Psych disorders Flashcards
Brief overview of general anxiety disorder as described in the DSM-V
Excessive anxiety and worry occurring on more days than not over 6 months about a NUMBER of events or activities. The worry is difficult to control and also experience physical symptoms of the anxiety
Brief overview of panic disorder as described in the DSM-V
Recurrent, unexpected panic attacks followed by at least one month of persistent concern about having another panic attack.
What is a panic attack
An abrupt surge of intense fear or discomfort in which 4+ symptoms develop within a few minutes to reach peak intensity (palpitations, sweating, SOB, autonomic symptoms)
Brief overview of agoraphobia as described in the DSM-V
Anxiety about being in particular places or situations from which escape may be difficult or help may not be available in the event of a panic attack or other embarrassing/incapacitating symptom (falling, incontinence, vomiting)
Brief overview of specific phobia as described in the DSM-V
Marked, persistent fear of clearly discernible objects or situations which invoke an immediate anxiety response when exposed to it
Brief overview of social phobia/ social anxiety disorder as described in the DSM-V
Marked or persistent fear of one or more social or performance situations in which person is exposed to possible scrutiny by others - fear behaving in an embarrassing way leading to total (physical absence) or partial (minimal eye contact) avoidance
Brief overview of obsessive compulsive disorder as described in the DSM-V
Unwanted, intrusive and recurrent obsessions which the client attempts to suppress or ignore but usually end up performing compulsions to neutralise and reduce the anxiety associated. Usually obsessions about contamination, orderliness etc.
Brief overview of post-traumatic stress syndrome as described in the DSM-V
Following threat that is perceived to be potentially life threatening or cause physical harm (direct experience, witnessing, learning of event occurring to close family member, repeated or extreme exposure to aversive details) - relive traumatic event with intrusive memories, avoidance of stimuli, persistent hyper-arousal symptoms (insomnia, irritability, exaggerated startle response etc.)
Acute stress disorder: 2d-1 month post trauma lasting 3d-1m
Post-traumatic stress disorder: symptoms persist more than 1m
DSM for generalised anxiety disorder
Excessive anxiety and worry more days than not for more than 6 months about a number of different events/activities
Difficulty controlling worry
3+ physical symptoms (restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance)
Stressful life events occurring or have had since childhood/adolescence
Symptoms of post traumatic stress disorder
Reliving of event: intrusive memories, flashbacks, nightmares
Avoidance of stimuli associated with trauma
Emotional numbing
Persistent hyper-arousal: insomnia, irritability, impaired concentration, hypervigilance
Negative alterations in cognition and mood: inability to recall key features, persistent -ve beliefs and expectations about self
- marked diminished interest
- feeling alienated from others
- constricted affect
Symptoms persisting for more than 1 month
Onset of symptoms within 2 days to 1 month after traumatic event
Clinical features of a panic attack
Abrupt surge of intense feat plus 4+ of the following:
- palpitations
- sweating
- trembling and shaking
- SOB
- feeling of choking
- chest pain/discomfort
- nausea/abdominal distress
- dizzy, unsteady, faint, light-headed
- chills or heat sensations
- paraesthesia
- de-realisation or de-personalisation
- fear of losing control or going crazy
- fear of dying
Differential diagnoses of panic attack
IHD Cardiac arrhythmias Cardiac valve pathologies Pulmonary embolus Asthma Hyperthyroidism Hypoglycaemia Phaeochromocytoma Hypoparathyroidism TIA Seizure
Assessment and management of panic attacks
CVS and resp exams ECG etc. rule out IHD, arrhythmias Immediate management: - slow-breathing exercises - muscle tension-relaxation exercise - benzodiazepines Short-long term manageemnt - CBT - Cognitive therapy - interoceptive and in vivo exposure - antidepressants (SSRIs, TCAs)
Brief overview of anorexia nervosa as described in the DSM-V
Self-induced starvation due to relentless drive for thinness or fear of fatness with presence of medical signs and symptoms resulting from starvation, body weight less than 85% expected
Can be restricting type or binging/purging type
Brief overview of bulimia nervosa as described in the DSM-V
Client has a goal to reduce weight but cannot tolerate prolonged periods of starvation, leading to binge eating - panic about amount eaten and secondary attempts to prevent weight gain (e.g. purging)
Brief overview of binge-eating disorder as described in the DSM-V
Recurrent episodes of binge eating, sense of lack of control over eating at least once a week for 3 months
Subtypes of anorexia nervosa
Restrictive type:
- reduced food intake +/- increased exercise
- not engaged in binge eating or purging behaviour
Binge-eating/purging type:
- have periods of binge eating followed by panic and secondary attempts to lose weight (vomiting, misuse of laxatives, diuretics or enemas)
Physical complications of anorexia nervosa
Endocrine/metabolic: - hypoglycaemia - hypoK - arrhythmias - hypoCl alkalosis - hypoMg - hypoNa - Delayed puberty - amenorrhoea - anovulation - increase GH - reduced ADH - hypercortisolism - arrested growth - osteoporosis CVS: - ECG changes - cardiomyopathy - MV prolapse - arrhythmias (due to hypoK) - hypotension - bradycardia Renal: - Reduced GFR - increased urea - dependent oedema - renal calculi GI: - constipation Other: - lanugo - hair loss - dry skin - hypothermia - anaemia - leukopenia - thrombocytopenia
What are the complications of bulimia nervosa
Mallory-Weiss tears (rare)
Dry skin
Menstrual irregularity
Infertility
Secondary to laxative abuse:
- chronic constipation
- cathartic colon
Risk factors associated with anorexia nervosa
Teenage female Developed country Certain professions (ballet, gymnastics) Gay orientation Close and trouble relationships with parents Isolation Low levels of nurturance
Risk factors associated with bulimia nervosa
Early adulthood Females Sometimes past history of obesity Industrialised countries More conflictual families, parents neglectful and rejecting Angry, outgoing, impulsive clients Alcohol dependence
What is meant by the term somatic symptom and related disorders
A group of diseases where bodily signs and symptoms are a major focus, which are medically unexplained, and patients are convinced suffering comes from some undetected bodily condition
Types of somatic symptom and related disorders
Somatic symptom disorders: - somatisation disorders - hypochondriasis - body dysmorphic disorder - pain disorder Conversion disorder
DSM-V of somatisation disorder
Many physical symptoms before age of 30y
Occurring over a period of years
Multiple medical consultations, significant impairment in functioning
Pain, GI, sexual/reproductive, pseudoneurological symptoms
DSM-V summary of hypochondriasis
Generalised and non-delusional (not fixed) preoccupation with fears of having a SPECIFIC illness
Based on misinterpretation of bodily symptoms
Persists despite appropriated evaluation and reassurance
Brief overview of Body dysmorphic disorder as described in the DSM-V
Preoccupation with an imagined defect in appearance causing significant distress or impairment due to ideas or delusions of reference
Excessive mirror checking or avoidance
If anomaly is present, person’s concern is excessive and bothersome
Hair, nose, skin, head/face
Present to dermatologists, plastic surgeons, internists
Brief overview of pain disorder as described in the DSM-V
A psychological disorder where pain is the main focus, and of sufficient severity to warrant clinical attention. It is not intentionally produced or better accounted for by another medical conditions - may have begun in response to real condition but persists chronically
Brief overview of conversion disorder as described in the DSM-V
Conversion of emotional pain or energy into physical, NEUROLOGICAL symptoms:
- motor symptom deficit
- sensory symptom deficit
- seizure or convulsions
- mixed presentations
initiation or exacerbation of the symptom is preceded by conflicts or stressors
How would you explain the diagnosis of conversion disorder to a patient that may in your opinion have the condition?
would explain as the mind being unable to express strong emotions AS emotions, and as such, converts into a physical symptom which cannot be explained by stressors
Approach to managing conversion disorder
95% remit spontaneously within 2w of hospital admission
Therapeutic relationships with a caring and confident psychotherapist
insight-oriented supportive or behaviour therapy
ACKNOWLEDGE THAT PATIENTS SYMPTOMS ARE REAL
Hypnosis, anxiolytics, behavioural relaxation exercises
Psychodynamic psychotherapy
What are the common causes of acute agitation
FIND ME Functional - i.e. psychiatric Infectious - encephalitis, delirium etc. Neurologic - ICH, SOL etc. Drugs - substance intoxication or withdrawal, issues related to psychotropic medications
Metabolic
Endocrine
Risk factors for suicide
SAD PERSONS
Sex: male
Age: under 19 or over 45
Depression/psychiatric illness
Previous attempt Excess alcohol or substance abuse Rational thinking loss Social supports lacking Organised plan No spouse Sickness (chronic physical illness)
Indigenous Rural location Family history of suicide Sexual identity issues Custody issues Childhood sexual abuse Unemployment
Factors which may determine suicidal intent
Plan
Access to lethal means
Alcohol or drug intoxication (or withdrawal)
Impulsive, aggressive or antisocial behaviour
Tidying up personal affairs
Writing notes etc.
Expressed intent to die
Risks that clinician may need to consider in the clinical setting
Risks to self: - suicide - self-inflicted injury - self-neglect Risk to others: - homicidal intent - harmful intent - unintentional (e.g. reckless driving) - neglect of dependents (e.g. children, elderly) Vulnerability: - risk to personal finances - risk of marriage etc. - risk of STDs/pregnancy etc. Reputation Crime/violence Homelessness
Typical format for a psychiatric risk assessment
Static (historical, unmodifiable) - age - sex (M more than F) - marital status (divorced) - past history of self harm/suicide attempts - family history of suicide attempts - diagnosis of mental illness - childhood adversity (e.g. abuse) Stable (long-term but CAN be altered) - substance dependence - personality disorders/traits DYNAMIC: (present for uncertain amount of time, fluctuating) - suicidal ideation - neurovegetative features of depression - agitation - active psychological symptoms - substance intoxication/withdrawal - psychosocial stressors - impulsivity/problem-solving deficits FUTURE (can be anticipated and will result from changing circumstances) - access to preferred method of suicide - future stress (e.g. anniversary of deaths) - discharge from inpatient treatment - future response to drug treatment PROTECTIVE - resilience, personality style - good relationships with support system - children/partner
De-escalation techniques
Offer patient a choice:
- would you like something to eat or drink
- would you like some medication to reduced that stress
- would you like a room which is more quiet and private
Give personal space (+safer for you)
Soothing, caring tone of voice
Calm, open, respectful approach
Give undivided attention
Non-judgemental
Clarify messages
Ensure safe practice (room set up, chaperones etc.)
When should you consider the use of physical restraint in the clinical setting
When de-escalation is not fully effective and it is otherwise unsafe to administer medication
AND there is substantial risk of patient harming themselves, others or hospital equipment
When would you consider using medications in the acute management of agitation? Which agents would you use
De-escalation not fully effective or patient has made choice to have voluntary medication
+ it is safe to administer
Offer voluntarily first (oral or parenteral)
Patient must be detained for forced medication administration
Aiming for a calm, alert patient + some sedation
Oral (20-30m onset)
- diazepam, lorazepam or olanzapine wafer
Parenteral (IV immediate, Im 10-20m onset)
- midazolam IM or IV
Olanzapine IM
Potential adverse effects of using medications in acute management of agitation
Respiratory depression Airway compromise Sedation Paradoxical effects (midazolam only) Hypotension and tachycardia (olanzapine, diaz and loraz)
What are the main clinical symptom domains of depressive disorders
Mood:
- depressed mood
- anhedonia
- loss of interest
- apathy
- numbness
Psychomotor retardation:
- latent response
- downcast gaze
- slumped posture
- few spontaneous movements
- poor concentration
- indecisiveness
- slow, quiet speech
Cognitive:
- related to self, world and future (beck’s triad)
- themes of guilt, worthlessness, hopelessness, death, suicide
- ruminating
- may become psychotic
Vegetative:
- terminal insomnia
- fatigue
- reduced appetite (+/- weight loss)
- reduced libido
What are the main clinical symptom domains for manic episodes
Mood:
- elevated
- euphoric
- elation
- jubilation
Psychomotor AGITATION:
- fidgeting, restlessness
- energetic
- disinhibitied
- impulsive
- rapid, pressured speech
- flight of ideas
- inattention
- distractibility
Cognitive:
- around self world and future (Becks)
- self: gradiosity, inflated slef-esteem
- world: expansive
- future: optimistic
- mood congruent delusions if psychotic mania
Vegetative symptoms
- reduced need for sleep
- hypersexuality
What is the difference between biploar I and II
I: presence of mania, currently in manic or depressed episode with history of at least one depressed, manic or mixed episode
II: presence of one or more major depressive episodes, presence of at least one HYPOmanic episode - no history of manic or mixed episodes
What are the clinical features for a mixed episode
Presence of manic OR depressive episode + at least 3 symptoms from the other
(both manic and major depressive episode criteria are met nearly every day during at least one week)
How is mania different to hypomania
Shorter period: 4d for hypomania
No psychotic symptoms in hypomania
Hypomania causes unequivocal change in functioning BUT not to the extent that there is significant impairment of socio-occupational functioning or requiring hospitalisation to prevent harm to self/others
how is adjustment disorder different from a depressive disorder
There is a clearly identifiable stressor precipitating the symptoms (within 3 months of onset of symptoms)
- causes clinically significant emotional or behavioural symptoms
- disturbance does not meet criteria for depressive disorder
- once stressor is terminated, symptoms do not persist for more than an additional 6m
What is meant by the term dysthymic disorder
AKA persistent depressive disorder
Depressed mood + at least 2 other symptoms of depression
Occurring most days over last 2 years, with no asymptomatic period longer than 2 months
Does not meet criteria for major depressive disorder
What is meant by the term mood-congruent delusion?
General TONE of the delusion matches the mood
e.g. mania - grandiose delusion OR if persecutory, is so because so good everyone jealous
OR
depression - guilt, nihilistic or persecutory
What medical conditions are typically associated with depression or present with depression as a major clinical features
Post viral (flu, EBV, HEP, encephalitis)
Cancer
Cardiopulmonary disease with chronic hypoxia
Sleep apnoea
Endocrine (hypothyroid, adrenal hypofucntion, post-partum, post-menopause, premenstrual)
Collagen (vascular disease, SLE)
CNS: MS, brain tumours, strokes, complex partial seizures
Brain structures which have been associated with aetiopathogenesis of mood disorders
Psychomotor activity;
- NAd in prefrontal cortex and cerebellum
- Serotonin in prefrontal cortex, nucleus accumbens and cerebellum
- DA in prefrontal cortex, nucleus accumbens and striatum
VEGETATIVE SYMPTOMS
- change in serotonin, NAd and DA in the midbrain
COGNITIVE AND MOOD SYMPTOMS:
- changes in serotonin in VMPFC, amygdala and orbitofrontal cortex
Risk factors for developing depression
- Separation/divorce
- lower socioeconomic status
- less physical activity
- cumulative/chronic life stressors
- early life adversities
- early parental death
- social isolation
Family history
Anxious, impulsive, obsessional personality
Risk factors for developing bipolar
- Separation/divorce
- lower SES
- seasonal influence (summer)
- disruption of circadian rhythm
- negative and positive stress
- family history
Definition of delirium
Acute, reversible, fluctuating impairment of cognitino that often has an identifiable underlying medical cause
What are the core clinical features of delirium
3Cs
Conscious state (hypervigilance v drowsiness)
Cognitive impairment (inattention, disorientation, global cognitive impairment)
Course is fluctuating, with acute onset in setting of medical morbidity
What are the most common causes of delirium
Infections - UTI - pneumonia - sepsis Medications: - polypharmacy - sedatives - anticholinergics Organ failure - severe lung or liver failure - hypoxia or metabolic/endocrine disturbance Other: - urinary retention - constipation - pain - post anaesthetic
Different forms of dementia
Alzheimer's (70-80%) Dementia with Lewy bodies (15-30%) Vascular (5-20%) Frontotemporal lobar degeneration (5%) Others: - parkinson's, Huntington's, neurological (e.g. MS) - Endocrine (hypothyroid) - nutritional (thiamine) - infectious (HIV, neurosyphilis) - metabolic - traumatic - poisoning
What are defining clinical features of ALZHEIMERS type dementia
Insidious onset
Early memory loss (short-term)
Long term memory remains intact early on
Motor and behavioural changes are a late sign
What are defining clinical features of dementia with LEWY BODIES
Fluctuating cognitive impairment
Visual hallucinations
Parkinsonism
What are defining clinical features of FRONTOTEMPORAL dementia
Emphasis on prominent personality and behavioural changes
Less prominent memory loss early in disease
Disinhibition, impulsivity, distractibility, excessive eating etc.
Prominent primitive reflexes
What are the risk factors and protective factors for dementia
Age (over 85)
Female gender
Vascular risk factors (DM, HTN, lipids)
Protective factors:
- higher level of education
- mentally active
- social engagement
- regular exercise
What is meant by the term pseudodementia
Resembles dementia but is caused by reversible conditions such as depression or drugs
Acute onset, patient is aware of cognitive impairment, and makes no attempt to cover it up, makes poor and inconsistent effort with cognitive testign
What is confabulation and in which conditions does it typically occur
The pathological, unintentional lying to fill gaps in memory due to amnesia.
It commonly occurs in Wernicke’s or Korsakoff’s syndrome, other dementias, including Alzheimer’s and brain damage
What are the common neuropsychiatric presentations and complications of epilepsy
Deja vu and psychic abilities
Depression, anxiety, psychoses are common
Post ictal psychosis may occur
What are the common neuropsychiatric presentations and complications of thyroid disease
Hyper: confusion, seizures
Hypo: depression, impaired memory and cognition, poor concentration, psychosis (myxoedema madness)
What are the common neuropsychiatric presentations and complications of MS
Anxiety, depression
Progressive dementia syndrome
Definition of psychosis
A syndrome of impairment of thoughts, affective response, ability to recognise reality and the ability to communicate and relate to others to an extent that it interferes significantly with the capacity to deal with reality (diordered reality testing)
Clinical features of psychosis
- Disturbances of perception: hallucinations
- Disturbances of reality interpretation: delusions
- Disturbances of though organisation; formal thought disorders
- Disturbances of motor function: catatonia
What is the definition of formal thought disorder
“normal” thinking consists of the features of constancy, organisation and continuity.
Formal thought disorders lack these features so there is a disturbance in the structure or “form” of thinking - has nothing to do with the content of one’s speech but more the ability to express thoughts and ideas in an ordered, logical manner.
May be disorders of thought tempo, continuity or of conceptual/abstract thinking
Types of disorders of thought tempo
Flight of ideas: rapid flow of though, abrupt changes from topic to topic
Inhibition
Circumstantiality: focus of the conversation drifts and there is a delay in getting to the point because of the interruption of unnecessary details and irrelevant remarks
Types of disorders of thought continuity
Perseveration: persistent repetition of the same idea
thought block: when speech is suddenly interrupted by silence
Types of transient thinking
Derailement: one idea following a completely unrelated idea
Substitutions: words substituted for unrelated word that makes no sense
Omissions
Loosening of associations
GRAMMAR AND SYNTAX ARE DISTURBED
What is drivelling thinking
nonsense
Preliminary outline of thought but loses organisation
What is desultory thinking
Jumpy/lacking a plan
fusion = same thing said more than one time in short period of time
Stock words = words used repeatedly that could have different meanings in different contexts
Sudden ideas = ideas that form themselves into a developing thought
GRAMMAR AND SYNTAX ARE INTACT
Typical clinical manifestations of catatonia
Abnormal execution of movements:
- catatonic excitement
- mutism
- stupor
- catalepsy (passive movement into one position and keeping it there for sustained time)
- catatonic posturing (psychological pillow)
- catatonic rigidity
Abnormal movements when interacting with others:
- opposition/negativism
- automatic obedience
- echolalia, echopraxia (parroting)
- waxy flexibility
Important differentials of a first presentation with psychosis in an adolescent or young adult
Medical differentials: - head injury - epilepsy - space occupying lesion - autoimmune encephalitis (NMDA receptor associated) Substance induced: - amphetamines, methamphetamines, stimulants - alcohol - cannabis Psychiatric: - schizophrenia - schizophreniform - brief psychotic episode
Which illegal psychoactive substances are most commonly associated with “drug-induced psychosis” in Australia
Amphetamines (speed)
Methamphetamines (crystal meth, Ice)
Cannabis
Important differentials of a first presentation with psychosis in an elderly patient
Medical: - delirium (UTI, sepsis, dehydration) - dementia - parkinson's Substance induced: - corticosteroid use - dopamine (e.g. for PD)
Most important differentials for recurrent episodes of psychosis
Chronic schizophrenia
Substance abuse
main symptom domains of schizophrenia
Psychotic symptoms (+ve)
- hallucinations
- delusions
- catatonia
Disorganisation (+ve)
- formal thought disorder
- inappropriate affect
- bizarre behaviours
Negative symptoms: (5As)
- Avolition (lack of drive/motivation to fulfill purposeful goals)
- anhedonia
- apathy
- affective blunting
- alogia
may be primarily due to schizophrenia or secondary to medications
Tend to have poor response to treatment
Poor prognostic factor if present at diagnosis
Neurocognitive impairment:
- present prior to onset of manifest illness
- memory
- attention
- executive functions
- social cognition
- associated with functional impairment
- pharmacological treatment not effective in improving symptoms
Neurotransmitter systems involved in pathophysiology of schizophrenia
Normally the mesocortical pathway inhibits the mesolimbic pathway
In schizophrenia, mesocortical pathway is dysfunctioning - loss of inhibitory feedback to limbic araeas - excessive stimulation of limbic area - positive symptoms
+ reduced stimulation of prefrontal cortex via mesocortical pathway - negative symptoms
What are the reasons for high medical comorbidity and reduced lifespan associated with schizophrenia
Smoking
Substance abuse
Sedentary lifestyle
Low SES
Adverse effects of medications (e.g. antipsychotics - gain weight)
Less likely to present for medical attention
Less able to communicate symptoms (esp. if delusional etc.)
Symptoms often attributed to psych condition and assumed to be delusions etc.
Poor self-care, including that for chronic illness
Delusional disorder
Delusions are chronic (at least 1 month), well-systematised and non-bizarre. Criteria for schizophrenia is not met. There is no longitudinal functional or cognitive deterioration
What clinical symptoms define “substance abuse”
- taking substance in larger amounts or for longer than you mean to
- wanting to cut down or stop using but not managing to
- spending a lot of time getting, using or recovering from the use of substance
- cravings and urges to use the substance
- not managing to do what you should at home/work/school due to use
- continuing to use even when causing problems in relationships
- giving up on important social, occupational or recreational activities because of substance use
- using substances again and again, even when it puts you in danger
- continuing to use even when you know you have a physical/psychological problem that could have been caused or made worse by the substance
- needing more of the substance to get the effect you want (tolerance)
- development of withdrawal symptoms relieved by taking more of the substance
2-3=mild, 4-5=moderate 6+=severe
Cage questions and what is their value in clinical setting
Ever felt you should CUT down on substance use
Have people Annoyed you by criticising your use
Have you ever felt bad or Guilty about substance use
Have you ever used first thing in morning to get rid of hangover/comedown (Eye-opener)
Rapid screening tool to assess if someone has a problem of substance abuse, rapid, can be used in any setting, non-judgemental
Clinical features of alcohol withdrawal
- recent cessation or reduction in alcohol use that has been heave and/or prolonged
- autonomic hyperactivity (sweating, tachycardia)
- hand tremor
- insomnia
- nausea/vomiting
- transient visual, tactile or auditory hallucinations or illusions
- psychomotor agitation
- anxiety
- grand mal seizures
Clinical features and cause of delirium tremens
SEVERE ALCOHOL WITHDRAWAL
- delirium
- autonomic hyperactivity (diaphoresis, tachycardia, hypertension)
- hypervigilance, agitation
- tremors
- often with hallucinations, especially visual and tactile
- increased risk of alcohol-withdrawal seizures and death
Management of alcohol withdrawal
Monitor with alcohol withdrawal scales - assess severity of withdrawal and continue to monitor to ensure not an underlying medical condition
Routine obs
Supportive care (Paracetamol for headaches, metoclopramide for n/v, loperamide for diarrhoea)
Long-acting benzos (Diazepam 1st line, lorazepam if significant liver dysfunction, clonazepam if require IV)
Thiamine to prevent Wernicke’s encephalopathy
Common complications of abusing psychostimulants
Acute:
- agitation
- psychosis (esp paranoia)
- hyperthermia
- cerebrovascular and neuro complications
- cardiac complications (chest pain, MI, HTN, tachycardia, arrhythmia)
- delirium
- HypoNa, HyperK
- hypoglycaemia
- rhabdomyolysis
- serotonin toxicity of varying severity
Chronic:
- memory and neurocognitive deficits
- liver toxicity
- cardiac failure
- brain haemorrhage
- cerebral toxicity - seizures
Common complications of abusing cannabis
Acute:
- paradoxical anxiety
- panic
- paranoid reactions
Long-term:
- reproductive dysfunction (low sperm count in men, high testosterone in women)
- weakened immune system
- respiratory problems (sinusitis, pharyngitis, bronchitis)
- emphysema
- pulmonary dysplasia
Common complications of abusing narcotics
Acutely:
- analgesia
- sedation
- euphoria
- respiratory depression
- small pupils, bloodshot eyes
- nausea, vomiting
- itching skin, flushed
- constipation
- slurred speech
- confusion, poor judgement
- track marks on skin
long-term:
- infectious disease (IE, HIV, Hep)
- cellulitis
- pneumonia
- liver dysfunction
- seizures
- neurological complications
- loss of menstrual cycle
- OD and death
- neonatal withdrawal, premature and IUGR
- memory problems
management of delirium tremens
Sedate with benzos (oral diazepam or IV midaz) Olanzapine if not settle Thiamine (300mg TDS) Supportive management - IV fluids and electrolytes - restraints as required - monitoring for infection/medical issues - special nurse to re-orient patient
Medications that can be used as an adjunct therapy in alcohol dependence
Naltrexone 50mg daily
Acamprosate 2 tablets TDS
Disulfiram
Mechanism of naltrexone in alcohol dependence
Blocks the effect of endogenous opioids following alcohol intake (m-opioid receptor antagonism)
- less pleasureable effects of drinking alcohol, though impairment is unchanged
Mechanism of acamprosate in alcohol dependence
Reduces neuronal hyperexcitability of alcohol withdrawal, i.e. reduces the symptoms of protracted alcohol withdrawal (anxiety, irritability, insomnia, craving)
Mechanism of disulfiram for alcohol dependence
Acetaldehyde dehydrogenase inhibitor - increases negative (hang-over-like) symptoms of alcohol intake (flushing, sweating, palpitations, tachycardia, dyspnoea, hyperventilation, pounding headache)
What are the options for the management of smoking cessation in nicotine dependence
- Abstinence
- Abstinence + Nicotine replacement therapy
- oral (gum/inhaler)
- transdermal - Abstinence supported with non-NRT pharmacotherapy
- varenicline (Champix): nicotine partial agonist
- bupropion
- nortriptyline (antidepressant)
Mechanism of varenicline/champix
Partial neuronal nicotinic agonist - prevents nicotine stimulation of mesolimbic dopamine system associated with nicotine addiction
Stumulates dopamine activity (to a lesser degree to nicotine) resulting in decreased craving and withdrawal symptoms
Side effects of varenicline/Champix
Nausea (30%) - reduce by taking with food
Typical v atypical antipsychotics
Typical (first generation)
- chlorpromazine
- haloperidol
Atypical
- Olanzapine
- Clozapine
- Risperidone
Side effects of typical v atypical antipsychotics
Typical:
- sedation
- postural hypotension
- EPS (tremor, dystonia)
- risk of NMS
Atypical
- Less EPS
- more metabolic side effects
General:
- Weight gain
- sedation
- sexual dysfunction
- anticholinergic effects (blurred vision, dry mouth, urinary retention)
Serious adverse effects and monitoring of clozapine
Agranulocytosis
Cardiomyopathy
Neutropenia
Weekly CBE and neutrophils
Cardiac monitoring Day 7, 14, 28, and week 12
Clozapine levels week 4 and 9
Metabolic monitoring
Clinical features of neuroleptic malignant syndrome
Secondary to TYPICAL antipsychotic toxicity
- bradyreflexia
- lead pipe rigidity
- constipation
- Serum CK rise
- elevated temperature
- mutism
Unlikely to occur later than 1 month of beginning of treatment
Increased risk if:
- dehydrated
- brain injury
- use of lithium
- parenteral use
- rapid escalation of dose
What assessment and monitoring approaches should be adopted for metabolic risks associated with atypical antipsychotics?
Weight Waist BMI Blood glucose Lipid and cholesterol studies Urine ACR
Extrapyramidal side effects of antipsychotics and their management
Parkinsonism (shuffling gait, tremor, muscle rigidity)
- responds to dose reduction or anticholinergic (benzotropine)
Dystonia (involuntary muscle contraction)
- benzotropine
Akathisia (inner feeling of restlessness)
- dose reduction, propanolol or diazepam
Tadrive dyskinesia (involuntary movements of ilp, mouth and tongue )
- reduce or withdraw
- tetrabenazine
Examples of NDRIs, side effects and indications
Bupropion
S/E: insomnia, headache, constipation, dry mouth, nausea, tremor
Indications: used adjunctively to treat sexual dysfunction with SSRIs (+ non-NRT pharmacotherapy for smoking cessation)
What are the main drug interactions to be concerned about when using MAOI
SSRI - serotonin syndrome Stimulants - hypertensive crisis Antihypertensives - hypotension Oral hypoglycaemics - hypoglycaemia Opiate analgesics - autonomic instability and death
What are the main drug interactions to be concerned about when using an SSRI
MAOI - serotonin syndrome
St John’s Wort - serotonin syndrome
Warfarin, anticonvulsants, antiarrhythmias - elevated plasma levels due to CYP450 competitive inhibition
Clinical features of serotonin syndrome
- Neuromuscular excitation: Hyperreflexia, clonus, hypertonia, tremor
- Cognitive/CNS effects: confusion, agitation, hypomania, hyperactivity, restlessness
- Autonomic effects: hyperthermia, sweating, shivering, tachycardia, hypertension, flushing, mydriasis
Management of serotonin syndrome
Supportive care:
- IV hydration
- monitoring
- cooling
Benzodiazepines if seizing
Serotonin antagonists for severe (cyproheptadine)
Lithium toxicity: monitoring/prevention, clinical features, management
Monitoring of Li levels every 3-6m
Features: diarrhoea, dizziness, nausea, stomach pains, vomiting, weakness, tremors, incoordination, fasciculations, seizures, slurred speech, nystagmus
Management: IV hydration +/- dialysis, monitor cardiac function
Major drug interactions with lithium
Increased lithium level:
- Diuretics
- NSAIDs
- ACE-inhibitors
- Metronidazole
Reduce lithium levels:
- Antacids
- Caffeine
- Theophylline
- Osmotic diuretics
Side effects of benzodiazepines
Drowsiness, dizziness, reduced concentration, impaired driving, decreased coordination (falls)
Indications for psychostimulants
Narcolepsy Aid in smoking cessation Reduced appetite ADHD Relieve nasal congestion
Medications for Alzheimer’s dementia and their indications
Cholinesterase inhibitors - Donepezil, galantamine, rivastigmine, memantine
Indications: low score in MMSE, with improvment shown by at least 2 points over the first 6 months of treatment
Side effects of medications used to treat dementia
Cholinesterase inhibitors (donepezil, galantamine, rivastigmine, memantine)
Mostly GI: anorexia, nausea and vomiting, diarrhoea
Other: insomnia, vivid dreams, cramps, dizziness, lethargy, fatigue, drowsiness, tremor, weight loss, urinary incontinence, sweating
Definition of ECT (electroconvulsive therapy)
Passing of an electrical current through the brain following administration of a general anaesthetic and muscle relaxant to produce a controlled seizure
Indications for ECT
Severe depression - very low appetite - hig acute suicidal risk/intent - treatment-resistant - catatonic Depression where ECT is safer than medications (e.g. pregnancy, elderly) Psychotic depression Bipolar Schizophrenia Medical conditions (e.g. Parkinson's)
Contraindications for ECT
Raised ICP
Recent CVA
Cerebral aneurysm or vascular malformations
Unstable cardiovascular condition or recent MI
High anaesthetic risk
Side effects of ECT
Muscle aches Headaches Confusion Cognitive impairment (short term memory) Temporary difficulty learning
Rare:
Death (1 in 100,000 from anaesthesia), skin burns, chipped tooth
Procedure involved in ECT
Patient is put under general anaesthesia + muscle relaxant
Leads placed on head to monitor electrical activity in the brain
Electrodes placed on head to deliver electrical current to the brain
Seizure is induced
Usually performed 3 times per week
Factors contributing to the aetiology of anorexia nervosa
Biological:
- HPA axis dysfunction
- Endogenous opioids (deny hunger)
- inc. caudate nucleus metabolism
- genetic factors
Social:
- society/media
- chaos, hostility, isolation etc. in family environment
- vocational factors (ballet, athletes, wrestling/boxing)
- gay orientation
Psychological and psychodynamic factors
- reaction to demand of adolescents to behave more independently and increase social and sexual functioning
- lack of sense of autonomy and selfhood
- oral desires are greedy and unacceptable
Investigations to perform in a patient with anorexia nervosa
BSL: hypo
CBE: leukopenia with lymphocytosis
EUC: hypoK, hypoCl alkalosis, HypoMg
ECG: flattening/inversion of T waves, ST depression, QT prolongation
Triglycerides: high serum cholesterol
TFT: mildly hypo
Corticotrophin releasing hormone: mildly elevated
DSM V criteria for anorexia nervosa
A. restriction of energy intake relative to requirements leading to refusal to maintain normal bodyweight over 85% expected for age and height
B: intense fear of gaining weight or of becoming fat even though underweight
C: Disturbance in experience of one’s own body weight or shape, undue influence of bodyweight and shape on self-evaluation, denial of seriousness of the current low body weight
When to hospitalise someone with anorexia nervosa
Renal or cardiac compromise
Concomitant viral illness
Rapid weight loss or weight loss of over 25% body weight
Sucidal tendencies
Lack of response to outpatient interventions
Psychological therapy for anorexia nervosa
Motivational interviewing
Behavioural management - positive and negative reinforces
Individual psychotherapy
Family education and therapy
Pharmacological therapy for anorexia nervosa
Psychotropic drugs: - cyproheptadine - Amitryptilline - Clomipramine - Pimozide - Chlorpromazine - SSRIs Others: - metoclopramide (facilitate digestion and promote gastric emptying) - Vit D and calcium (if osteopenia)
Complications of anorexia nervosa
Malnutrition Secondary amenorrhoea Infertility Osteoporosis (due to low oestrogen) Erectile dysfunction Arrhythmias Hypotension Valvular disease Heart faiulre Seizures Kidney failure Liver failure Miscarriage or premature birth if anorexic during pregnancy
Prognosis of Wenicke’s encephalopathy
25% recover completely with adequate treatment
25% show significant improvement
25% show partial improvement
25% show no improvement
Prognosis improves if treated early
Aetiology of Wernicke’s encephalopathy
Thiamine is an important cofactor for key metabolic enzymes (involved in cerebral metabolism)
Chronic alcohol misuse results in thiamine deficiency due to inadequate intake, reduced absorption (less than half of normal), and reduced hepatic storage.
Deficiency inhibits metabolism in brain regions with high metabolic demand, causing neuronal injury
Classic triad of Wernicke’s encephalopathy
(all three signs are only present in 10% of cases)
- Confusion or mental impairment
- Ataxia
- Eye movement disorders (ophthalmoplegia or nystagmus)
Treatment of Wernicke’s encephalopathy
Parenteral thiamine of at least 500mg per day for 3-5 days followed by 300mg/day for 1-2 weeks
+/- long term oral thiamine 100mg/day until long term abstinence has been achieved
Timeline of symptoms of alcohol withdrawal
Seizures occur in first 48 hours
Mild withdrawal symptoms occurs in first 86 hours
Severe withdrawal symptoms (vomiting, DT etc) occurs between 48h to 7 days (peaks around 4 days)
Post-ictal signs in epilepsy v alcohol withdrawal
Epilepsy:
- Drowsy
- Calm
- no tremor or sweating
- haemodynamically normal
- normal temperature
- normal ABG
- pathological EEG
AWS:
- sleepless
- anxious/agitated
- tremor and sweating
- elevated BP and HR
- low-grade fever
- respiratory alkalosis on ABG
- normal, low-amplitude EEG
Diagnostic criteria for Paranoid personality disorder
SUSPECT (4/7) Spousal fidelity suspected Unforgiving (bears grudges) Suspicious of others Perceives attacks Everyone viewed as an enemy Confiding in others is feared Threats perceived in benign events
Diagnostic criteria for schizoid personality disorder
DISTANT (4/7) Detached or flat affect Indifferent to criticism Sexual experiences of little interest Tasks performed solitarily Absence of close friends Neither desires nor enjoys close relations Takes pleasure in few activities
Diagnostic criteria for schizotypal personality disorder
ME PECULIAR (5/10) Magical thinking/odd beliefs Experiences unusual perceptions Paranoid ideation Eccentric behaviour Constricted affect Unusual thinking and speech Lacks close friends Ideas of reference Anxiety in social situations Rule out psychotic disorder and pervasive developmental disorder
Diagnostic criteria for narcissistic personality disorder
SPEEECIAL (5/9) Special Preoccupied with fantasies of unlimited success Envious Entitlement Excessive admiration required Conceited Interpersonal exploitation Arrogant Lacks empathy
Diagnostic criteria for histrionic personality disorder
PRAISE ME (5/8)
Provocative
Relationships considered more intimate than they are
Attention (uncomfortable when not centre of attention)
Influenced easily
Speech (impressionistic, lacks detail)
Emotions shifting and shallow
Make up (physical appearance used to draw attention)
Exaggerated emotions (theatrical)
Diagnostic criteria for antisocial personality disorder
CORRUPT (3/7) Conformity to law is lacking Obligations ignored Reckless disregard for safety of self/others Remorse lacking Underhanded (deceitful, lies) Planning insufficient (Impulsive) Temper
Diagnostic criteria for avoidant personality
CRINGES (4/7)
Certainty of being liked before relationship
Rejection possibility preoccupies thoughts
Intimate relationships avoided
New relationships avoided
Gets around occupational activities that involve interpersonal contact
Embarrassment potential prevents new activities
Self viewed as unappealing, inept, inferior
Diagnostic criteria for obsessive compulsive personality disorder
LAW FIRMS (4/8)
Loses point of activity
Ability to complete tasks compromised by perfectionism
Worthless objects unable to discard
Friendships, leisure excluded due to preoccupation with work
Inflexible, scrupulous, overconscientious
Reluctant to delegate
Miserly
Stubborn
Diagnostic criteria for dependent personality disorder
RELIANT (5/8)
Reassurance required for decisions
Expressing disagreement difficult
Life’s responsibilities assumed by others
Initiating projects difficult
Alone - feels helpless
Nurturance - goes to excessive lengths to obtain nurturance and support
Companionship sought urgently when close relationships end
Exaggerated fears of being left to care for themselves
