Psych Flashcards
Indication for haloperidol in agitation
Cautions
First line for ETOH intoxication
Small risk of long QT - do not use IV in pts at risk
Extrapyramidal side effects - do not give in Parkinson’s, Lewy Body
Indication for second generation antipsychotics in agitation
Cautions
Use in agitation due to psychiatric illness and delirium in elderly
1. oral risperidone
2. IM ziprasione or olanzapine
Lower risk of EPSE
Quetiapine - high rates of orthostatic hypotension
Aripiprazole - less effective
Indication for benzos in agitation
Cautions
Use in recreational drug intoxication (except ETOH)
ETOH withdrawal
Risk of respiratory depression
Can make delirium worse
Anxiolytics for levels of risk for QTc prolongation
No long QT, no risk
- clozapine
No long QT, risk factors present
1. olanzapine, aripiprazole
2. risperidone, quietiapine, haloperidol
Long QT <500ms
- Aripiprazole, olanzapine, risperidone, quetiapine
Long QT >500ms
- Aripiprazole, valproate, trazodone, benzos
Risk factors for suicide
Male
Age 15-24
Maori
Has a plan
Recent suicide attempt
Family/friend suicide
Lack of supports
Psychiatric illness
Less: single, sexual minority, general medical illness, chronic pain, TBI, unskilled occupation, childhood trauma, rural, family hx, relationship loss
Vulnerability factors: low self-esteem, poor social skills, family conflict, bullying, frequent moving, homelessness, parent with mental illness/ETOH/drug, low SES, school suspension, abuse/neglect
Protective factors for suicide
Family support
Cultural identity
Spiritual belief that discourages suicide
Belonging to community
Makes valued contributions
Supportive friends
Developing skills, volunteering, contributing
Most common method of suicide
Asphyxiation (hanging, suffocating, ligature)
Comorbidity triangle in youth for suicide
Depression, substance abuse, victim of abuse
PH-2 screening for depression
PH-9 questions and scoring
Over last 2 weeks:
Feeling little interest or pleasure in doing things
Feeling down, depressed, hopeless
0- not at all
1 - several days
2 - more than half days
3 - nearly every day
Score 3+ proceed to PH-9 questionnaire - above plus:
- Sleep
- Energy
- Appetite change
- Feeling bad about yourself
- Trouble concentrating
- Moving/speaking slow or restless
- Thoughts of death, self-harm
1-4 minimal
5-9 mild
10-14 moderate
15-19 mod-severe
20+ severe
Medications for depression
Start in moderate - severe depression
SSRIs first line
Citalopram - lowest interactions
Sertraline - lowest exposure in breastfeeding
Fluoxetine - evidence for <18
Paroxtine - lowest long QT risk
Delirium vs acute psychosis symptoms
Delirium
- Inattention, easily distracted, disoriented, fluctuating course
Psychosis
- normal attention, alert, intact memory, disorganised thinking
3 manifestations of psychosis
Delusions - false unshakeable belief, out of keeping with education/culture/social background
Hallucinations - auditory most common
Thought disorder - lack of coherent, logically connected thoughts
Medications for psychosis
Cause unknown
- Haloperidol 0.5-5mg + lorazepam 0.25-2mg
- Benztropine/diphenydramine to prevent EPSE/dystonia
OR risperidone/olanzapine/ziprasidone
Likely psychotic illness
- pt’s regular antipsychotic
- Olanzapine 5-10mg
- or risperidone 0.5-2mg + lorazepam 0.5-2mg
- or haloperidol + lorazepam, olanzapine, ziprasidone
Suspect acute mania
- Above antipyschotics PLUS
- valproate 600mg daily divided
Risk factors for anxiety
Females
Young adults
Family history
Comorbid psych condition
Drug and ETOH
Chronic medical condition
Hx trauma, abuse, family violence
Maori, Pacific, Asian
Low SES
Loss of employment, relationship, stress
Ongoing conflict - sexual, spiritual, cultural
GAD-7 anxiety screening
Over last 2 weeks:
- Feeling nervous/anxious/on edge
- Unable to stop/control worrying
- Worrying about different things
- Trouble relaxing
- Hard to sit still
- Easily annoyed, irritable
- Afraid something awful will happen
0 = not at all
1 = several days
2 = more than half days
3 = nearly every day
5 mild
10 moderate
15 severe
Types of anxiety disorders
GAD - most common
OCD
Panic disorder
Social phobia
Specific phobia
PTSD
Medication for anxiety
Consider in severe GAD, panic disorder, OCD
Short term benzos for crises
SSRIs
Screening for drug abuse
3 questions
Have you ever used drugs more than you meant to in the last year?
Have you felt like you want to cut down?
If yes, is this something you would like help with?
Symptoms of acute dystonia
- Involuntary sustained muscle contractions to maximal degree
- Lasts minutes to hours
- 1 or more sites of the body - generalised in young people, focal in elderly
- Twisting, repetitive movements (consistent and predictable), abnormal posture
- Sensation of rigidity and traction in affected part
Not to confuse with dyskinesia - rhythmic contraction of large muscle groups - rolling or writhing
Common sites in acute dystonia
Neck (30%)
Protrusion of tongue (17%)
Jaw (15%)
Extraocular muscles - oculogyric crisis: eyes rolling back, neck arching (6%)
Opisthotonus - body arching (3.5%)
Hyperpronation of arms
Wrist flexion
Plantarflexion of feet
Adductor spasm of thigh
Medication causes of acute dystonia
Within 1 week of starting or increasing dose of antipsychotic
50% within 48 hours
90% within 5 days
Haloperidol, long acting fluphenazines most common
Management of acute dystonia
Discontinue medication
Anticholinergics: Benzatropine 2mg IV, or procyclidine
Diphenhydramine - available PO only
Benzos additional if anticholinergics not enough
Baclofen 60-120mg/day - segmental/generalised/oromandibular dystonia
Mexiletine 450-1200mg/day - cervical dystonia
Definition of mental disorder per Mental Health Act
- Abnormal state of mind - delusion, disorders of mood, perception, volition, cognition
- Behaviour poses risk to health or safety of self/others, or diminished capacity to care for self/others
Mental Health Act sections
8A - completed by anyone with concern
8B - completed by medical practitioner
Assessment by psychiatrist/senior reg
10 - preliminary assessment (5 day inpatient)
12 - further assessment (14 days inpatient)
Certificate of final assessment
Compulsory treatment order - inpatient or community
Reassess in 6 months
