Psychiatric treatment and medication Flashcards
define the dopamine hypothesis for schizophrenia
suggest:
1-hyperactivity of the mesolimbic dopamine pathways
-accounts for the positive syx of schizophrenia
2-defifcinecy of dopamine in the mesocrotical dopamine pathway
-accounts for negative and cognitive syx of schizophrenia
examples of first generation antipsychotics 4
flupentixol
chlorpromazine hydrochloride
haloperidol
sulpride
examples of second generation antipsychoticvs 6
amisulrpide
aripiprazole
clozapine
olanzapine
quetiapine
rispperidone
indications for antipsychotic use 2
schizoprhrenia and related disorders
bipolar affective disorder
movement disorder adverse effects of antipsychotis 4
acute dystonia
-involuntary contractions of skeletal muscle
pseudo-parkinsonism
-tremor, rigidity and hypokinesia
akathisia
-motor restlessness
-subjective feeling of tension and inability to tilerate inactivity which gives rise to restless movement
tardive dyskinesia
-late onset hyperkinetic, involuntary movement s
autonimic affects of antipsychoics 4
anti-adrenergic
-postural hypotension
-ECG chagnes (QTc prolongation) (can cause torsades)
anti-cholinergic
-dry mouth
-blurring of vision
-constipation
-dificultuy with micurtiion and retention
other adverse effects of antipsychotics
neuroleptic malgingant syndrome
-potentially fatal
-causes muslce rigidit, extreme EPS, severely elevate body temp and hyperteions and tachycardia
convulsant activity
-antispychotics (esp chlorpromazine) can lower seizure threshold
pigmentation of the skin
metabolic effects of antipsychotics 2
weight gain
-occurs with clozapine and olanzapine
-linked to DM
Endocrine
-hyperprolactinaemia
-can cause reduced labido and sexual dysfunction men
-menstrual irregularities and lactation in nonpregnnat females
hypersensitivity reactions to antipsychotics 2
cholestatic jaundice
-phenothiazine class (chlorpromazine)
skin reactions
photo seneisivty rahses
what is clozapine licsended for
treatment ressitant schizophrenia
why are second generation APs favourable to first generation
have fewer extrapyradimal side effects
-dont cause tradive dyskinesia
-not elevate prolactin
have more metabolic effects tho (weight gain)
most important side effect to consider for clozapine
-how is this managed
potenially fatal agranulocytosis
occurs in 0.5-2% of ptx
-managed by WBC monitoring initially as inpatient then community
-weekly for 18wks
-then fortnightly for up to one year
-then monthly
describe the link of clozapine and smoking and the risk associated
tobacco induces hepatic enzymes
-patients on clozapine will have reduced plasma levels
reduction or cessation in smoking will result in increased clozapine plasma levels
-this can cause dose related adverse effects
define hypomania vs mania
Mania and hypomania differ with respect to duration, intensity, and functional impairment:
Duration: In mania, an elevated or irritable mood lasts at least one week. In hypomania, symptoms last for at least 4 days.
Intensity: In mania, symptoms are severe, and in hypomania, they are mild to moderate.
Functional Impairment: In mania, critical life activities such as work and social relationships are impaired. In hypomania, there is no functional impairment.
definition of bipolar disorder
repeated (at least two) episodes were patients mood andactivityu levels are significantly disturbed
-on some occasion an elevation of modd and increased energy and acitivyt (hypo(mania))
-on some occasions lowering of moood and decreased energy and activity (depression)
describe the young mania rating scale
This is an 11-item instrument used to assess the severity of mania (Young et al 1978). (2)
Elevated Mood
Increased Motor Activity Energy
Sexual Interest
Sleep
Irritability
Speech (rate and Amount)
Language-Thought Disorder
Content
Disruptive-Aggressive Behaviour
Appearance
Insight
state the three main mood stabilisers used in the UK 3
lithium
carbamazepine
valporate
describe the uses of lithium in psychiatry 5
acute treatment of hypo(mania)
prophylaxis of bipolar or schizo
prophylaxis of recurrent depressive illness
augmentaiton of antidepressants in acute depressive illness
treatment of depresison in bipolar disorder
goals of acute treatment of mania 3
reducing mental and physical overactivity
improving features of psychosis
prevent deterioration in health due to exhaustion, sleep deprivation and poor fluid intake
options for acute treatment of mania 5
mood stabilisers
-lithium first line
antipsyhotic drugs
other mood stabilites
-lamotrigine and gabapentin
benzos- lorazepman and clonazepam
ECT
predictors of poor responses to lithium
rapid cycling disorders or chornic depresion
mixed affective states
alcohol and drug misuse
mood-incongruent psychotic features
define mixed affective staet
simultaneous presenc of features of mania and depression
define rapid cycling disorders
4 distinct periods of abnormal mood within the year
lithium use in pregnancy
lithium is teratogenic
-causes tricuspid valve deformity and thyroid function of the new born infants
what is checked before commencement of lithium 3
need TFTs, ECG and kideny function tests before commenced
main drug interactions with lithium 2
NSAIDs
Thiazide diuretics
what physcial state in lithium a danger in
dehydration (diarrhoea or excess sweating)
as toxicity can occur
common side effects of lithium 7
N+V
diarrhoea
metalic taste in mouth
cognitive dulling
tremor
muscle weakness
weigh gain
serious side effects of ltihium 4
hypothyroidism -MAIN
hyperparathyroidism
renal tubular necorsis- renal failure
nephrogenic diabetes inspidius
presentation of lithium induced hypothyroidism and managemnt
can occur with a frank goitre
(lithium interfere with thyroid function by competing with iodine for absorption into thyroid gland)
corrected by giving thyroxine
-reversible on stopping lithium
renal tubular necrosis in lithium use overview
rare
-unlear origin
develop renal failure with progressive reduction in renal clearance
management:
-therapueitc bloods monitoring checked 3/12 allows early detection ie eGFR
importantt roles of multidisaplinary memebrs for psychaitric patients 5
- Community Psychiatric Nurse allocated and their role would be to monitor mental state and adherence with medication.
- Housing Officer present to monitor and report on state of housing and related issues.
- Occupational Therapy assessment to assess Activities of Daily Living (ADL) (3 marks)
4. General Practitioner for physical health review. - Social Work to perform a Needs Assessment focusing on social functioning.
management of lithium overdose 3
prinicple - reduction of ansopriong and increased clearance of lithium
-diuresisi via IV fluids
-Gastirc lavage
-Whole bowel irrigation
basic prinicples of prescribing antidepressants
discuss w ptx- choice of drug and utility/vaiblilt
discuss w patient likely outcomes-
-gradual relief from depressive syx over several weeks
pprescibre dose of antidepressants -
that is likely to be effective
withdraw antidepressants gradually
-always inform patients of risk and nature of discontinuation syx
for a single episode
-contine treatment for 4066months after resolution of syx
what is the prinicple theory that underpins use of antidepressants and describe ti
monoamine theory of depression
depressive syndrome is due to an absolute or relative decrease in monoamines, or of receptor sensitivity at certain receptor sites in the brain
state the monoamine neurotransmitters in the brain 3
noradrenaline (NA)
dopamine (D)
serotonin (5HT)
state the different types of antidepressants and some examples 4
tricyclics
-amitryptylin
SSRI
-sertraline, fluoextine, citalopram
SNRI
-venlafaxine
Monoamine oxidate inhibiotrs (MAOIs)
-phenalzine
MOA of antidepressants
enhance functional activity of NA and/or 5HT
-*wait 6 weeks to evaluate effects of antidepressants on an individual basis
first choice antidepressants
SSRIs
-safe in overdose and heart disease
-good adverse effect profile
SSRI side effects 7
GI
-Nausea
-appeitie loss
-dry mouth
-diarhoea
CNS
-insomia
-dizziness
-anxietry
-fatigue
other
-sweating
-delyaed orgasm and anorgasmia
worry with St john worts use
if coprescribed with SSRI or other 5-HT potentiating drugs can cause serotonergic syndrome
neurological features of serotonin syndrome 6
Neurological
-myoclonus
-nystagmus
-headache
-tremor
-rigidity
-seizures
mental state features of serotonin syndroem 4
mental state
-irritability
-confusion
-agitation
-hypomania
other features of serotonin syndrome
hyperpyrexia
sweating
diarrhoea
cardiac arrhymias
death
CBT concepts
thoughts feelings physcial sensations and behvaiours interconnected
negative thoughts and feelings can trap you in a vicious cycle
what is the focus of CBT
dealing with automacitv negative thoughts
automatic negative thoughts are a nromal everyday occurrence but why are they worse in anxiety and Depression 3
experieced more frequently
harder to challenge
helpful/balancing thoughts are crowed out
CBT approach 5
here and now
problem focused
specific strategies
homework
more directive than other therapies
5 areas model of CBT
a life situation, relationship or practical problem
-then with the CBT approach you do:
-altered thinking
-altered physical sensations/syx
-altered emotions
-altered behaviours
what is CBT good for 6
depression
anxiety
OCD
eating disorders
phobias
panic
describe psychodynamic psychotehrapy
past relationships recreated in current relationship:
-transference
-counter transfernce
aims
-improve insight (identify unhelpful unconicous processes and defense mechanisms
-improve management of distress
define defence mechanisms
protect us from emotioal distres by preventing experience of unacceptable feelings/impulses/conflicts
can be on spectrum from conscious to unconscious
everyone uses them not necessarily pathological
regarding defence mechanisms:
-define projection
attributing unacceptable feelings/thougths to someone else
regarding defence mechanisms:
-define splitting
all good/ all bad
regarding defence mechanisms:
-define displacement
an individual transferring negative feelings from one person or thing to another.
regarding defence mechanisms:
-define
repression and suppression
repression- unconscious
suppression- concious
both- ‘forgetting’
regarding defence mechanisms:
-define intellectualisation
focusing on facts, ignoring emotional content
regarding defence mechanisms:
-define rationalisation
rational justifications/ excuses for behaviour
regarding defence mechanisms:
-define sublimation
unacceptable feelings/thoughts into acceptable channel
what is the main principle of family (systemic) therapy
mainly in CAMHS
-family seen together
based on:
-syx is not a problem of the child but a problem of the family system
-no one person to blame
family is seen as a system of relationships
-all contribute to maintaining the system and hence the symptoms
method of family therapy
promote effective communication patterns within the family
-therapist and team take a ‘one-down’ position
postmodern approach
-family are experts and have the answers
overview of counselling
most common psychotherapy
-mainly promary care and usually short term
aim to help person become celare about problems and then come up with own answers
-therapist tend to avoid giving answers
not aim to bring fundamental change but instead bolster existing coping strategies
what is the danger with tricyclic antidepresants
dangerous in overdose
-seizures
-comas
-arrythmias
an example of a noradrenaline and specific serotonin antidepressant (NaSSAs)
mirtazapine
important info on antidepressants for exams 3
selec drug based on side effect profile
-ie poor appetite and poor sleep- mirtazpaine
wathc for discontinuation symptoms vs addiction
sexual side effects could be hidden agenda
info on antipsychotics for exams 3
differences betweeen first generation and second generation
monitoring
-weight
-BP
-ECG
-glucose/HbA1c
-lipids
remind patient to wear sunscreen
what is the teratongenic effect of valporate
neural tube defects
what is the teratogenic effect of lithium
ebsteins anomaly -a rare heart defect that’s present at birth (congenital). In this condition, your tricuspid valve is in the wrong position and the valve’s flaps (leaflets) are malformed
why is ECT one of teh safest psych treatments 2
least side effects
fastest acting- life saving
what happens in ECT
controlled siezure
-improves mood and psychotic syx
indications for ECT 3
severe depression- sucidal ideation, psychomotor retardation
catatonia
treatment resistant psychosis
contraindications for ECT
no absolute contraindications
how often is ECT usually performed
twice/week
up to 12 sessions
consent for ECT?
patinet needs to give consent or 2nd opinion from mental welfare commission
what is given for ECT 2
general anaesthetic
muscle relaxant
risks of ECT 4
mainly from anaesthetic
dentition
headache and muslce pains, vomiting
long term: memory can be affected
mainstay of psychosurgery
anterior cingulotomy
-targets anterior cingulate cortex (part of. limbic system)
what is anterior cingulotomy psychosurgery used for 2
treatment resistant mood disorder
treatment resistant OCD
other psychosurgery exmaples 2
transcranial magentic stimualtion
vagal nerve stimulation
