Phenomenology, psychopharmacology, counselling, hypnotics, ECT Flashcards

Question

Examples and doses of Noradrenaline serotonin specific antidepressants (NASSAs)

Answer 1

Mirtazapine (15-45 mg a day)

Answer 2

2nd line depression - benefit of weight gain and suffer from insomnia

Answer 3

Weak noradrenaline reuptake inhibiting effect Anti histaminergic properties Is an a1 and a2 blocker Therefore Inc appetite and is a sedative

Answer 4

Inc appetite weight gain dry mouth postural HT oedema drowsiness fatigue tremor dizziness dreams abnormal confusion anxiety insomnia arthralgia myalgia

Answer 5

Elderly Cardiac disorders Hypotension urinary retention glaucoma diabetes psychoses seizures blood disorders

Answer 6

8-12 mg a day

Answer 7

2nd or 3rd line for major depression

Answer 8

Highly specific noradrenaline reuptake inhibitor

Answer 9

Nausea Dry mouth constipation Anorexia Tachycardia palpitations vasodilation Postural hypotension headache insomnia dizziness chills

Answer 10

CVD Epilepsy bipolar urinary retention prostatic hypertrophy pregnancy glaucoma

Answer 11

1. Overall safety profile: Most national and local guidelines suggest SSRIs as first choice because of their safety profile in overdose as well as their effectiveness. 227 2. Patient preference: After discussing side effects of each antidepressant, it is appropriate and important to involve the patient in the decision making. 3. Prior treatment: If a patient has had benefit from a previously used antidepressant, that same one should be used, provided no contraindications have developed; equally if an antidepressant has already been tried and not benefited, another one should be trialled. 4. Type and severity of depression: SSRIs are usually indicated for all severities of depression and when there is mixed anxiety and depression. In SSRI-resistant cases, SNRIs should be tried. When insomnia is present or weight gain is desired, mirtazapine can be given. 5. Suicidal ideation: Avoid drugs that are toxic in overdose such as TCAs and MAOIs (see Key facts 2). SSRIs should still be used with caution and appropriate review (see DO and DO NOT boxes). 6. Age and co-morbidities: SSRIs are usually the safest in elderly. Sertraline is the safest drug post-MI. See Table 12.2.2 for all other cautions and contraindications. 7. Drug–drug interactions: Avoid SSRIs in those on blood-thinning agents such as warfarin, heparin and the newer anticoagulant agents (e.g. rivaroxaban, apixaban and dabigatran), as well as NSAIDs. See BNF if in doubt. 8. Pregnancy and breast feeding: All antidepressants should be used with caution and if required, the lowest effective dose should be used. Sertraline and fluoxetine are the safest during pregnancy along with some TCAs such as amitriptyline. The SSRIs paroxetine and sertraline are most likely suitable first-line agents during breast feeding. 9. History of mania: All antidepressants have the potential to trigger a manic episode but SSRIs are usually the safest (avoid TCAs).

Answer 12

The serotonin syndrome is a rare but life-threatening complication of increased serotonin activity, usually rapidly occurring within minutes of taking the medication. It is most commonly caused by SSRIs but can be caused by other drugs such as TCAs and lithium. Clinical features include: 1. Cognitive effects → headache, agitation, hypomania, confusion, hallucinations, and coma. 2. Autonomic effects → shivering, sweating, hyperthermia, hypertension and tachycardia. 3. Somatic effects → myoclonus (muscle twitching), hyperreflexia, and tremor. Management involves stopping the offending drug and supportive measures

Answer 13

Classic triad - Neuromuscular abnormalities - Altered mental state - Autonomic dysfunction Beware co-administration of antidepressants Treatment Depends on presentation, ranges from supportive to use of Cyproheptadine (5-HT2 antagonist)

Answer 14

Prescribe SSRIs first-line for moderate to severe Co-prescribe NSAIDs and SSRIs, but if you have to, prescribe a proton pump inhibitor too. 228 depression unless contraindicated. Be cautious when prescribing to children and adolescents – fluoxetine is the drug of choice in this age group. Prescribe sertraline post myocardial infarction as there is more evidence for its safe use in this situation over other antidepressants. Review patients after 2 weeks of prescribing SSRIs – patients <30 years of age or at ↑ risk of suicide should be reviewed after 1 week. Warn patients about side effects – GI being the most common. Counsel patients to be vigilant for ↑ anxiety and agitation after starting an SSRI.

Answer 15

Co-prescribe NSAIDs and SSRIs, but if you have to, prescribe a proton pump inhibitor too. Co-prescribe SSRIs and heparin/warfarin. Stop SSRIs suddenly – if stopping an SSRI, the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Prescribe citalopram or escitalopram in congenital long QT syndrome, known pre-existing QT interval prolongation, or in conjunction with other medicines that prolong the QT interval, as they are associated with dose-dependent QT interval prolongation

Answer 16

Amitriptyline, clomipramine, dosulepin, doxepin, imipramine, lofepramine, nortriptyline, trimipramine.

Answer 17

Depressive illness, nocturnal enuresis in children, neuropathic pain (unlicensed), migraine prophylaxis (unlicensed).

Answer 18

TCAs work by inhibiting the reuptake of adrenaline and serotonin in the synaptic cleft. They also have affinity for cholinergic receptors and 5HT2 receptors and these contribute to side effects.

Answer 19

Complicated, but down stream effect is to reduce dopamine release Therefore, antagonism cuts the brake and increases dopamine release in both striatum and nucleus accumbens. This is one of many mechanisms.

Answer 20

Anticholinergic: dry mouth, constipation, urinary retention, blurred vision, confusion. Cardiovascular: arrhythmias, postural hypotension, tachycardia, syncope, sweating. Hypersensitivity reactions: urticarial, photosensitivity. Psychiatric: hypomania/mania, confusion or delirium (especially in elderly). Metabolic: ↑ appetite and weight gain, changes in blood glucose levels. Endocrine: testicular enlargement, gynaecomastia, galactorrhoea. Neurological: convulsions, movement disorders and dyskinesias, dysarthria, paraesthesia, taste disturbances, tinnitus. Others: headache, sexual dysfunction and tremor.

Answer 21

Cautions → cardiac disease, history of epilepsy, pregnancy, breast-feeding, elderly, hepatic impairment, thyroid disease, phaeochromocytoma, history of mania, psychoses (may aggravate psychotic symptoms), susceptibility to angle-closure glaucoma, history of urinary retention, concurrent electroconvulsive therapy; drowsiness may affect performance of skilled tasks (e.g. driving); effects of alcohol enhanced. Contraindications → recent myocardial infarction, arrhythmias (particularly heart block), mania, severe liver disease, agranulocytosis.

Answer 22

Amitriptyline (50–200 mg/day), doxepin (30–300 mg/day, up to 100 mg as single dose), dosulepin (75–225 mg/day), imipramine (50–200mg/day, up to 100 mg as single dose), clomipramine (30–250 mg/day in divided doses or as a single dose at bedtime), lofepramine (140–210 mg/day)

Answer 23

Irreversible: Phenelzine, isocarboxide. Reversible: Moclobemide.

Answer 24

Third-line for depression: atypical or treatment-resistant depression. NOTE: Its use is substantially limited by toxicity, interaction with food and inferior efficacy compared to SSRIs and TCAs (see Key facts 2). Social phobia.

Answer 25

MAOIs inactivate monoamine oxidase enzymes that oxidize the monoamine neurotransmitters dopamine, noradrenaline, serotonin (5- HT), and tyramine. There are two main forms of MAO enzymes: MAO-A and MAO-B. Moclobemide is comparatively recent compared with the other MAOIs and binds selectively to MAO-A, therefore nullifying the need for dietary restrictions.

Answer 26

Cardiovascular (postural hypotension, arrhythmias), neuropsychiatric (drowsiness/insomnia, headache), GI (↑ appetite, weight gain), sexual (anorgasmia), hepatic (↑ LFTs), hypertensive reactions with tyramine containing foods Cheese effect: inhibitor of MAO in the gut and the effect of tyramine rich foods Drug interactions

Answer 27

Cautions → Avoid in agitated or excited patients (or give with sedative for up to 2–3 weeks), thyrotoxicosis, hepatic impairment, in bipolar disorders (may provoke manic episodes), pregnancy and breast-feeding. Contraindications → acute confusional states, phaeochromocytoma.

Answer 28

MAOIs also metabolize tyramine; therefore, eating tyramine-rich foods such as cheese, pickled herring, liver (of beef or chicken), Bovril, Oxo, Marmite and some red wine can cause hypertensive crisis. These foods should be avoided when taking MAOIs. Clinical features of the hypertensive crisis: headache, palpitations, fever, convulsions and coma. MAOIs also interact with other drugs including insulin, opiates, SSRIs, and TCAs as well as anti-epileptics.

Answer 29

Hallucinations Delusions

Answer 30

Flattened affect Cognitive difficulties Poor motivation Social withdrawal

Answer 31

Mesolimbic tract Nigrostriatal tract Mesocortical tract Tuberoinfundibular tract

Answer 32

The dopamine hypothesis” All known antipsychotics are dopamine antagonists A relative underactivity in the meso-cortical pathway and a relative overactivity in the mesolimbic.

Answer 33

VTA -> Nucleus accumbens Associated with reward. The so-called “pleasure centre”. Activated by drugs of abuse. What is “reward”. Blocking this pathway reduces the positive symptoms of psychosis. BUT, might also reduces the ability to feel pleasure! There’s evidence that drug abusers need more/seek more drugs after starting antipsychotics.

Answer 34

The function of ascending dopamine signalling may be the attribution of salience to a stimuli. Psychosis is the misattribution of salience. Think of the dinner party effect. Now imagine that any stimulus could trigger salience…

Answer 35

Arises from VTA Fibres spread throughout neocortex Required for executive function and cognitive control of emotions. A relative deficiency thought to cause negative symptoms of schizophrenia Can anybody see the problem with giving a dopamine antagonist…? “Neuroleptic dysphoria”

Answer 36

Fibres from the substantia nigra which innervate the striatum in basal ganglia. Dopamine signal favours the direct pathway. (causes movement). Therefore D2 antagonists….?

Answer 37

Acute dystonia - Procyclidine Akathisia Tardive dyskinesia

Answer 38

Links hypothalamus to pituitary DA inhibits prolactin release Symptoms of hyperprolactinaemia?

Answer 39

Neuroleptic malignant syndrome Tremor, muscle cramps, fever, autonomic instability, delirium Raised Ck. Can progress to rhabdomyolysis Slower onset. Idiosyncratic (increased risk in dementia with lewy body) Treated with DA agonists (eg. Bromocriptine)

Answer 40

The difference between these groups is primarily the extent to which they cause extrapyramidal side effects (EPSE).

Answer 41

Haloperidol Chlorpromazine Flupentixol Fluphenazine Sulpiride Zuclopenthixol

Answer 42

Olanzapine Risperidone Quetiapine Amisulpride Aripiprazole Clozapine

Answer 43

CUtLASS and CATIE Huge pragmatic clinical trials - Government funded - Wide inclusion criteria Neither were more effective nor less tolerated! Confirmed the clozapine effect Caveat – Not powered sufficiently to look at TD (because it’s relatively rare).

Answer 44

True in the 1970s A definite improvement can be detected in the first 24 hours!!1 Early reduction in behavioural impact of symptoms and preoccupation, with perspective and conviction reducing later2. More improvement in first 2 weeks than in any subsequent 2 weeks3

Answer 45

“I’m over it now doctor, let’s draw a line in the sand and forget the whole episode”. WRONG – There is irrefutable evidence that discontinuation is associated with relapse (for at least up to 18 months following first episode. Possibly due to ‘super sensitivity’

Answer 46

Act fast Go slow (and titrate to side effects) Listen to the patient Offer clozapine quickly Encourage compliance

Answer 47

According to NICE guidelines, atypical antipsychotics should be used first-line in patients with schizophrenia. Indeed, the main advantage of the atypical agents is a significant reduction in extrapyramidal side effects. The efficacy of different antipsychotics is similar, therefore the choice of drug is often determined by the side effect profile and price. An exception is clozapine. Clozapine is the only antipsychotic that has been found to be superior in efficacy to other antipsychotics and is therefore indicated for treatment-resistant schizophrenia.

Answer 48

Agree choice of antipsychotic with patient or worker or just start second gen antipsycho > titrate to minimum effective dose > adjust dose according to response and tolerability > assess over 2-3 weeks >1. effective: Continue at dose established 2a. Not effective: change drug and follow above process, use typical or atypical 2b. This not effective then Clozapine 3. Not tolerated or poor compliance: Depot injection possibly

Answer 49

They can also be used for other conditions when they present with positive psychotic symptoms (e.g. delusions and hallucinations) such as depression, mania, delusional disorders, acute and transient psychotic disorders, delirium and dementia, as well as those with violent or dangerously impulsive behaviour and psychomotor agitation.

Answer 50

Clozapine is licensed as a third-line treatment for schizophrenia and it is the only antipsychotic that has evidence that it is more effective than other antipsychotics. Clozapine should only be prescribed after failing to respond to two other antipsychotics (treatment-resistant schizophrenia).

Answer 51

Evidence for use in treatment resistance. Should be offered when 2 or more treatments have been tried unsuccessfully. Causes agranulocytosis – monitoring needed ++ Also hypersalivation and constipation

Answer 52

All antipsychotics work on D2/D3 receptors to reduce dopamine transmission Typical antipsychotics usually have a higher affinity

Answer 53

Most atypical antipsychotics Thought to improve affective and negative symptoms Responsible for metabolic side effects

Answer 54

Blocking these receptores

Answer 55

By reducing abnormal transmission of dopamine, through blocking dopamine receptors in the brain. The mechanism of action of atypical antipsychotics varies, but unlike typical antipsychotics, they have a specific dopaminergic action, blocking the D2 receptor, and they also have serotonergic effects.

Answer 56

Antipsychotics work on the mesolimbic and mesocortical dopamine pathways to inhibit positive and negative symptoms of schizophrenia, respectively. Antipsychotics cause EPSE via the nigrostriatal pathway and endocrine side effects via the tuberoinfundibular pathway.

Answer 57

One of the main properties of antipsychotics is that they block dopamine receptors, in particular D2 receptors. However, they also have an affinity for muscarinic, 5HT, histaminergic and adrenergic receptors

Answer 58

Extrapyramidal side effects are more common in typical antipsychotics (see Key facts 1). Anti-muscarinic (‘can’t see, can’t wee, can’t spit, can’t s**t’) – blurred vision (can’t see), urinary retention (can’t wee), dry mouth (can’t spit), constipation (can’t s**t). Anti-histaminergic: sedation and weight gain. Anti-adrenergic: postural hypotension, tachycardia and ejaculatory failure. Endocrine/metabolic: ↑ prolactin (sexual dysfunction, reduced bone mineral density, menstrual disturbances, breast enlargement, and galactorrhoea), impaired glucose tolerance, hypercholesterolaemia. Neuroleptic malignant syndrome Prolonged QT interval: QT interval prolongation is a particular concern with pimozide and haloperidol. There is a higher probability in any antipsychotic drug (or combination of drugs) with doses exceeding the recommended maximum. Cases of sudden death have occurred through fatal arrhythmias (e.g. torsades de pointes). Clozapine has the specific side effects of hypersalivation (patients may wake up with their pillows soaking with saliva) and agranulocytosis requiring special monitoring

Answer 59

1. Parkinsonism: Bradykinesia, ↑ rigidity, coarse tremor, masked facies (expressionless face), shuffling gait. This typically takes weeks or months to occur (Fig. 12.3.4). 2. Akathisia: Unpleasant feeling of restlessness. Occurs in the first months of treatment. It is managed by reducing the dose of antipsychotic and temporarily giving propranolol. 3. Dystonia: Acute painful contractions (spasms) of muscles in the neck, jaw and eyes (oculogyric crisis). This can occur within days (Fig. 12.3.4). 4. Tardive dyskinesia: Late onset (years) of choreoathetoid movement (abnormal, involuntary movements). May occur in 40% of patients and may be irreversible. Most commonly presents as chewing and pouting of the jaw

Answer 60

Definition: Neuroleptic malignant syndrome is a rare but life-threatening condition seen in patients taking antipsychotic medications. It may also occur with dopaminergic drugs (such as levodopa) for Parkinson’s disease, usually when the drug is suddenly stopped or the dose reduced. Epidemiology: Carries a mortality of up to 10%. It is more common in young male patients. Clinical features: Onset usually in first 10 days of treatment or after increasing dose. Presents with pyrexia, muscular rigidity, confusion, fluctuating consciousness and autonomic instability (e.g. tachycardia, fluctuating blood pressure). May have delirium. Investigations: CK (↑ creatinine kinase is usual), FBC (leucocytosis may be seen), LFTs (deranged). Management: Stop antipsychotic, monitor vital signs, IV fluids to prevent renal failure, cooling, dantrolene (muscle relaxant) may be useful in select cases, bromocriptine (a dopamine agonist) may be used, consider benzodiazepines. Complications: Pulmonary embolism, renal failure, shock.

Answer 61

Cautions: Cardiovascular disease (an ECG may be required), Parkinson’s disease (may be exacerbated by antipsychotics), epilepsy (and other conditions predisposing to seizures), depression, myasthenia gravis, prostatic hypertrophy, susceptibility to angle-closure glaucoma, severe respiratory disease, history of jaundice, blood dyscrasias (perform blood counts if unexplained infection or fever develops). Contraindications: Comatose states, CNS depression, phaeochromocytoma.

Answer 62

FBC UEs LFTs FBG Blood Lipids ECG BP Prolactin Weight Physical Health Creatine phosphokinase Go back to page 236

Answer 63

It should be recommended to patients for antipsychotics to be continued for at least 1–2 years following an episode of psychosis and some recommend continuing for 5 years to prevent relapse. Patients tend not to adhere to this advice and stop taking antipsychotics much before this. It is therefore essential to take appropriate measures to improve compliance. If stopping antipsychotics, it is important to advise patients to taper their medication over a period of approximately 3 weeks as opposed to stopping suddenly. The relapse rate in the first 6 months after abrupt withdrawal is double that seen after gradual withdrawal.

Answer 64

It should be recommended to patients for antipsychotics to be continued for at least 1–2 years following an episode of psychosis and some recommend continuing for 5 years to prevent relapse. Patients tend not to adhere to this advice and stop taking antipsychotics much before this. It is therefore essential to take appropriate measures to improve compliance. If stopping antipsychotics, it is important to advise patients to taper their medication over a period of approximately 3 weeks as opposed to stopping suddenly. The relapse rate in the first 6 months after abrupt withdrawal is double that seen after gradual withdrawal.

Answer 65

The mode of administration of antipsychotics is usually oral. Some of the antipsychotics can also be given by short-acting intramuscular (IM) injection. Some antipsychotics can be given as depot injections every 1–4 weeks (see Key facts 3). The patient should be started on the lowest possible dose and then the dose should be titrated to the lowest dose known to be effective. Dose increases should then take place only after 1 or 2 weeks of assessment during which the patient shows poor or no response. Typical doses of 1st and 2nd generation antipsychotics are listed in

Answer 66

Name Route Oral Intramuscular Haloperidol 2–20 mg 2–12 mg (short-acting injection). A longacting Haldol depot is also available 50– 300 mg (every 4 weeks) Chlorpromazine 75–300 mg but up to 1 g daily may be required IM short-acting is available but rarely used Flupentixol 3–18 mg (18 mg max./day) 50–300 mg (every 2–4 weeks) Fluphenazine n/a 25 mg (every 2 weeks) Sulpiride 400–800 mg (max. 800 mg in predominantly –ve symptoms; 2.4 g in predominantly +ve) n/a Zuclopenthixol 20–30 mg daily in divided doses, increasing to a max. of 150 mg daily 200 mg (every 2 weeks)

Answer 67

Name Route Oral Intramuscular 238 Olanzapine 5–20 mg 150–300 mg (every 2–4 weeks) Risperidone 2–16 mg 25–50 mg (every 2 weeks) Quetiapine 50–750 mg n/a Amisulpride 400 mg–1.2 g (for acute episode); 50–300 mg for predominantly –ve symptoms n/a Aripiprazole 10–30 mg 400 mg (monthly) Clozapine 200–900 mg n/a

Answer 68

These are long acting, slow release medications given intramuscularly every 1–4 weeks. There are numerous typical antipsychotic depots such as flupentixol, fluphenazine, zuclopenthixol and several atypical (risperidone, olanzapine and aripiprazole). Depot injections bypass first-pass metabolism. They are used to improve adherence with medication for patients who may find it difficult to take oral medication regularly.

Answer 69

TYPICAL antipsychotics ATYPICAL antipsychotics Have more extrapyramidal side effects Have fewer extrapyramidal side effects Less tolerability Overall greater tolerability ↓ Efficacy against depressive and cognitive symptoms ↑ Efficacy against depressive and cognitive symptoms Metabolic syndrome less likely Metabolic syndrome more likely Weight gain less likely Weight gain more likely Less likely to cause type 2 diabetes More likely to cause type 2 diabetes Less likely to cause stroke in the elderly More likely to cause stroke in the elderly More likely to cause tardive dyskinesia Less likely to cause tardive dyskinesia More likely to cause high prolactin levels Less likely to cause high prolactin levels

Answer 70

Discuss the benefit and side effect profile with each patient before starting antipsychotics. Start the patient on the lowest possible dose and then the dose should be titrated. Perform ECG and bloods before starting on antipsychotic (see Table 12.3.2). Monitor and record the following regularly: efficacy, side effects, adherence, physical health, nutritional status, rationale for continuing, changing or stopping medication. Consider offering depot/long-lasting injectable antipsychotic medication to avoid non-adherence (intentional or unintentional). Offer clozapine to people who have not responded adequately to at least two different antipsychotic medications.

Answer 71

Use a loading dose of antipsychotic medication. Routinely initiate regular combined antipsychotic medication (except for short periods, e.g. when changing medication). Prescribe antipsychotics without thought in patients with a significant cardiovascular history. Stop antipsychotics abruptly.

Answer 72

Anxiolytics (previously called minor tranquillizers) are any drugs that are licensed for a variety of anxiety disorders. They are called hypnotics if they are used to induce sleep.

Answer 73

Benzodiazepines (BZD) used to be the main drug choice for anxiety disorders, but with increasing knowledge that these drugs cause dependency and withdrawal effects, the first-line drugs for anxiety disorders are antidepressants, notably SSRIs

Answer 74

barbiturates (not used any more due to side effect profile and toxicity in overdose), buspirone, beta-blockers and antipsychotics.

Answer 75

Hypnotics are used to improve sleep but should only be used short term. The following drugs can be used as hypnotics: Benzodiazepines, low dose amitriptyline, the socalled Z drugs: Zopiclone, Zolpidem and Zaleplon.

Answer 76

Long-acting (>24 hours duration of action): diazepam, nitrazepam, chlordiazepoxide, clonazepam, flurazepam. Short-acting (<12 hours duration of action): lorazepam, oxazepam, temazepam, midazolam, triazolam

Answer 77

(1) Insomnia (short-term use). (2) Anxiety disorders including panic disorder and phobic anxiety disorder. They are indicated for short-term (2–4 weeks) relief if the anxiety disorder is severe, disabling or causing the patient unacceptable stress. (3) Delirium tremens and alcohol detoxification: Chlordiazepoxide is commonly used, starting with a dose that is high enough to control withdrawal symptoms and then reducing over approximately a week. (4) Acute psychosis: To augment antipsychotics for sedation. (5) Violent behaviour: Although they can exacerbate the situation.

Answer 78

BZDs enhance the effect of the inhibitory neurotransmitter gammaaminobutyric acid (GABA) by increasing the frequency of chloride channels via the benzodiazepine-binding site of the GABA-A receptor. These receptors are located throughout the cortex and limbic system in the brain and function to inhibit neuronal activity.

Answer 79

Drowsiness and light-headedness the next day, confusion and ataxia (especially in the elderly), amnesia, dependence; paradoxical increase in aggression, muscle weakness, respiratory depression. See BNF for full list of side effects.

Answer 80

Respiratory depression and hepatic impairment (where they can precipitate coma). See BNF for full list.

Answer 81

Diazepam: 2–5 mg OD or BD (PO). Lorazepam: 1–4 mg QDS (PO, IV or IM). Max. dose 4 mg/24 hours. See BNF for doses of other benzodiazepines

Answer 82

PO (most common); IM, IV and PR benzodiazepine preparations are used mainly for non-compliant patients and status epilepticus.

Answer 83

Benzodiazepines can be dangerous in overdose. Clinical features of benzodiazepine overdose include: ataxia, dysarthria, nystagmus, coma, respiratory depression. As with all emergencies, an ABCDE approach should be adopted and IV flumazenil should be given as the specific antidote for BZD poisoning.

Answer 84

May develop at any time up to 3 weeks after stopping a long-acting benzodiazepine, but may occur within a day in the case of a short-acting one. Effects include insomnia, anxiety, loss of appetite, tremor, muscle twitching, sweating, tinnitus, perceptual disturbances and seizures (rarely).

Answer 85

Antidepressants are licensed for a variety of anxiety disorders. SSRIs are firstline and are particularly useful for OCD. Unlike BZDs their optimal effectiveness is delayed. They are not addictive and therefore can be used long term.

Answer 86

Beta-blockers (antagonists), notably propranolol at a starting dose of 40 mg can be used in anxiety disorder for reducing somatic symptoms such as tachycardia, palpitations and tremor. Contraindicated in asthma, COPD, bronchospasm, heart block, marked hypotension and acute left ventricular failure

Answer 87

Buspirone is a non-sedating anxiolytic that can be used for GAD. It works as a 5HT-1A agonist. It does not cause dependence, but its anxiolytic effect develops more slowly. Side effects include nausea, headache, light-headedness, and dizziness.

Answer 88

Examples include phenobarbital, mephobarbital, amobarbital sodium. Like benzodiazepines they act on GABA-A receptors. They were used as antiepileptics as well as anxiolytic medication. Due to their side effect profile and their toxicity in overdose they have now mainly been replaced by BZDs, and are no longer used.

Answer 89

Pregabalin does not act directly on GABA-A, but rather is an inhibitor of glutamate, noradrenaline and substance-P. It is an anticonvulsant and is licensed to be used in GAD, and is also used for neuropathic pain. Side effects include dizziness, drowsiness, blurred vision, diplopia, confusion and vivid dreams.

Answer 90

Include zopiclone, zolpidem and zaleplon. They work like BZDs by enhancing GABA transmission but are mainly used as hypnotics as they have shorter half-lives, reduced risk of tolerance and dependence and reduced psychomotor and hangover effects as compared to BZDs.

Answer 91

Antipsychotics are potent anxiolytics. However, their side effect profile does not make them suitable to be used as anxiolytics in their own right.

Answer 92

Wean patients off benzodiazepines as sudden cessation can cause benzodiazepine withdrawal syndrome. Warn patients that hypnotics and anxiolytics may impair judgement and increase reaction time, and so affect their ability to drive or operate machinery. Use benzodiazepines for insomnia only when it is severe, disabling, or causing the patient extreme distress. This should only be for a short period of time. Warn patients that consuming alcohol can enhance sedative effects of hypnotics and sometimes cause dangerous respiratory depression.

Answer 93

Use readily, as sometimes discussing feelings and providing reassurance may be enough. Consider long-term psychotherapy instead of a prescription. Prescribe benzodiazepines long term. They should not be prescribed for more than 2–4 weeks. Use benzodiazepines to treat short-term ‘mild’ anxiety. Withdraw anxiolytics abruptly. Forget alternatives – antidepressants have secondary anxiolytic effects and are safer for long-term use

Answer 94

Electroconvulsive therapy (ECT) is the passage of a small electrical current through the brain with a view to inducing a modified epileptic seizure which is therapeutic.

Answer 95

ECT is only performed by psychiatrists under controlled conditions. A thorough pre-anaesthetic assessment (with physical examination, blood tests, ECG and chest radiograph) is required to ensure patient safety. An electric current is applied (via electrodes) to the patient’s skull, aiming to induce a seizure for at least 30 seconds. (An ECT machine is shown in Fig. 12.6.1.) The procedure occurs under general anaesthetic. A muscle relaxant (e.g. suxamethonium) is given by the anaesthetist which limits the motor effects of the seizure. One electrode can be placed on each side of the head (bilateral ECT) or both electrodes on the non-dominant cerebral hemisphere alone (unilateral ECT). Bilateral ECT has been shown to be more effective but with more cognitive side effects. Unilateral is considered if cognitive side effects were suffered with previous ECT, and in the elderly. Physiologically, there are EEG changes which are monitored (Fig. 12.6.2). The pulse and BP ↑ and cerebral blood flow ↑ by 200%.

Answer 96

The patient usually requires around 6–12 treatment sessions, delivered twice a week. The seizure threshold is the minimum electrical stimulus required to induce a seizure and it is used in calculating the electrical current dose. Several drugs affect this threshold: Drugs which ↑ seizure threshold: Anaesthetic drugs, anticonvulsants, benzodiazepines, barbiturates. Drugs which ↓ seizure threshold: Antipsychotics, antidepressants (TCAs, SSRIs, MAOIs), lithium.

Answer 97

According to NICE, the main indications for ECT are ‘ECT’ (Euphoric Catatonic Tearful): 1. Prolonged or severe mania (Euphoric). 2. Catatonia (Catatonic). 3. Severe depression (Tearful): Treatment-resistant depression. Suicidal ideation or serious risk to others. Life-threatening depression, e.g. when the patient refuses to eat or drink. 250 NOTE: (1) Severe depression is the most common indication for the use of ECT. (2) The use in schizophrenia is controversial with critics claiming that it is harmful and that it invades patient autonomy.

Answer 98

SHORT-TERM side effects (‘PC DAMS’) Peripheral nerve palsies Cardiac arrhythmias, Confusion Dental and oral trauma Anaesthetic risks → laryngospasm, sore throat, N+V Muscular aches and headaches Short-term memory impairment, Status epilepticus

Answer 99

Anterograde and retrograde amnesia – the deficit is greater in those who receive bilateral ECT versus unilateral ECT.

Answer 100

MI (<3 months ago), Major unstable fracture. Aneurysm (cerebral). Raised ICP, e.g. intracranial bleed, space-occupying lesion (the only absolute contraindication). Stroke <1 month ago, a history of Status epilepticus, Severe anaesthetic risk (e.g. severe cardiovascular or respiratory disease).

Answer 101

Descriptive Psychopathology- objective description of abnormal states of mind avoiding, as far as possible, preconceived ideas or theories, and limited to the description of conscious experiences and observable behaviour Elucidate the essential qualities of morbid mental experiences and to understand each patient’s experience of illness. Requires ability to elicit, identify and interpret symptoms of psychiatric disorders

Answer 102

ensory Distortions Changes in intensity Changes in quality Changes in spatial form Distortions of experience of time Sensory Deceptions Illusions Hallucinations

Answer 103

In Illusions, stimuli from a perceived object are combined with a mental image to produce a false perception. Types: - completion Illusions - affect illusions - pareidolia Illusions should be differentiated from intellectual lack of understanding. Illusions are misperceptions of real external stimuli

Answer 104

Definition- A perception without an object Visual Auditory Somatic and tactile Gustatory Olfactory

Answer 105

2nd person YOU are a bad person YOU are the next messiah YOU’RE going to die 3rd Person Running commentary Voices discussing / commenting

Answer 106

Can range from elementary (flashes of light) to fully organised (visions of people, animals) Can be seen in organic states, e.g. delirium More common in acute organic states with clouding of consciousness than in functional psychosis

Answer 107

Functional- An auditory stimulus causes a hallucination Reflex- stimulus in one sensory modality produces a sensory experience in another Extracampine- hallucination that is outside the limits of the sensory field- e.g. hears voices talking in Paris when they are in Sydney Hypnagogic and Hypnapompic- these occur when the subject is falling asleep or waking up respectively

Answer 108

Disorders of Stream of Thoughts Disorders of Possession of Thoughts Disorders of Content of Thoughts Disorders of Form of Thought

Answer 109

thoughts follow each other rapidly Connections between successive thoughts appear to be due to chance factor, but, can be unerstood

Answer 110

Disorders of Tempo - Flight of Ideas - Inhibition or Slowness of Thinking Circumstantiality Discrders of continuity of thought - Perseveration - Thought blocking

Answer 111

irrelevant wandering in conversation. Talking at great length around the point

Answer 112

repetition of a word, theme or action beyond that point at which it was relevant and appropriate

Answer 113

sudden interruption in the train of thought, leaving a blank A more common experience is losing train of thought when one is exhausted or very anxious

Answer 114

Sense of loss of control or personal possession of thinking can be lost in some psychiatric disorders Thoughts are in control of an outside agency Obsessions and Compulsions - Thought Alienation - Thought Insertion - Thought Withdrawal - Thought Broadcasting

Answer 115

Delusions Primary Delusions: A new meaning arises in connection with some other psychological event. Three types: delusional mood, delusional perception and sudden delusional idea Secondary delusions: can be understood as arising from some other morbid experience False, unshakable belief that is out of keeping with the patient’s social and cultural background https://www.youtube.com/watch?v=SwC3AdUgf_E

Answer 116

Persecutory Infidelity Love- the patient is convinced that some person is in love with them, although the alleged lover may never have spoken to them Grandiosity Guilt- patient believes they are bad/ evil person Nihilistic- patient denies the existence of their body,their mind, their loved ones and the world around them Poverty- convinvced that they are impoverished and believe that destitution is facing them and their family

Answer 117

Loosening of association - there is a lack of logical association between succeeding thoughts. It gives rise to incoherent speech (in the absence of brain pathology). It is impossible to follow the patients train of thought (knight’s move thinking/derailment).

Answer 118

Dissociative amnesia- Sudden amnesia that occurs during periods of extreme trauma and can last for hours or even days Confabulaltion- Falsification of memory occuring in clear consciousness in association with organic pathology. It manifests itself as the filling- in of gaps in memory by imagined or untrue experinces that have no basis in fact.

Answer 119

Normal emotional reactions Abnormal emotional reactions Abnormal expressions of emotion Morbid expressions of emotion

Answer 120

is defined as the inability to experience pleasure from activities usually found enjoyable

Answer 121

Often described as emotional indifference with a sese of futility. May manifest as lack of motivation.

Answer 122

Emotional responses which seem grossly out of tune with the situation or subject being discussed.

Answer 123

Conversion - Unconscious mechanism of symptom formation, which operates in conversion hysteria, is the transposition of a psychological conflict into somatic symptoms which may be of a motor or sensory nature. Belle Indifference or La belle indifférence is characterized by a lack of concern and/or feeling of indifference about a disability or symptom. Links to conversion.

Answer 124

Depersonalisation Derealisation Passivity phenomena

Answer 125

a feeling of some change in the self, associated with a sense of detachment from one's own body. Perception fails to awaken a feeling of reality, actions seem mechanical and the patient feels like an apathetic spectator of his own activities.

Answer 126

a sense of one's surroundings lacking reality, often appearing dull, grey and lifeless.

Answer 127

Somatic passivity: delusional belief that one is a passive recipient of bodily sensations from an external agency Made acts, feelings & drive: Made bit – the object in question is experience or carried out by the person, but is considered as alien or imposed. Act – action, feeling – feeling, drive – impulse

Answer 128

In schizophrenia, the patient may not only lose the control over their thoughts, actions or feelings, but may also experience them as being foreign or manufactured against their will by some foreign influence

Answer 129

Catatonia - a state of excited or inhibited motor activity in the absence of a mood disorder or neurological disease. It includes a number of other terms: Waxy flexibility- the patient's limbs when moved feel like wax or lead pipe, and remain in the position in which they are left. Found rarely in (catatonic) schizophrenia and structural brain disease. Echolalia - automatic repetition of words heard. Echopraxia - an automatic repetition by the patient of movements made by the examiner. Logoclonia - repetition of the last syllable of a word. Negativism - motiveless resistance to movement Palilalia- repetition of a word over and again with increasing frequency. Verbigeration - repetition of one or several sentences or strings of fragmented words, often in a rather monotonous tone.

Answer 130

Living and working conditions Work environment Unemployment Water and sanitisation Education Health care Housing Age Sex Constitutional factors

Answer 131

Personal Good life What you CAN do Journey and/or destination

Answer 132

Connectedness Hope and Optimism Identity Meaning Empowerment

Answer 133

Community mental health nurses Social workers Psychiatrists Occupational therapists STR wroker Psychologists Psychoterapists Social Prescribing Link workers

Answer 134

Goes beyond diagnosis “Why” rather than “What” Ongoing process of constructing a meaningful narrative of the person’s symptoms and problems as part of a life story

Answer 135

3 X 4 table Top 3: Biological, Psychological, Social Going down 4: Precipitating, prolonging, protective

Answer 136

Biological: Family history / genetics In utero exposures Birth complications Developmental disorders Physical / sensory impairments Psychological: Attachment style Personality Affect dysregulation Low self-esteem Social: Poverty / low SE status Early trauma / ACES Security – housing,, finance Schooling, bullying Immigration, marginalisation, racism

Answer 137

Biological: Medical illness / injury Alcohol / drugs Pregnancy / adolescence / hormones Sleep deprivation Psychological: Negative core beliefs / cognitions Unconscious repetition of early relationships Grief / loss / change Social: Loss / separation from family / partner Interpersonal trauma Work / academic / financial stressors Recent immigration, loss of home Climate change

Answer 138

Biological: Chronic illness Medication difficulties Substance use Psychological: Chronic negative thoughts Psychological defences – e.g. denial Unhelpful coping styles – e.g. avoidance Social: Poor relationships Ongoing social stressors Poor finances Isolation, unsafe environment

Answer 139

Bio: Good physical health Good medication response Psycho: Resilience and distress tolerance Mentalize – see other’s perspectives Positive sense of self Psychological flexibility Insight Social: Positive relationships Religious / spiritual beliefs Financial / disability support

Phenomenology, psychopharmacology, counselling, hypnotics, ECT Flashcards

(166 cards)