Psychiatry Flashcards
obsession v compulsion
· Obsession = intrusive unpleasant and unwanted thought/image/urge
Compulsion = repetitive senseless action taken to reduce the anxiety caused by the obsession
syndrome of person believing they are dead or non-existent
cotard syndrome
lithium SE
• N/V/D
• fine tremor
• nephrotox: polyuria, secondary to nephrogenic diabetes insipidus
• thyroid enlargement, can»_space; hypothyroidism
• ECG: T wave flattening/inversion
• weight gain
• idiopathic intracranial hypertension
• leucocytosis
hyperparathyroidism and resultant hypercalcaemia
lithium monitoring
- how to and when to
- what else needs monitoring
Monitoring
- inadequate monitoring is common - an exam hot topic - when checking lithium levels: sample 12 hours post-dose - after starting lithium: levels weekly + after each dose change until concentrations are stable - once established, lithium should 'normally' be checked every 3 months - after a change in dose: level should be taken a week later and weekly until the levels are stable. - TFTs and renal function: every 6 months
lithium therapeutic range
0.4-1
which ssri to use when
Pref SSRIs: fluoxetine, citalopram
- Children/teens: fluoxetine (caution w SSRIs generally)
- Post-MI: sertraline
Caution w citalopram RE QT interval
SE of SSRI
SE: GI syms most common. Increased risk of GI bleed.
low Na
After starting can be more anxious/agitated
Citalopram/escitalopram: dose-dep QT interval prolongation. (max dose 40mg in adults, 20 in >65y old or hepatic impairment)
interactions of SSRIs
- Fluoxetine/paroxetine have higher propensity for drug interactions
- NSAIDs/aspirin: ‘do not normally offer SSRIs’, but if given co-prescribe a PPI
- warfarin/heparin: avoid SSRIs and consider mirtazapine
- Triptans/MAOIs increased risk of serotonin syndrome
if on triptans avoid SSRI
if good response how long to conitnue on SSRI
If good response: continue on tx for at least 6 months after remission as this reduces the risk of relapse.
discontinuation symptoms
how to prevent
what ssri causes these syms most
When stopping: reduce dose gradually over 4 weeks
- (don’t need to w fluoxetine). - Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms • increased mood change • restlessness • difficulty sleeping • unsteadiness • sweating • GI syms: pain, cramping, diarrhoea, vomiting Paraesthesia
ssris in pregnancy - safe?
SSRIs and pregnancy
• Use in first trimester: small increased risk of congenital heart defects
• Use in third trimester can > persistent pulmonary hypertension of the newborn
• Paroxetine: increased risk of congenital malformations, esp in first trimester
delusion that a famous is in love with them, with the absence of other psychotic symptoms
de clerambault’s syndrome
believe a relative/friend has been replaced by an identical imposter
capras syndrome
pt believes different people are the same person in disguise
fregoli delusion
delusion of sexual infidelity on part of a sexual partner
othello syndrome
mx of PTSD
• Mild syms <4wks: watchful waiting may be used
• More severe: trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) therapy
• drug treatments should not be routine first-line treatment for adults.
○ venlafaxine or SSRI, such as sertraline should be tried
Severe: risperidone may be used
conversion disorder
somatisation
hypochondriasis
Conversion disorder: usually involves loss of motor or sensory function. May be caused by stress
Somatisation: multiple physical symptoms for >2y
Hypochondriasis: persistent belied in presence of an underlying serious disease
couvade syndrome
fathers suffer somatic features of pregnancy
atypical antipsychotics
- used for?
- why are they better than older ones?
- SE (5)
- EG of them
Examples of atypical antipsychotics
• clozapine
• olanzapine: higher risk of dyslipidemia and obesity
• risperidone
• quetiapine
• amisulpride
• aripiprazole: generally good SE profile, esp for prolactin elevation
Use: 1st line for schizophrenia
Adv: sig reduction in EPSE
SE
- Weight gain - Hyperprolactinaemia - Clozapine: agranulocytosis - In elderly: increased risk of stroke and VTE
clozapine
- when to use
- SE
- when might you need to change dose
- Only use if schizophrenia is not controlled despite the sequential use of two or more antipsychoticss (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.
SE of clozapine
• agranulocytosis (1%), neutropaenia (3%)
• reduced seizure threshold - can induce seizures in 3% of pts
• constipation
• myocarditis: baseline ECG should be taken before starting tx
• Hypersalivation
Dose adjustment might be necessary if smoking is started or stopped during tx
RF for suicide (8)
RF of a previous attempt that increases risk in future (5)
protective factors (3)
RF: • Male • history of deliberate self-harm • alcohol or drug misuse • history of mental illness: depression, schizophrenia (10% w schizo will complete suicide) • history of chronic disease • advancing age • unemployment or social isolation/living alone • being unmarried, divorced or widowed
If has attempted suicide, factors ass w an increased risk of completed suicide at a future date:
• efforts to avoid discovery
• planning
• leaving a written note
• final acts such as sorting out finances
• violent method
Protective factors
• family support
• having children at home
religious belief
diff between mania and hypomania
Mania:
- >7ds - severe functional impairment in social or work setting - Psychotic symptoms - Might need hospitalisation due to risk of harm to self or others
Hypomania: <7ds (usually 3-4ds), no impairment of function, no psychotic syms, unlikely to need admission
EPSE - types and mx
- parkinsonism
- akathisia (severe restlessness)
- tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, 40% pts, may be irreversible, most common is chewing and pouting of jaw)
- acute dystonia: sustained muscle contraction (e.g. torticollis, oculogyric crisis) - mx procyclidine
se of typical antipsychotics (apart from epse)
Elderly: increased risk of VTE and stroke
Other side-effects
- antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
- sedation, weight gain
- raised prolactin - can > galactorrhoea
○ due to inhibition of the dopaminergic tuberoinfundibular pathway
- impaired glucose tolerance
- neuroleptic malignant syndrome: pyrexia, muscle stiffness
- reduced seizure threshold (greater with atypicals)
prolonged QT interval (particularly haloperidol)
typical v atypical antipsychotics
- action
- SE
typical: Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
- EPSE and high prolactin common
- haloperidol, chlorpromazine
atypicals Act on a variety of receptors (D2, D3, D4, 5-HT) EPSE and high prolacitn less common metabolic effects Clozapine Risperidone Olanzapine
whats the strongest RF for psychotic disorders
FHx
TCAs
- SE
- which 2 are most dangerous in OD
- which is least dangerous
Common side-effects • drowsiness • dry mouth • blurred vision • constipation • urinary retention • lengthening of QT interval
Choice of tricyclic
• low-dose amitriptyline: neuropathic pain and prophylaxis of headache ( tension or migraine)
• Lofepramine: lower incidence of toxicity in overdose
amitriptyline and dosulepin (dothiepin): most dangerous in OD
physical and medication causes of anxiety to r/o
- Hyperthyroidism
- cardiac disease
- medication-induced anxiety: salbutamol, theophylline, corticosteroids, antidepressants and caffeine
GAD mx
- 1: education about GAD + active monitoring
- 2: low-intensity psych interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
- 3: high-intensity psychological interventions (CBT or applied relaxation) or drug treatment.
- 4: highly specialist input e.g. Multi agency teams
Drug treatment
• 1st line: sertraline
• ineffective, offer an alternative SSRI or a SNRI (EG duloxetine and venlafaxine)
• If can’t SSRIs or SNRIs: offer pregabalin
<30y old: warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up for the first month
panic disorder mx
• 1: recognition and diagnosis
• 2: treatment in primary care: CBT or drugs
○ 1st line SSRI
○ If CI or no response by 12wkL imipramine or clomipramine
• 3: review and consideration of alternative treatments
• 4: review and referral to specialist mental health services
5: care in specialist mental health services
bulimiia mx
- whats the only med licensed?
• referral for specialist care
• Adults: bulimia-nervosa-focused guided self-help
• If unacceptable, CI, or ineffective after 4 weeks: individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
• Children: bulimia-nervosa-focused family therapy (FT-BN)
Pharm tx have limited role - a trial of high-dose fluoxetine is currently licensed for bulimia
ECT - tx for? - absolute CI (1) - short term SE (5) long term SE 1
Tx: severe depression refractory to medication with psychotic symptoms
Absolute CI: raised ICP
Short term SE:
- Short-term memory impairment - Headache - Nausea - Memory loss of events prior to ECT - Cardiac arrhythmia
Long term SE: some report impaired memory
benzodiazepine
- pharm action?
- how to withdraw
- withdrawal fts
Enhance the effect of GABA (main inh neurotransmitter) by increasing frequency of chloride channels
On how to withdraw a benzodiazepine.
- withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight.
- A suggested protocol for patients experiencing difficulty is given:
○ switch patients to the equivalent dose of diazepam
○ reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
○ time needed for withdrawal can vary from 4 weeks to a year or more
If patients withdraw too quickly: - may occur up to 3 weeks after stopping a long-acting drug. · insomnia • irritability • anxiety • tremor • loss of appetite • tinnitus • perspiration • perceptual disturbances Seizures
Alcohol withdrawal peak incidence of
- Symptoms
- Seizures
DT
- Symptoms 6-12h
- Seizures 36h
DT 72h
- Seizures 36h
poor prognostic indicators for schizophrenia
- Strong FHx
- Gradual onset
- Low IQ
- prodromal phase of social withdrawal
- Lack of obvious trigger
diabetic neuropathy 1st line
duloxetine
atypical antipsychotic pharm action
- Block serotonin receptors (esp 5-HT2) + D2 dopamine recs
when stopping SSRI how do you do it?
which one is an exception
When stopping, gradually reduce dose over 4wk (except fluoxetine: longer half life so don’t need to)
anorexia
- fts
- blood abns
Features • reduced body mass index • bradycardia • hypotension • enlarged salivary glands
Physiological abnormalities - hypokalaemia - low FSH, LH, oestrogens and testosterone - raised cortisol and growth hormone - impaired glucose tolerance - hypercholesterolaemia - hypercarotinaemia low T3
fts to suggest depression over dementia
- short history, rapid onset
- biological syms e.g. weight loss, sleep disturbance
- patient worried about poor memory
- reluctant to take tests, disappointed with results
- mini-mental test score: variable
- global memory loss (dementia characteristically causes recent memory loss)
