Psychiatry Flashcards
Categories of personality disorder
Mad: Paranoid, schizoid
Bad: Borderline (emotionally unstable), histrionic,, anti/dissocial, narcissistic
Sad: Avoidant, dependent, anankastic (obsessive compulsive)
Dissocial PD aetiol
Lifetime prevalence 1-4%
1-18.3% in psychiatric settings
Much higher in substance use disorders
M»F
Predicated on diagnosis of conduct disorder or age15
Heritability ~38%
Diagnostic criteria for dissocial PD
Callous unconcern for feelings of others
Gross and persistent irresponsibility and disregard for social norms, rules and obligations
Incapacity to maintain enduring relationships
Low tolerance go frustration with low threshold for aggression and violence
Incapacity to experience guilt or to profit from experience, especially punishment
Blames others/rationalises
(N.B. Eg Mark in the Hustvedt What I Loved book)
Treatment for dissocial PD
CBT, assess risk and adjust intensity as needed. Enable patients to attend, not frequently pharmacological.
However largely deemed treatment resistant, although symptoms may decline with age if socialization, marriage, poss brief incarceration… Earlier onset = worse orognosis
Emotionally unstable PD prevalence and risk
About 1.2 to 5.9% in community
Risks:
Early abusive experiences (altho with low effect size)
Approx 75% female in clinical samples but more equal in community
Diagnostic criteria for emotionally unstable PD
Interpersonal hypersensitivity
- fear of abandonment
-unstable relationships
-chronic emptiness
Affective/emotion dysregulation
-affective instability
-inappropriate/intense anger
Behavioral, dyscontrol
-recurrent suicidality, threats, self harm
-impulsovity sex, driving, bingeing
Disturbed self
-uncertain sense of self
-depersonalisatiln/paranoid ideation under stress
Managing EUPD
Avoid brief interventions
Avoid admissions (may increase risk and reinforces sick role)
Avoid medications
Manage risk
Dialectical behavioral therapy, mentalisation based therapy, democratic community therapy and cognitive analytic therapy all have an evidence base
Prognosis really not bad and about 80% remitted after 8 years FU
ParanoidPD diagnostic criteria
Excessive sensitivity to perceived setbacks and rebuffs
Bears grudges persistently
Suspicious, misconstrues actions as hostile
Combative, tenacious sense of personal rights
Suspicions regarding fixelkty of partner
Excessive self importance
Conspiratorial explanations of events
Schizoid PD behavuour
finds few activities pleasurable
Emotional coldness, detachment or flattened affect
Limited capacity to express feelings
Apparent indifference to praise of criticism
Little interest in sexual experiences with another person
Preference for solitary activities
Preoccupation with fantasy and introspection
Lack of desire for close friends or confiding relationships
Insensitivity to social norms and conventions
Histrionic PD behaviurs
Self-dramatization, theatricality, exaggerated expression of emotions
Suggestibility
Shallow and labile affectivity
Continual seeking for excitement/centre of attention
Inappropriate seductiveness
Over concern with physical attractiveness
anxious PD behavuours
Persistent and pervasive feelings of tension and apprehension
Belief that one is socially inept, personally unappealing or inferior to others
Excessive preoccupation with being criticized or rejected in social situations
Unwillingness to become involved with people unless certain of being liked
Restrictions in lifestyle because of need for physical security
Avoidance of social pr occupational activities that involve significant interpersonal conduct
Anankastic PD thoughts and behaviours
Feelings of excesssiive foubt and caution
Preoccupation sith details, rules, lists, order
Perfectionism that interferes with task completion
Excessive conscientiousness and scrupulousness
Undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships
Excessive pedantry and adherence to social conventions
Rigidity and stubborness
Dependent PD thoughts and behaviours
Encouraging or allowing others to make most of ones important life decisions
Subordination of ones own needs to those of others on whom one is deodnfent, and undue compliance with their wishes
Unwillingness go make even reasonable demands on the person one depends on
Feeling uncomfortable or helpless when alone because of exaggerated fears of inability to care for oneself
Preoccupation with fears of being left to care for oneself
Limited capacity to take everyday decisions without an excessive amount of advice and reassurance from others.
Psychoses : What are they?
illnesses characterized by abnormal thoughts (delusioms) and abnormal perceptions (hallucinations). Along with other features.
Then further establishment of whayntype of psychosis.
Different types of delusions
ll are false, unshakeable beliefs held without evidence. Not accepted by person’s culture or religion
Often persecutory
Grandiose are feature of mania
Nihilostic - feature of psychotic depression
Bizarre delusions- especially in scz
Different types of auditory hallucinations
Third person - voices discuss or argue about the patient
Running commentary
Gedankenlautwerden and echo de la pensée - patients thoughts are heard as or shortly after they are formulated
Diagnostic categories in which psychosis can occur
Schizophrenia
Bipolar disorder
Schizoaffective disordef
Substance induced psychosis
Organic psychosis
Delusional divorced
Psychotic depression
Delirium
Different delusions of contol
passivity of affect, volition and impulses (under control of external agrncy)
Somatic passivity
Specific features of SCZ acutely
First is very variable, positive symptoms predominant
Florid, psychotic features, often bizarre or disturbed behaviour, odd appearance.
Classic third person auditory hallucinations. First rank symptoms
Formal thought disorder possible
Sometimes catatonic symptoms
Dopamine hypothesis of scz
Snyder 1976:
Increased level of dopamine on br
ain, and involvement of amphetamines and dopaminergic agents exacerbating symptoms. Positive symptoms from hyperactive dopamine activity in mesolimbic activity, but negative from dopamine hypoactivity in mesocortical system.
Major genetic element and ~80% heritable.
Associated with adverse childhood events eg severe abuse and early cannabis use.
Clinical diagnosis of scz
Features must be present for at least a month.
Usually insidious onset with increasing isolation, odd behaviour and free diced performance for several months
Must not be explained by any other psychotic diagnosis
Chronic scz
Acute symptoms can flare, but negative symptoms predominant: Poverty of speech, sociL isolation, lack of interest
Epidemiology of scz
affects 0.8% population
Age of onset usually in 20s, altho prodrome from late teens
Equal sex ration althon,em tend to get earlier and more severely
Course variable. 20% recover, 40% remit and relaps, 40% chronic symptoms and impairment
Increased mortality artic due to suicide and also incr natural causes. Life expectancy reduced by >15 years
Comorbidity common esp substance abuse
Huge costs for patient, family, society and NHS
Structural abnormalities in schizophrenia
Reduction in brain mass and size by about 3%, principally frontal and temporal lobes and medial temporal lobe structures eg hippocampus. Deck in neuronal size rather than degenerative
Ventricular enlargement of around 25%
Cytoarchitectural abnormalities
Functionally abnormal eg hypofrontality, maybe abnormal proprioception, abnormal eye tracking, EEG changes.
Extra pyramidal side effects with antipsychotics
Occur in up to 70% of patients
Acute dystonia’s, akasthisias, Parkinson symroms and tardive dyskinesia.
Beyond a threshold occupancy of 80% of D2 receptor occupancy there is no additional clinical efficacy and significantly incr risk of EPSEs.
Antidopaminergic side effects of antipsychotics
Extrapyramidal side effects (dystonia, akathisia, PD like symptoms, tardive dyskinesia)
Hyperprolactinaemia
Neuroleptic malignant syndrome
Weight gain
Serotonergic side effects of antipsychotics
Anxiety
Insomnia
Change in appetite leading to weight gain
Hypercholesterolaemia
Diabetes
Antihistaminergic side effects if antipsychotics
Sedation (can be good)
Weight gain
Antiadrenergic side effects of antipsychotics
Postural hypotension
Tachycardia
Ejaculatory failure
Anticholinergic side effects of antipsychotics
Dry mouth
Blurred vision
Constipation
Urinary retention
What is acute dystonia
Often painful spastic contraction of muscles commonly affecting the neck, eyes and trunk. Eg tongue protrusion, grimacing, torticollis.. May respond to anticholinergics
What is akasthisia
Distressing feeling of inner restlessness manifested by fidgety leg movements, shuffling of feet, pacing etc. Mat respond to anticholinergics, propranolol, benzos etc
What is tardive dyskinesia
Involuntary, repetitive, purposeless movements of the tongue, lips, face, trunk and extremities that may be generalized or only affect some muscle groups, typically orofacial muscle group. Typically several months or years after antipsychotic treatment and is often irreversible. No beneficial treatment and mat be exacerbated by anticholinergics.,.
Neuroleptic malignant syndrome
Potentially fatal idiosyncratic reaction to antipsychotic medication, resulting from blockade of dopaminrgic hypothalamospinal tracts which normally tonically inhibit preganglionic sympathetic neurons.
Characterized by hyperthermia, muscle rigidity, autonomic instability and altered mental status. Rhabdomyolysis with high CK may lead to renal failure. lso generally possinle complication to respiratory and cardiovascular collapse and DIC. management is stop the drug and support. If left untested then mortality is as high as 20-30%
Adverse effects of SSRIs
GI symptoms are the most common. Incr risk of GI bleed in patients taking SSRIs. PPI should be prescribed if patient also taking a NSAID.
Patients should be counselled to be vigilant for increased anxiety and agitation after starting SSRI
Fluoxetine and paroxetine have higher propensity for drug interactions
DiscontinuAtion symptoms of SSRI
Partic with paroxetine, may get:
Increased mood change
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
GI symptoms, pain cramping, diarrhoea, vomiting
Paraesthesia
Delusional parasitosis
Relatively rare condition where patient has a fixed delusion that they are infested by ‘bugs’ eg worms, parasotes, mites, bacteria, fungi. May occur in conjunction eith other psychiatric conditions of present alone. Patients may be quite functional tho
Also called Ekbom syndrome
Capgras syndrome
Delusional misidentification syndrome where patient believes someone significant I.in their life, eg a spouse or friend, has been replaced by an identical impostor
Fregoli syndrome
A delusional misidentification syndrome where the patient believes that multiple people are all in fact the same person, who is constantly changing their appearance.
Common side effects of tricyclic antidepressants
Drowsiness
Dry mouth
Blurred vision
Constipation
Urinary retention
Lengthening of QT interval
More sedative tricyclic antidepressants
amitryptyline
Clomipramine
Dosulepin
Trazodone
Less sedative tricyclic antidepressants
Imipramine
Lofepramine
Nortriptyline
De Clerembault’s syndrome
Also called erotomania, form of paranoid delusion with an amorous quality. Belief that a famous person is in love with them
Munchausen Disorder
The intentional production of physical or psychological symptoms
Symptoms of alcohol withdrawal
tremor, sweating, agitation, anxiety, sensitivity tonsound, visual disturbance and delirium
Classic triad of Wernicke’s encephalopathy
Ataxic gait, fluctuating consciousness and nystagmus
Symptoms of Korsakoff’s
Anterograde amnesia, islands of memory and confabulation
FRAMES alcohol interventio
Feedback: About personal risk and impairment
Responsibility: Personal responsibility for change
Advice: To cut down or abstain
Menu: Options to change behaviour and targets
Empathic interviwwing: Listen and avoid confrontation
Self-efficacy: Interviewing style to promote persons self belief to make changes
Acamprosate
Neuroprotective drug when detoxifying from alcohol, start on day 1 and continue while not drinking and 6 weeks after relapse
Naltrexone and nalmefene
Reduces drinking in those not abstaining. Good for binge drinkers, recently licensed in UK, reduces imouksivity.
Disulfiram
Blocks acetaldehyde dehydrogenase
Build up of acetaldehyde leads to:
Flush reaction, reduced BP, headache
Works by threat of unpleasant consequences
need supervision to ensure compliance
Warn of hidden sources of alcohol, eg mouthwash or perfume
Avoid if vascular disease, psychosis, suicidality.
Psychopharmacology of alcohol
Is an agonist at the GABA benzo receptor and antagonist at NMDA receptor.
Acute intoxification: Increase in GABA and reduction in glutamate
Chronically: Reduction in GABA, increase in glutamate
Withdrawal: Excess excitation from Imbalance of flu to GABA. Can lead to excitotoxic brzin damsge, Nd damage to hippocampus causing memory loss
Differentiating dementia and depression
mental decline relatively rapid in depression.
Dementia: Confused and disorientated, difficulty with short tern memory, writing speaking and motor skills are impaired (whereas slowed in depression but normal). Depression will notice or worry about nenort oroblems
Cotard syndrome
patient holds delusion that they (or part of their body) are dead or non existent. Associated with severe depression/psychotic disorders, and can have significant detrimental effects on patients with self neglect and withdrawal from others,
Charles Bonnet syndrome
A psychophysical visual disorder where patients with significant vision loss have vivid, often recurrent visual hallucinations. These hallucinations can be simple (i.e. shapes, patterns) or complex (i.e. detailed objects, people) but patients almost always have insight into the fact that they are not real and do not suffer from any other forms of hallucinations (e.g. auditory) or delusions.
NICE indications for ECT
Catatonia
A prolonged or severe manic episode
Severe depression that is life threatening
Side effects of ECT
Short term: Headache, nausea, short term memory impairment, memory loss of events prior to ECT, cardiac arrhythmia
Long term: Some report impaired memory
Somatic symptoms in depression
Loss of emotional reactivity
Duiurnal mood variation
Anhedonia
Early morning waking
Psychomotor agitation or retardation
Loss of appetite and weight
Loss of libido
Side effects of clozapine
weight gain
Excessive salivation
Agranulocytosis’
Neutropaenia
Myocarditis
Arrhythmias
What is catatonia
the stopping of voluntary movement or staying still in an unusual position . Believed to occur due to abnormalities in balance of dopamine and other neurotransmitter systems. Most commonly associated with certain types of scz.
Amisulpride
Antiemetic and antipsychotic.
Selective dopamine receptor antagonist
Amitryptylline
for neuropathic pain. But is a triptan so needs to be avoided with SSRIs, as both have serptonergic action, so incr risk of serotonin syndrome
DOLS
deprivation of liberty safeguards
Amendment to the Mental Capacity Act. If lacking capacity to consent to their care and treatment, can detain in order to keep them safe from harm.
Section 2
Section for assessment and treatment. Recommended by two doctorsl and Application made by AMHP. Max 28 days and cannot be extended,
Section 3
Longer term civil section. AMHP appplies for admission based on recommendation of 2 doctors. Initially 6 months, then renewed for further 6, then for periods of 12 months.
Section 4
Basically for the GP, admission for emergency treatment for up to 72h. Not commonly used.
Section 5
Holding powers for up to 72 hours if from F2 up (5.2), ot up to 6 hours if nurse (5.4)
Section 37
Person convicted of offense punishable with imprisonment instead sentenced to hospital order (by crown or magistrates court). Initially 6 months then renewed for 6, then every 12.
Requirements for sectioning
Suffering from mental disorder of nature and/or degree which makes it appropriate for them to be detained in hospital for assessment and or treatment. AND that they ought to be detained in the interests of their own health or safety, or with a view to the protection of other persons. AND the appropriate treatment is available.
Section 37/41
Hospital order with restrictions. Risk of committing further offfences or necessary for protection of public, basically means Ministry of Justice consent required for section 17 leave, transfer to another hospital or discharge.
Section 47
Prisoner can be transferred to hospital,and then treated as if under a 37, and can have 47/49 when then transferred back??
Investigations for organic causes of psychosis
LFTs and macrocytosis (if abnorm = alcohol misus?)
Serological tests for syphillis
Screen for AIDS
Urine screen for recreational drugs
CT brain if focal signs
PTSD predisposing and maintaining factors
Pre: Family history, female sex,
Maintaining: Drugs, avoidance behavioura
PTSD time period
must be present for at least 4 weeks, otherwise an acute stress reactiom
Clozapine-induced gut hypomobility
Most common cause of clozapine related fatality
Constipation in up to 60% of patients
Severe has mortality of 20-30%
Most severe during first four months
Advice: Fluids, fibre, regular exercise, bowel ‘awareness’, avoid anticholinergics, medical team awareness
Lithium side effecrs
polyuria, renal failure, metallic taste, sedation, tremor
Optimum lithium level
0.4-0.9mmol/L
Lithium toxicity
initially coarse tremor, nausea and diarrhoea. Then confusion, ataxia, dysarthria, renal failure, hyperreflexia, progressing to coma and death.
Add IV fluids to increase renal excretion, and may need dialysis.
Benzo withdrawal
insomnia, flu like symptoms, anxiety and muscle twitfhing
Donepezil
Indic: Mild to moderate AD
Mech: Acetylcholinesterase inhibitor
SE: Nausea, dizziness, diarrhoea and insomnia
Galantamine
Indic: Mild to moderate AD
Mech: Acetylcholinesterase inhibitor
SE: Nausea, dizziness, diarrhoea and insomnia
Rivistigmine
Indic: Mild to moderate AD, dementia assoc w PD
Mech: Acetylcholinesterase inhibitor
SE: Nausea, dizziness, diarrhoea and insomnia
Memantine
indic: Moderate-severe AD
Mech: Glutamine NMDA receptor antagonist
Antenatal depression risks
lack of partner/social support
History of abuse/domestic violence
Personal history of mental illness
Unwanted or unplanned pregnancy
High perceived stress
Present/past pregnancy complications
Pregnancy loss
Wing’s triad of impairment in ASD
Impaired reciprocal social interaction
Impaired verbal and non verbal communication
Restricted repertoire of activities and interests
Psychological theories of ASD
Executive dysfunction theory: Embedded figures test (eg easier to count triangles in picture than see whole)
Weak central coherence theory: The Navon Test (see many small as making up large letter H)
Mindblindness theory: Sally Anne Test
Common associated diagnoses w ASD
epilepsy, developmental disorders, mental health disorders
Alcohol withdrawal timings
symptoms 6-12 hours
Seizures 36 hours
Delirium tremens 72 hours
Anorexia biochem findings
Most things low, Gs and Cs high:
Growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Core symptoms of AN
BMi 17.5 or less, weight at least 15% below expected
Food restriction and one of: Excessive exercise, self induced vomiting, laxative use, appetite suppressants
Body image distortion
Morbid fear of fatness
Amenhorrhoea or pubertal delay
If lacking some of these = atypical AN
Long term metabolic complications of AN
Hypoproteinaemia - oedema, renal damage
Vitamin deficiencies
Hypercholesterolaemia - cardiovasculae and hepatic damage
Long term endocrine consequences of AN
Decr sex hormones - infertility
Decr growth hormone - restarted growth, esp if prepubertal
Long term cardiovascular consequences of AN
Hypotension, heart or valve damage - congestive heart failure
Long term GI consequences of AN
Gastric dilation - dumping syndrome
Induced vomiting - peptic ulceration, gastritis
Malabsorption - constipation, folate or B12 deficiencies
Long term renal consequences of AN
Renal calculi- acute and chronic renal failure
Long term neurological consequences of AN
malnutrition, electrolyte abnormalities - epilepsy, autonomic and peripheral neuropathies
Long term musculoskeletal consequences of AN
Hypocalcaemia, hormone changes - osteoporosis so broken bones, spinal injury. Myopathies
Hematological consequences of long term AN
anaemia, esp iron deficiency
Bulimia nervosa diagnostic criteria
ALL of:
Persistent preoccupation with eating and craving for food (patient succumbs to overeating)
Morbid dread of fatness - patient sets a sharply defined weight threshold
Attempts to counteract the fattening effect of food (purging, alternating starvation, laxatives/diuretic use)
If missing some of these = atypical BN
Dermatological consequences of BN
Alopecia
Pruritus
Nail fragility
Russell’s sign (callouses on knuckles)
eyes, ears, nose consequences of BN
Subconjunctival haemorrhage
Recurrent epistaxis
Dental consequences of BN
Dental erosion
Periodontal erosion
Dry mouth
Electrolyte consequences of BN
metabolic alkalosis
Hypokalaemia (->prolonged QTc,/torsades/ v fib)
Peripheral oedema (due to aldosterone upregulation)
GI consequences of BN
GORD
Barrett’s esophagus
Boerrhaave’s
Consequences of laxative abuse
effects on GI system and electrolytes
Cathartic colon = loss of normal peristalsis due to prolonged use
Hypovolaemia and electrolyte abnormalities esp hypokalaemia
Binge eating disorder
regularly eating excessive food over a short period of time until uncomfortably full.
Eating when not hungry
Eating very fast during binge
Eating alone or secretly
Felling depressed, guilt, ashamed or disgusted after a binge
Avoidant restrictive food intake disorder (ARFID)
Avoiding certain foods or has restricted intake of overall amount consumed, or both because of:
Increased sensitivity to taste, smell, temperature or appearance of certain foods
Concerns about consequences of food, eg has choked/vomited in the past
Low interest in eating, reduced appetite
Acute stress reaction
response to exceptional physical/mental stress
Mixed and changing picture
Initial state of ‘daze’, narrowing of attention, disorientation
Followed by further withdrawal, or agitation and hyperactivity
Subsides over a period of days to weeks
Adjustment disorder
Significant life change or stressful event, eg bereavement, becoming a patent
Variable symptoms between anxious, depressed, mixed, inability to cope/plam ahead, continued to interfere with function
Less than six months
Management of panic disorder
1st line: CBT
2nd line: Pharmacotherapy -
Benzos for 2-4wk if severe disabling anxiety
TCAs:clopiramine can be used for OCD and panic disorder
Beta blockers - reduce autonomic symptoms eg palpitation, tremor
Antipsychotics at low dose for long term severe anxiety
ECT use
Severe depression refractory to medication (eg catatonia), those with psychotic symptoms
Typically in older patients
67% female
Raised intracranial pressure = the only absolute contraindication
Side effects of ECT
Short term: Headache, nausea, short term memory impairment, cardiac arrhythmia (need ECG before)
Long term: Plss memory impairment, partic anterograde
Mania vs hypomania
mania
At least 7 days
Severe functional impairment in social and work situations
May require hospitalization due to risks to self or others
Often psychotic features.
Hypomania:
Lesser version, typically 3-4 days, does not impair function in same way.
Unlikely to require hospitalization
Does not exhibit any psychotic symptoms
Paradoxical disinhibition with benzos
<1% of people given benzo. Become aggressive, impulsive and hyperactive. More common at extremes of age or with neurodisability. Mark in notes and avoid in future
Withdrawal from benzos
if prescribed for more than a few weeks.
Typical sympt: Apprehension and anxiety, flu like symptoms, insomnia, tremor, heightened sensitivity to stimuli, muscle twitching, very rarely seizures if withdrawing rapidly from large dose.
Advice about benzps
use sparingly
Brief treatment, max 3 weeks
Withdraw gradually and warn patients
Short acting fof intermittent anxiety, long acting for lasting
Consider alternatives
Most classic features of alcohol withdrawal
at 6-12 hours
Tremor, sweating, tachycardia, anxiety
Peak incidence of seizures at 36 hours
Fearures of delirium tremens
48-72 hours
Coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Stepwise management of GAD
- Education about GAD and active monitoring
- Low intensity psychological interventions
3, high intensity psychological interventions, or drug treatment: 1st line = sertraline, if not offer alternative SSRI or SNRI (duloxetine, venlafaxine). If not tolerated, consider pregabalin
Treatment of panic disorder in primary care
CBT and SSRIs are first lime
If contraindicated or no response after 12 weeks, should offer imipramine or clomipramine
Factors indicating poor prognosis for schuzophrenia
strong family histoey
Slow inset
Low IQ
Prodromal phase of social withdrawal
Lack of obvious precipitant
Somatisisation disorder
multiple physical symptoms present for at least 2 years
Patient doesn’t accept reassurance or negative teest results
Illness anxiety disorder (hypochondriasis)
persistent belief in presence of an underlying serious disease, eg cancer
Patient doesn’t accept reassurance or negative test results
Conversion disorder
typically loss of motor or sensory function
Not consciously feigned
Patients may be indifferent to their apparent disorder??
Chronic insomnia disfnosis
trouble falling asleep or stating asleep at least 3 nights a week for 3 months or longer
Typically reduced daytime functioning, decreased periods of sleep or incteadrf accidents due to poor concentration
Short term management of insomnia
Identify any possible causes, eg mental or physical health or poor sleep hygiene
Advise not to drive whilst sleepy
Good sleep hygiene
Only consider use of hypnotics if daytime impairment severe
Korsakoff’s syndrome what is
Marked memory disorder in alcoholics
Thiamine deficiency over long term causes damage and haemorrhage to mamillary bodies of hypothalamus and medial thalamus
Often following untreated Wernicke’s encephalopathy
Korsakoff’s syndrome features
anterograde amnesia - inability to acquire new memories
retrograde amnesia
Confabulation
Wernicke’s encephalopathy triad
Confusion
Ataxia (broad based gait)
Oculomotor dysfunction (eg CN 6 palsies and nystagmus)
Interactions with SSRIs
warfarin/heparin/aspirin: NICE recommend mirtazapine instead due to GI effects
Triptans and MAOIs incr risk of serotonin syndrome
Fearures of PTSD
reexperiencing: Flashbacks, nightmares, repetitive and distressing intrusive images
Avoidance: Avoiding people, situations or circumstances resembling or associated with the event
Hyperarousal: Hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
Emotional numbing: Lack of ability to experience feelings, feelings detached
Symptoms present >1 month
Adverse effecrs of SSRIs
GI side effects common
Incr risk of gastro bleeding, should hVe PPI if also taking NSAID
Hyponatraemia
Increased anxiety and agitation esp in first 2 weeks - patients under 30 should be reviewed a week after starting,
SSRIs and pregnancy
NICE says consider benefits and risks
Use during first trimester gives small incr risk of congenital heart defects - BUMP says this is no longer latest evidence
Use during third trimester can result in persistent pulmonary hypertension of newborn (around 1/300 babies whose mother takes SSRI)
Neonatal abstinence syndrome
What to do before starting SNRIs
check BP as associated with development of hypertension
