Mental Health Flashcards
15%
List of mood and affective disorders
- Depressive Disorders
- Bipolar and Related Disorders
List of depressive disorders
a) Major Depressive Disorder
b) Persistent Depressive Disorder
(Dysthymia)
List of anxiety disorders
- GAD (most common)
- OCD
List of Bipolar and related disorders
a) Bipolar I Disorder
b) Bipolar II Disorder
c) Cyclothymic Disorder
Antidepressants classification
- First line: SSRIs Depression, anxiety
- Second line: Atypical Antidepressants (Depression, anxiety)
-SNRIs: 75% Depression & 25% anxiety, chronic pain
-TCA’s: Depression, anxiety disorder, chronic pain, migraine
- MAOIs: Atypical Depression
List of 1st line antidepressants
- Fluoxetine (safe in pregnancy)
- Sertraline (safe in pregnancy)
- Paroxetine (avoid in pregnancy)
- Citalopram (Prolongs Q-T - safe in pregnancy)
- Escitaprolam (safe in pregnancy)
- Fluvoxamine
List of 2nd line antidepressants
BMT
Atypical Antidepressants:
- Bupropion (less sexual side effects)
- Mirtazapine
- Trazodone (sedation & priapism)
List of SNRI’s
- Venlafaxine
- Desvenlafaxine
- Duloxetine
SNRI indications
For treating depression AS WELL AS anxiety (75% depression 25% anxiety)
Venlafaxine contraindication
DBE
- Diastolic Hypertension
- Breast feeding
- Epilepsy (Decreases seizure threshold)
List of TCA’s
- Nortriptyline
- Amitriptyline
- Imipramine
- Desipramine
- Dothiepin
List of MAOI’s
PS
- Phenelzine
- Selegiline
List of mood stabilisers
LSLC
- Lithium
- Sodium Valproate
- Lamotrigine
- Carbamazepine
List of Typical Antipsychotics (1st Generation)
HDFTCP
- Haloperidol (causes arrhythmias)
- Droperidol
- Fluphenazine
- Thioridazine
- Chlorpromazine
- Prochlorperazine
Typical Antipsychotics (1st Generation) use and side effects
H-A
C-S
T-R
Treatment of POSITIVE symptoms.
- Haloperidol: Arrithmyas.
- Chlorpromazine and Thioridazine: More epileptogenic, orthostatic hypotension, and anticholinergic effects (dry mouth, constipation, and urinary retention)
- Chlorpromazine causes sedation
- Thioridazine causes retinal pigmentation
Typical Antipsychotics: Mechanism of Action
- Mainly dopaminergic neurotransmission inhibition.
- Also noradrenergic, cholinergic, and histaminergic inhibition.
Typical Antipsychotics: General Side Effects
- Extrapyramidal Symptoms: Acute dyskinesias, tardive dyskinesia, Parkinsonism, akinesia, akathisia.
- Agitation
- Lower seizure threshold
- Prolonged QT interval
- Hyperprolactinemia (> 2000): Galactorrhea, amenorrhea, impotence, and anorgasmia
Extrapyramidal symptoms: days
Acute Dystonia (2-3d)
- Torticollis (neck muscles spasm & twists to the side)
- Buccolingual crisis (rotruding or pulling sensation of the tongue)
- Oculogyric crisis (upward deviation of the eyeball)
- Opisthotonus: spastic contraction of the extensor muscles of the neck, trunk, and lower extremities (Banana shape)
*Treatment:
1. Reduce the dose of antipsychotic
2. Change to another with less EPS (ACQ)
3. For symptom relief: Benztropine, diphenhydramine, procyclidine
Extrapyramidal symptoms: (weeks)
Akathesia (weeks): Legs restlessness
*Treatment:
1. Reduce doses or change the drug.
2. Propranolol, diazepam, benztropine
Extrapyrimidal smyptoms: MONTHS
Tardive Dyskinesia (3-6m)
- Lip-smacking
- Head nodding
- Tongue protrusion
*Treatment:
1. Reduce the dose of antipsychotic
2. Change to Clozapine.
Extrapyrimidal symptoms (6 months):
Neuroleptic-induced parkinsonism (> 6 months):
Classic parkinson symptoms.
Treatment:
1. Reduce the dose of antipsychotic
2. Change to another with less EPS (ACQ).
3. For symptom relief: Benztropine, diphenhydramine, procyclidine
List of Atypical Antipsychotics (2nd Generation)
CROQA
Order from lowest to highest potency
- aripiprazole
- quetiapine
- olanzapine
- risperidone
- clozapine
- ziprasidone
- lurasidone
- paliperidone
- amisulpride
Atypical Antipsychotics (2nd Generation) features
Treatment of NEGATIVE symptoms.
- Decreased risk of extrapyramidal symptoms.
- Increased risk of stroke in older people.
Atypical Antipsychotics that don’t cause extrapyramidal symptoms
ACQ:
Aripiprazole, Clozapine, Quetiapine
Atypical Antipsychotics: Mechanism of Action
D2-dopamine & serotonin receptor antagonists
Atypical antipsychotic side effects
The overall ones
- Hyperprolactinemia (>2000ml)
- significant weight gain
- metabolic syndrome
Atypical Antipsychotics with minimal weight gain
Aripiprazole and Lurasidone
Risperidone features
Which conditions is it used for?
It causes drug induced
Must switch to ?
- Used for Tourettes, ADHD, mania/hypomania, postpartum psychosis,schizophrenia
- Main cause for drug-induced cause hyperprolactinemia (Switch to aripiprazole).
Olanzapine features
- Causes weight gain & HbA1c >7.5% (Change to Aripiprazole)
- Cause Hypertriglyceridemia (but not cholesterol)
METABOLIC SYNDROME
Clozapine side effects
- Agranulocytosis: Stop when WBC goes < 3000.
- Myocarditis: Measure troponin
- Tachycardia
- Hypersalivation
Quetiapine features
- Causes sleeping: Drug of choice for psychosis with insomnia
- Doesn’t cause hyperprolactinemia
Antidepressants side effects
- GI distress: Most common and temporary. Nausea, Vomiting, Diarrhoea (sertraline)
- Sexual side effects: Erectile dysfunction, anorgasmia, delayed ejaculation and decreased libido
- Nervous System: Agitation, insomnia, tremor
- SSRRs: GI bleeding in combination with AAS or NSAIDs. The best option is TCA’s
- Serotonin Syndrome
SSRI’s Withdrawal
Some adverse effects are likely, but most will go away after 1–2 weeks
[incomplete flash card]
Tardive dyskinesia vs Drug-Induced Parkinsonism
Identical symptoms:
- rigidity
- bradykinesia
- postural instability
Differentiating symptoms:
- Tardive: involuntary movements of face and tongue
- Parkinsonism: Stiffness
Drug-induced extra-pyramidal disease features
- Common in the elderly due to diminished brain dopamine stores
- Caused by neuroleptic drugs
- Tardive dyskinesia is the primary symptom
- Treatment is to cease offending neuroleptic
Paroxetine contraindication
Avoid in pregnancy:
-causes pulmonary HT in the fetus.
Bupropion Features
CI -
- Indicated: smoking cessation
- Contraindicated: Seizures and eating disorders
- Decrease seizure threshold
- Minimal Sexual Side Effects
Mirtazapine Features
- Causes weight gain and sedation
- Indicated for patients with history ofother drug overdose
MOA: NA and serotoninergic antidepressant.
Venlafaxine contraindication
- Contraindicated in HTA because it causes diastolic HTN
Fluoxetine features
- Long half-life: most likely to cause serotonin symptoms, sleep, and paralysis.
- Useful for post-stroke depression
- Indicated in pregnancy and adolescents
Serotonin Synd & NMS Synd SHARE symptoms
- Altered mental status
- Hyperthermia > 40C
- Hypersalivation
- Autonomic Dysregulation: Tachycardia, hypertension, muscle spasms, diaphoresis, erythema
Serotonin Symptoms specific symptoms
- Onset: < 24 h
- Dose dependant. Increasing doses
- Severe muscle WEAKNESS, CLONUS, and HYPERreflexia
- Nausea, vomiting
- Increased bowel sounds
- Dilated pupils (Mydriasis)
Serotonin Syndrome causes
- SSRIs
- MAOIs
- TCAs
- Opioids: Tramadol, Morphine, Meperidine
- Illicit drugs
- St John’s wort
Serotonin Syndrome step by step management
- DRABCDE
- Stop medications
- Cyproheptadine + BZD
- Chlorpromazine
NMS specific symptoms
- Onset: Days / Weeks
- **Not dose dependant. ** Occurs any time
- Severe muscle RIGIDITY with HYPOreflexia
- No nausea or vomiting
- Reduced bowel sounds
- Normal pupils
NMS causes
Dopamine Antagonist (Antipsychotics/Neuroleptics) such as haloperidol
NMS step by step management + medicatons
- DRABCDE
- Stop medications
- Benzodiazepines + Bromocriptine
Usually medication is never withdrawn immediately. In what situation is this the exception
- Serotonin syndrome (SS)
- Neuroleptic malignant syndrome (NMS)
TCAs Side Effects
3C’s + Anticholinergic symptoms
TCAs DON’T cause impotence!
TCA Mechanism of action
Alpha-adrenergic inhibition
TCA 3C’s
- Cardiac arrhythmias (prolong QT, MCC of death)
- Convulsions (drowsiness)
- Coma (Respiratory depression, hypoxia)
TCA anticholinergic symptoms
- Hyperreflexia
- Urinary retention
- Dilated pupils (mydriasis)
TCA Overdose Complications
- Cardiac Arrhythmias
- Aspiration pneumonia
Tricyclic antidepressants (TCAs) are a type of medication that can be dangerous in large amounts (overdose). Here’s why an overdose can lead to cardiac arrhythmias and aspiration pneumonia in simple terms:
- What Happens: TCAs affect the electrical signals in the heart that control the heartbeat.
- Why It’s a Problem: In an overdose, TCAs can interfere with these signals, leading to irregular heartbeats (arrhythmias). This means the heart might beat too fast, too slow, or in an uncoordinated way.
- Why It’s Dangerous: Irregular heartbeats can reduce the heart’s ability to pump blood effectively, which can be life-threatening.
- What Happens: TCAs can make a person very drowsy or even unconscious.
- Why It’s a Problem: When someone is unconscious or has a reduced level of consciousness, they may vomit and accidentally inhale (aspirate) some of the vomit into their lungs instead of clearing it out of their airway.
- Why It’s Dangerous: The stomach contents that enter the lungs can cause a serious lung infection known as aspiration pneumonia. This happens because the lungs are not meant to handle anything other than air, so inhaled vomit can cause inflammation and infection.
- Cardiac Arrhythmias in TCA overdose occur because the drug disrupts the heart’s electrical signals, leading to potentially dangerous irregular heartbeats.
- Aspiration Pneumonia can happen if the person vomits while unconscious from the overdose and inhales vomit into their lungs, causing a serious lung infection.
Both of these complications are serious and require immediate medical attention.
TCA overdose in suicidal attempt initial investigations
- ECG
- Paracetamol levels (30-40 min after arrival)
TCA Overdose step by step management
- < 1hr: Gastric lavage and ECG for 48hrs
- > 1hr: Alkalinisation w/ IV sodium bicarbonate (antidote)
- if severe Hypotension: IV NS + IV glucagon + Mg sulphate (stabilizes the cardiac membrane)
- if seizures: IV Diazepam
Major Depression Criteria
2 core symptoms + 5 other symptoms > 2 weeks
MSIGECAPS
Major depression core symptoms
- Low mood
- Anhedonia
- Lethargy
Major depression non-core/other symptoms
- Change in appetite and weight
- Poor concentration
- Early morning awakening
- Suicidal ideations
- Tiredness
- Guilt
Major depression MSIGECAPS
Mood (low)
Sleep
Interest (low)
Guilt
Energy (low)
Concentration
Appetite (low)
Psychomotor Retardation
Suicidal ideation
Major Depression progression Management
Counseling (CBT) + medication
- Monotherapy preferred
- 1st episode: Treatment for 6-12m
- > 1 episode: Treatment for 3-5y
- SSRI (Sertraline)
- Change to another SSRI
- Augmentation therapy by adding Lithium (1st) and atypical antipsychotics (2nd).
- Change to an SNRI
- ECT (Very severe)
Effect size of most treatments of depression
ECT (0.8) > CBT (0.5) > Anti-depressants (0.4)
Moderate Depression Diagnose
Criteria: > 2w with 2 core symptom + ≤ 3 other symptoms
Moderate Depression management
- CBT
- SSRI
Mild Depression criteria
1 core symptom + ≤ 3 other symptoms > 2w
Mild depression management
CBT
Atypical Depression clinical features
- Weight gain
- Hypersomnia
- Rejection sensitivity
- Reverse diurnal variation
Atypical Depression management
MAOI’s
Dysthymia criteria
Depression before puberty (usually) + less severe and persisting symptoms > 2y
Dysthymia management
- CBT
- SSRI
Lithium side effects
- Weight gain
- Fine tremors
- Stomach pain
- Hypothyroidism
- Hyperparathyroidism
- Diabetes insipidus
- Hair loss
Lithium Contraindications
- Chronic renal failure
- Hypothyroidism
Lithium intoxication
Seizures
Tremors
Fever
Hyperreflexia
Lithium in pregnancy
In cases of severe bipolar disorder, the benefits outweigh the risks
- 1st-trimester low risk of Epstein’s anomaly (0.05%) & midfacial and other defects.
- displacement of the tricuspid valve
- US & ECHO at 16-20w (2nd trimestrer) to exclude foetal anomalies, especially cardiac anomalies
Risk of developing Ebstein’s anomaly on patients on lithium?
approximately 1 in 1000 to 2000
compared with 1 in 20000 in the general population.
Ebstein’s anomaly definition
The tricuspid valve is incorrectly formed and located lower than usual in the heart.
Lithium dosage during 1st trimester
1 - 12 weeks
Keep the same dose as before pregnancy
Lithium dosage during 2nd trimester
13 - 26 weeks
Continue the same lithium dosage. But heavily monitor the fetus by US at 16-20 weeks.
Lithium dosage during 3rd trimester
Since 27 weeks
Decrease lithium dosage by 25% to avoid floppy baby syndrome due to neonatal toxicity.
Post Natal Lithium dosage
After delivery immediately increase lithium dosage due to
increased risk of relapse in the postpartum period.
NO BREASTFEEDING!!!!
Causes of Lithium Toxicity Syndrome
- Dehydration (vomiting, gastro)
- Diuretics (Thiazides)
- NSAIDs
- Exercise
- Renal failure
Here’s how and why each of these factors can cause lithium toxicity:
- Dehydration (vomiting, gastro): When you’re dehydrated, your body retains more lithium because there’s less fluid to dilute it, leading to higher concentrations in the blood.
- Diuretics (Thiazides): These medications increase urine production, causing the kidneys to retain more lithium to compensate for the loss of other electrolytes, raising lithium levels.
- NSAIDs: Nonsteroidal anti-inflammatory drugs reduce kidney function, which can decrease the elimination of lithium from the body, causing it to accumulate.
- Exercise: Intense exercise can lead to dehydration and electrolyte imbalances, both of which can reduce lithium excretion and increase its levels in the blood.
- Renal failure: If the kidneys aren’t working properly, they can’t filter out lithium efficiently, causing it to build up in the body.
Lithium Toxicity Syndrome clinical features
- Polyuria
- Polydipsia
- Coarse tremors
- Hypertonia
- Seizures
- Arrhythmias
Lithium toxicity occurs when there is too much lithium in the body, often due to an overdose or poor kidney function. Here’s why and how it causes the symptoms listed:
- Polyuria (frequent urination) and polydipsia (excessive thirst): Lithium affects the kidneys’ ability to concentrate urine, leading to increased urine production and, consequently, increased thirst.
- Coarse tremors: High levels of lithium interfere with the normal function of nerves and muscles, causing noticeable shaking.
- Hypertonia (increased muscle tone): Lithium can disrupt the balance of electrolytes and nerve signals, causing muscles to become unusually stiff or tight.
- Seizures: Excessive lithium can overstimulate the brain’s electrical activity, leading to seizures.
- Arrhythmias (irregular heartbeats): Lithium affects the electrical conduction system of the heart, potentially causing abnormal heart rhythms.
Lithium Toxicity Syndrome Management
1 hour mark
- < 1 hour: Gastric lavage
- > 1hr: Check lithium levels:
Normal: 0.6-0.8
2 Hospitalisation
4 haemodialysis until zero.
Monitor for the next 7d because lithium can rebound
Sodium Valproate dosage in pregnancy
1st trimester: decrease dose to prevent neural tube defects + High dose folic acid (5mg)
2nd semester: continue decreased dosage through to 3rd semester
3rd trimester: increase the dosage to prevent seizures
If a patient, who has successfully been stable on prophylactic dose of a particular mood stabilizer, develops acute depression, what is the next best step in management?
- Adding an antidepressant to the prophylactic mood stabilizer: the choices of the drug would be the same as for major depression. SSRls first line.
- Increasing the dose of prophylactic mood stabilizer: ONLY if the patient’s psychosis is indicated in coming back, otherwise continue the same dose
Mania criteria
Symptoms ≥7 days + Functional impairment + Delusions
Mania clinical features
- Grandiosity
- Decreased sleep
- Talkative, flight of ideas,
- Distractibility
- Psychomotor agitation
- Excessive involvement in pleasurable activities
Mania General Management
High person
a
- Antipsychotics + Mood Stabilisers.
Antipsychotics: Olanzapine first, Risperidone if olanzapine not given
Mood stabilizers: Lithium, Sodium Valproate, Carbamazepine
- Combine 2-3 of these drugs
- ECT
NOTE: Psychosis requires hospitalization
Mania agitated patient management
- Verbal de-escalation and psychological intervention
- Agitation:
- If agitation is caused by drug intoxication, then benzodiazepine (Midazolam)
- If agitation is caused by psychosis atypical antipsychotic is preferred.
- Zuclopenthixol (according to eTG) or
- Haloperidol (less preferred I think)
Mania Drug Management in Pregnancy
1st trimester: Lithium, quetiapine, olanzapine, risperidone
2nd trimester: Carbamazepine
Hypomania Criteria
- Symptoms ≥4 days + NO Functional impairment + NO Delusions and hallucinations
- NO Hospitalization
Hypomania Management
Olanzapine or Risperidone
Bipolar Depression Clinical Features
Bipolar I: 1 manic episode + depression
Bipolar II (True bipolar)
1 hypomania + 1 Depression episode
Bipolar Depression familial risk
1 parent: 15-30%
2 parents: 50-70%.
Fraternal twins: 15-25%
Bipolar Depression Management
- First-line drugs:
- lamotrigine
- lithium
- lurasidone
- olanzapine
- quetiapine - If no response: add SSRI (any)
For PROPHYLAXIS: Use lithium
Bipolar Depression Management in Pregnancy
- Lamotrigine, quetiapine, olanzapine
- Lithium
Lurasidone: May cause extrapyramidal or withdrawal symptoms in neonates when exposed in the third trimester.
Difference between BPD and Cyclothymic disorder?
BPD:
- impulsivity in at least two areas that are potentially self-damaging
- unstable and intense interpersonal relationships
- alternating between extremes of idealization and devaluation
Cyclothymic:
- many periods of depressed mood
- many episodes of hypomanic mood for at least 2 years
- 1 year in children and adolescents
- During the above 2-year period the hypomanic and depressive periods are present for at least half the time and
- the individual has not been without the symptoms for more than 2 months at a time
Cyclothymia criteria
Alternating episodes of hypomania and moderate depression for >2y
Karla: is the managmeent of this disorder the same as BPD?
Postpartum Blues criteria
< 2 weeks of delivery.
-80% of the postpartum women
Postpartum Blues clinical features
- neglects baby BUT no thoughts of hurting it
- low mood
- sadness
- mild depression
Postpartum Blues management
Family support, usually resolves in 1m
Postpartum Psychosis criteria
Appears within 2-w post delivery.
Postpartum Psychosis Clinical Features
- thoughts of hurting the baby
- Hallucinations
- Delusions
Postpartum Psychosis Management
- If hurting baby: CPS and organize psych review
- If the prior history of previous postpartum psychosis: start antipsychotics after delivery
- Antipsychotics: Olanzapine, risperidone NO CLOZAPINE
- ECT: Initial treatment-resistant
Postpartum Psychosis breastfeeding prophylactic management
Breastfeeding:
YES: Sodium Valproate
NO: Lithium
Drugs to suppress lactation (postpartum) or treatment for hyperprolactinemia
- Bromocriptine: Can lead to post partum psychosis!!!
- Cabergoline
Bromocriptine can cause postpartum psychosis because it messes with the hormones that change after childbirth. This hormonal disruption can trigger severe mental health problems in some women, leading to symptoms like delusions and mood swings.
Postpartum Depression criteria
Appears 1-3m postdelivery.
Postpartum Depression Clinical Features
- Thoughts about hurting baby
- Features of depression.
- Risk in future pregnancies: 20-40%.
Postpartum Depression Management
- Antidepressants: Sertraline or Paroxetine
Avoid Fluoxetine (Karla: why?)
- ECT
NOTE: If mum took SSRI or SNRI during pregnancy, observe the baby for 3 days (observing for what?) in the hospital, then discharge
Postpartum obsession criteria
- Appears 1-3m postdelivery.
- Obsession of hurting the baby
ECT process
1–3 sessions per week for 8–12 sessions total
Prior procedure:
- 8 h Fasting
- 2 h refrain from smoking
- Dentures and jewelry removed
- Ensure hair is clean
During the procedure: EEG monitoring
Initial ECT method
Unilateral therapy
Alternative to ECT
Transcranial direct current electromagnetic stimulation
- No anesthetic is required, and less invasive
ECT indications
- Psychotic depression (e.g. delusions, hallucinations)
- Melancholic depression unresponsive to antidepressants
- Severe postnatal depression and psychosis
- Substantial suicide risk
- Ineffective antidepressant treatment and/or previous response to ECT
- Severe psychomotor depression (catatonia): refusal to eat or drink, depressive stupor, severe personal neglect
ECT absolute contraindication
Raised intracranial pressure
ECT relative contraindications
- Hypertension
- Myocardial Infarction <3 m
- Bradyarrhythmia
- Cardiac Pacemakers
- Intracranial Pathology
- Aneurysms
- Epilepsy
- Osteoporosis
- Skull Defect
- Retinal Detachment
- Benzodiazepines (lower seizure threshold)
- Water (amitriptyline)
ECT common adverse effects
headache, myalgia, nausea, and drowsiness.
- 10 to 30 mins after: Acute confusion
- Resolves at 2w: Anterograde amnesia
- Appears in weeks to months: Retrograde amnesia
ECT uncommon adverse effects
- Acute post-ECT delirium:
- Mild: Impaired comprehension and disorientation. Mx: Supervision
- Severe: Psychomotor restlessness. Mx: IV Psychotropics - Confusion can be Ongoing ictal activity (non-convulsive status epilepticus)
Ix: EEG monitoring
Mx: Midazolam.
ECT Combination with Antidepressants
- Cause seizures. Taper them, washout, and then ECT
- TCA’s + cardiac disease = life-threatening
ECT Combination with Benzodiazepines
- Advisable to withdraw completely
- Alternative: Use short-term sedative antipsychotics in low-dose
(treat both, night sedation and agitation)
ECT Combination with Mood Stabilisers
Carbamazepine and sodium valproate: increase seizure threshold. Reducing or ceasing (EXCEPT epilepsy)
ECT Combination with Lithium
Can cause post-ECT delirium.
Could be suspended during ECT unless there is a strong reason for its continuation
1st line treat for malignant catatonia?
ECT
Malignant catatonia is a severe form of catatonia, a condition where a person has difficulty moving normally and may become almost completely immobile. In malignant catatonia, the symptoms are extreme and can include severe muscle stiffness, fever, confusion, and autonomic instability (like blood pressure and heart rate changes). It can be life-threatening and requires urgent medical treatment.
Mental Health Act
Involuntary hospitalization of a patient who is at risk of harming himself or others. Ideally, the mental health team treats and reviews the patient.
Common terms: Perseveration
Inability to switch ideas along with the social context
Schizophrenia negative symptom
Perseveration in schizophrenia is when a person repeats the same words, phrases, or actions over and over, even when it no longer makes sense to do so. This can happen because their thoughts get “stuck” on certain ideas or actions, making it hard for them to move on to something else.
Common terms: Circumstantiality
Inability to answer a question without unnecessary and excessive detail
Schizophrenia negative symptom
Circumstantiality in schizophrenia is when a person talks in a roundabout way, giving many unnecessary details before finally getting to the main point. Their thoughts and speech might wander, but they eventually circle back to the original topic.
Common terms: Delusion
Fixed false belief
Common terms: Overvalued idea
Same as delusion but holds stronger, and occupies a person’s mind
Common terms: Illusion
Misperception of a real external stimulus
Common terms: Hallucination
Misperception without a real stimulus
Common terms: Pareidolia
Misperception of a real external stimulus and association with meaning known to the observer. Eg. Moon rabbit
Pareidolia is when you see patterns or familiar images in random objects. For example, seeing a face in the moon or in the clouds is a common experience of pareidolia.
Common terms: Hypnagogic hallucinations
Happen as you’re falling asleep
NOTE: It’s normal
Hypnagogic hallucinations are vivid, often strange sensory experiences that happen just as you’re falling asleep. They can include seeing, hearing, or feeling things that aren’t really there.
Common terms: Hypnopompic hallucinations
Happen as you’re waking up
NOTE: It’s normal
Hypnopompic hallucinations are vivid, often unusual sensory experiences that occur just as you’re waking up. For example, you might see a figure standing by your bed or hear someone calling your name as you’re transitioning from sleep to being fully awake.
Common terms: Egosyntonic
Responsive appropriate to the environment gives the situation
OCPD
Egosyntonic means that a person’s thoughts, behaviors, or feelings are in harmony with their self-image and values, so they don’t see them as a problem. For example, someone with anorexia might see their extreme dieting as a positive, healthy choice rather than recognizing it as harmful.
Common terms: Egodistonic
Responses and behaviors that are against a person’s beliefs and will
OCD
Egodystonic means that a person’s thoughts, behaviors, or feelings are in conflict with their self-image and values, so they find them distressing or upsetting. For example, someone with obsessive-compulsive disorder (OCD) might be troubled by their intrusive thoughts and rituals because they know these behaviors are irrational and unwanted.
Common terms: Concrete Thinking
Inability to think of abstract terms
Schizophrenia symptom
Concrete thinking refers to a literal, straightforward way of understanding things, without abstract or symbolic interpretation. It’s focused on facts, actual objects, and immediate experiences rather than deeper meanings or concepts. For example, someone with concrete thinking might struggle to understand metaphors or sarcasm because they interpret language very literally.
Capgras Syndrome
Disorder in which a person believes that a relative or friend has been replaced by an identical impostor.
Defence Mechanisms
NIMA
- Narcissistic
- Immature
- Anxiety/Neurotic
- Mature
Narcissistic Defence Mechanisms
PDS
- Projection (mirror)
- Denial (don’t accept)
- Splitting (Black or White)
Immature Defence Mechanisms
BRSII
- Blocking (temporary inability to remember)
- Regression
- Somatization
- Introjection (idea or object)
- Identification (people)
Anxiety/Neurotic Defence Mechanisms
DRIIARRUPD
- Displacement (emotion shifted to another person)
- Repression (Bad feelings or ideas removed from the consciousness)
- Isolation of affect (Reality accepted without emotions)
- Intellectualization (Use the intellectual process to avoid the emotions)
- Acting out (tantrums)
- Rationalization (EXCUSES. Rational explanations to justify behaviors)
- Reaction Formation (Unacceptable impulse transformed in its opposite) “Pyromaniac to a firefighter”
- Undoing (Acting out an unacceptable behavior) “Pyromaniac burning down”
- Passive-Aggressive (Unconscious passive hostility)
- Dissociation (Separates the experience to the body)
Mature Defence Mechanisms
HSS
- Humor #foreveralone
- Sublimation (Unacceptable impulse into an acceptable channel) “Pyromaniac working in a special effect company”
- Suppression (Conscious forgetting)
List of Personality Disorders
Cluster A: Odd, eccentric behavior or withdrawn personality.
Cluster B: Dramatic, emotional and erratic personality
Cluster C: Anxious and fearful personality
Other
Personality disorders: Cluster A
Withdrawn Cluster
- Paranoid: Suspicious but not delusional, accept explanations for their wrong ideas.
DDx: In paranoid delusion, they are suspicious about one thing only, and functioning is normal. - Schizoid: Happy loner. Emotionally cold
- Schizotypal: Bizarre, magical thinking. Doesn’t fulfill the criteria for schizophrenia “ISOLATED HIPPIE”
Personality disorders: Cluster B
Antisocial cluster
- Antisocial: Breaking the law with no remorse.
a) Deliberate psychopaths (villains)
b) Impulsive psychopaths (dumbs)
- cruel to animals
- vandalism
•Treatment: extremely difficult to treat
• •
The aim of treatment si usualy ot prevent existing symptoms from progressing.
Older individuals with antisocial personality disorder are typically incarcerated.
- Histrionic: Usses seduction to attract attention but sexually frigid. Suggestible. Very dramatic.
- Narcissistic: I’m the best. Can’t take criticism. Lack of empathy.
- Borderline: Mood instability + impulsive. Self-harm can lead to suicide or parasuicide
Mx: Dialectal behavioural therapy
Personality disorders: Cluster C
ADO
Dependent cluster
- Avoidant: Fears rejection, “Unhappy loner”
- Dependent: Avoids responsibility. Seek protection. Difficulty making everyday decisions.
- Obsessional OCPD: No insight. Egosyntonic.
Other personality disorders
Personality Change:
- Labile type
- Masochistic
- Disinhibited type
- Aggressive type
- Passive Aggressive type
- Apathetic type
- Combined type
- Unspecified type
List of Anxiety Disorders
- Generalized Anxiety Disorder
- Panic Disorder (≠ Panic Attack)
- Acute stress disorder
- Social Anxiety Disorder (Social Phobia)
- Agoraphobia (afraid to leave environments considered to as safer)
- Separation Anxiety Disorder
- Specific Phobia
- Substance/Medication-Induced Anxiety Disorder
- Anxiety Disorder Due to Another Medical Condition
Anxiety Causes
- Genetic.
- Psychological.
- Environmental.
Anxiety Risk Factors
- Females.
- Social history
- Family history.
- Past mental illness.
List of Obsessive-Compulsive and Related Disorders
- Obsessive-Compulsive Disorder
- Body Dysmorphic Disorder
- Hoarding Disorder
- Trichotillomania (Hair-Pulling Disorder)
- Excoriation Disorder (Skin-Picking)
Trauma- and Stressor-Related Disorders
- PTSD
- Acute Stress Disorder
Generalised Anxiety Disorder criteria
Excessive anxiety for at least 6 months.
Most common anxiety in general practice
The most common psychiatric disorder is depression, however.
Generalised Anxiety Disorder management
- CBT - SPS (structured problem-solving)
- Severe or CBT ineffective after 3M:
- SSRI: Suspend after symptom-free for 6M
Generalised Anxiety Disorder alternative management
- SNRI
- Benzodiazepine: Short term (2W and tapered over next 2W)
- Buspirone (Anxiolytic)
- Beta-blockers: palpitation / tremors.
Panic Attack criteria
- Intense symptoms: palpitations, tachycardia, sweating, shaking, SOB, choking, fear of dying, paraesthesia.
- develop abruptly and reaches a peak in 10m. Total 30 min duration
- Trigger identified
Panic Attack differential diagnosis
- Hyperthyroidism.
- Hypoglycaemia.
- Pheochromocytoma.
Panic Attack management
SSRI - P to P
- Perform physical examination and/or initial investigations to exclude medical conditions.
- Distraction methods (breathing in and out in a paper bag)
- BDZ: Diazepam / Lorazepam
- To prevent future attacks: CBT (flooding), stress management, exposure and desensitization, SSRI (Paroxetine)
Panic Disorder criteria
- Recurrent panic attacks.
- triggers identified.
- At least 1 panic attack within 1 m
Panic Disorder management
- CBT
- Behavioural therapy (Graded exposure)
- SSRI for 6-12m (Fluoxetine)
NOTE: if there is no trigger, exposure therapy is not indicated
Social phobia criteria
- Persistent fear of social performance
- linked to panic attacks
- avoidance of social events.
- Kids: symptoms > 6 m for making a diagnosis
Social phobia management
- CBT
- BT (exposure-based)
- Training for social skills
- B-Blockers (situational)
- SSRI/SNRI/MAOI
Agoraphobia criteria
- Anxiety about being in open places where escape might be difficult (theatre, queue, public transport)
- Avoidance of situations
Agoraphobia greatest risk of developing
Depressed mood and feeling of guilt
Agoraphobia management
- CBT
- SSRI
Separation Anxiety Disorder Management
Most common anxiety disorder in
children.
- Psychotherapy- CBT.
- Family therapy.
- Medications if severe.
Phobias criteria
Excessive fear of stimulus which interferes with lifestyle
Phobias management
- CBT
- Behaviour Therapy: Exposure and desensitization therapy
- Teach relaxation techniques and breathing exercises.
- Hierarchy of unpleasant stimulus
Obsessive-Compulsive Disorder (OCD) clinical features
- Obsessive (not inserted thought) and compulsive (do it with rituals, they know it’s unreasonable and excessive) intentional rituals.
- Have insight
- Egodystonic
- Functioning impaired.
OCD types
- Cleanliness - order.
- Counting
- Hoarding
- Safety checking.
- Sexual issues.
- Religious / moral issues.
Combinations can happen too.
OCD management
CBT + SSRI together
- CBT: Psycodyniamic Psicotherapy
- BT: Exposure and response prevention
- SSRI: Fluoxetine, sertraline, paroxetine
OCD patients are egosyntonic or egodystonic with how they view their disorder?
Egodystonic
List of eating disorders
- Anorexia Nervosa
- Bulimia Nervosa
Body Dysmorphic Disorder criteria
- Belief that some part of the body is abnormal or defective (face or secondary sexual character)
- Significant functional impairment
Body Dysmorphic Disorder management
- CBT - BT counseling.
- Might require SSRI if depression is associated.
Eating disorders Risk Factors
– Female Adolescent
– Low self-esteem
– Personal or family history of depression
– Family history of obesity
– High personal expectations
– Family history of eating disorders
– Disturbed family interactions
- Social factors
- Childhood sexual abuse
- Perfectionism and obsessionist
Common clinical features of Anorexia Nervosa
- < 17.5 BMI
- Significant electrolyte disturbance (K < 3.0 or Na < 130)
– Amenorrhoea
– Constipation.
– Lanugo.
– Cold intolerance.
– Cachexia.
– Hypothermia.
– Bradycardia. (< 40bpm)
– Hypotension (< 90mmHg) - Raised liver enzymes and Albumin < 35g/L
Complications of Anorexia Nervosa
- Secondary amenorrhoea due to low levels of LH and FSH
- Low TSH levels (Hypothermia)
- Depression
- Obsessive-compulsive disorder
- Increased risk of fractures in later life due to osteoporosis
Posttraumatic Stress Disorder (PTSD) criteria
3 symptoms for >1m after a serious stressor (threatened death or serious injury):
- Response with intense fear, horror, and helplessness.
- Flashbacks
- Difficulty falling asleep
- Irritability
PTSD types/classification
- Acute <3m
- Chronic >3m
- Delayed onset: >6m after traumatic event
PTSD management
- CBT
- Behavioural therapy (Graded exposure/eye movement desensitization and reprocessing)
- SSRI for 6-12m
Acute stress disorder (AST) criteria
occurring within 4 weeks of trauma and resolving within 4 weeks
Acute stress disorder (AST) management
- Debriefing and counselling
- Stress based psychotherapy
Adjustment Disorder with Anxiety criteria
- Within 3 months of the new stressor (new job, migration, divorce)
- Resolves within 6 months
**associated with a very increased risk of suicide **
Adjustment Disorder with Anxiety criteria management
- Listen and empathy (counselling)
- CBT
- Intermittent BZD x 2w (Diazepam 20 mg max. per day)
- SSRI
Gambling disorder
4 symptoms lasting at least 12 months
- preoccupation on gambling
- increasing stakes on gambling
- unsuccessful attempts to stop
- gamble to escape reality
- lie to cover up the problem
- rely financially on others
- get into criminal activities
- loss of job
- irritable anxious
List of Impulsive Control Disorders
- Intermittent Explosive disorder (anger therapy)
- Kleptomania
- Pyromania
List of Impulsive Control management
CBT – BT
List of Psychosomatic Disorders
- Somatic Symptom Disorder: With
predominant pain (4) / sexual sympoms (1) / neurological (1) / GI (2) - Conversion Disorder (Functional Neurological Symptom Disorder) “la belle indifférence”
- Factitious Disorder: purposely getting sick or by self-injury
Dissociative disorders
- Dissociative Identity Disorder
- Dissociative Amnesia: With dissociative fugue
- Depersonalization/Derealization Disorder
Dissociative amnesia
Amnesia to escape from distress but they don’t travel away
Dissociative amnesia is a condition where a person experiences memory loss that can’t be explained by ordinary forgetfulness. It often occurs after a stressful or traumatic event and involves forgetting important personal information, such as their identity or significant life events. This memory loss is typically temporary and can vary in severity.
Dissociative Identity Disorders
Different personalities at different times
Dissociative fugue
Amnesia to get away from intolerable situations, sudden travel away from home.
They don’t remember the previous episode
Depersonalisation
Out-of-body experience.
Changes in body shape or size, cannot be recognized in the mirror, feel like watching characters in a boring movie.
Associated with: Schizophrenia, borderline, temporal lobe epilepsy, and PTSD
Derealisation
The external world seems unreal.
The feeling of being transported to
place you don’t know and don’t understand
Schizophrenia/psychosis Prodrome Symptoms: Early pre-psychotic
Recurrent depressive symptoms over the course of 3-5 years
“Prodrome symptoms” in schizophrenia or psychosis refer to early warning signs or changes that happen before a full-blown psychotic episode. These signs might include things like social withdrawal, trouble sleeping, difficulty concentrating, or unusual thoughts or beliefs. Essentially, it’s like a warning signal that something might be going wrong with a person’s mental health, and it could be an opportunity to intervene early and prevent a more severe episode from happening.
Schizophrenia/psychosis Prodrome Symptoms: Late pre-psychotic
P-O
- Paranoid ideation
- Odd beliefs
2nd earliest symptoms seen in pre-psychotic prodrome of schizophrenia/psychosis
Loss of motivation and social disability developing within 12 to 18 months of first recurrent depressive symptoms
Anorexia Nervosa Clinical Features
BMI<17.5
Amenorrhoea
Loss of body fat
Increased lanugo
Bradycardia (MC finding)
Feelings of inferiority
Anorexia Nervosa Admission criteria
BBABA
BP: Postural drop >10mmHg
Bradichardia <45
Albumin <20
BMI<15
Arrhythmias
Haemonamicly unstable
Severe dehydration
Bulimia & Anorexia Management
CBT + SSRI’s ???
Anorexia Nervosa: Refeeding Syndrome
Refeeding Syndrome: high mortality rate
Clinical Features:
- Hypophosphatemia (hallmark) Leads to acute respiratory failure
- Hypokalemia. Leads to metabolic alkalosis
- Hypomagnesemia (+ Hypokalemia = torsades de pointes)
- Thiamine deficit. Leads to Wernicke’s and Korsakoff’s encephalopathy.
Bulimia Clinical Features
BMI>18
Dry skin
Parotid gland swelling
Erosion of dental enamel
Hair loss
Calluses on dorm of hands (Russell’s sing)
Amenorrhoea
Hypokalemia
Psychotic Disorders
- Delusional Disorder: 1 month
- Schizophreniform disorder: > 1 month and < 6 months
- Schizophrenia: > 6 months.
- Schizoaffective/psychogenic
disorder: Schizophrenia + major
affective disorder. - Folie a Deux
Delusional Disorder Criteria
- 1 month of JUST delusions with
no other psychotic symptoms. - The delusions are not bizarre
and can occur in real life (being followed, having an infection, etc)
Delusional Disorder Management
- Antipsychotics
- Psychotherapy
Types of Delusions: Persecutory
Commonest type. Believes they are being persecuted or harmed.
Fregoli syndrome
Delusional belief that one or more familiar persons, usually persecutors following the patient, repeatedly change their appearance.
Types of Delusions: Delusional mood
The patient feels something is going on around them but cannot describe what. It usually becomes clearer and more specific when a delusional idea or perception occurs.
Types of Delusions: Delusion of love or Erotomaniac
The patient thinks that another is in love with them, even if they have never met them before. Usually of higher status, the version involves a celebrity or famous person (Cleraumbault’s Sx).
It’s a secondary delusion
Types of Delusions: Delusional perception
Occurs when the delusion forms in response to an ordinary object. For example, the traffic light turns green, and Bert therefore knows he is the King of England.
Types of Delusions: Delusional ideas
Arise out of nowhere are termed autochthonous delusions. Can rarely occur in people without mental illness.
Types of Delusions: Grandiose
Believes that has inflated worth or power.
Types of Delusions: Somatic
Somatic delusions are false beliefs related to the body or physical health. Here’s a simple way to understand them:
- Body Not Functioning: The person might believe that a part of their body isn’t working properly, even though there’s no medical evidence of a problem. For example, they might think their organs are failing or that their stomach doesn’t digest food.
- Infested with Insects: The person might believe that they are infested with bugs or parasites, even though there’s no physical sign of this happening. They might feel like insects are crawling under their skin.
- Emitting a Foul Odor: The person might believe that their body is giving off a terrible smell, even though no one else can smell it and there’s no reason for them to have this odor.
Somatic delusions involve strong, false beliefs about the body—thinking it’s not working right, believing they’re infested with insects, or fearing they smell bad when there’s no actual problem.
Delusions around the body function like parts not functioning, infested with insects, emitting a foul odor.
Brief Psychotic Disorder Criteria
- Symptoms between 1d and 1m
- 1st Depression, then psychosis
(Brief) with a stressor present
Brief Psychotic Disorder
Management
- Only antipsychotic for 1 month.
- Don’t treat the depressive part.
Schizophreniform disorder criteria
Symptoms like schizophrenia lasting at least 1 month but less than 6 months duration
Schizophreniform disorder Management
Treated as first psychotic episode.
Then like schizophrenia.
ECT for drug-resistant cases.
Schizophrenia Epidemiology
Affects about 1 in 100 people
Men and women equally affected
Usually diagnosed between the ages of 15 and 35.
Age of onset tends to be slightly earlier in men (18-25) and later in women (25-35).
Higher incidence in urban areas and among migrants, and lower socioeconomic classes
Clinical Features of Schizophrenia
Criteria:
- Symptoms >6m.
- 1 of Positive Symptoms (DHD):
- 2 of Negative Symptoms:
usually have poor insight
- MCC of death: CV disease.
Positive symptoms of Schizophrenia
- delusions
- hallucinations
- thought disorder
- disorganized speech and behaviour
Negative symptoms of Schizophrenia
- flat affect
- poverty of thought
- lack of motivation
- social withdrawal
- reduced speech output
Schizophrenia familial risk
0 parents: 1% risk
1 parent: 13% risk
2 parents: 45% risk
Schizophrenia: Management of 1st Psychosis Episode
- Treatment of agitation:
- Admission and control agitation with verbal de-escalation.
- If pt tolerates oral/Cooperative: Diazepam or Lorazepam.
- If doesn’t: Haloperidol or midazolam IM - Antipsychotics: All except olanzapine because of metabolic side effects.
- Symptoms last <6m, keep for 1y
- Symptoms last >6m, keep for 2y
Definitive Management of Schizophrenia
- Antipsychotics
- Typical: Positive symptoms (DHD)
- Atypical: Negative symptoms.
*If using typical and not responding, change to atypical.
*Increase dose if there is no response in 3-4w
*Change to another antipsychotic if
no response in 4-6w doing crossover period
*If 2 different antipsychotics were
tried, and there was no change after 6-12w: ECT
- Psychotherapy, family counseling
Schizoaffective Disorder Criteria
Schizophrenia + major affective disorder
If psychotic symptoms are present despite full treatment of depression (bipolar or unipolar) is schizoaffective
1st Psychosis, then depression.
The best way to make the DD is that this px will need a combination of drugs ALWAYS, not only during an episode
Schizoaffective disorder is a mental health condition that includes symptoms of both schizophrenia and a mood disorder, such as depression or bipolar disorder. This means a person might experience delusions or hallucinations (like in schizophrenia) along with mood swings, depression, or mania. Treatment usually involves a combination of medication and therapy to manage both the psychotic and mood symptoms.
Folie a Deux: Shared psychotic disorder
Criteria: Delusion in a person in a close relationship with another who already has established delusion.
Folie a Deux Management
- Separate the people
- Antipsychotics
Opioids Intoxication Clinical Features
Pinpoint pupils
Resp depression
Euphoria
Constipation
CNS depression
Opioids Intoxication Management
Naloxone and naltrexone
Opioid Withdrawal Clinical Features
Flu-like reaction with rhinorrhoea
Dilated pupils
Piloerection
Cramps
Diarrhea
Yawning
NO FEVER according to Bluebook
When someone stops using opioids, their body reacts to the sudden lack of the drug, leading to withdrawal symptoms. Here’s what happens:
- Restlessness and Anxiety: The brain’s reward system is disrupted, causing feelings of unease and anxiety.
- Muscle Aches: Without the opioid’s pain-relieving effects, people may feel widespread muscle pain.
- Sweating and Chills: The body’s temperature regulation is thrown off, causing sweating and chills.
- Runny Nose and Yawning: The nervous system becomes overactive, leading to these symptoms.
- Nausea, Vomiting, and Diarrhea: The digestive system is affected, resulting in stomach cramps, nausea, and other gastrointestinal issues.
- Dilated Pupils: The withdrawal removes the drug’s constriction effect on pupils, causing them to dilate.
- Insomnia: Disruption in brain chemicals makes it hard to sleep.
These symptoms occur because opioids mimic natural pain-relieving chemicals in the brain, and when the drug is stopped, the body has to readjust to functioning without it.
Opioid Withdrawal Management
Buprenorphine or methadone
Amphetamine & Cocaine Intoxication Clinical Features
Agitation
Tachycardia
Fever
Diaphoresis
Arrhythmias
Seizures
Midriasis
HTN
ALSO COCAINE:
- ECG alterations
- Fever
When someone is intoxicated with amphetamines or cocaine, their body goes into overdrive because these drugs stimulate the central nervous system. Here’s what happens:
- Increased Heart Rate and Blood Pressure: These drugs make the heart pump faster and harder, which raises blood pressure.
- Dilated Pupils: The drugs cause the pupils to widen.
- Increased Energy and Alertness: Users feel very awake, energetic, and may talk a lot or move around more.
- Euphoria: There’s a strong feeling of happiness or pleasure because the drugs increase levels of dopamine, a “feel-good” neurotransmitter, in the brain.
- Reduced Appetite: These drugs decrease feelings of hunger.
- Restlessness and Agitation: Users can feel jittery, anxious, or overly excited.
- Hyperthermia: Body temperature can rise because the body’s metabolism is ramped up.
These effects happen because amphetamines and cocaine increase the levels of certain neurotransmitters (dopamine, norepinephrine) in the brain, which stimulate the nervous system.
Amphetamine Intoxication Management
H-A
Haloperidol
Amphetamine & Cocaine Withdrawal Clinical Features
Crash with:
Anxiety
Lethargy
Headache
Cramps
Fatigue
Nightmares
Methamphetamine antidote
What do you do?
What if it’s 2 hours?
Wait it out?
Activated charcoal of option is given history of patient ingesting within 2 hours
Methamphetamine withdrawal treatment of choice?
Mood disorder? What to give?
No proper medication to treat withdrawal. but to treat symptoms that arise such as mood disorders in which case : TCA
Methamphetamine overdose can cause what fatal symptoms?
SSH
- Stroke
- seizures
- hyperthermia
how to treat sympathomimetic symptoms?
Agitation: benzodiazepines (lorazepam IV if not cooperative, diazepam oral if patient cooperative)
Hypertension: nitrates (nitroprusside), beta blockers (metoprolol 2-5mg IV)
Hyperthermia: evaporative cooling, icepacks and maintenance of intravascular volume and urine flow with IV normal saline solution.
Seizures: Phenothiazines as last resort
Cocaine & Amphetamine Withdrawal Management
Antidepressants
When someone stops using cocaine or amphetamines, they might experience withdrawal symptoms like depression, fatigue, and irritability. These drugs cause a spike in feel-good chemicals (like dopamine) in the brain, so when the drugs are stopped, levels of these chemicals drop suddenly, leading to withdrawal symptoms.
To help manage these symptoms, doctors sometimes prescribe antidepressants. Antidepressants can help by:
- Increasing Neurotransmitters: They boost levels of certain neurotransmitters (like serotonin and norepinephrine) in the brain, which can improve mood and energy levels.
- Stabilizing Mood: They help stabilize the brain’s chemistry, reducing feelings of depression and anxiety that come with withdrawal.
- Improving Sleep and Appetite: They can also help regulate sleep and appetite, which are often disrupted during withdrawal.
By addressing these symptoms, antidepressants can make the withdrawal process more manageable and support recovery.
Cocaine Intoxication Management
Everything is high so it’s need to slow down.
Benzos
Sertraline and ecstasy drug interaction
They are synergistic
(increase concentration of serotonin in the body) –> Serotonin Syndrome
Phencyclidine (PCP) or angel dust intoxication Clinical Features
Severe violence
Psychomotor agitation
HTN
Nystagmus
Phencyclidine (PCP) or angel dust intoxication Management
Benzos or haloperidol
Phencyclidine (PCP) intoxication can present with a range of symptoms, from mild agitation to severe psychosis, seizures, and life-threatening complications. Management focuses on symptomatic treatment and supportive care.
- Safety First: Ensure the safety of healthcare providers and the patient, as individuals intoxicated with PCP may exhibit unpredictable and violent behavior.
- Airway, Breathing, Circulation (ABCs): Prioritize stabilization of vital signs.
- Monitoring: Continuous monitoring of vital signs, cardiac rhythm, and oxygen saturation.
-
Agitation and Psychosis:
- Benzodiazepines (e.g., lorazepam, diazepam): First-line treatment for agitation, anxiety, muscle spasms, and seizures.
- Antipsychotics (e.g., haloperidol): May be used for severe agitation or psychosis, though benzodiazepines are generally preferred due to fewer side effects and lower risk of exacerbating PCP-related symptoms.
-
Severe Hypertension:
- Benzodiazepines: First-line to reduce anxiety and hypertension.
- Antihypertensives: If hypertension persists, consider agents like nitroprusside or labetalol, carefully titrated to avoid rapid blood pressure changes.
- Hydration: Intravenous fluids to maintain hydration and support renal function.
- Cooling: If hyperthermia is present, initiate cooling measures such as external cooling with ice packs or cooling blankets.
- Electrolyte Monitoring: Regular monitoring and correction of electrolyte imbalances.
- Seizures: Treat with benzodiazepines, and consider additional anticonvulsants if seizures persist.
- Rhabdomyolysis: Suspected if there is muscle rigidity, elevated creatine kinase levels, or myoglobinuria. Manage with aggressive hydration and monitoring of renal function.
- Cardiac Arrhythmias: Continuous cardiac monitoring and management according to ACLS protocols if arrhythmias occur.
- Mental Health Assessment: Once stabilized, patients should receive a psychiatric evaluation to address any underlying mental health issues or substance use disorders.
- Referral: Consider referral to addiction specialists for ongoing treatment and support.
- Safety and Initial Stabilization: Ensure a safe environment and stabilize vital signs (ABCs).
-
Symptomatic Treatment:
- Benzodiazepines: For agitation, seizures, and muscle spasms.
- Antipsychotics: For severe psychosis.
- Antihypertensives: For persistent severe hypertension.
- Supportive Care: Hydration, cooling, electrolyte monitoring.
- Complications Management: Seizures, rhabdomyolysis, cardiac arrhythmias.
- Psychiatric Evaluation and Referral: Address underlying mental health and substance use disorders.
This approach provides a clear framework for managing PCP intoxication, focusing on safety, symptom control, and addressing potential complications.
Marihuana Intoxication Clinical Features
Euphoria
Social withdrawal
Can’t drive
Conjunctival injection
Hallucinations
Marijuana Intoxication Management
CBT
Marijuana Withdrawal Clinical Features
Insomnia
Night sweats
Nausea
Depression
Irritability
Anger
Benzodiazepine Intoxication Clinical Features
Hypotension
Bradycardia
Resp failure (mixed with alcohol)
Benzodiazepine Intoxication Management
- Monitor with IV fluids
- Flumazenil
Benzodiazepine withdrawal Clinical Features
Rebound anxiety
Depression
Seizure
Insomnia
HTN
Tachycardia
Noise sensitivity
Insomnia Clinical Features
- In anxiety: Difficulty in initiation
sleep - In depression: Early morning
awakening
Insomnia Management
- Tx comorbidities causing insomnia
- Implementing good sleep hygiene
- Sleep restriction and stimuli control programs
- Cognitive therapy (Best for chronic >4w)
- Drugs:
Best for acute: Short-acting Benzos – Temazepam, zolpidem, zopiclone, eszopiclone (do not give with alcohol->resp depression).
Chronic >55w (>1 year): Melatonin
Diagnosis of chronic insomnia
- A self-reported complaint of poor sleep quality
- Sleep difficulties occur despite adequate sleep opportunity.
Impaired sleep produces deficits in daytime function. - Sleep difficulty occurs three nights per week and is present for three months
Chronic insomnia management
- Treat the comorbidities causing insomnia
- Implementing good sleep hygiene
- Sleep restriction and stimulus
control programs - Cognitive therapy (Best for chronic >4w)
- Drugs:
*Acute: Short-acting Benzos (Temazepam, zolpidem, zopiclone, eszopiclone. DO NOT give with alcohol —-> Resp depression)
Chronic insomnia for >55 weeks (1y): Melatonin
Grief Stages
1 Denial
2 Grief and despair (until 6m)
3 Acceptance (6m-1y).
*If it continues then treatment
NOTE: It’s normal to have a relapse of symptoms during the anniversary
Grief Management
Normal grief
1. Short-acting benzos
Abnormal grief: Stage 2 sx for >6m
1. Psychotherapy
2. SSRI-Antipsychotics
3. CBT
4. ECT
Suicide
- More common season: Spring
- More common season in
schizophrenics: Winter - Highest risk:
1. After discharge from hospital.
- After improvement of tx
2 questions that MUST be asked to assess suicidal ideation
- Do you feel hopeless?
- Have you felt that you’ve lost interest in your usual activities?
Suicide Assessment (SAD PERSONS)
S: Male SEX 1
A: AGE < 20 and > 45 1
D: DEPRESSION/depressed mood 2
P: PREVIOUS attempts 1
E: EXCESSIVE alcohol/substances 1
R: RATIONAL thinking Loss 2
S: SEPARATE (no spouse) 1
O: ORGANIZED plan 2
N: NO Support 1
S: Sickness (chronic or fatal) 1
Suicide Assessment (SAD PERSONS) RESULTS
0–4: Low
Fleeting thoughts of self-harm or suicide but no current plan or means
5–6: Medium
Suicidal thoughts and intent but no current plan or immediate means
7–10: High
Continual/specific suicidal thoughts, intent, plan and means
Suicide Assessment Management: Low Risk (0–4)
- Discuss the availability of support and treatment options.
- Arrange a follow-up consultation.
- Identify relevant community resources and provide contact details.
Suicide Assessment Management: Medium Risk (5–6)
- Discuss the availability of support and treatment options.
- Organize reassessment within 1 week.
- Have a contingency plan in place for rapid reassessment if distress or symptoms escalate.
- Develop a safety plan (a prioritized written list of coping strategies and sources of support to use when experiencing suicidal thinking).
Suicide Assessment Management: Hight Risk (7-10)
- Ensure that the person is in an appropriately safe and secure environment.
- Reassessment within 24 hours and monitoring for this period.
Follow-up outcome of assessment:
*If there is concern about suicide risk and treatment is supervised outside the hospital, prescribe drugs that are less toxic in overdosage (e.g. mianserin or fluoxetine).
Suicide Risk Factors
- Substance abuse
- Chronic health issues, pain, or physical disability
- Feelings of isolation or helplessness
- Negative life events: Abuse history, significant loss, financial crisis (Adjustment Disorder)
- Previous suicide attempts or exposure to suicide behavior in others (family, friends)
- Young men in rural areas
- Borderline personality disorder
Paraphilias
Criteria:
Sexual fantasies for >6m with clinical impairment.
Management:
1. Insight-oriented psychotherapy
Premature ejaculation
The most common sexual disorder in Australians
Management:
- Short term:
*Lignocaine before sex
- Long term:
*SSRI/TCA
Sexual impotence CF & Ix
MCC: Vascular problem
Investigation:
Detailed Hx including information about libido and morning erections
Sexual impotence Management
- Optimise RFs and comorbidities
- Phosph 5 inhibitors: Sildenafil
- PgE1 for Erection
Narcolepsy Management
- Daytime: Amphetamines/Modafinil
- Nightime: Sodium oxybate
Bruxism
Seen in stress, heavy alcohol
drinkers.
Management:
Place a hot towel against the side of face, counseling, yoga, relaxation
exercises, meditation
Alcohol intoxication Clinical Features
Impaired judgment and coordination
Gait instability
Slurred speech
Mood and behavior changes
Nausea and vomiting
Hypothermia
Dysarthria
Amnesia
Diplopia and nystagmus
Onset of alcohol withdrawal
6 and 24 hours after the last drink
Alcoholic hallucinosis Clinical Features
Time
Onset within 12-24 hours of
abstinence with normal
consciousness
Severe alcohol withdrawal: Delirium Tremens CLINICAL FEATURES
Onset after 2-3 days of abstinence
Visual hallucinations
Confusion
Tachycardia
Hypertension
Hyperthermia
Agitation
Diaphoresis
Seizures
Delirium Tremens Risk Factors
History of Delirium Tremens
Concurrent illness
Advanced age
Hypokalemia
Prior withdrawal symptoms or detoxification
Initial Investigation in Delirium Tremens
Most reliable investigation to diagnose alcoholism: Carbohydrate
deficient transferrin
NO RELIABLE INFO:
- ECG: cardiac arrhythmias
- ABG: Lactic acidosis
- Electrolytes: hypoglycemia, hypomagnesemia, hyponatremia, and hypophosphatemia
- Liver function test; prothrombin time
- Brain CT scan to rule out intracranial pathology
Delirium Tremens Management
Acute:
1. Diazepam or Midazolam IV
- Tiamine IV
- Glucose IV
- Metoclopramide IV
Prophylaxis:
- Disulfiram, Naltrexone, Baclofen, or Acamprosate
NOTE:
*Unresponsive to benzodiazepine: Add phenobarbital or propofol + Mechanical Ventilation
*Rapid correction of HypoNatremia can cause central pontine myelinolysis
*ACUTE NOT USE: Neuroleptic drugs (Antipsychotics)
CAGE questionnaire:
C- Have you ever felt you should Cut down on your drinking?
A- Have people Annoyed you by criticizing your drinking?
G- Have you ever felt bad or Guilty about your drinking?
E- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (Eye-opener)
Treatment of alcohol withdrawal
Can be agitated and anxious
Benzodiazepine (Diazepam)
Hypochondriacs come for cause in relation to their…?
Diagnosis
Criteria for Somatic Symptom Disorder criteria
-1 or more somatic symptoms that are distressing or result in significant disruption of daily life
- Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
- Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
- Persistently high level of anxiety about health or symptoms.
- Excessive time and energy devoted to these symptoms or health concerns.
- Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months)
Difference between hypochondriasis & Illness anxiety disorder
hypochondriasis: already have a diagnosis failure to respond to reassurance is an explicit criterion
illness anxiety disorder: has as its primary focus preoccupation with having or acquiring a serious (and undiagnosed) medical illness (think general overall health)
St John’s Wort interactions: Antidepressants
Serotonin syndrome
St John’s Wort interactions: COCP
- SJW reduces the effectiveness of COCs and increases the risk of unintended pregnancy
-Induce the cytochrome P450 enzymes CYP1A2, CYP2C9, and CYP3A4. Therefore metabolizing COCPs at a faster rate, decreasing its effectiveness.
St John’s Wort interactions: Warfarin
- SJW reduces the effectiveness of warfarin and increases the risk of stroke, ischemia, arterial blockage etc.
- SJW’s extracts have been reported to induce the cytochrome P450 enzymes CYP1A2, CYP2C9, and CYP3A4. Therefore metabolizing COCPs at a faster rate, decreasing its effectiveness.
Mental Status Exam DOMAINS
Appearance
Attitude
Behavior
Mood
Affect
Speech
Thought process
Thought content
Perception
Cognition
Insight
Judgment
MMSE score interpretation
Normal: 25 - 30
Mild Dementia: 20 - 25
Moderate Dementia: 10 - 25
Severe Dementia: < 10
Pseudo-dementia/ Depression > 24
If the patient has scored just below the normal threshold of MMSE due to sight impairment. What should be done?
Correct sight impairment and redo test, or perform other cognitive tests that do not require sight (Six-item Cognitive Impairment Test)
After MMSE is done to determine cognitive decline (<25), what investigation is best indicated?
CT scan (to see if there’s any degeneration of brain tissue, such as atrophy)
Pseudodementia clinical features
MMSE >24
Depression with cognitive impairment.
The symptoms are worse in the morning
The patient has insight
Common in elderly
“Give up patient”
Dementia Types
- Alzheimer’s disease
- Frontal Lobe Dementia (FLD)
- Vascular Dementia (VD)
- Lewy body dementia (LBD)
- Parkinson’s dementia
- Alcohol-related dementia:
- Korsakoff’s syndrome
- Wernicke’s encephalopathy
Alzheimer’s Disease Clinical Features
It is the most common form of dementia.
Short-term memory loss.
Repeatedly saying the same thing
Disability to plan, problem solve, organize, and think logically
Language and comprehension difficulties, such as problems finding the right word
Disorientation in time, place, and person
Changes in behavior, personality, and mood.
Alzheimer’s Disease Management
Acetylcholinesterase inhibitors: donepezil, galantamine or rivastigmine
Moderate to severe: Add Memantine
Severe agitation:
- Citalopram
- Avoid antipsychotics. If it’s indispensable, review every 4–12 w
Acetylcholinesterase inhibitors side effects
Overstimulation of the parasympathetic nervous system, such as increased hypermotility, hypersecretion, bradycardia, miosis, diarrhea, and hypotension, may be present.
Cholinergic crisis, also known as SLUDGE syndrome:
S: Salivation
L: Lacrimation
U: Urination
D: Diaphoresis
G: Gastrointestinal upset
E: Emesis
Same in toxicity by organophosphates
Acetylcholinesterase inhibitors TOXICITY management
Atropine + Pralidoxime (2-PAM) –> Synergistic effect
Seizures = Diazepam
Atropine is given to manage acetylcholinesterase inhibitor toxicity because it blocks the effects of excess acetylcholine, a chemical that can build up to dangerous levels due to the toxicity. By blocking acetylcholine, atropine helps reduce symptoms like muscle twitching, difficulty breathing, and excessive saliva production.
Acetylcholinesterase inhibitors Contraindications
Gastric ulcer (increased risk of gastrointestinal bleeding)
Urinary retention
Bradycardia or cardiac conduction diseases (sick sinus syndrome).
Antihypertensive medications –> Reduce the dose of antihypertensive, risk of severe hypotension.
NOTE: The two previous conditions can be evidenced by syncopal episodes.
Adult ADHD main features
-Symptoms are more subtle and are subject to change:
*Hyperactivity may be replaced with restlessness
*Impulsivity may be replaced with the inability to control emotions or social inappropriateness.
- 60% of the children will continue to exhibit symptoms into adulthood
Mechanism of action of ADHD medication
Inhibition of dopamine and norepinephrine reuptake
Define Diogenes syndrome
- Squalor and decline in personal hygiene
- Sometimes hoarding useless items
- Significant frontal lobe impairment
Define Charles Bonnet syndrome
👓👓👓👓👓👓👓👓👓👓👓👓
- Formed visual hallucinations in blind or partially sighted elderly who are not delirious.
- Always ocular or occipital disease not psychiatric.
- The patient has good insight
- Hallucinations characteristics:
*Last for seconds or hours at a time
*Vivid, colorful, and well-organized.
*Not distressing but may be quite engaging
Define Ekbom syndrome
Two forms:
- ‘restless legs’ syndrome
- Delusional infestation with parasites or worms in schizophrenic patients
Treatment: treat the underlying iron deficiency anaemia, and levodopa
Define Cotard syndrome
The patient believes they have lost important body parts, blood, internal organs, or even their soul
Prevalent in schizophrenia, bipolar disorder, non-dominant temporoparietal lesions, and migraine.
Psychiatric Drugs that cause HYPOnatremia
Antipsychotics
Carbamazepine
SSRIs
SNRIs
Symptoms of HYPOnatremia in psychiatric patients under treatment
More common in the elderly
- Confusion
- Lethargy
- Worsening of psychosis or dementia
Neurotransmitters abnormalities
SADPHAM
Schizophrenia: ↑ dopamine
Alzheimer’s: ↓ acetylcholine
Depression: ↓ serotonin/norepinephrine
Parkinson’s: ↓ dopamine
Huntington’s: ↓ acetylcholine
Anxiety: ↓ GABA
Mania: ↑ serotonin/norepinephrine
Neurotransmitter abnormalities occur when the chemicals in the brain that send messages between nerve cells (neurotransmitters) are out of balance. This can affect mood, behavior, and bodily functions. For example, low levels of serotonin are linked to depression, while high levels of dopamine can be associated with schizophrenia.
paracetamol intoxication protocol
