance Previous and FH of NMS Organic mental disorders Low serum iron levels Raised CK levels Comorbid substance misuse Higher loading dose Faster rate of loading High potency Sudden withdrawal
NMS vs serotonin syndrome
SS has acute onset, NMS more insidious
SADHART study
Found sertraline to be a safe treatment for depression post-myocardial
infarction.
Hyponatraemia a/w antidepressant use
Recurs upon rechallenge, even if a different antidepressant is rx
Sx: n&v, confusion, lethargy, irritability, muscular spasm and cramp, seizures
SIADH
Drug induced hyponatraemia (due to excessive secretion of ADH)
Fluid overload
Antidepressants and antipsychotics
Risk factors: elderly, female, smokers, med co-morbidity, polypharmacy, low body weight, reduced renal function, warm weather
Normally develops within a few weeks of starting the new drug
Antidepressants a/w SIADH
SSRIs TCAs Trazodone Phenelzine Tranylcypromine Venlafaxine
Antipsychotics a/w SIADH
Chlorpromazine Fluphenazine Trifluoperazine Thioridazine Thiothizene Haloperidol Clozapine
Treatment of SIADH
Fluid restriction
Sometimes demeclocycline
Consider switching to noradrenergic drug such as nortriptyline and lofepramine or an MAOI such as moclobemide
Tamoxifen (SERM)
Metabolised by CYP2D6 - some antidepressants inhibit this therefore decrease the anticancer effect.
Paroxetine, fluoxetine, bupropion, duloxetine interact (strong).
Sertraline, escitalopram, doxepin are moderate inhibitors.
Venlafaxine is a weak inhibitor.
Teratogens - valproic acid
Spina bifida (1-2% vs 0.2-0.5% background risk), hypospadias
Teratogens - Lithium
Ebstein’s anomaly
Teratogens - alcohol
Fetal alcohol syndrome
Teratogens - phenytoin
Craniofacial defects, limb defects, cerebrovascular defect, mental retardation
Teratogens - carbamazepine
Fingernail hypoplasia, craniofacial defects
Teratogens - diazepam
Cleft lip/palate
