Psychiatry Flashcards
What should you cover in a psychiatric history?
HOPC Past psychiatric hx PMhx Drug hx, concordance with meds & side effects of psychiatric medication Social hx Personal hx Premorbid personality Strengths Carer responsibility Forensic hx Family hx
What should you cover in a risk assessment for someone with psychiatric symptoms?
Risk to self Risk to others Risk of self neglect Risk of exploitation Risk to dependents Other risks - absconding
What should you include in a mental state examination? 8 things
Appearance Behaviour Speech Mood and effect Thoughts - form, content, possession Perceptions Cognition Insight
What should you evaluate for the appearance of a person during a MSE?
Distinctive features Clothing Posture/gait Grooming/hygiene Evidence of self-harm
What should you evaluate for the behaviour of a person during a MSE?
Eye contact
Facial expression
Psychomotor activity –motor activity related to mental processes (can be slowed or increased)
Body language / gestures / mannerisms
Level of arousal –calm / agitated /aggression
Rapport / engagement
How should you evaluate the speech of a person during a MSE?
Rate of speech– pressured / slowed
Quantity of speech– minimal(e.g.only in response to questions) /excessive speech/complete absence of speech. Spontaneous?
Tone of speech –monotonous / tremulous
Volume of speech –loud / quiet
Fluency and rhythm of speech–articulate / clear / slurred
How should you evaluate the mood and affect of a person during a MSE?
Mood – their description
Affect – your observation
Quality of affect:
Sad/agitated/hostile
Euphoric/animated
Range of affect:
Restricted
Normal
Expansive
Intensity of affect:
Normal
Blunted
Flat
Fluctuations in affect:
Labile –easily changed between states
How should you evaluate a persons thoughts during a MSE?
FORM
Speed –accelerated / racing / retarded
Flow/ coherence:
Linear – in a logical order
Incoherent – makes no logical sense
Circumstantial – lots of irrelevant/unnecessary details (not to the point)
Tangential – the patient goes off on tangents relating loosely to the initial thought (flight of ideas)
Perseveration –repetition of a particular response despite the absence/removal of the stimulus
CONTENT Abnormal beliefs/ delusions Obsessions –patient is aware they are their own irrational Suicidal thoughts Homicidal/violent thoughts
POSSESSION
Thought insertion –belief that thoughts can be put into the patient’s mind
Thought withdrawal –belief that thoughts can be removed from patient’s mind
Thought broadcasting –belief that others can hear the patient’s thoughts
How should you evaluate a persons perceptions during a MSE?
Hallucinations –a sensory perception without any external stimulation of the relevant sensethat the patient believes IS real(e.g. hears voices but no sound present)
Illusions –illusions are misinterpreted perception such as mistaking a shadow for a person
How can you test someones cognition during a MSE?
Basic testing:
Orientation(time/place/person)
Attention and concentration
Short-term memory
How can you test if someone has insight during a MSE?
Can they recognise what they’re experiencing is abnormal?
What do they think is the cause of their experiences?
Do they want help with their problem?
What is acute stress reaction?
An acute stress reactions that occurs in the first 4 weeks after a person has been exposed to a traumatic events (PTSD is diagnosed after 4 weeks)
features of acute stress reaction
intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance
Mx of acute stress reaction
trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
benzodiazepines
sometimes used for acute symptoms e.g. agitation, sleep disturbance
(should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation)
What is an illusion?
A false perception of a real external stimulus.
What is a hallucination?
A percept that is experienced in the absence of an external stimulus to the corresponding sense organ.
What are the different types of auditory hallucinations?
Second person hallucinations : voices address the patient directly (depression)
Third person hallucinations : voices talk to one another, referring to the patient as ‘he’ or ‘she’ (schizophrenia)
Gedankenlautwerden : voices speak the patients thoughts as they are thinking them
Echo de la pensee : voices repeat the patients thoughts after they have thought them
What is an over valued idea?
An unreasonable and sustained intense preoccupation maintained with less than delusional intensity. The belief is demonstrably false and not normally held by others of the same subculture. There is marked associated emotional investment.
Schizophrenia
What is a delusion?
A false belief based on incorrect inference about external reality that is firmly sustained despite what constitutes inconvertible and obvious proof or evidence to the contrary. The persons belief is not normally accepted by other members of the same subculture.
What is passivity?
The belief than an external agency is controlling aspects of the self that are normally entirely under ones own control. Includes thought alienation, made feelings, made impulses, made actions and somatic passivity.
Name some types of delusions
Delusion of control Persecutory delusion delusion of poverty Delusion of reference Delusion of self accusation Erotic delusions Delusion of infidelity Delusion of grandeur Delusion of doubles Nihilistic delusion
What is de Clerambault’s syndrome?
Delusional belief that another person is deeply in love with one (usually occurs in women, with the object often being a man of much higher social status). The supposed lover is usually inaccessible.
What is delusional jealousy/Othello syndrome?
Delusional belief that ones spouse or lover is being unfaithful. Jealousy is used on unsound evidence and reasoning.
More common in men.
What is a delusional perception?
A new and delusional significance is attached to a familiar real perception without logical explanation.
Is a 1st rank symptom of schizophrenia
What is thought alienation?
The delusional belief that ones thoughts are under control of an outside agency, or that others are participating in ones thinking. Includes thought insertion, thought withdrawal and thought broadcasting.
Is a 1st rank symptom of schizophrenia
What is thought insertion?
A belief that thoughts are being put into the mind by an external agency
1st rank symptom of schizophrenia
What is thought withdrawal?
A belief that thoughts are being removed from the mind by an external agency
1st rank symptom of schizophrenia
What is thought broadcasting?
A belief that thoughts are being read by others, as if they’re being broadcast
1st rank symptom of schizophrenia
What is thought block?
A sudden interruption in the train of thought occurs, leaving a ‘blank’, after which what was being said cannot be recalled
Schizophrenia
What is concrete thinking?
A lack of abstract thinking, normal in childhood, and occurring in adults with organic brain disease and schizophrenia. Theres inability to understand abstract concepts + theres extreme literalism.
Schizophrenia and ASD
What is perseveration?
Persistent and inappropriate repetition of the same thoughts or movements. Mental operations carry on beyond the point at which they are appropriate.
Dementia / frontal lobe injury
What is flight of ideas?
The speech consists of a stream of accelerated thoughts, with abrupt changes from topic to topic and no central direction. The connections between the thoughts may be based on chance relationships, verbal associations (e.g. alliteration and assonance), clang associations ( a second word with a sound similar to the first), puns, rhymes and distracting stimuli.
Mania
what is loosening of associations?
A loss of the normal structure of thinking. To the interviewer, the patients thoughts seem muddled, illogical of tangential to the matter in hand. With further questioning, the less clear the patients thoughts are.
3 characteristics of loosening of associations : talking past the point, Knights move & Verbigeration
Schizophrenia
What is knights move speech?
Odd, tangential associations between ideas, leading to disruptions in the smooth continuity of speech.
A transition from one topic to another, either between sentences or mid sentence, with no logical relationship between the 2 topics and no evidence of the associations described in flight of ideas.
What is verbigeration (world salad)?
When speech is reduced to the senseless repetition of words, sounds or phrases. This occurs with severe expressive aphasia + in schizophrenia.
What is tangentiality?
Tendency to speak about topics unrelated to the main topic of discussion. The patient wanders from the topic and never returns to it or provides the information requested.
What is conversion disorder?
a person has blindless, paralysis or other neurologic symptoms that cannot be explained by medical evacuation
Define tolerance
Takes place when the desired CNS effects of a psychoactive substance diminish with repeated use, so that increasing doses need to be administered to achieve the same effects.
Define dependence
A cluster of psychological, behavioural and cognitive phenomena in which the use of psychoactive substances takes on a much higher priority for the individual than other behaviours that once had higher value. There is a desire, which is often strong and overpowering, to take the substance on a continual or periodic basis. There is the development of tolerance, Dependence can be physical or psychological or both
Define withdrawal
A group of physical + psychological symptoms occurring on absolute or relative withdrawal of a psychoactive substance after repeated, and usually prolonged or high dose, use of that substance. It lasts for a limited time
Define alcohol dependence
Need 3+ of the following:
- Strong desire to drink
- Difficulty in controlling drinking behaviour
- Withdrawal when drinking stops
- Tolerance to alcohol
- Neglect of alternative pleasures or interests
- Keep drinking despite harmful consequences
Risk factors for problem drinking
Male High stress job Family hx Depression Bereavement Schizophrenia Bipolar disorder Peer group / lifestyle
What are the questions in the CAGE questionnaire?
(answer yes to 2 or more questions = problem drinking) :
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticising your drinking?
Have you ever felt Guilty about your drinking?
Have you ever had drink first thing in the morning (Eye opener) to steady your nerves or get rid of a hangover?
What questionnaires are used to screen for alcohol dependence?
AUDIT - 10 screening questions
CAGE questions
What are withdrawal symptoms from stopping alcohol?
agitation Nervousness Seizures Delirium Shaking / tremors Dilated pupils tachycardia Hypertension Hallucinations Delirium tremens
Ix to see if someone is alcohol dependent
Breath and blood alcohol levels CDT - carbohydrate deficient transferrin Gamma-GT (raised in 70% of alcohol misusers) MCV - raised in 60% of alcohol misusers FBC - low Hb and Low platelets AST & ALT - elevated if liver damage
Consequences of problem drinking
Falls / ataxia Vomiting / inhalation of vomit Hypothermia Impulsivity Respiratory depression Confusion / reduced LOC / coma Gi conditions Malnutrition Liver: fatty infiltration, alcoholic hepatitis, cirrhosis Pancreatitis Iron deficiency anaemia & macrocytosis Delirium tremens Wernicke's encephalopathy
Clinical features of delirium tremens
delirium agitation confusion paranoia visual/auditory hallucinations tremor disorientation sweating hypertension tachycardia
DT begins 2-4 days after last drink and usually lasts 3-4 days
Tx for delirium tremens
Oral lorazepam
What is wernickes encephalopathy?
A neurological emergency resulting from thiamine deficiency secondary to alcohol abuse
Clinical features of wernickes encephalopathy
delirium, ataxia, pupillary abnormalities, eye movement abnormalities, nystagmus, peripheral neuropathy, impaired concentration, apathy
Tx of wernickes encephalopathy
IV thiamine
Magnesium sulfate
Multivitamin
What is korsakovs syndrome
an amnesic syndrome that follows the acute phase of wernicke’s encephalopathy
Tx of alcohol withdrawal
Benzodiazepines - choldiazepoxide or diazepam
Thiamine, folic acid and magnesium sulphate
Supportive treatments
What questionnaire is used to assess if someone who is alcohol dependent will have a difficult withdrawal?
Use ‘The Severity of Alcohol Dependence Questionnaire’ (SADQ) to assess the risk of a patient having difficulty during withdrawal. Score of 15-30+ is indication for inpatient detoxification
Mx for alcohol misuse
Motivational interviewing
Detoxification - inpatient or at home (decide using SADQ questionnaire)
If inpatient = chlordiazepoxide or diazepam/lorazepam (use these if liver failure)
CBT
Alcoholic anonymous
Drugs used to prevent relapse of drinking
Acamprosate - stimulates GABA and decreases glutamate like alcohol does = less urge to drink
Naltrexone - opioid antagonist that blocks the effects of alcohol
What is the reason behind alcohol withdrawal?
chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
When after stopping alcohol do symptoms of withdrawal start and what are those symptoms?
6-12 hours later = tremor, sweating, tachycardia, anxiety
36 hours - peak incidence seizures
48-72 hours - DT (coarse tremor, confusion, delusions, hallucinations, fever, tachycardia)
What is the pathology behind Korsakoff’s syndrome
marked memory disorder often seen in alcoholics
thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus
often follows on from untreated Wernicke’s encephalopathy
symptoms of korsakoffs syndrome (RACK)
(RACK)
- retrograde amnesia
- anterograde amnesia: inability to acquire new memories
- confabulation
- Korsakoff’s psychosis
symptoms of wernickes encephalopathy (COAT)
COAT
- Confusion
- Ophthalmoplegia
- Ataxia
- Thiamine deficiency
Mechanism of action of benzodiazepines
Benzodiazepines enhance the effect of the inhibitory neurotransmitter GABA by increasing the frequency of chloride channels opening.
Symptoms of benzodiazepine withdrawal syndrome and when does it happen?
If patients withdraw too quickly from benzo
Can occur up to 3 weeks after stopping a long acting drug
INsomnia Irritability Anxiety Tremor Loss of appetite Tinnitus Perspiration Perceptual disturbances Seizures
What is generalised anxiety disorder?
at least 6 months of persistent anxiety associated with chronic uncontrollable and excessive worry.
It may fluctuate in severity but is NOT paroxysmal (as with panic disorder), situational (as with phobia), life long (as with personality disorders) or clearly stress related (as with stress related disorder).
Symptoms of generalised anxiety disorder
Theres anxiety with excessive, disproportionate and uncontrollable worry for at least 6 months
Easily startled, on edge (exaggerated startle response)
Sleep disturbance
Fatigue
Restlessness
Irritability
Poor concentration
Somatic symptoms include : multiple chronic aches, headaches, tension, sweating, dizziness, GI symptoms, increased HR, SOB, trembling, dry mouth, dysphagia, frequency of urination, flushes
Associated with : depression
Risk factors for generalised anxiety disorder
Family Hx of anxiety Physical or emotional stress Hx of physical or emotional trauma Other anxiety disorder Female sex
Mx of generalised anxiety disorder
Antidepressant e.g. SSRI Benzodiazepines CBT Applied relaxation Meditation training Sleep hygiene and education Exercise Self help
What is post traumatic stress disorder?
a delayed response, usually within 6 months, to an exceptionally severe traumatic event, which is likely to cause pervasive distress to almost anyone.
what are the 5 key symptoms of PTSD? and how long do they need to be present for a diagnosis to be made
Symptoms present for more than 1 month
1 Experience of a major trauma
2 Intrusive recollections - thoughts, nightmares and flashbacks
3 Sense of numbness and emotional blunting. Avoidance of reminders.
4 increased arousal and hypervigilance
5 onset follows the trauma after a latency period of a few weeks to months (no more than 6 months)
Mx of PTSD
Eye movement desensitisation and reprocessing (EMDR)
Trauma focused CBT
Antidepressants - venlafaxine or SSRI
Treat comorbid psychiatric disorders/substance abuse
What is obsessive compulsive disorder?
a non-situational pre-occupation in which there is subjective compulsion despite conscious resistance. Such pre-occupations can be thoughts (ruminations or obsessions) or acts (rituals or compulsions).
Define obsession
an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind.
Define compulsion
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.
risk factors for ocd
genetic
psychological trauma
pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS)
mx of OCD
- CBT
- Exposure and response prevention – learning to cope with the increasing tension associated with increasing tension from not performing rituals
- Thought stopping technique – therapist shouts ‘stop’ as the patient ruminates
- SSRI e.g. fluoxetine
- Tricyclic antidepressant e.g. clomipramine
What can be used to grade the severity of OCd?
Yale-Brown Obsessive-Compulsive scale
Symptoms of OCD
Obsessive thinking - recurrent and intrusive thoughts
Ruminations - recurrent thoughts that are absurd/unwelcome to the patient
Compulsions - repetitive actions to provide relief from anxiety
Rituals - repetitive time consuming and done to relieve an anxiety
Anxiety
Egodystonic - behaviour patterns that aren’t in agreement with ideal self image
What is bipolar disorder?
the occurrence of at least one episode of mania, usually but not necessarily accompanied by at least one depressive episode.
Symptoms of mania
- Elevation of mood – can manifest as elation or can be irritable/angry
- Increased energy
- Overactivity
- Pressure of speech
- Reduced sleep
- Loss of normal social and sexual inhibitions
- Elated self-esteem / grandiosity
- Flight of ideas
- Increased goal directed activity or psychomotor agitation
- Poor concentration and attention
- Overspending
- Start unrealistic projects
- Neglect of eating/drinking/personal hygiene
Risk factors for bipolar disorder
- Family history of bipolar disorder
- Stressful life events
- History of depression
- Presence of anxiety disorder
Mx for bipolar disorder
- Hospitalisation of patients suffering from mania
- a. MOOD STABILISERS e.g. lithium (lithium carbonate or lithium citrate) or carbamazepine
- ECT
- Psychosocial therapy
CIs for lithium use
renal insufficiency, cardiovascular insufficiency, Addison’s disease, untreated hypothyroidism
What monitoring is required for lithium and why?
Has a very small therapeutic range = 0.4-1.0 mol/L
Has a long plasma half life (excreted mainly by the kidneys)
Check lithium levels 12 hours post dose
After starting - check lithium levels weekly and after each dose change until stable
Once stable, check lithium levels every 3 months
After a change in dose, check lithium levels a week later then weekly until stable
Check TFTs and U&Es every 6 months
Side effects of lithium
Nausea vomiting diarrhoea Fine tremor Nephrotoxicity - polyuria, secondary to nephrogenic diabetes insipidus Hypothyroidism ECG - T wave flattening/inversion Weight gain Idiopathic intracranial hypertension Leucocytosis Hyperparathroidism = Hypercalcaemia
Symptoms of lithium toxicity
Coarse tremor (is fine tremor at therapeutic levels) Hyperreflexia Acute confusion Polyuria Seizure Coma
Mx for lithium toxicity
Mild-moderate = normal saline
Severe = haemodialysis
Causes of lithium toxicity
Dehydration Renal failure Diuretics ACei/ARBs NSAIDs metronidazole
Mx for patient presenting with mania/hypomania
stop any antidepressants
start an antipsychotic e.g. olanzapine or haloperidol
How long should patients stay on antidepressants for?
Continue antidepressants for at least 6 months after remission of depression symptoms to decrease the risk of relapse
What is cotard syndrome?
patient believes that they (or in some cases just a part of their body) is either dead or non-existent.
What is somatisation disorder?
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
What is illness anxiety disorder (hypochondriasis)?
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
What is conversion disorder?
typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
What is dissociative disorder?
dissociation is a process of ‘separating off’ certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
what is factitious disorder?
also known as Munchausen’s syndrome
the intentional production of physical or psychological symptoms
What is malingering?
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
What is delirium?
Acute generalised psychological dysfunction and change in mental status, that usually fluctuates in degree and includes inattention, disorganised thinking & altered levels of consciousness.
What are the symptoms of delirium?
- Prodrome: agitation & sensitive to light/sound
- Impairment in consciousness
- Hallucinations
- Mood changes e.g. anxiety, lability, agitation, combativeness or depressed mood
- Cognitive impairment e.g. disorientation in time and place, poor concentration and impaired new learning, registration, retention and recall
- Develops over hours to days
- Symptoms fluctuate throughout the day (typically worse in the evening = sundowning)
Causes of delirium - I WATCH DEATH
Infections e.g. UTI, pneumonia, meningitis, HIV, syphilis
Withdrawal e.g. alcohol
Acute metabolic disorders e.g. DKA
Trauma
CNS pathology e.g. stroke / brain tumour
Hypoxia e.g. anaemia, cardiac failure, COPD, pulmonary embolism
Dehydration / deficiencies e.g. B12, folic acid, thiamine
Endocrine e.g. hyperthyroidism/hypothyroidism, Addison’s disease (Primary hypoadrenalism), Cushing’s syndrome
Acute vascular e.g. MI, shock, vasculitis
Toxins/drugs e.g. Anticholinergics, benzodiazepines, antidepressants, antipsychotics, antihistamines, opioids, diuretics, recreational drugs, alcohol use disorder
Heavy metals e.g. arsenic, lead, mercury
Causes of delirium PINCH ME
Pain Infection Nutrition Constipation Hydration Meds Environment/electrolytes/endocrine
Mx of delirium
- Identify and treat underlying cause
- Supportive care
a. Hydrate and good nutrition
b. Avoid drugs that can worsen delirium e.g. benzo’s, anticholinergics, opioids
c. Reorientate the patient regularly
d. Reduce the amount of noise, procedures and medication administration at night
e. Arrange regular visits from family and friends & for constant observation (by family or friend)
f. Physical and occupational therapy to mobilise the patient
g. Minimise use of restraints - Pharmacology
a. Haloperiodol (antipsychotic) oral or IM – to reduce agitation - Pharmacology for the prevention of delirium:
a. Dexmedetomidine – a sedative that doesn’t cause respiratory depression like opioids do
b. Cholinesterase inhibitors e.g. rivastigmine or donepezil
c. Second generation antipsychotics
2 screening questions for depression
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
What tools can be used to assess if someone is depressed?
Hospital anxiety and depression score (HAD)
Patient health questionnaire (PHQ-9)
Criteria for diagnosing depression
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss or weight gain when not dieting 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, or indecisiveness nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
what is depression?
Depression is a mental state characterised by persistent low mood, loss of interest and enjoyment in everyday activities, neurovegetative disturbance, and reduced energy, causing varying levels of social and occupational dysfunction.
How can the severity of depression be graded?
- Mild depressive episode - 2-3 clinical features & patient can continue functioning
- Moderate depressive episode - 4+ clinical features & patient may have difficulty functioning
- Severe depressive episode without psychotic symptoms - several clinical features that are marked & distressing. Theres loss of self-esteem, ideas of guilt and worthlessness. Suicidal. Biological/somatic symptoms present.
- Severe depressive episode with psychotic symptoms - as with severe depressive episode + hallucinations/delusions/psychomotor retardation/stupor. There’s increased risk of suicide, dehydration & starvation.
what is seasonal affective disorder?
a regular temporal relationship between the onset of the depressive episode and a particular time/season of the year. During the depressive episode theres carb craving, hypersomnia (excessive sleepiness) & weight gain.
Ix for person presenting with depression
Clinical diagnosis U&E, LFT, TFTs, LFTs Vitamin B12 and folate Syphilitic serology EEG/CT/MRI if indicated
What are the dementia screening bloods?
FBC Folate B12 LFT U&E TFT BMs Cholesterol Calcium
Risk factors for depression
Post natal
Personal/family hx depression
Co-existing medical condition
Psychosocial stressors
Mx of mild depression
Sleep hygiene active monitoring Individual guided self help CBT Group physical activity programme Group CBT
don’t give antidepressant unless hx of severe depression, symptoms present for long time, mild depression persists despite above interventions or patient has chronic health condition
Treatment of moderate to severe depression
Hospitalise when there is risk to self
i. Selective serotonin reuptake inhibitors (SSRIs) - fluoxetine & sertraline
ii. Serotonin-noradrenaline reuptake inhibitor (SNRI) – venlafaxine & duloxetine
iii. Noradrenaline reuptake inhibitor (NARI) - reboxetine
iv. Monoamine oxidase inhibitors (MAOIs) - phenelzine (is a non-selective one used for atypical depression)
1. Subclass of this: Reversible inhibitor of monoamine oxidase A (RIMA)
v. Noradrenergic and specific serotonergic antidepressant (NaSSA) - mirtazapine
Other mx:
- Electroconvulsive therapy
- Phototherapy for SAD
- CBT
- Group therapy
- Family/marital therapy
How long should antidepressants be taken for?
Risk of relapse reduced if antidepressants used for a continued 6 months after the end of an episode
Give 3 examples of an SSRI and when should you prescribe each one?
Citalopram, fluoxetine, sertraline
1) Citalopram - preferred SSRI for 1st line depression tx
2) Fluoxetine - preferred SSRI for 1st line depression tx and chosen for treating children/adolescents
3) Sertraline - useful post MI as there’s more evidence for its safe use in this situation
Side effects of SSRIs
GI symptoms
GI bleeding risk increased
Anxiety/agitation after first starting
Hyponatraemia
Increased risk of suicide in first 2 weeks
Stay on for 6 months after remission to reduce risk of relapse
ECG changes with citalopram
QT interval prolongation (dose dependent)
Drug interactions with SSRIs
NSAIDs/aspirin - increased GI bleed risk (prescribe with PPI)
Warfarin/heparin - prescribe mirtazapine instead of SSRI
Triptans - increased risk of serotonin syndrome
MAOIs - increased risk of serotonin syndrome
How do you stop an SSRI?
Gradually reduce the dose over 4 weeks
Don’t have to taper the dose of fluoxetine, can just stop
Discontinuation symptoms of SSRIs
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
Are SSRIs safe in pregnancy?
Weigh up risk v benefits
Use during the first trimester gives a small increased risk of congenital heart defects
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
How do serotonin and noradrenaline reuptake inhibitors work?
Inhibiting the reuptake increases the concentrations of serotonin and noradrenaline in the synaptic cleft leading to the effects
Give 2 examples of SNRIs
venlafaxine and duloxetine
Side effects of monoamine oxidase inhibitors
hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
anticholinergic effects
Example tricyclic antidepressants and what they’re used for
used less commonly now for depression due to their side-effects and toxicity in overdose but used for neuropathic pain
Sedative ones: Amitriptyline Clomipramine Dosulepin Trazodone
Less sedating ones:
Imipramine
Lofepramine
Nortriptyline
Common side effects of tricyclic antidepressants
drowsiness dry mouth blurred vision constipation urinary retention lengthening of QT interval
ECG change with tricyclic antidepressants?
Lengthened QT interval
How does mirtazapine work?
works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters
Side effects of mirtazapine
Sedation (take in the evening)
Increased appetite
Useful SEs for people who aren’t sleeping or eating
What can cause serotonin syndrome?
monoamine oxidase inhibitors
SSRIs
(St John’s Wort, often taken over the counter for depression, can interact with SSRIs to cause serotonin syndrome)
ecstasy
amphetamines
Symptoms of serotonin syndrome
neuromuscular excitation:
- hyperreflexia
- myoclonus
- rigidity
autonomic nervous system excitation:
- hyperthermia
- sweating
altered mental state:
- confusion
dilated pupils
tachycardia
Mx of serotonin syndrome
1) supportive including IV fluids
2) benzodiazepines
3) more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine
Mx of paracetamol overdose
activated charcoal if ingested < 1 hour ago
N-acetylcysteine (NAC)
liver transplantation
Mx of salicylate overdose (aspirin)
urinary alkalinization with IV bicarbonate
haemodialysis
Mx of opioid overdose
naloxone
Mx of benzodiazepine overdose
1) supportive
2) flumazenil - risk of seizures so use in severe cases or iatrogenic overdoses
Mx of tricyclic antidepressant overdose
1) IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity
2) arrhythmias: class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation. Class III drugs such as amiodarone should also be avoided as they prolong the QT interval. Response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in management of tricyclic induced arrhythmias
3) dialysis is ineffective in removing tricyclics
Mx of lithium overdose
1) mild-moderate toxicity = normal saline
2) haemodialysis may be needed in severe toxicity
3) sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion
Tx of warfarin overdose
Vitamin K
Prothrombin complex
Mx of beta blocker overdose
1) if bradycardic = atropine
2) in resistant cases glucagon may be used
Mx of ethylene glycol (antifreeze, solvents, paints) overdose
1) fomepizole
2) ethanol
3) haemodialysis
Mx of methanol poisoning
fomepizole or ethanol
haemodialysis
Mx of digoxin overdose
Digoxin-specific antibody fragments
Mx of iron overdose
Desferrioxamine, a chelating agent
Mx of lead poisoning
Dimercaprol, calcium edetate
Mx of carbon monoxide poisoning
100% oxygen
hyperbaric oxygen
What is anorexia nervosa?
An eating disorder characterised by restriction of caloric intake leading to deliberate weight loss and low body weight, an intense fear of gaining weight and body image disturbance
Symptoms of anorexia nervosa
Restriction of calorie intake
Significantly low body weight
Disturbance of body image
Preoccupation with maintenance of low body weight
Denial of seriousness
Amenorrhoea
Poorly developed secondary sexual characteristics
fatigue / poor concentration
bradycardia, prolonged QT, AV heart block
lanugo hair
Risk factors for anorexia nervosa
female
adolescent
family hx depression
adverse parenting
Mx of anorexia nervosa
structured eating plan with oral nutrition
give multivitamin, phosphorus, magnesium, calcium and thiamine
CBT
Family interventions
Potassium repletion
fluoxetine/sertraline if depression
what is bulimia nervosa?
Recurrent episodes of uncontrollable binge eating and compensatory behaviour (vomiting / fasting / excessive exercise / misuse of laxatives, diuretics or enemas)
Binge eating episodes are characterised by eating a larger amount of food than normal, in a discrete period of time and a sense of lack of control during the episode. Theres an irresistible & recurrent urge to overeat.
Risk factors for bulimia nervosa
Female sex Personality disorder / impulsivity Body image disturbance Hx of sexual abuse family Hx alcoholism, depression, eating disorder, obesity Exposure to media pressure Early onset of puberty
Mx of bulimia nervosa
CBT
Nutritional and meal support : help from dietician about their concerns, feelings, habits and beliefs about eating
SSRI or SNRI e.g. fluoxetine, sertraline or venlafaxine
Psychological therapies e.g. interpersonal psychotherapy, family therapy in younger patients and self help groups
What is a personality disorder?
Severe disturbance in the personality and behavioural tendencies of an individual.
Behaviour is inflexible, maladaptive and dysfunction.
Distress is caused to self and others.
Presentation is stable & longstanding (starting in childhood/adolescence)
What are the 3 clusters of personality disorders?
Cluster A = withdrawn, odd and eccentric
Cluster B = dramatic, emotional and erratic
Cluster C = dependent and inhibited
What are the personality disorders in cluster A?
Paranoid
Schizoid
Schizotypal
What are the personality disorders within cluster B?
Antisocial Emotionally unstable (borderline) Impulsive Histrionic Narcissistic
What are the personality disorders within cluster C?
Avoidant (anxious) Dependent Obsessive compulsive (anakastic)
What are the traits of someone with a paranoid personality disorder?
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
Unwarranted tendency to perceive attacks on their character
What are the traits of someone with a schizoid personality disorder?
Indifference to praise and criticism Preference for solitary activities Lack of interest in sexual interactions Lack of desire for companionship Emotional coldness Few interests Few friends or confidants other than family
What are the traits of someone with a schizotypal personality disorder?
Ideas of reference (differ from delusions in that some insight is retained) Odd beliefs and magical thinking Unusual perceptual disturbances Paranoid ideation and suspiciousness Odd, eccentric behaviour Lack of close friends other than family members Inappropriate affect Odd speech without being incoherent
What are the traits of someone with an emotionally unstable personality disorder?
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
What are the traits of someone with an antisocial personality disorder?
Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;
More common in men;
Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
Impulsiveness or failure to plan ahead;
Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
Reckless disregard for the safety of self or others;
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
What are the traits of someone with a histrionic personality disorder?
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are
What are the traits of someone with a narcissistic personality disorder?
Grandiose sense of self importance Preoccupation with fantasies of unlimited success, power, or beauty Sense of entitlement Taking advantage of others to achieve own needs Lack of empathy Excessive need for admiration Chronic envy Arrogant and haughty attitude
What are the traits of someone with an obsessive compulsive personality disorder?
Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Demonstrates perfectionism that hampers with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare time activities
Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
What are the traits of someone with an avoidant personality disorder?
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
Unwillingness to be involved unless certain of being liked
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks due to fears of embarrassment
Views self as inept and inferior to others
Social isolation accompanied by a craving for social contact
What are the traits of someone with a dependent personality disorder?
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
Mx of personality disorders
psychological therapies: dialectical behaviour therapy
treatment of any coexisting psychiatric conditions
symptoms of schizophrenia in the acute syndrome
Positive symptoms are seen in the acute syndrome and positive symptoms include a specific set of symptoms called (Schneider’s) first rank symptoms that are given particular weight in the diagnosis.
There may be a prodrome of negative symptoms/psychosis.
- First rank symptoms:
o Hearing thoughts spoken aloud
o Third person hallucinations
o Hallucinations in the form of a commentary
o Somatic hallucinations: feel something touching them / insects crawling about inside their body
o Thought withdrawal or insertion
o Thought broadcasting
o Delusional perception
o Passivity - feelings or actions experienced as made or influenced by external agents
Other symptoms:
- impaired insight
- incongruity/blunting of affect
- decreased speech
- neologisms - made up words
- catatonia
- persecutory delusions
symptoms of schizophrenia in the chronic syndrome
many recover from the acute syndrome but some progress to the chronic syndrome
Negative symptoms:
- Apathy
- Anhedonia
- Social withdrawal / antisocial behaviour
- Poor self care
- Blunted affect
risk factors for schizophrenia
family history black/caribbean Migration urband environment cannabis use
Mx of schizophrenia - acute psychotic episode
1) hospitalisation
2) 1st line = second generation antipsychotic e.g. risperidone, paliperidone, quetiapine
3) 2nd line = other second generation antipsychotics e.g. olanzapine, clozapine or a low potency 1st gen antipsychotic e.g. chlorpromazine
4) 3rd line = high potency 1st gen antipsychotic e.g. haloperidol, fluphenazine, perphenazine
5) don’t respond to 2 adequate trials of 2 different 2nd gen antipsychotics = clozapine
in pregnancy - 1st gen seem less harmful than 2nd gen antipsychotics
Extreme agitation/violence = IM lorazepam
Electroconvulsive therapy
What shouldn’t you combine with IM lorazepam?
olanzapine
- risk of sudden death
what’s another name for 1st and 2nd generation antipsychotics
1st gen = typical antipsychotic
2nd gen = atypical antipsychotics
What side effects are second generation antipsychotics less likely to cause than 1st gen?
extra-pyramidal side effects
but they are more likely to cause metabolic side effects - weight gain and hyperglycaemia
How do 1st gen/typical antipsychotics work?
Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
Side effects of 1st gen/typical antipsychotics
Extrapyramidal side effects:
- Parkinsonism
- Acute dystonia - sustained muscle contraction (torticollis, oculogyric crisis). Mx with procyclidine
- Akathisia - severe restlessness
- tardive dyskinesia - late onset of abnormal. involuntary movements that may be irreversible e.g. chewing and pouting of the jaw
Hyperprolactinaemia = galactorrhea
antimuscarinic SE = dry mouth, blurred vision, urinary retention, constipation
sedation weight gain impaired glucose tolerance neuroleptic malignant syndrome prolonged QT interval
what is acute dystonic reaction, symptoms and management
an acute neurological condition, commonly seen in the emergency department that is characterized by involuntary muscle contractions that may manifest as torticollis, opisthotonus, dysarthria and/or oculogyric crisis
caused by antipsychotics (1st gen), antiemetics, antidepressants
mx = procyclidine
ECG changes with haloperidol
prolonged QT interval
Side effects of 2nd gen/atypical antipsychotics
weight gain
clozapine = agranulocytosis (low neutrophils)
hyperprolactinaemia
Specific warnings about antipsychotics in elderly patients
Increased risk of stroke
increased risk of VTE
examples of 2nd gen/atypical antipsychotics
clozapine
olanzapine: higher risk of dyslipidemia and obesity
risperidone
quetiapine
amisulpride
aripiprazole: generally good side-effect profile, particularly for prolactin elevation
Side effects of clozapine
agranulocytosis neutropenia reduced seizure threshold constipation myocarditis hypersalivation
might need to dose adjust if smoking is started/stopped during treatment
example 1st gen/typical antipsychotics
haloperidol
chlorpromazine
what is neuroleptic malignant syndrome?
: a potentially life-threatening side effect of both first generation and second generation antipsychotics.
symptoms of neuroleptic malignant syndrome
muscle rigidity,
hyperthermia,
autonomic instability (tachycardia, labile blood pressure, tachypnoea, diaphoresis, dysrhythmias) mental status change (confusion, delirium, stupor)
Diagnosis of neuroleptic malignant syndrome
high creatinine kinase & leucocytosis
Tx of neuroleptic malignant syndrome
stop antipsychotic supportive measures (ICU),
dantrolene (a ryanodine receptor antagonist that prevents the release of calcium in striated muscle = reduced muscle rigidity & hyperthermia)
what monitoring/ix are required on starting an antipsychotic?
FBC - then annually U&E - then annually LFT - then annually lipids - then at 3 months & annually weight - then at 3 months & annually fasting blood glucose - then at 6 months & annually prolactin - then at 6 months & annually BP - check frequently at dose titration ECG
+ do cardiovascular risk assessment annually
How often should FBC be checked in patients on antipsychotics?
Annually
But more often with clozapine - weekly intially
What is Wernicke’s encephalopathy?
a neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics (is the acute phase)
Causes of wernickes encephalopathy
Alcohol
Persistent vomiting
stomach cancer
dietary deficiency of thiamine
Triad of symptoms seen in wernickes encephalopathy
confusion
ophthalmoplegia/nystagmus
ataxia
(thiamine)
COAT
Symptoms of wernickes encephalopathy
nystagmus (the most common ocular sign) ophthalmoplegia ataxia confusion, altered GCS peripheral sensory neuropathy
ix for wernickes encephalopathy
decreased red cell transketolase
MRI
mx of wernickes encephalopathy
thiamine
complication of untreated wernickes encephalopathy
Korsakoffs syndrome
anterograde and retrograde amnesia + confabulation
what is ECT
electroconvulsive therapy
treatment for severe depression refractory to medication
CI for ECT
raised ICP
Short term side effects of ECT
headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia
Long term side effects of eCT
some patients report impaired memory
