MH Flashcards
Pharmacology of Alcohol use disorder-NAD
Naltrexone
Acamprosate
Disulfiram
Drug and alcohol history- PCWHTA
Also, check their motivation to stop
Pattern
Control
Withdrawal
Persistence despite harm
Tolerance + Abstinence
Motivation to stop
Mood in MSE
-SOA
Subjective–> I feel like shit too
Objective–> Euthymic, dysthymic and maniac
Affect–> outward manifestation of mood
Is it congruent
Is it reactive
Is it labile
Substance dependence- two things you have to look for if they are dependent on a substance
Substance tolerance and withdrawal
A maladaptive change in behaviour, resulting from substance tolerance and substance withdrawal. Namely, the patient perceives a need for the substance to avoid unpleasurable feelings–> Monopolization, loss of control and social changes
Monopolization
Multiple hospitalizations
Loss of control of use
Symptoms of tolerance and withdrawal
Why is ETOH and benzo dangerous
Although the extent of respiratory depression differs from one benzodiazepine to another, severe, life-threatening episodes such as those seen in opioid intoxication are uncommon in benzodiazepine monotherapy. However, respiratory depression can be quite severe when benzodiazepines are combined with other respiratory depressants (e.g., alcohol).
The antidote for Benzo overdose
Antidote: flumazenil
Indications
Severe respiratory depression
Overdose in benzodiazepine-naive patients (e.g., accidental ingestion in children, periprocedural oversedation with benzodiazepines)
Routine use of flumazenil for benzodiazepine overdose is not recommended.
Why should you be cautious when using flumazenil in Benzo OD in a chronic benzo user
Can precipitate seizures
Most cases of benzodiazepine overdose occur in patients who are on chronic benzodiazepine therapy. Flumazenil can precipitate withdrawal symptoms and seizures in patients with benzodiazepine dependence.
Benzodiazepine overdose is very rarely life-threatening unless associated with the co-ingestion of alcohol, opioids, barbiturates, 1st generation antihistamines (e.g., diphenhydramine) or other respiratory or CNS depressants!
ECT electrode placement
Unilateral placement- all dependent on the tragus of the ear on non-dominant hemisphere, one goes to the temporal fossa and the other close to the vertex
Bitemporal- Placed on the temporal fossa
Bi-frontal- outer the canthus of the eye
LOOK AT THE PICTURE for electrode placement in ECT
What are the absolute contraindications and relative for ECT
No absolute contraindications.
Relative contraindications include:
Elevated intracranial pressure and space-occupying lesions in the brain
Recent myocardial infarction (within the last 3 months)
Severe arterial hypertension
Narcotic intolerance
Acute glaucoma
Changes in the cerebral arteries, e.g., aneurysm, angioma
Pregnancy and pacemakers contraindicated in ECT-True or false
False
Pregnancy and pacemakers are not a contraindication for ECT!
What are some side effects of ECT
- common
- uncommon
- Reversible memory loss: retrograde more often than anterograde amnesia
- Tension headache
- Nausea
- Transient muscle pain
Less common
Skin burns
Temporary, short-term functional disorders (such as amnesic aphasia)
Prolonged seizure
Delusion vs illusion vs hallucination
Delusion- fixed false belief
Illusion- Misintreparation of an external stimulus
Hallucination- Perception in the absence of an external stimulus
5A of schizophrenia- negative symptoms
Anhedonia Affect(Flat) Avolition Alogia- a poverty of speech Attention(poor)
Positive, negative and cognitive symptoms of schizophrenia
Think of positive symptoms as things that are ADDED to normal behaviour
Think of negative symptoms as things that are SUBTRACTED or missing from normal behaviour
cognitive symptoms–> impairment in attention, executive function, and working memory
Three phases of schizophrenia
Prodromal
Psychotic
Residual
Which pathway responsible in schizophrenia
- positive symptoms
- negative symptoms
mesolimbic for +
Mesocortical for -
What happens in the blockage of
- tuberoinfundibular
- nigrostriatal
Tubo–> gynacomastia, galactorrhea, and menstrual irregularities
Nigrostriatal–> EPS–> tremor, slurred speech, akathisia, dystonia and other abnormal movements
What are the difference between delusional and schizophrenia
Schizophrenia
- Bizzare delusions
- Daily functioning impairment
- Must have 2 or more of the following
- Delusions
- Hallucinations
- Disorganized speech
- Disorganized behaviour
- Negative symptoms
Delusional disorder
- Non-bizzare
- Not impaired
- Does not meet the schizophrenia criterion
Delusion
- defintion
- bizzare
- non-bizzare
Delusions: fixed, false beliefs that are not amenable to reason, despite evidence to the contrary
Bizarre: impossibility of being true or not consistent with the patient’s social and cultural norms(having super-powers and all)
Non-bizarre: possibility of being true or consistent with the patient’s social and cultural norms(winning the lottery,when you haven’t)
May be grandiose , ideas of reference , paranoid, or erotomanic
Catatonia
- definition
- treatment
- types
A behavioral syndrome characterized by abnormal movements and reactivity to the environment
Treatment- benzo and ECT
Retarded catatonia: immobility, posturing, negativism (resisting external commands), staring, mutism
Excited catatonia: excessive, purposeless movement in both the upper and lower limbs, restlessness, and impulsivity
Malignant catatonia: fever, autonomic instability (e.g., tachycardia, tachypnea, abnormal BP, and sweating), rigidity, and delirium (resembles neuroleptic malignant syndrome)
What will schizophrenia show with brain imaging
Brain imaging of schizophrenia patients often shows cortical atrophy and enlargement of the cerebral ventricles.
Psychotic symptoms lasting > 6 months
Schizophrenia
Psychotic symptoms lasting > 1 day but ≤ 1 month
Triggered by stressful situations
Brief psychotic disorder
Psychotic and residual symptoms lasting 1–6 months
Schizophreniform disorder
Schizoaffective disorder
Features of schizophrenia AND a major mood disorder (depression or bipolar disorder)
Remeber that it can happen with any MOOD DISORDER- EVEN BIPOLAR–> so you have maniac epsiode with it haha
Psychosis must have been present for at least 2 weeks in the absence of any mood disturbance.
Mood symptoms do not appear in the absence of psychosis
DDX for psychosis
Psychosis secondary to GMC Drug-induced psychosis Delirium/Dementia Bipolar disorder, maniac/mixed episode MDD with psychotic features BPD Schizo ones Delusional disorder
≥ 1 delusion with a duration of ≥ 1 month and no other psychotic symptoms
Functioning is not markedly impaired and behavior is not obviously bizarre or odd
Delusional disorder
Mood disorder with psychotic features
How is it different to schizoaffective disorder
Meets criteria for a mood disorder (e.g., depression or manic phase of bipolar mood disorder)
Psychotic features appear exclusively during manic or depressive episodes.
Mood symptoms may be present in the absence of psychosis.
Mood symptoms do not appear in the absence of psychosis - this is schizoaffective disorder
If delusions and hallucinations are not mood congruent it is
If delusions and hallucinations are mood congruent it is likely due to
- psychotic or schiz etc disorder
2. Mood disorders
Differences between mania vs hypomania
Mania
Lasts at least 7days
Causes severe impairment in social or occupational functioning
May necessitate hospitalization to prevent harm to self for others
May have psychotic features
Hypomania
- Lasts at least 4 days
- No impairment
- Does not require hospitalization
- No psychotic features
MDD and sleeping patterns
Two most common sleep disturbances are:
- Difficulty falling asleep
- Early morning awakening
What are the unique types and features of depressive disorder
- Melancholic
- Atypical
- Catatonic
- Psychotic
What if pregnant women comes in with maniac episode
ECT is the best treatment for a maniac woman in pregnancy. It provides a good alternative to antipsychotics and can be used with relative safety in all trimesters
Dysthymic disorder
Double depression
-Pt. with MDD with dysthymic disorder during residual periods
Adjustment disorder vs PSTD
and Define adjustment disorder
In adjustment disorder, the stressful event is not life-threatening(such as a divorce, death of a loved one, or loss of a job).
In PTSD it is
Adjustment disorder occurs when maladaptive behavioural or emotional symptoms develop after a stressful life event.
- symptoms begin 3 months after the event
- end within 6 months
- cause significant impairment in daily functioning or relationships
Obsessions
- Recurrent and persistent intrusive thoughts or impulses
That cause marked anxiety
and are not simply excessive worries about real problems
- The person attempts to suppress the thoughts
- The person realises thoughts are products of his or her own mind
Compulsions
- Repetitive behaviours that the person feels driven to perform in response to an obsession
- The behaviours are aimed at reducing distress, but there is no realistic link between the behaviour and the distress
Intrusive thoughts, images, and urges that trigger repetitive, compulsive behaviour
Time-consuming (E.g., ≥ 1 hour/day), or result in significant distress/impairment (school, work)
Obsessive compulsive disorder
Excessive perfectionism and rigid control regarding real-life concerns
Obsessive-compulsive personality disorder
Recurrent thoughts revolve around real-life concerns, e.g., work, as opposed to the obsessions in OCD, which tend to be of an irrational nature.
GAD
Acute stress disorder vs PTSD
Acute stress disorder
- the event occurred < 1 month ago
- symptoms last < 1 month
PTSD
- event occurred at any time in the past
- symptoms lasts >1 month
What 2 things should you rule out in any anxiety disorder
- Hyperthyroidism
2. Caffeine intake
Major complaint: anxiety in response to unspecific events or themes (e.g., health, relationships)
Impaired memory, sleep disturbances, muscle tension, and/or fatigue
Impaired functioning
Lasts > 6 months
GAD
EtOH withdrawal monitoring scale
CIWA-Ar
Withdrawal from which 2 substances are lethal
Alcohol and benzo
In general, withdrawal from drugs that are sedating is life-threatening, while withdrawal from stimulants is not.
Pharmacotherapy to promote alcohol cessation
Block positive effects of alcohol: Naltrexone (first-line agent), acamprosate, or topiramate.
Create a toxic reaction when alcohol is ingested: Disulfiram.
Nose bleeding and history of drug use think
Cocaine
The complication of using cocaine–> Cocaine-induced vasospasm
↓ Reuptake of norepinephrine → ↑ α- and β1‑stimulation → vasoconstriction and vasospasm → myocardial infarction, cerebrovascular accident, or ischemic colitis
Amphetamine use clinical features
↑ libido, constipation, tachycardia with arrhythmias, mydriasis, ↑ body temperature, ↑ perspiration, ↓ appetite, weight loss, grinding teeth
What is the treatment of choice for opiate overdose
Naloxone
Naloxone
immediate acute opioid antagonist–> used in Opioid OD
Methadone
full opioid AGONIST–> used to wean off the opioid tolerance without going into withdrawal
Helps with weaning off
Buprenorphine
partial opioid agonist –> opioid withdrawal in patients with opioid dependence
similar to methadone but partial
Naltrexone
-what are the 2 uses
opioid antagonist –> used to help people maintain their opioid abstinence.
Keep them not going back to using opioids
2 uses->
- help people get off alcohol
- help people stay off opioids(heroin)
Treat associated comorbidities of IV opioid addiction
HIV, hepatitis C, endocarditis
Clinical features of opioid intoxication
Altered mental status
Bilateral miosis (pinpoint pupils)
Respiratory depression (decreased respiratory rate and tidal volume) and hemorrhagic lung edema
Seizures
Decreased bowel sounds
Decreased heart rate and blood pressure, hypothermia
Naloxone vs naltrexone
Naloxone: rapid onset, short duration (1–2 hours) → preferred for treatment of acute opioid intoxication
Naltrexone: long duration (24–48 hours) → used for withdrawal treatment after acute detoxification
What is suboxone
Combination drug Buprenorphine+naloxone
Triad of an opioid overdose-RAM
Respiratory depression, ALOC and Miosis
Altered mental status, respiratory depression, and miosis are the classic triad of opioid intoxication! However, the absence of miosis does not rule out opioid intoxication!
How do you monitor withdrawal from opioids
COWS- clinical opioid withdrawal scale–>
- SOWS- subjective opioid withdrawal scale
- OOWS- objective opioid withdrawal scale
Drug history always ask- if they said they had used drugs in the past
When was the last time you took said drug? like how long has it been
Can opioid withdrawal kill you
Opioid withdrawal causes severe discomfort, but is not life threatening!
Treatment options for nictoine
Varenicline- Champix (alpha-4-beta-2 nACHR partial agonist): reduces positive symptoms and prevents withdrawal
Bupropion: reduces craving and withdrawal symptoms
Nicotine replacement therapy (inhaler, lozenges, transdermal patch, nasal spray, or gum)
What are 2 typical symptoms of delirium
Visual hallucinations and short attention span
Impairment in recent memory is the most finding in delirium
What is the workup for dementia
- FBC
- Electrolytes
- TFTs
- VDRL/RPR
- B12 and folate levels
- Brain CT and MRI
Fact-Dementia due to Parkinson’s disease is exacerbated by antipsychotic medication
Visual hallucinations early in dementia suggest a diagnosis of dementia with Lewy bodies. DO NOT GIVE THESE patients antipsychotics
EPS- grimacing and tongue protrusion
Tardive dyskinesia
EPS- twisting and abnormal postures
Acute dystonia
EPS-characterized by the inability to sit still
Akathisia
EPS-characterized by a decrease or slow body movement
Bradykinesia
Hypertensive crises with MAOI
Caused bt a build-up of stored catecholamines, MAOIs plus food with tyramine(red wine, cheese, chicken liver, cured meats) or plus sympathomimetics
What is the black box warning with SSRIs
increased suicidal thinking and behaviour
PTSD- which drug can help with nightmares
Nightmares: Prazosin is effective for improving sleep.
Anorexia nervosa-AN- what are 2 management
1) Medical management- this is the 1st priority
2) Psychiatric management
What is the mainstay treatment for TCA OD
IV sodium bicarbonate
Major complications of TCAs- 3Cs
Cardiotoxicity
Convulsions
Coma
What are the anti-HAM effects of typical antipsychotics
Caused by the action of
Histamine
Adrenegeric
Muscarinic
Anti-histamine–> results in sedation and weight gain
Anti-alpha Adrenergic–> results in orthostatic hypotension, cardiac abnormalities and sexual dysfunction
Anti-muscarinic–> anticholinergic effects: results in dry mouth, tachycardia, urinary retention, blurry vision, constipation, and precipitation of narrow-angle glaucoma
Neuroleptic malignant syndrome-FALTERED
Fever Autonomic instability(tachycardia, labile hypertension and diaphoresis) Leukocytosis Tremor Elevated CPK Rigidity--> lead pipe rigidity Excessive rigidity Delirium
Atypical antipsychotic/SGA-increase in prolactin
Risperidione
Atypical antipsychotic/SGA-sedation
Quetiapine
Atypical antipsychotic/SGA-olanzapine
O-o–> weight gain
Atypical antipsychotic/SGA-unqiue partial D2 agonism
Aripiprazole
Atypical antipsychotic/SGA-Depo from
Paliperidone
Lithium and suicide tendencies
Lithium is the only mood stabilizer shown to decrease suicidality
Mnemonic for suicide risk assessment- modified SADPERSONS
–> how do you assess for
low
moderate
increased
S: Male sex → 1
A: Age 15-25 or 59+ years → 1
D: Depression or hopelessness → 2
P: Previous suicidal attempts or psychiatric care → 1
E: Excessive ethanol or drug use → 1
R: Rational thinking loss (psychotic or organic illness) → 2
S: Single, widowed or divorced → 1
O: Organized or serious attempt → 2
N: No social support → 1
S: Stated future intent (determined to repeat or ambivalent) → 2
0–5: Maybe safe to discharge (depending upon circumstances)
6-8: Probably requires psychiatric consultation
>8: Probably requires hospital admission
The 2 point ones are DR.SO
Lithium toxicity- tell me the main points
May occur at any Li toxicity(>1.5)
Nausea, vomiting, slurred speech, ataxia and incoordination, myoclonus, hyperreflexia, seizures, delirium, coma and nephrogenic diabetes insipidus
Discontinue Li
Hydrate aggressively
Consider dialysis with acute kidney impairment
Suicide risk assessment
KIR(pip)E
Kill
Ideation
R(risk)- PIP–> plan, intent and previous Hx
E-explore ideation
1) Ask every patient
2) Classify ideation–> passive and active
3) Assess risk- plan, intent and past attempts
Mental health-admission blood(8)
1.UEC
2.LFT
3.CMP
4.TFT
5FBC
6.UDS
7.ECG
8.beta-HCG
9.Syphilis serology
If you are starting a pt. an antipsychotic what are the levels in the body are you worried about
- Prolactin
- Fasting lipids
- B12
- Folate
- Vitamin D
For Bipolar depression which medication should not be used alone
Do not use antidepressants alone in the treatment of bipolar depression.
What is the treatment for bipolar depression-eTG
an antidepressant + a drug recommended for prophylaxis of bipolar disorder
OR
quetiapine
After last dose when should lithium levels be checked
When monitored, the serum lithium concentration should be measured 8 to 12 hours after the last dose.
What is the therapeutic level of lithium
The therapeutic range for lithium has previously been established at 0.6 - 1.2 mmol/L but recent studies have suggested a range of 0.6 - 1.0 mmol/L.
0.6-1 is a good answer
For most patients, the therapeutic serum lithium concentration for prophylaxis of bipolar disorder is 0.6 to 0.8 mmol/L
Some may need 0.8-1
YOU NEED TO PSYCHOEDUCATE them about the early warning signs of lithium toxicity
At which level does lithium toxicity occur at
Toxicity usually occurs at concentrations more than 1.5 mmol/L, but may develop at lower concentrations,
Which 4 drugs interact with Lithium
1) NSAIDs
2) Diuretics
3) ACEI
Other medications: tetracyclines, cyclosporine(immunosuppressant- similar to tacrolimus)
The most common side effect of lithium
Fine tremor
Nephrogenic diabetes insipidus with lithium, what is the treatment
Treatment: amiloride
Which organ does lithium get excreted by
Kidneys
LITHIUM mneomic
Leukocytosis
I–>inspidius–> polyuria, polydipsia, decrease GFR and AKI
T–> tremor and ataxia
H-Hypothyroidism
I- increase weight
U- underactive mind
M–> mother–> Tetratogenic–> tricuspid atresia
GIT–>Nausea, vomiting and diarrhea
Lithium induced arrhythmias
Lithium induced nephropathy
What are some early/mild lithium toxicity signs
Gastrointestinal symptoms dominate in acute poisoning.
Nausea, vomiting Tremor Agitation Proximal weakness Vision changes was a bit thing that the reg told us- double vision
Dehydrated
Late signs of lithium toxicity
Altered mental status: confusion, delirium, somnolence, encephalopathy
Coarse tremor
Dysarthria
Disorientation
VALRPOATE
Vomiting and nausea Anorexia Liver toxicity(hepatically excreted) Pancreatitis Retention of weight Odema Alopecia Teratogen, tremors E
CPL causes Steven-johnson syndrome
Carbamazepine
Phenytoin
Lamotrigine
