Psychiatry Flashcards
Schizophrenia
the most common form of psychosis, generally a lifelong condition that can take a chronic or relapsing & remitting form with episodes of acute illness
Schizophrenia epidemiology
usually presents in adolescences & early 20s
generally females have a later age of occurrence
responsible for 25% of all psychiatric hospitalisations of 10-18 year olds
Risk factors for schizophrenia
family history* cannabis use obstetric/perinatal complications ACEs psychological stress migrant status
Presentation of schizophrenia
deterioration in functioning over the preceding months
4 symptomatic domains
Positive symptoms:
hallucinations (usually auditory), delusions, thought disorders (e.g. broadcasting, withdrawal, insertion), speech disorder, derealisation
Negative symptoms:
asocial behaviour, affective blunting, anhedonia, alogia (↓ speech), abolition (↓ motivation), social withdrawal, self neglect
Catatonia:
extreme loss or malignant excess of motor activity
catatonic stupor/rigidity/negativism/excitement
cognitive deficits/affctive symptoms/physical symptoms:
problems with language/memory/attention/excutive function, depression, elation, motor coordination deficits, left-right disorientation, sensory integration deficit
Positive symptoms of schizophrenia
hallucinations (usually auditory) delusions thought disorders (e.g. broadcasting, withdrawal, insertion) speech disorder derealisation
Negative symptoms of schizophrenia
asocial behaviour affective blunting anhedonia alogia (↓ speech) abolition (↓ motivation) social withdrawal self neglect
Catatonic symptoms fo schizophrenia
extreme loss or malignant excess of motor activity
catatonic stupor/rigidity/negativism/excitement
cognitive deficits/affective symptoms/physical symptoms of schizophrenia
problems with language/memory/attention/excutive function depression elation motor coordination deficits left-right disorientation sensory integration deficit
DSM-5 criteria for schizophrenia
Schizophrenia can be diagnosed if the following conditions are met.
Two or more of the following symptoms are present: delusions, hallucinations, disorganised speech, disorganised/catatonic behaviour, or negative symptoms. At least one of the symptoms must be a positive symptom.
Symptoms occur for a period of at least 1 month (less, if treated) and are associated with at least a 6-month period of functional decline
Symptoms do not occur concomitantly with substance use or with a mood disorder episode.
ICD-11 criteria for schizophrenia
Criteria for schizophrenia require a combination of at least one first-rank psychotic symptom or at least two other symptoms, including other positive psychotic symptoms, disorganised thinking or speech, negative symptoms, or catatonia.
First-rank psychotic symptoms include thought echo, thought insertion or withdrawal and thought broadcasting, delusions of control, influence or passivity, delusional perception, other strange delusions, and auditory hallucination commenting on the patient’s behaviour or talking about the patient in the third person.
Investigating schizophrenia
clinical diagnosis
consider FBC & LFTs, urine drug screen
Management of schizophrenia
1st line: PO atypical antipsychotic e.g. risperidone/olanzapine
NB clozapine = antipsychotic of choice for treatment resistant schizophrenia
Cognitive behavioural therapy (CBT) electroconvulsive therapy (ECT) - if resistant to pharmacological treatment
Monitoring of treatment for schizophrenia
- extrapyramidal effects/metabolic syndrome/excessive prolactin
- cardiac abnormalities (baseline ECG, motor for QT prolongation)
- postural hypotension
poor prognostic factors for schizophrenia
↑ duration of untreated psychosis early/insidious/gradual onset of schizophrenia male sex negative symptoms FHx continued substance misuse
Bipolar disorder
Also known as bipolar affective disorder
chronic episodic mental illness associated with behavioural disturbances which is characterised by episodes of mania (or hypomania) and depression
Types of bipolar disorder
Type I: presents with manic episodes interspersed by major depressive episodes (most common type)
Type II: pt do not meet criteria for full mania & are described as hypomanic, has ↓ associated dysfunction
NB: rapid cycling - defined as four or more cycles of depression and mania a year, with no intervening asymptomatic episodes
Bipolar disorder epidemiology
usually develops in late teen years
usually seen <25 y/o
Risk factors for bipolar disorder
family history (50-10x ↑ risk) onset of mood disorder <20y/o stressful life events ACEs history of depression history of substance misuse presence of anxiety disorder
Presentation of bipolar disorder
Manic phase:
elevated mood, ↑quantity&speed of physical/mental activity, grandiose ideas, pressure of speech, ↑energy, racing thoughts/flight of ideas, overactivity, ↑appetite, sexual disinhibition, ↓need for sleep, hallucinations, delusions, lack of isnight
Hypomanic phase:
persistent mild elevation in modd
↑ activity/energy levels
NO psychotic symptoms
Depressive phase: low mood (worse in mornings), ↓energy levels, unkempt, anhedonia, ↓self-esteem, despair, guilt, ↓appetite, weight loss, loss of libido, altered sleep pattern, self neglect
Psychological functioning:
difficulties in relationships & at work
Manic symptoms of bipolar disorder
elevated mood ↑quantity&speed of physical/mental activity grandiose ideas pressure of speech ↑energy racing thoughts/flight of ideas overactivity ↑appetite sexual disinhibition ↓need for sleep hallucinations delusions lack of insight
Depressive symptoms of bipolar disorder
low mood (worse in mornings) ↓energy levels unkempt, anhedonia ↓self-esteem despair, guilt ↓appetite weight loss loss of libido altered sleep pattern self neglect
Differentiating hypomania and mania
NO psychotic symptoms in hypomania
Hypomania does not impair functional ability significantly
hypomania is shorter lasting than mania
ICD-10 criteria for bipolar disorder
≥2 episodes of a persons mood & activity levels being significantly disturbed (at least one of which is mania/hypomania)
3 of the following confirm mania
-grandiosity/inflated self esteem, pressured speech, ↓need for sleep, flight of ideas, distractibility, psychomotor agitation, excessive involvement in pleasurable activity without thought for consequence
±psychotic symptoms e.g. hallucinations/delusions
frequency & duration of episodes are variable and may even vary day to day/within a day between mania/depression/hypomania
Management for bipolar disorder
self help/support groups
CBT/interpersonal therapy
Mood stabilisers
1st line: lithium (valproate/olanzapine if lithium not tolerated)
2nd line: add valproate if lithium alone ineffective
For acute mania:
give antipsychotic e.g. haloperidol/olanzapine/risperidone
consider IM sedation e.g. bentos
For acute depression:
offer fluoxetine ± olanzapine/quetiapine
Depression
refers to both negative affect (low mood) and/or absence of positive affect (loss of interest/pleasure in most activities) which is usually accompanied by a variety of emotional/cognitive/physical/behavioural symptoms
Risk factors for developing depression
female gender history of depression/suicide family history of depression/suicide significant/chronic physical illness history of other mental health problems psychosocial factors (ACEs, unemployment, poverty)
Presentation of depression
depressed/low mood anhedonia functional impairment weight change loss of libido sleep disturbance low energy/fatigue poor concentration suicidal ideation excessive guilt ↓ self-esteem feeling of worthlessness
Screening for depression
PHQ-2 questionnaire
over past month have you:
-felt low/depressed/hopeless
-had little interest/pleasure in doing things
Assessment of depression (assessing degree)
PHQ-9 questionnaire
9 items from DSM-5 criteria scored 0-3 (0 not at all, 3 nearly everyday)
HAD scale
14 questions, 7 for anxiety, 7 for depression scored 0-3
DSM-5 criteria for depression
Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning. At least one of the symptoms is either depressed mood or loss of interest or pleasure:
Depressed mood most of the day, nearly every day, as self-reported or observed by others
Diminished interest or pleasure in all or almost all activities most of the day, nearly every day
Significant weight loss when not dieting, weight gain or decrease, or increase in appetite nearly every day
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation nearly every day
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt nearly every day
Diminished ability to think or concentrate nearly every day
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan.
In addition, these symptoms:
Cause functional impairment (e.g., social, occupational)
Are not better explained by substance abuse, medication side effects, or other psychiatric or somatic medical conditions.
Management of sub-threshold or mild-to-moderate depression
1st line: Cognitive behavioural therapy (CBT), exercise programmes, counselling
antidepressants not routinely used
Management of unresponsive or severe depression
antidepressants + CBT/interpersonal therapy
antidepressants:
SSRIs = 1st line e.g. citalopram, fluoxetine, sertraline
SNRIs = 2nd line e.g. venlafaxine, duloxetine
Schizoaffective disorder
psychiatric condition with features of both schizophrenia & mood disorders which commonly presents in early adulthood
generally more responsive to mood stabilisers than schizophrenia
generally a non-deteriorating course
DSM-5 criteria for schizoaffective disorder
uninterrupted period of illness during which there is an episode of mood disorder (major depression/mania) concurrent with a schizophrenic episode
characterised by 2 of the following symptoms present for a considerable part of 1 month:
delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, negative symptoms (affective flattening, apologia, avoliiton)
should have period of at least 2 weeks of hallucinations/delusions in absence of prominent mood disorder
Management of schizoaffective disorder
atypical antipsychotics e.g. clozapine
antidepressants e.g. fluoxetine, sertraline
mood stabilsiers e.g. lithium or valproic acid
Generalised anxiety disorder (GAD)
syndrome of ongoing anxiety & worry about many events or thoughts that the pt generally recognises as excessive & inappropriate
maybe chronic & debilitating
Risk factors for generalised anxiety disorder (GAD)
family history of anxiety physical/emotional stress history of physical/emotional/sexual trauma chronic health conditions social isolation
Screening for generalised anxiety disorder (GAD)
GAD-7 score screening tool & severity measure 7 items scored 0-3 score of 5 = mild score of 10 = moderate score of 15 = severe
DSM-5 criteria for generalised anxiety disorder (GAD)
excessive anxiety&worry regarding several issues are present most of the time for >6months
difficulty controlling worry
≥3 symptoms associated with anxiety for >6 months
restlessness/feeling on edge, easily fatigued, difficulty concentrating, muscle tension, sleep disturbance (restless sleep/difficulty falling asleep)
anxiety causes significant distress or impairment in social/occupational/other areas of functioning
Symptoms of generalised anxiety disorder (GAD)
persistent nervousness trembling muscular tension light headedness palpitations dizziness epigastric discomfort sleep disturbance (restless sleep/difficulty falling asleep)
Management of generalised anxiety disorder (GAD)
Step 1: education & active monitoring
Step 2: low intensity psychological intervention e.g. CBT
Step 3: high intensity psychological intervention or drug therapy e.g. CBT or Sertraline (1st line)
NB alternative to sertraline is venlafaxine
Drug therapy of generalised anxiety disorder (GAD)
Sertraline = 1st line
Venlafaxine = alternative
consider pregabalin if SSRI/SNRI not tolerated
Panic disorder
severe & disabling illness common in primary care which often coexists with agoraphobia
NB agoraphobia rarely occurs without panic disorder
common condition, more frequent in women
DSM-5 criteria of panic disorder
recurring & unexpected panic attacks least one of which is followed by a 1-month period in which the individual worries about having additional attacks or their implications + the individual has changed they behaviour in a maladaptive way
Panic attacks are characterised by sudden surge in intense fear/physical discomfort reaching peak within a few minutes
≥4 of the following symptoms are present during panic attacks
palpitations/heart pounding/tachycardia, sweating, muscle trembling/shaking, SOB, choking sensation, dizziness/lightheadedness/instability/feeling faint, fears of losing control, numbness/tingling
Management of panic disorder
- avoid anxiety inducing substances e.g. caffeine
- trigger avoidance
- CBT
- SSRIs e.g. fluoxetine/sertrlaine (1st line)
- TCAs e.g. imipramine/clomipramine (2nd line)
Agoraphobia
fear of open spaces, especially those in which getaway/escape may be difficult which leads to avoidance of these situations
being in a provoking situation usually leads to panic attacks
the 3 basic elements of agoraphobia
Phobia
severe anxiety
avoidance of situations that might provoke anxiety
DSM-5 criteria for agoraphobia
marked fear/anxiety in ≥2 of the following group situations:
public transport, open spaces, being in shops/cinemas/theatres, standing in line/being in crowd, being outside of home alone
person fears/avoids these situations due to thought that escape may be difficult or help not available
situations are actively avoided, require a companion or are endured with marked fear/anxiety
Management of agoraphobia
CBT + medication
1st line SSRIs eg. fluoxetine/sertrlaine
2nd line imipramine/clomipramine (if no improvement after 12 weeks of SSRI)
Social anxiety disorder (SAD)
the fear of being around people & having to interact with them
one of the most common anxiety disorder especially in young people
Symptoms of social anxiety disorder (SAD)
trembling, blushing, sweating palpitations
chronic insecurity about their relationships with others
excessive sensitivity to criticism
profound fear of being judged negatively
fear of being rejected by other
fear of being mocked
Management of social anxiety disorder (SAD)
CBT based supported self help
SSRIs e.g. escitalopram/sertraline
if no response consider paroxetine or vanlafaxine
Post traumatic stress disorder (PTSD)
may develop at nay age following exposure to 1 or more traumatic events such as deliberate acts of interpersonal violence/sevre accidents/disasters/military action or any situation of exceptionally threatening/catastrophic nature
PTSD risk factors
precipitating events is life threatening refugees/asylum seekers first responders (police/ambulance/fire department) combat exposure low morale poor social support history of drug/alcohol abuse history of psychiatric illness
Presentation of PTSD
re-experiencing:
flashbacks, nightmares, repetitive & distressing intrusive images
avoidance:
avoiding people/situations/circumstances resembling or associated with event
hyperarousal:
hyper vigilance for threat, exaggerated startle response, sleep disturbance, irritability, difficulty concentrating, reckless/self-destrcutive behaviour
Emotional numbing:
feeling detached, lack of ability to experience feelings, persistent negative/distorted beliefs, distorted ideas of blame, anhedonia
Other:
depression, alcohol/substance misuse, anxiety, angerq
Length of symptoms for diagnosis of PTSD
> 1 month
Management of PTSD
watchful waiting if symptoms mild & ,4 weeks
trauma focused CBT or eye movement desensitisation & reprocessing (EMDR)
drug therapy (not 1st line): SNRIs e.g. venlafaxine or SSRIs e.g. sertraline/paroxetine
Phobias
involves intense fears of specific objects or situations that are triggered upon actual/anticipated exposure to the phobic stimuli
more common in women
One of the most common & most treatable psychiatric conditions
Presentation of phobia
usually set in childhood/early adulthood nausea dizziness disgust fainting tachycardia hyperventilation exaggerated startle
Types of phobias
animals (e.g. spiders, snakes, rats) situations (e.g. flying) environmental (e.g. heights) blood/needles/injuries others (e.g. clowns)
Management of phobias
CBT including exposure therapy
SSRIs
Obsessive compulsive disorder (OCD)
characterised by obsessions or compulsions but most frequently both
onset usually in late adolescence & early 20s
Risk factors for OCD
Family history*
DSM-5 criteria for OCD
Must exhibit obsessions, compulsions, or both.
The obsessions and/or compulsions cause marked distress, are time consuming (take more than 1 hour per day), or interfere substantially with the person’s normal routine, occupational or academic functioning, or usual social activities or relationships.
The obsessions and/or compulsions are not attributable to the physiological effects of a substance or other medical condition.
The disorder is not better explained by the symptoms of another mental disorder, such as obsession with food in the context of an eating disorder.
Obsessions are:
Recurrent and persistent thoughts, urges, or images experienced, at some time during the disturbance, as intrusive and unwanted and in most individuals cause marked anxiety or distress.
There is some effort by the affected person to ignore or suppress such thoughts, impulses, or images, or to neutralise them with some other thought or action (i.e., by performing a compulsion).
Compulsions are: Repetitive activities (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly. These behaviours or mental acts are performed in order to prevent or reduce distress, or prevent some dreaded event or situation. However, they are either clearly excessive or not connected in a realistic way with what they are designed to neutralise or prevent.
specify the degree of insight
specify if the disorder is tick related
Presentation of OCD
obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.
Compulsions are repetitive behaviours or mental acts that the person feels driven to perform.
A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.
OCD associated diseases
depression schizophrenia Tourettes anorexia nervosa body dysmorphic disorder easting disorders ASD
Management of OCD
Mild functional impairement:
low intensity psychological interventions e.g. CBT +exposure and response prevention (ERP)
Moderate functional impairment:
SSRI e.g. fluoxetine or high intensity psychological interventions e.g. CBT + ERP
severe functional impairment:
high intensity CBT + ERP & SSRI
Seasonal affective disorder
a variant of depression characterised by depressive episodes that recur annually at the same time each year usually during winter months
Presentation of seasonal affective disorder
onset of depressive symptoms in autumn/winter
full resolution of symptoms during spring/summer
atypical vegetative symptoms of depression are common e.g. hypersomnia, weight gain, hyperphagia, lethargy
Diagnosis of seasonal affective disorder
over last 2 years ≥2 major depressive episodes have occurred that demonstrated the temporal seasonal pattern
Management of seasonal affective disorder
Education
CBT
SSRIs
Postnatal depression (PND)
refers to the development of a depressive illness following childbirth & may form part of a bipolar or more usually unipolar illness
onset of depression within 6 weeks of childbirth
affects ~9% of new mothers
Presentation of postnatal depression
depressive symptoms e.g. low mood, anhedonia, ↓appetite, poor concentration, low self-esteem, fatigue, ↓energy, ↓ libido, suicidal ideation
fears about babies health/maternal deficiencies
marital tension
Assessment of postnatal depression
via Edinburgh postnatal depression scale
Management of postnatal depression
self-help strategies
antidepressants (SSRIs/SNRIs) at lowest effective dose
CBT/interpersonal therapy
Postnatal blues
occurs in ~50% of women after childbirth
usually 48-72h post partum, symptoms peak at 5-7 days and subside by 10-14 days
Symptoms include tearfulness, irritability, poor concentration, anxiety about the baby, emotional lability, mood swings
if persistent >14 days = postnatal depression
Postpartum psychosis/puerperal psychosis
severe mental illness which develops acutely in the early postnatal period which is a psychiatric emergency
usually develops within 1 month of birth, most commonly within 3-14 days
rapidly develops over 48h generally
Risk factors for postpartum psychosis
personal history of postpartum psychosis
history of bipolar disorder
family history of postpartum psychosis.bipolar disorder
Presentation of postpartum psychosis
rapid transition form normal state/sudden onset
early symptoms:
perplexity, fear, restless agitation, insomnia, purposeless activity, uncharacteristic behaviour, irritation, fleeting anger, resistive behaviours, elation & grandiosity
fear for her own/babys health
late symptoms:
psychosis (hallucinations, delusions, mania, depressive symptoms)
Management of postpartum psychosis
psychiatric emergency
admission to mother-baby-unit
antipsychotics ± mood stabilisers (give rapidly to reduce impact on mother-baby relationship)
Risks of postpartum psychosis
major ↑ in risk of maternal suicide
Delirium (acute confusional state)
hard to define clinical syndrome involving abnormalities of thought, perception level of awareness typically with acute onset and fluctuating change in mental states
Risk factors for delirium
age ≥65 history of dementia polypharmacy severe comorbidity previous episodes of delirium substance misuse frailty multimorbidity drug/substance use/misuse/dependance ITU admission dehydration visual/hearing impairment
Aetiology of delirium
- infection: particularly urinary tract infections
- metabolic: e.g. hypercalcaemia, hypoglycaemia, hyperglycaemia, dehydration
- change of environment
- any significant cardiovascular, respiratory, neurological or endocrine condition
- severe pain
- alcohol withdrawal
- constipation
Presentation of delirium
acute/subacute presentation with fluctuating course
disorientation, impaired cognition, change of consciousness, poor concentration, memory problems, mood changes, agitation, withdrawal, poor attention, disturbed sleep cycle, emotional lability, abnormalities of perception (hallucinations, illusions), psychotic signs (delusions, hallucinations)
Sub types of delirium
hypoactive:
apathy/quiet confusion/withdrawal, easily missed
hyperactive:
agitation/delusions/disorientation are prominent
mixed
Management of delirium
- treat underlying cause
- supportive management (clear communications, reminders of time/location, staff consistency, familiar objects from home)
- environmental measures (avoid sensory extremes, side room, adequate nutrition)
NB if medical management needed
1st line = PO Lorazepam
2nd line = PO haloperidol
Dementia
a syndrome characterised by an appreciable deterioration in cognition resulting in behavioural problems/impairment in the activities of daily living
decline of cognitive function often affects multiple domains of intellectual functioning
Symptoms of dementia
Cognitive impairment:
causing difficulties with memory, language, attention, thinking, language, orientation, calculation, problem solving
Psychiatric/behavioural problems:
changes in personality/emotional control/social behaviour, depression, agitation, hallucinations, delusions
difficulties in activities of daily living
Alzheimers disease
involved progressive degeneration of cerebral cortex with widespread cortical atrophy
most common cause of dementia
Risk factors for Alzheimers
ageing caucasian Down's syndrome hyperlipidaemia smoking obesity alcohol abuse high fat diet diabetes HTN
Genetic factors of Alzheimers
Presenilin-1 (PSEN1) - most common form of familial AD
Presenilin-2 (PSEN2) - rare
amyloid precursor protein (APP) - linked to early onset AD
ApoE4 (apolipoprotein E4) - risk of late onset AD, NB ApoE2 is protective
Presentation of Alzheimers
insidious onset of 7-10 years
memory lapses/short term memory impairment (especially episodic memory)
forgetting appointments/names/places/people
trouble finding words
language impairment
temporal/spatial disorientation
impaired executive function & judgement
behavioural change (apathy/agitation/aggression/irritability)
pathophysiology of Alzheimers
wide spread cerebral atrophy
cortical/senile plaques (extracellular deposition of beat-amyloid)
neurofibrillary tangles (intracellular aggregation hyperphosphorylated tau protein)
Investigating Alzheimers
neurophysiological Testung (MMSE, MoCa) FBC, U&Es, TFTs, Vti B12, urine drug screen, CT?MRI head
Management of Alzheimers
MDT approach with multiple therapies & support e.g. memory enhancement strategies
Pharmacological:
1st line: accetylcholinesterase inhibitors e.g. donepezil, galantamine, rivastigmine
2nd line: memantine (NMDA receptor antagonist)
Vascular dementia (VD)
a group of syndromes of cognitive impairment caused by different mechanisms that cause ischaemia or haemorrhage secondary to cerebrovascular disease (multiple infarcts, single strategic infarct, small vessel disease)
2nd most common form of dementia
Risk factors for vascular dementia
obesity HTN smoking AF history of TIA CHD diabetes family history of CVS disease/stroke genetics e.g. CADASIL
Presentation of vascular dementia
progressive disease with sudden deteriorations in a stepwise manner*
focal neurological abnormalities e.g. visual disturbances, sensory/motor symptoms etc
seizures
difficulty with attention & concentration
memory disturbance
mood disturbance
emotional lability
bladder symptoms
gait disturbance
speech distrubance
Management of vascular dementia
MDT approach with therapies, cognitive stimulation programmes and structured exercise programmes
Pharmacological:
no specific approved pharmacological treatment
Lewy body dementia
neurodegenerative disorder with parkinsonism, progressive cognitive decline, prominent executive dysfunction & visuospatial impairment
dementia characterised by eosinophilic intracytoplasmic neuronal inclusion bodies formed of alphasynuclein
Lewy body dementia presentation
dementia is usually the presenting feature with memory loss, ↓ problem solving ability, spatial awareness difficulties
earlier impairments of attention & executive function compared to AD
fluctuating cognition
Parkinsonism (bradykinesia, resting tremor, rigidity, poverty of facial expression)
frequent falls
sleep disorders (REM sleep disorders)
Management of lewy body dementia
MDT approach with therapies, cognitive stimulation programmes and structured exercise programmes
Pharmacological:
AChE inhibitors e.g. donepezil or memantine may be used
NB avoid neuroleptic drugs (may cause permanent parkinsonism)
Alcohol use disorder
common psychiatric condition that is multifactorial in aetiology, chronic in nature & associated with a wide variety of medical & psychiatric sequelae
major problem in the UK
Risk factors for alcohol use disorders
family history of alcoholism male sex ACEs stressful life events low socio-economic status other substance related disorders mood disorders
Presentation of alcohol dependence
withdrawal symptoms tolerance (↓ response to alcohol) signs of liver disease peripheral neuropathy (due to thiamine deficiency) impaire nutritional status
DSM-5 criteria for alcohol use disorder
Alcohol-use disorder is defined as a problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least 2 of the following criteria over the same 12-month period:
- Alcohol used in larger amounts or over a longer period of time than intended
- Persistent desire or unsuccessful attempts to cut down or control alcohol use
- Significant time spent obtaining, using, and recovering from the effects of alcohol
- Craving to use alcohol
- Recurrent alcohol use leading to failure to fulfil major role obligations at work, school, or home
- Recurrent use of alcohol, despite having persistent or recurring social or interpersonal problems caused or worsened by alcohol
- Recurrent alcohol use, despite having persistent or recurring physical or psychological problems caused or worsened by alcohol
- Giving up or missing important social, occupational, or recreational activities due to alcohol use
- Recurrent alcohol use in hazardous situations
- Tolerance: markedly increased amounts of alcohol are needed to achieve intoxication or the desired effect, or continued use of the same amount of alcohol achieves a markedly diminished effect
- Withdrawal: there is the characteristic alcohol withdrawal syndrome, or alcohol is taken to relieve or avoid withdrawal symptoms.
Assessment of alcohol use disorder
CAGE (cut down, annoyed guilt eye opener)
alcohol use disorder identification test (AUDIT)
Investigating alcohol use disorder
Alcohol level
FBC, LFTs, clotting, U&Es
Management of alcohol use disorder
advise & education
avoidance of drinking triggers
CBT
assisted withdrawal (usually community based)
if drinking >15 units/day or AUDIT score ≥20
with chlordiazepoxide + pabrinex
acamprosate (to ↓ cravings for alcohol)
naltrexone & nalmefene (↓ pleasurable effects from alcohol)
disulfiram (amplifies negative effects of alcohol by blocking acetaldehyde dehydrogenase)
Alcohol withdrawal
occurs in pts who are alcohol dependent & who have stopped/↓ their alcohol intake within hours/days of presenting
symptoms typically begin 6-12h after last alcoholic drink
Presentation of alcohol withdrawal
typically after 6-12h without drink
tremor, sweating, tachycardia, anxiety, nausea&vomiting, headache, restlessness, agitation, insomnia
cravings fro alcohol
alcoholic hallucinosis (12-24h after last drink) auditory/visual/tactile hallucinations
withdrawal seizures (24-48h after last drink) generalised tonic clonic seizures
delirium tremens (48-72h after last drink)
Management of alcohol withdrawal
admit if previous difficult withdrawal or <18y/o
chlordiazepoxide (reducing dose over 5-7 days)
Pabrinex (Vit B complex to replace thiamine)
Delirium tremens
medical emergency die to hyperadrenergic state usually occurring 48-72h after alcohol withdrawal
features include a coarse tremor, altered mental state (severe agitation/hallucinations/confusion), disorientation, tachycardia, HTN, nausea, sweating, insomnia, hyperreflexia
managed with IV benzodiazepines + parbinex
Substance use & addictive disorders
substance related disorders are a class of psychiatric disorder characterised by craving for, the development of tolerance to, difficulties controlling the use of a particular substance/set of substances and withdrawal symptoms upon cessation of substance use
generally more common in males
Features of a substance disorder
≥2 within 1 year
- impaired control (e.g. repeated failed attempts to cut down use, intense desire to obtain/use substance, spending a great deal of time on substance related activities such as buying/using/recovering)
- social impairment (problems fulfilling educational/family/social/occupational obligations, problems with interpersonal relationships, social isolation)
- risky use (use in physically hazardous situations e.g. while driving, continued use despite awareness of problems related to substance use)
- pharmacological indicators (tolerance & withdrawal)
Opioid use disorder
e.g. with fentanyl, heroin, oxycodone, morphine
biggest cause of drug related death
overdose = mitosis, respiratory depression, CNS depression, ↓ GCS, apnoea
Overdose management with naloxone (400 micrograms IM/IV)
detoxification using substitutes such as methadone or buprenorphine
needle exchanges
cocaine use disorder
stimulant drug
intoxication: euphoria, arousal, tachycardia, hypertension, mydriasis, sweating
withdrawal: depression, fatigue, sleep disturbance, anhedonia, suicidal thoughts
overdose: tachycardia, coronary vasospasm, hypertension, hyperthermia, agitation, diaphoresis, mydriasis, seizures
management: benzodiazepines, CBT, motivational interviewing
Complications of cocaine use
psychosis excited delirium hypertensive crisis cerebrovascular event seizures crack lung MI tachyarrythmias mood disorders serotonin syndrome
Cannabis use disorder complications
psychosis (cannabis induced)
anxiety disorders
sleep disorders
cannabinoid hyperemesis syndrome
Benzodiazepine overdose
myadirasis (dilated pupil), hypotension, bradycardia, respiratory depression, apnoea, ↓GCS, ataxia, slurred speech
management with supportive care ± flumazenil
Personality disorders
characterised by deeply rooted egosyntonic behavioural traits that differ significantly from the expected & accepted norms of an individuals culture
personality disorders epidemiology
generally more common in men
histrionic & borderline disorders occur more frequently in women
Cluster A of personality disorders
includes paranoid, schizoid, schizotypal PD
general behaviour:
odd, eccentric, unable to form close interpersonal relationships, classically no psychosis
Cluster B of personality disorders
includes borderline, histrionic, antisocial, narcissistic PD
general behaviour:
dramatic, erratic, emotional
Cluster C of personality disorders
includes avoidant, dependent, obsessive-compulsive PD
general behaviour:
fearful, avoidant, anxious
Paranoid personality disorder
pervasive distrust & suspicion distrust of others reluctance to confide in others unwarranted tendency to question loyalty of others unjustly suspicious of others deceiving/harming them suspicion of infidelity in partners holding grudges fears others are exploiting them
Schizoid personality disorder
voluntary detachment from social relationships
prefers solitary activities
no/little interest in sexual relationships
lacks close friends/people they trust
indifferent to promise/criticism
restricted emotional expression
comfortable with social isolation
Schizotypal personality disorder
odd/eccentric behaviour/physical appearance
magical thinking
social awkwardness
excessive social anxiety
ideas of reference
bizarre thinking/speech (metaphorical & overelaborated)
paranoia & suspicion of others
social anxiety & preference for social isolation
Anti social personality disorder
deceitfulness/manipulative
history of hostility & repeated aggression
deception
repeatedly engaging in criminal activity
impulsivity/failure to plan ahead
reckless disregard for one’s own safety / the safety of others
lack of remorse
emotional indifference to the plight of others
Borderline personality disorder
unstable mood
intense anger that can be difficult to control
feeling of emptiness
self damaging acts (unsafe sex, alcohol, drugs)
self harm/suicidal behaviour
splitting (relationship categorically good or bad)
fear of abandonment
difficulty controlling temper
unstable personal relationships
Histrionic personality disorder
attention seeking dramatic seech exaggerated emotional expression feeling often shallow & unstable sexually provocative and/or seductive behaviour overestimating degree of intimacy suggestibility wants to be centre of attention
Narcissistic personalty disorder
excessive sense of self importance
fantasises disproportionately about power/success
believe in being special/feeling of superiority
great need for affirmation
exploitation of others to achieve own goals
lack of empathy
fragile self-esteem
struggles to deal with criticism
avoidant personality disorder
avoidance of interpersonal contact due to fear of criticism/rejection
restrained intimate relationships due to fear of being shamed
preoccupation with & hypersensitivity to criticism
feeling of inadequacy
low self esteem
avoids taking risks & seldom engaged in new activities
strong desire for social relationships but limited by extreme shyness & social anxiety
Dependent personality disorder
disproportionate need for support
difficulty making everyday decisions
avoids disagreeing with other due to fear of losing their support
always seeking support from others
feeling of helplessness when alone
seeking new relationships when one fails
often stuck in abusive relationships
obsessive compulsive personality disorder
excessive preoccupation with rules/lists/details
obsession with work & productivity at the expense of social relationships/pleasurable activities
perfectionism interferes with task completion
unwillingness to delegate work or collaborate with others
inflexible about matters of morality/ethics
rigid routines
perfectionism & obsession with control
NB unlike OCD there are no intrusive thoughts or repetitive behaviours
Management of personality disorders
psychotherapy group therapy cognitive therapy interpersonal therapy CBT
Anorexia nervosa
An eating disorder characterised by restriction of caloric intake leading to low body weight an intense fear of gaining weight and body image disturbance
most common cause of admission to child&adolescent psychiatric ward
90% of pts are female
usually seen in young adults & adolescents
Risk factors for anorexia nervosa
female gender adolescent & puberty obsessive/perfectionist traits middle/upper socioeconomic classes high pressure career/sports unrealistic beauty standards Family history of eating disorders
associated mental health conditions with anorexia nervosa
OCD
anxiety disorders
mood disorders
personality disorders
Presentation of anorexia nervosa
refusal to maintain normal body weight ↓BMI (generally BMI <18.5) dieting/restrictive eating practices significant preoccupations with thoughts on food rapid weight loss fear of gaining weight body image disturbance excessive exercise amenorrhoea fatigue fainting cold intolercane bradycardia
Investigations for anorexia nervosa
FBC (normocytic normochrmic aneamia, thrombocytopenia) U&Es (↓K+, ↓Na+, ↓Cl-, ↓Mg2+, ↑bicarb) LFTs (↑cholesterol, ↓ albumin) TFTs (↓T3) amylase (↑) FHS/LH/oestrogen/testosterone (↓) impaired glucose tolerance ECG DEXA scan (↓bone mineral density, osteopenia)
Management of anorexia nervosa
assess physical risk via MARSIPAN criteria
Family therapy (if <18y/o)
eating disorder focused CBT (if >18y/o)
nutritional support (vitamin/mineral supplements)
Criteria for hospital admission in anorexia nervosa
BMI <15 bradycardia/hypothermia/hypotension arrhythmias hypoglycaemia dehydration/electrolyte disturbances rapid weight loss suicide risk medical complications
Bulimia nervosa
An eating disorder characterised by recurrent episodes of binge eating followed by behaviours aimed at compensating the binge i.e. purging
mainly affects women, usually in their 20s
Risk factors for bulimia nervosa
parental/childhood obesity
family dieting
body dysmorphia
personal/family history of eating disorders/depression/substance misuse
Presentation of bulimia nervosa
recurrent episodes of binge eating (occurs ~1x per week for 3 months)
recurrent inappropriate compensatory behaviour i.e. purging (vomiting/laxatives/enemas) or non purging (exercise/fasting)
BMI maintained >17.5
concerns about weight/body shape
dental erosion
Russel’s sign (scarring of dorm of hand from inserting into mouth)
preoccupation of food
Investigating bulimia nervosa
normal BMI U&Es (↓K+, ↓Cl-, ↓Ca2+) ABG (↑pH, metabolic alkalosis) FBC (-/↓ Hb) LFTs, creatinine
Management of bulimia nervosa
In adults:
bulimia focused guided self help programme (1st line)
individual eating disorder focused CBT (CBT-ED)
In <18s:
bulimia focused family therapy (1st line)
CBT-ED
trial of fluoxetine
Binge eating disorder
recurrent episodes of binge eating without purging behaviour, feeling lack of control over the amount of food consumed with ≥1 of eating faster than normal/eating until uncomfortably full/feeling of disgust and/or guilt after eating
treatment: CBT ± SSRIs or Lisdexamfetamine
PICA (eating disorder)
eating disorder characterised by appetite for & ingestion of nonnutritive substances
treatment: nutritional rehabilitation & behavioural intervention
Avoidant/restrictive food intake disorder (ARFID)
people eat in a extremely narrow repertoire of foods or having restricted intake in terms or overall amount eaten or both
Treament: CBT in adults
systematic desensitisation (in children)
Body dysmorphic disorder
An excessive preoccupation with an imagined defect in appearance or excessive concern over a slight physical anomaly
onset often in adolescence
Body dysmorphic disorders associated conditions
often associated with OCD and may often coexist with OCD
Diagnostic criteria for body dysmorphic disorder
persistent preoccupation with a perceived flaw in one’s physical appearance
flaws mild/not observable by others
repetitive behaviours (constantly checking the mirror) or thoughts about ones appearance
management of body dysmorphic disorder
Adults:
CBT + exposure & response prevention (ERP)
SSRIs
<18s:
guided self help
CBT+ERP
Dissociative disorders
characterised by the disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment
with abnormalities seen in behaviour, control of motor function & body representation
usually manifests in childhood due to overwhelming traumatic experience in childhood
Dissociation
creative mechanism of survival whereby the mid shields itself by segregating the experience or splitting off into its constituent parts rather than experiencing it as what would be an unendurable whle
Types of dissociative disorder
Dissociative amnesia:
most common
inability to recall autobiographical information about stressful/traumatic event
Depersonalisation/derealisation:
recurrent/persistent episodes of sense of unreality & detachment from oneself (depersonalisation) or sense of unreality with detachment from ones environment (derealisation)
Dissociative identity disorder:
alternation of at least 2 separate personality sates that cause identity disruption & dominant at different time with frequent gaps of recall in normal daily events/personal information
Somatic symptom disorder
individuals have multiple physical symptoms causing significant distress & also have a history of extensive & fruitless diagnostic testing/medical procedures
excessive preoccupation with their symptoms & health concerns over an extended period of time
pt often refuses to accept negative test results
symptoms & motivations are unconscious, symptoms are not intentionally produced
Conversion disorder
pt presents with neurological symptoms (e.g. sensory/motor symptoms) that are not fully explained by a neurological condition
motivation is unconscious, symptoms are not intentionally produced
pts may be calm & unconcerned when describing symptoms
Hypochondriasis/Illness anxiety disorder
presents with persistent preoccupation with having/developing a serious illness despite recurrent medical examinations finding otherwise
major anxiety over helath
somatic symptoms are usually mild/absent
motivation is unconscious
Pseudocyesis
false belief of being pregnant associated with physical signs/symptoms of early pregnancy
common in women who wish to conceive & have a history of several failed attempts
Factitious disorder/Münchausen syndrome
may be imposed on self (Münchausen) or imposed on others (Münchausen by proxy)
individuals intentionally falsify symptoms/signs (physical) even through self harm to assume role of pt
or intentionally falsifies disease signs/symptoms or intentionally induces injuries in others (often a child/ageing parent)
associated with willingness to undergo invasive/risky interventions
occurs in the absence of external rewards
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Adjustment disorder
maladaptive emotional or behavioural response to a stressor lasting <6months following resolution of the stressor
Acute stress disorder
distressing symptoms related to traumatic events that last between 3 days to 1 month following exposure
similar to PTSD but lasting <1 month
Self harm
intentional act of self-poisoning or self injury irrespective of motive or apparent purpose of the act
not an attempt at suicide in most cases
~5% lifetime prevalence
more common in younger people (up to 10% of girls/3% of boys)
50-100x ↑ risk of suicide in 12 month period
Management of self harm
risk assessment
care plan including crisis support
psychological interventions
Suicide
refers to the act of intentionally ending ones life, if that action fails = attempted suicide
suicidal ideation
a preoccupation with ending ones life
Suicide demographics
Males = 3/4 suicides
highest risk in 45-49 y/o age group
NB overall suicide attempts are more common in women but more often unsuccessful
men tend to chose more violent methods e.g. hanging while women chose things like overdose
Risk factors for suicide
previous suicide attempt psychiatric disorders male sex (↑ risk of completed suicide) previous self harm unemployment social isolation/living alone being unmarried/divorced/widowed history of chronic illness recent contact with mental health services
protective factors for suicide
having children at home
having a support network
strong religious faith
family support
Indicator for upcoming suicide attempt
sudden improvement of symptoms in a depressed pt may indicate imminent suicide plan
Risk factors for completed suicide after attempted suicide
efforts to avoid discovery previous planning leaving a written note violent method finals acts e..g sorting finances perception of no social support hopelessness no plans for future feeling of entrapment regret at being found significant pain/chronic physical illness
Management of suicide
suicide risk assessment
care plans (MDT focused with short & long term management)
counselling
regular follow up
take care with medication e.g. SSRIs may initially ↑ suicidal ideation/behaviour
Autism spectrum disorder (ASD)
characterised by persistent impairments in social communication/interaction & restrictive, repetitive and stereotyped patterns of behaviours/interests/activities
Epidemiology of autism spectrum disorder
~1% of population affected
4:1 male:female ratio
~50% have intellectual disability
Presentation of autism spectrum disorder in childhood
delay/absence of spoken speech
lack of pretend play
not engaging with others
lack of imitation of activity/social play
impaired non-verbal communication
unusual repetitive hand/finger mannerisms
unusual/lack of reaction to sensory stimuli
easily overwhelmed by social stimuli
Presentation of autism spectrum disorder in adults/adolescent
long standing difficulties in social behaviours/communication/coping with change
socially naive
language/social/non-verbal communication problems
difficulty making/maintaining friendships
lack of awareness of personal space & social norms
rigid thinking & behavioural preferences
trouble obtaining/sustaining employment/education
Management of autism spectrum disorder
early educational & behavioural interventions family support & counselling social programmes CBT psychosocial interventions
Pharmacological
- SSRIs (for anxiety, aggression, repetitive stereotyped behaviours)
- antipsychotics (for aggression & self-injury)
- methylphenidate (for ADHD)
ADHD
neurodevelopment disorder presenting with inattentiveness, impulsivity & hyperactivity persisting into adulthood
affected ~5% of children
usually diagnosed around age 3-7 yrs
3:1 male:female ratio
Diagnosis of ADHD
≥Six of the following symptoms of inattention have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social or academic/occupational activities. For older adolescents and adults (age 17 years and older), at least 5 symptoms are required.
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
- Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
- Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
- Often has difficulty organising tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganised work; has poor time management; fails to meet deadlines).
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
- Often loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
- Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
Hyperactivity-impulsivity
≥Six of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social or academic/occupational activities.For older adolescents and adults (age 17 years and older), at least 5 symptoms are required.
- Often fidgets or taps with hands or feet, or squirms in seat.
- Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
- Often runs about or climbs excessively in situations where it is inappropriate (note: in adolescents or adults, may be limited to feeling restless).
- Often unable to play or engage in leisure activities quietly.
- Is often ‘on the go’ or acting as if ‘driven by a motor’ (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
- Often talks excessively.
- Often blurts out an answer before a question has been completed (e.g., completes other people’s sentences; cannot wait in turn in conversation).
- Often has difficulty waiting his or her turn (e.g., while waiting in line).
- Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).
Management of ADHD
Behavioural interventions = 1st line
Pharmacotherapy:
1st line = methylphenidate
2nd line = lisdexamfetamine/atomoxetine
NB lower threshold for pharmacotherapy in adults
Tourettes syndrome & tic disorders
Tourettes is a childhood onset neurodevelopment disorder characterised by motor & vocal tics and often accompanied by psychiatric problems e.g. OCD & ADHD
peak of symptoms usually around start of puberty
more common in males
Presentation of tourettes
Tics: temporarily suppressible, an urge/sensation preceding the tick is relieved by its onset
vocal tics: e.g. throat clearing, grunting, lip smacking, barking, swearing
motor tics: e.g. facial grimacing, blinking, head jerking
other features:
echolalia (copying others words), palalia (repeating one’s own words), copropraxia (making obscene gestures), coprolalia (compulsively saying dirty words)
NB coprolalia is pathognomonic
Management of tourettes
behavioural & psychosocial interventions
habit reversal training
pharmacological
Haloperidol (only licensed drug)
alpha adrenergic agonists e.g. clonidine
Learning disabilities
defined as a reduced intellectual ability & difficulty with everyday activities with onset in childhood
degree of disability can vary
NB this is presentation not a diagnosis, is usually linked to conditions such as Down’s syndrome or Turners syndrome
Core criteria of Intellectual disability
↓ intellectual ability (IQ<70)
significant impairments of social/adaptive functioning
onset in childhood
Examples of Typical antipsychotics
haloperidol
chlorpromazine
perphenazine
fluphenazine
MOA of typical antipsychotics
dopamine D2 receptor antagonists, blocking dopaminergic transmission in mesolimbic pathways of brain
Route of administration for typical antipsychotics
all can be given oral
NB haloperidol & fluphenazine can be given as long acting depots
typical antipsychotics available in depot form
haloperiodl
fluphenazine
Side effects of typical antipsychotics
Extrapyramidal side effects
hyperprolactinaemia (leading to gynaecomastia, amenorrhoea, galactorhoea)
sedation
anticholinergic effects (dry mouth, constipation, urinary mention, blurred vision)
Cardiac affects (prolonged QTc especially with haloperidol)
orthostatic hypotension
neuroleptic malignancy syndrome
Cause of hyperprolcatinameia with typical antipsychotics
duo to blockage of dopamine receptors in the tuberoinfundibulnar pathway which usually inhibit prolactin production
Cardiac side effect of of typical & atypical antipsychotics
↑QT interval which can lead to arrhythmia
Examples of atypical antipsychotics
clozapine olanzapine risperiodne aripripazole quetiapine
MOA of atypical antipsychotics
serotonin-dopamine receptor antagonists working on a variety of receptors, mainly 5-HT2 & D2 receptors
atypical antipsychotics available in long acting forms
risperidone
olanzapine
aripriprazole
Side effects of atypical antipsychotics
metabolic side effects (↑ weight, metabolic syndrome) agranulocytosis (mainly clozapine) ↓ seizure threshold (mainly clozapine) hyper salivation (mainly clozapine) cardiac (prolonged QT interval) sedation hyperprolactinaemia (most common with risperidone) anticholinergic effects (uncommon) neuroleptic malignancy syndrome
Side effects that are more common in typical antipsychotics
anti pyramidal side effects
hyperprolactinaemia (more severe with typical antipsychotics)
anticholinergic effects
Monitoring patients on antipsychotics
FBC/U&Es/LFTs:
at beginning & then annually
NB clozapine needs weekly FBC initally
Lipids & weight:
baseline, at 3 months, then annually
Fasting glucose, prolactin:
at baseline, at 6 months, then annually
BP:
baseline
ECG:
baseline, then every 1-3 months
Extrapyramidal side effects
more common with typical antipsychotics
may occur with atypical but usually on dose escalation
occur due to inhibition of nigrostriatal dpomainergic pathways
Acute dystonia presentation
develops over hours to days
painful & sustained muscle spasms & stiffness predominantly affecting the head, neck, tongue
include torticollosis, facial grimacing, tongue protrusion, oculogyric crisis (episodic spasmodic upward movement of eye lasting several minutes)
Management of acute dystonia
anticholinergics or antihistamines:
1st line: procyclidine or benztropine
switch antipsychotics
consider secondary prophylaxis with benztropine/procyclidine
Pseudoparkinsonism
acute onset usually within 1 week
presents with cogwheel rigidity, stiff gait, bradykinesia, tremor
NB bilateral symptoms are common in drug induced parkinsonism
Management:
dose reduction/switching antipsychotics
anti cholinergic e.g benztropine/procyclidine
dopamine agonists e.g. amantadine/bromocriptine
Akathisia
onset usually in first 8 weeks
movement disorder characterised by restlessness/a compelling urge to move & inability to sit/stand still, being fidgety
management:
↓ dose/switch antipsychotic
beta blockers: propanol (1st line)
Tardive dyskinesia
develops after years, ↑ risk with age
characterised by abnormal involuntary movements of mouth/face/tongue/limbs/respiratory muscles
including repetitive chewing, lip smacking, choleric movements, pouting of the jaw, tongue protrusion, body rocking
NB may be irreversible
Management:
discontinue antipsychotics
switch to atypical especially clozapine/quetiapine
Neuroleptic malignant syndrome (NMS)
rare but potentially life threatening idiosyncratic complication of treatment with antipsychotic medication
the underlying mechanism is not fully understood
relatively rare
Presentation of neuroleptic malignant syndrome (NMS)
autonomic instability:
hyperthermia, tachycardia, dysrhythmias, labile BP, tachypnoea, diaphoresis, urinary incontinence
muscle rigidity (lead pipe rigidity) akinesia tremor hyporeflexia confusion delirium stupor agiatation
Onset:
usually hours to days (within 10 days) after starting an antipsychotic
gradual onset over 1-3 days
Investigations for neuroleptic malignant syndrome (NMS)
creatine kinase (↑↑) FBC (↑WBC) U&Es (normal) Ca2+ (↑) LFT (↑ transmainases) myoglobin in urine/blood ABG (metabolic acidosis)
Management of neuroleptic malignant syndrome (NMS)
stop antipsychotics
transfer to ITU/HDU
IV fluids to counteract renal failure
Dantrolene
Serotonin syndrome vs neuroleptic malignant syndrome (NMS)
Serotonin syndrome caused by SSRIs/MAOIs/MDMA/Ecstasy
NMS caused by antipsychotics
serotonin syndrome has faster onset (~24h) while NMS usually develops over 1-3 days
serotonin syndrome presents with hyperreflxia while NMS has hyporeflexia
Examples of selective serotonin reuptake inhibitors (SSRIs)
fluoxetine paroxetine sertraline citalopram escitalopram
Preferred SSRI post MI
sertraline
Preferred SSRI in children
fluoxetine
MOA of SSRIs
inhibit reuptake of serotonin in CNS synapses thus leading to ↑ intrasynaptic serotonin levels
Indications for SSRIs
depression OCD Generalised anxiety disorder PTSD panic disorders bulimia nervosa social anxiety disorder binge eating disorder
Adverse effects of SSRIs
GI symptoms = most common (diarrhoea, nausea, constipation)
sexual dysfunction
agitation
insomnia
↑ QT interval (with citalopram/escitalopram)
serotonin syndrome
SSRIs in pregnancy
↑ risk of congenital heart defects
↑ risk fo PPHN
NB paroxetine has highest risk associated
Onset of action of SSRIs
roughly 4-6 weeks after commencing
NB there may be ↑ suicidal thoughts in the period before effect is shown
Interactions of SSRIs
NSAIDs (if given together must prescribe PPI)
warfarin/heparin/aspirin (use mirtazepine)
serotonergic drugs e.g. MAOIs/triptans/St Johns wart (↑ risk of serotonin syndrome)
Examples of serotonin noradrenaline reuptake inhibitors (SNRIs)
duloxetine
venlafaxine
desvenlafaxine
MOA of SNRIs
inhibition of serotonin & noradrenaline reuptake in the CNS synaptic cleft leading to ↑ serotonin & noradrenaline levels
Indications for SNRIs
GAD
Depression (2nd line)
neuropathic pain
stress incontinece (duloxetine)
fibromyalgia (duloxetine)
SAD/OCD/PTSD (venlafaxine)
Adverse effects of SNRIs
insomnia GI symptoms sexual dysfunction ↑ BP ↑ cholesterol/triglycerides serotonin syndrome
Tricyclic antidepressants (TCAs) examples
amitriptyline
imipramine
clomipramine
lofepramine
MOA of TCAs
inhibition of serotonin & noradrenaline reuptake in syntactic cleft but less selectively than SNRIs or SSRIs
Indications for TCAs
depression
neuropathic pain
chronic pain (including fibromyalgia)
migraine prophylaxis
OCD (clomipramine) nocturnal enuresis (imipramine)
Adverse effects of TCAs
risks of lethal overdose
orthostatic hypotension
cardiac effects (↑ QT interval, wide QRS arrhythmia)
tremor
anticholinergic effects (tachycardia, sedation, constipation, dry mouth, dry skin)
serotonin syndrome
Monoamine oxidase inhibitors (MAOIs) examples
selegiline
phenelzine
MOA of MAOIs
non-selective: inhibition of monamine oxidase = ↓ monoamine breakdown (noradrenaline/adrenaline/serotonin/dopamine) ↑monamine levels
selective MAO-B inhibition (e.g. selegiline) = mainly ↓ dopamine breakdown
Adverse effects of MAOIs
sexual dysfunction
weight gain
orthostatic hypotension
hypertensive crisis when eating food counting thiamine e.g. cheese
Serotonin antagonist & reuptake inhibitor
e.g. trazodone
used in insomnia, depression
may cause priapism, sedation, orthostatic hypotension
Mirtazepine
atypical antidepressant that blocks alpha2-adrenergic receptors causing ↑ release of neurotransmitters
useful in older people, those with insomnia/poor appetite
Side effects:
sedation (take in evening)
↑ appetite/weight gain
Bupropion
used for smoking cessation & depression
not associated with sexual dysfunction or weight gain
contraindicated with pt has eating disorders or seizures`
Antidepressant discontinuation syndrome
caused by abrupt withdrawal/dose reduction of antidepressants take for ≥4 weeks
typically occurs within 3 days of drug cessation
presentation:
flu like symptoms, insomnia, nausea, imbalance, sensory disturbance (electric shock sensations), hyperarousal, irritability
Management of antidepressant discontinuation syndrome
restart antidepressant therapy (slowly tapper dose if trying to change dose/stop)
taper dose over 4 weeks (not necessary with fluoxetine)
NB paroxetine has ↑ risk of this syndrome
key uses for mirtazepine
underweight/poor appetite pts with depression
elderly people ( due to fewer side effects and interactions)
pts with insomnia & depression
Serotonin syndrome
a life threatening condition cause by serotonergic overactivity due to excess of synaptic serotonin in the CNS usually due to therapeutic use or overdose of serotonergic drugs
Causes of serotonin syndrome
generally if combination of sertonergic drugs (i.e. taking ≥2, or when switching serotonergic medications without tapering)
MAOIs, SSRIs, SNRIs, TCAs
lithium, tramadol, fentanyl, ondansetron, metoclopromide
cocaine, MDMA, amphetamines, LSD
Presentation of serotonin syndrome
classic triad of neuromuscular excitability, autonomic dysfunction, altered mental state with onset over ~24h
neuromuscular excitation:
hyperreflexia, myoclonus, rigidity, tremor, ataxia
autonomic dysfunction:
hypertension, tachycardia, hyperthermia, diaphoresis, mydriasis
altered mental state:
anxiety, agitation, confusion, coma, psychomotor agitation, delirium, seizures
Management of serotonin syndrome
immediate discontinuation of serotonergic drugs
supportive care (IV fluids, bentos, antihypertensives)
serotonin antagonists:
cryptoheptadine or chlorpromazine
Mood stabilisers
a type of drug used to treat acute mania and/or prevent relapses of manic or hypomanic episodes
drugs include lithium, valproate/valproic acid, lamotrigine, carbamazepine
Lithium
psychiatric mood stabilising drug with a very narrow therapeutic window range (0.4 - 1.0mmol/L) & long plasma half life
primarily excreted by the kidney
Lithium therapeutic range
0.4-1.0mmol/L
Indications for lithium therpay
1st line mood stabiliser for bipolar disorder
adjunct therapy in refractory depression
Adverse effects of lithium
nausea, diarrhoea, weight gain, dry mouth fine tremor (none progressive, symmetric, fine postural tremor) acne worsening psoriasis nephrogenic diabetes insidious chronic interstitial nephritis idiopathic intracranial hypertension leucocytosis T wave flattening & inversion Teratogenic
Key drug interactions of lithium
ACE-Is
diuretics (particularly thiazide diuretics)
NSAIDs
SSRIs
Monitoring lithium
TFTs & Renal function:
check baseline & every 6 months
ECG:
at baseline and regularly during treatment
Monitoring lithium levels
take 12h post dose
take levels 7 days post change of dose
take weekly when initiating treatment or after changing dose until levels are stabilised
when levels stabilised measure 3 monthly for first year & then 6 monthly thereafter
Lithium toxicity
generally occurs in levels >1.5mmol/L
may be precipitated by dehydration, ↓renal function, concurrent infections
Features:
nausea, vomiting, diarrhoea, coarse tremor, altered mental state, slurred speech, fasciculations, renal failure
Management:
IV fluids, electrolyte correction
stop lithium
Sodium Valproate/Valproate/Valprooic acid
1st line medication used in general tonic clonic seizures but used in established status epileptics
2nd line mood stabiliser in bipolar disorder
adverse effects teratogenic P450 inhibition thrombocytopenia alopecia
Monitoring:
LFTs
FBC
Carbamazepine
1st line treatment of partial seizure
but also used in trigeminal neuralgia & bipolar
Adverse effects: P450 inducer Steven Johnson syndrome SIADH agranulocytosis teratogenic
Lithium in pregnancy
Teratogenic, especially causing cardiac malformations particularly Ebstein anomaly (characterised by low insertion of the tricuspid valve resulting in a large atrium and small ventricle. It is sometimes referred to as ‘atrialisation’ of the right ventricle.)
Lamotrigine
2nd line medication for epilepsy
also used as mood stabiliser in bipolar
Adverse effects:
steven johnson syndrome
Gi symptoms
Benzodiazepine examples
Lorazepam/Diazepam/Clonazepam (long acting)
midazolam/oxazepam (short acting)
Indications for benzodiazepines
sedation hypnotics anxiolytics anticonvulsants muscle relaxants
Adverse effects of benzodiazepines
dizziness
confusion
headache
tolerance commonly develops
Benzodiazepine overdose
Features:
CNS depression, respiratory depression, ataxia, slurred speech, hypotonia, hyporreflexia,
management:
supportive therapy
Flumazenil
Benzodiazepine dependence
can develop quickly over a couple fo weeks
should be prescribed as short courses of 2-4 weeks
if stopping benzodiazepines withdraw them slowly in stepwise dose reduction
Barbiturates
Examples
phenobarbitol, thiopental
rarely used due to superior safety of benzodiazepines
worse side effects and easier to overdose than benzodiazepines
Electroconvulsive therapy (ECT)
involves unilateral/bilateral electrode placement over non dominant hemisphere to induce tonic-clonic seizures under sedation
Indications:
refractory/life threatening psychiatric conditions (e.g. catatonia, depression with psychiatric features, schizophrenia, bipolar)
may be used in pregnancy for example
adverse effects:
reversible memory loss
transient muscle pain
N&V
Behavioural therapy
treatment approach based on clinically applying theories of behaviour
aim= change harmful & unhelpful behaviours and individual may have
Cognitive therapy
clinically applying research into role of cognition in the development of emotional disorders looking at how people think about & create meaning about situations/symptoms/events in their lives and their development of beliefs about themselves/others/the world
challenging ways of thinking to help produce more helpful & realistic patterns of thought
cognitive behavioural therapy (CBT)
indications:
depression, GAD, panic disorder, OCD, body dysmorphic disorder, PTSD, eating disorders)
Aims:
to adjust distorted, harmful, irrational or ineffective beliefs, attitudes & behaviour patterns
and teaches skills & strategies to help pt alter abnormal behaviour/beliefs
Family therapy
identifies family dysfunctions & individual problems
used in schizophrenia & eating disorders
Psychodynamic therapy
psychological interpretation of mental & emotional processes
to help people develop insight into their behaviours, feelings, thoughts, emotions
used in anxiety disorders
Interpersonal therapy (ITP)
aims to develop understanding of problematic interpersonal relationships to enable pt ti better control their mood & behaviour
used in depression, bipolar, postpartum depression
Mental health act (MHA)
legislation from 1983
mainly piece of legislation covering assessment, treatment and rights of people with mental health disorders
Pts specifically excluded from mental health act
pts under influence of drugs/alcohol
pts with learning disabilities unless associated with abnormally aggressive or seriously irresponsible conduct
Applying mental health act (MHA) and mental capacity act (MCA)
the MHA always trumps the mental capacity act, so in a situation where both can be applies the MHA should be used
Key points of mental health act
mental disorder: any disorder/disability of the mind
act is only for treatment of mental disorders not physical health problems
use principle of least restraint
Criteria for detention under mental health act
pt must be suffering from a mental disorder of a nature and/or degree that makes it appropriate & necessary for them to be detained in hospital in the interest of their own health/safety or the protection of others
appropriate treatment must be available
Section 2
detention for assessment and/or treatment
Duration: 28 days (cannot be renewed)
allows for compulsory treatment against pts wishes
requires 2x section 12 approved doctors + 1x approved mental health practitioner
Section 3
detention for treatment
Duration: 6 months (can be renewed for 6 months & then annually)
treatment may be given against pts wishes
requires 2x section 12 approved doctors + 1x approved mental health practitioner
Nearest relative (NR) role under mental health act (MHA)
is identified by approved mental health practitioner (AMHP)
NR has rights under MHA inculding
- apply for sectioning of pt
- object to a section
- apply for pt to be discharged
Section 4
emergency detention for assessment
Duration: 72h, cannot be renewed
does not allow for treatment against pts wishes
requires 1x doctor or approved mental health practitioner (AMHP)
Section 5
Detention of hospital inpatients
only applied to pts that are admitted to hospital (does not apply to pts in A&E)
Does not allow treatment against pts wishes
Section 5(2) = doctors holding power, pt detained for up to 72h
Section5(4) = nurses holding power, pt involuntarily defined for up to 6h
Section 135
Approved mental health practitioner (AMHP) applies to magistrate court for warrant to enter private premises & remove pt with help of police when there is a reasonable cause to suspect mental disorders/neglect/unable to care fro themselves
held up to 72h in place of safety
Section 136
Police detain someone found in a public place who appears to have a mental disorder/be in immediate need for care/risk to self or others and bring them to a place fo safety (e.g. hospital)
pt held for 24h, may be extended by 12h
for assessment
Fitness to plead
assessed via Pritchard criteria
- understands charges
- deciding whether to plead guilty or not
- exercising right to challenge a juror
- follow course of proceedings
- instructs lawyer
- giving evidence in own defence
Insanity in the eye of law
Assessed by McNaughton rules:
at the time of committing of the act the party accused was labouring under such a defect of reason, from disease of the mind as to not know the nature & quality of the act they were committing or if they did know they did not know what they were doing was wrong
if legally insane = hospital order/supervision/treatment
Mental health review tribunal (MHRT)
pts have right to appeal their MHA detention
Section 132 requires pts to be read their rights weekly
MHRT is completely independent
Pt is allowed 1 appeal per detention period & is represented by a solicitor
the burden of proof is with the detaining authority not the pt
Mental capacity act (MCA)
provides the legal frame work fro acting & making decisions on the behalf of an individual who lacks the mental capacity to make particular decisions for themselves
NB mental disorder does not guarantee lack of capacity
Key points of Mental capacity act (MCA)
The Act contains 5 key principles:
1) A person must be assumed to have capacity unless it is established that they lacks capacity
2) A person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success
3) A person is not to be treated as unable to make a decision merely because they makes an unwise decision
4) An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in their best interests
5) Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is least restrictive of the person’s rights and freedom of action
Two stage test of capacity
1) does the person have an impairment of the mind or brain or is there some sort of disturbance affecting the way their mind works
2) if so does they impairment or disturbance mean that the person is unable to made the decision in question at the time it needs to be made
When are people assumed to lack capacity
Individual is presumed to have capacity & make decision unless they:
1) are unable to understand the information material to the decision (must be able to provide info at appropriate levels & in an understandable way e.g. with translator)
2) are unable to retain that information
3) are unable to use or weigh up the information provided as part of the process of decision making
4) are unable to communicate their decision
Deprivation of liberties (DoLS)
applied when MCA is used in such a way to deprive a person of their liberties i.e. their not free to leave / subject to continuous supervision & control
authorisation lasts up to 1 year & cannot be extended
Reasons causing elevated clozapine levels
smoking cessation can significantly raise clozapine levels
Management of catatonia
Electro convulsive therapy
used for severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms.
Adverse effects of ECT (Electroconvulsive therapy)
Short-term side-effects
- headache
- nausea
- short term memory impairment
- memory loss of events prior to ECT
- cardiac arrhythmia
Long-term side-effects
-some patients report impaired memory
