Psychiatry Flashcards
Mental Status Examination
categories
https://www.ncbi.nlm.nih.gov/books/NBK546682/
- appearance
- behavior
- motor activity
- speech
- mood
- affect
- thought
- process
- thought content
- perceptual disturbances (delusions, illusions, Hallucionations)
- cognition (MMSE, MoCA)
- insight
- judgment.
Mental Status Examination
Irregular thought processes types
- circumstantial
- tangential
- the flight of ideas
- loose/disorganised
- perseveration
- thought blocking
Mental Status Examination
Circumstantial thought process
describes someone whose thoughts are connected but go off-topic before returning to the original subject
Mental Status Examination
Tangential thought process
Is a series of connected thoughts that go off-topic but do not return to the original topic.
Mental Status Examination
Flight of ideas thought process
Flight of ideas is a type of thought process similar to a tangential one in which the thoughts go off-topic, but without complting the thought or train of thoughts; and the connection between the thoughts is less obvious and challenging for a listener to follow.
Common in MANIA
Mental Status Examination
loose, disorganised thought process
No connection occurs between the thoughts AND no train of thought to follow.
it most often occurs in schizophrenia
Mental Status Examination
Perseveration
Perseverations are a thought process where the patient returns to the same subject, regardless of topic or question
May occur in DEMENTIA
Mental Status Examination
Thought Blocking
observed in psychosis when a patient has interruptions in their thoughts, making it challenging to either start or finish a thought.
Mental Status Examination
Affect - definition
affect reflects the person’s EXTERNAL emotional expression - which can be evaluated by the interviewer. It can be described as:
- EUTHYMIC (normal, well-balanced mood)
- DYSTHYMIC (sullen, flat)
- EUPHORIC (intensely elated mood)
Mental Status Examination
Mood - Definition
mood reflects person’s INTERNAL emotional experience (e.g. good, ok, frustrated, angry)
Mental Status Examination
Insight - Definition
It refers to a patient’s understanding of their illness and functionality. Insight is typically described as poor, limited, fair, or if a previous comparison depicts worsening versus improving
DEPRESSION Dx
2 core symptoms (depressed mood, low energy, anhedonia)
+
2 or more of the other symptoms
(<2 = mild; >2 + <5 moderate; >5 severe)
+
for at least 2 weeks
DEPRESSION Sx
Depressed mood (CORE) + SIGECAPS
– S = Sleep (decreased overall pattern and architecture)
– I = Interest/Enjoyment/
Anhedonia (low) (CORE)
– G = Guilt/Hopelessness/Pessimist/Self-blaming/Nihilistic
– E = Energy (low) (CORE)
– C = Concentration (decreased)
– A = Appetite (usually low, but can be increased)
– P = Psychomotor retardation
– S = Suicidal thoughts
typically, in depression, mood is worse in the morning and betters as the day progressed (this is called “diurnal variation”)
DEPRESSION
major depression with ATYPICAL features
- mood remains reactive (lifting of depressive symptoms during happy life events)
- reversed diurnal variation (i.e. evening are the most difficult time of the day for the mood)
- feeling rejected and unloved (interpersonal rejection sensitivity)
- leaden paralysis (dull/heavy limbs to lift)
- hyperphagia/weight gain
- hypersomnia
Rx: MAOi
Dysthymic Disorder (Persistent Depressive Disorder)
Chronic condition characterised by depressive symptoms that:
- occur for most of the day
- more days than not
- for > 2 years
common features:
- H: Hopelessness (despondency)
- E: Energy (decreased)
- S: Self-esteem (decreased)
- S: Sleep (decreased)
- A: Appetite (decreased)
- D: decision making (impaired)
DEPRESSION
Sleep disturbances features
MOST COMMON - waking up during the night and having trouble going back to sleep (also referred as middle insomnia). if successful [in going back to sleep], broken sleep thereafter
- early morning wakening and being unable to get back to sleep at all (also referred as terminal insomnia)
- increased REM stage
- Decreased stage 3 non-REM stage (less stage 3 means less restorative periods => daylight tiredness)
LESS COMMON/UNCOMMON
- increased sleep latency (i.e. difficulty falling asleep) = MORE COMMON IN ANXIETY or associated with the use of nocturnal stimulants (e.g. caffeine)
- Hypersomnia and oversleeping
- Dramatic dreams (including dreams about death) ARE NOT TYPICAL OF DEPRESSION
DEPRESSION
Risk Factors
- perfectionism
- obsessionality
- intellectual developmental delay
- Family history of depression.
- Family history of Autism
- Substance Misuse.
- Unemployment
- Low socioeconomic status.
- Elderly person with cognitive decline or bereavement.
- All family members who have experienced family violence.
– Experience of child abuse
DEPRESSION
groups are at higher risk of depression
- Women
- Postpartum women
- Young rural males
- Adolescents
DEPRESSION
Features in children/adolescents
- Anhedonia/Apathy may be as severe or more apparent than mood abnormalities (often expressed as severe boredom)
- impaired concentration
- sadness(sad appearance)
- psychomotor agitation (“jumpy”, not relaxed)
- despondency (hopelessness)
- excessive irritability
- feeling rejected, unloved, inadequacy, worhtlessness (interpersonal rejection sensitivity)
- somatic complaints (eg, headaches, abdominal pain, insomnia), and persistent self-blame.
- anorexia, weight loss (or failure to achieve expected weight gain)
- sleep disruption (including nightmares)
- suicidal ideation
DEPRESSION
Firstline choice of treatment in children/adolescents
Fluoxetine
TCA’s, Mirtazapine, Venlafaxine are not recommended/approved for use in adolescents
DEPRESSION vs SCHIZOPHRENIA
***PATTERN
- episodic
vs
- progressive
DEPRESSION
Treatment according to the classification
- Mild depression: CBT > antidepressants
-
Moderate depression: CBT = antidepressants
(initial choice of therapy based on patient preference) -
Moderate to Severe depression: Antidepressants > CBT
(although concurrent psychological therapies may often be helpful if the patient can concentrate enough to participate in these.)
DEPRESSION
Antidepressants alone are ————— effective in patients with severe depression
50% to 60%
DEPRESSION
ECT indications
ECT indicated in some forms of severe depression:
- psychotic depression
- melancholic depression
- voluntary patient with severe depression
- If previous good response to ECT in patients
with severe depression
DEPRESSION
Inpatient treatment indications:
- depression with psychosis (ie with delusions or hallucinations);
- significant risk of suicide, or homicide (eg ‘altruistic homicide’ by a woman suffering severe perinatal
depression); - inadequate support at home;
- seriously physically unwell
When the patient’s depression puts themselves or others at significant risk and the patient is not competent to agree to treatment, involuntary hospitalisation under the relevant mental health legislation must be considered
DEPRESSION
First-line drug options
- SSRIs
- SNRIs
- Mirtazapine
DEPRESSION
When to assess response to antidepressant
after 2 to 4 weeks of treatment
DEPRESSION
% of patients with major depression that will respond to AT LEAST one antidepressant medication
80%
DEPRESSION
Management if there is PARTIAL initial response
- increase the dose
⬇︎
- reassess in 2 to 4 weeks
⬇︎
- if no addtional response ➡︎ switch drug (first-line)
- if additional response, but effect is still inadequate:
➡︎ increase the dose further if possible within the
recommended dose range ➡︎ reassess in 2 to 4 weeks
➡︎ If a further dose increase is not possible, switch to a
different drug (first-line)
DEPRESSION
Management if there is No initial response
- increase the dose
⬇︎
- reassess in 2 to 4 weeks
⬇︎
- if no addtional response ➡︎ switch drug (first-line)
- if partial response, but effect is still inadequate:
➡︎ increase the dose further if possible within the
recommended dose range ➡︎ reassess in 2 to 4 weeks
➡︎ If a further dose increase is not possible, switch to a
different drug (first-line)
DEPRESSION
Antidepressant-free interval recommended when changing from one SHORT-ACTING SSRI to ANOTHER SHORT-ACTING DRUG or FLUOXETINE
Nil
DEPRESSION
Antidepressant-free interval recommended when changing from FLUOXETINE to a SHORT-ACTING SSRI
1 week
DEPRESSION
Full recovery after favourable response to first-line therapy
6 weeks or longer
DEPRESSION
How long should treatment be for
If single episode of major depression = 6-12 months
DEPRESSION
Indications for long-term prophylatic therapy
- 2 or MORE more depressive episodes within 5 years
- 3 previous episodes,
- single severe episode of psychotic depression
- serious suicide attempt
DEPRESSION
duration of long-term treatment
at least 3 to 5 years
(including continuing work on vulnerability factors)
Some patients may require lifelong antidepressant therapy.
DEPRESSION
When to consider failure to respond to initial antidepressant therapy?
after unsuccessful trials of at least two first-line treatments (either drug or psychological)
DEPRESSION
Drug options for unsuccesful trial with First-line therapy
- TCAs
- MAOIs
both require specialist support
DEPRESSION
Discontinuation syndrome Sx
- insomnia, nausea
- postural imbalance
- sensory disturbances
- hyperarousal
- flu-like symptoms.
SOME PATIENTS CAN EXPERIENCE THESE SYMPTOMS even after missing just 1 or 2 doses
DEPRESSION
Discontinuation Syndrome duration
these symptoms are mild, last 1 to 2 weeks
(usually does not require specific treatment)
If withdrawal symptoms occur due to abrupt discontinuation, symptoms are rapidly extinguished with the reinstitution of the antidepressant
DEPRESSION
Tapering regime to prevent Discontinuation syndrome
As a general rule
- dose should be 1/2 every week
⬇︎ - until the daily dose is half of the lowest unit strength available
⬇︎
antidepressant can be stopped after 1 week on this dose.
In general, antidepressants should be tapered slowly, rather than stopped abruptly, to reduce the risk of discontinuation
syndrome. Antidepressant discontinuation syndrome is more likely to occur with a higher dose, a longer duration of treatment
DEPRESSION
If a patient, who has successfully been stable on prophylactic dose of a particular mood stabiliser, develops acute depression, what is the next best step in management?
- Adding an antidepressant to the prophylactic mood stabilizer: the choices of the drug would be the same as for major depression. SSRls first line.
- Increasing the dose of prophylactic mood stabilizer (ONLY if the patient’s psychosis is indicated in coming back, otherwise continue same dose)
DEPRESSION
Whcih antidepressive is considered appropiate in childhood/adolescence depression
FLUOXETINE
ABSOLUTE CONTRA-INDICATIONS ARE:
- TCAs = should not be used in children < 16 years.
- Mirtazapine = due to its effects of sedation and weight gain, may cause problems in this age group
- Venlafaxine = increased reports of hostility and suicide-related adverse effects such as suicidal ideation and self-harm.
DEPRESSION
Considerations regarding pharmacological tretment in childhood/adolescence depression
Trail, change of therapy, discontinuation
- treatment trials should last:
– for 3 to 4 weeks before considering a dose increase (as oposed to 2-4 weeks in adults)
– and for 8 to 12 weeks before a change of therapy. - discontinuation trial should be considered **within 1 year **of starting treatment in children who have achieved a marked reduction in symptoms.
DEPRESSION
Patient with severe depression or suicidal ideation taking HCV treatment (interferon).
Management?
Stop interferon, start SSRI.
(Treat depression first. Recomence interferon once the depression is managed)
DEPRESSION
Drug of choice in post-cardiac depression
https://www1.racgp.org.au/ajgp/2023/november/incidence-and-impacts-of-post-cardiac-event-mental
Sertraline
Sertraline, citalopram, fluoxetine and mirtazapine in particular have been shown to be safe and effective for treating depression in cardiac patients. However, certain SSRIs, such as fluvoxamine, fluoxetine and paroxetine, can interact with antihypertensive medications, such as metoprolol and captopril, and should therefore be used with caution
Examples of Overvalued Ideas
Body dysmorphic disorder
Anorexia Nervosa
Hypochondriasis
BIPOLAR DISORDER
Dx
Elevated Mood + 3 of DIG FAST
or
Irritability + 4 of DIG FAST
FOR 1 week or more
BIPOLAR DISORDER
Sx
- D – DISTRACTIBILITY
- I – IMPULSIVITY (please seeking behaviours)
- G – GRANDIOSITY
(can border on the psychotic delusions and hallucinations. - F – FLIGHT OF IDEAS
- A – ACTIVITY
(psychomotor agitation/goal direct activity) - S – SLEEP = decreased need
- T – TALKATIVINESS
BIPOLAR DISORDER
MANIA ≠ HYPOMANIA by following features
- Minimum 7 days of symptoms
(4 days for hypomania) - Marked functional impairment
(no functional impairment in hypomania) - Delusions and hallucinations (psychotic features)
(absent in hypomania) - Patient often requires hospitalisation
(less commonly required in hypomania) - Insight and judgment are usually impaired in mania
“ELEVATED MOOD IS SEEN BOTH”
BIPOLAR DIORDER
Cyclothymia
≥ 2 years of fluctuating, mild hypomanic & depressive symptoms that do not meet criteria for hypomanic or
major depressive episodes
BIPOLAR DISORDER
Features more commonly seen in Bipolar Depression than in Unipolar Depression
- Psychomotor retardation.
- Increased appetite (hyperphagia)
- Increased sleep (hypersomnia)
- Positive family history of bipolar disorder
- Early onset of first depression before 25 years of age.
- Delusions and hallucinations (psychotic features)
BIPOLAR DISORDER
Suicidal Risk
- 15 x more likely to commit suicide
- 25% of BD patients will attempt suicide
- history of drug taking is an important finding as it can be considered as suicide attempt
BIPOLAR DISORDER
MANIA vs PSYCHOTIC DISORDERS
***NATURE of delusions
- grandiose
- reward-oriented
vs - conspiratorial thinking
- paranoia
- thought manipulation/control by outside force
***DISTINGUISHING SYMPTOMS
- flight of ideas, distraction
vs
- thought disorganisation + negative sx
***PATTERN
- episodic
vs
- progressive
BIPOLAR DISORDER
Hypomania vs HISTRIONIC PERSONALITY DISORDER
Some symptoms of hypomania overlap with histrionic personality disorder. These include:
- shallow emotions
- flirty nature
However:
- flirting in hypomania = increased sexuality
- flirting in histrionic personality disorder = attention seeking behaviour
BIPOLAR DISORDER
treatment of acute mania
1st OLANZAPINE VO
OR
1st RISPERIDONE VO
OR
2 HALOPERIDOL VO
OR
2 LITHIUM VO
BIPOLAR DISORDER
Treatment maitenance and recurrence prophylaxis
Lithium + CBT
BIPOLAR DISORDER
Duration of treatment following an acute mania episode
12 months
If an antipsychotic is used for acute treatment, it should be withdrawn within a few months after remission
BIPOLAR DISORDER
Acute mania Failure to respond to treatment
- ensure that maximum tolerable drug concentration has been achieved.
- switch to a different drug (eg from a second-generation antipsychotic to lithium)
- combine drugs (eg a second-generation antipsychotic + lithium)
- electroconvulsive therapy (ECT)—this is a proven treatment for mania and may be extremely effective even when patients fail to respond to one or more antimanic drugs
BIPOLAR DEPRESSION
Mx
1st Antidepressant (SSRI preferably)
+
Mood stabiliser
OR
1st Quetiapine Monotherapy
Mood-stabilising agents are SGAs (which carry the risk of metabolic syndrome. Although, for the acute resolution of symptoms agents from both classes have similar efficacy, SGAs may be slightly faster (possibly because of easier administration) and within the two classes
of agents there is a slight gradient of efficacy from lithium.
BIPOLAR DEPRESSION
When to cease antidepressant
preferably within 1 or 2 months of
successful resolution
BIPOLAR DEPRESSION
Treatment of ACUTE bipolar depression
https://www.racgp.org.au/afp/2013/september/bipolar-disorder
QUETIAPINE
Antidepressant monotherapy should be avoided due to the risk of inducing rapid cycling mania.
BIPOLAR DEPRESSION
Failure to respond to treatment
- change to a different antidepressant or a
different prophylactic drug - (ECT)
—this is an effective treatment for bipolar depression and should be considered especially if the patient is psychotically depressed or displays significant psychomotorretardation or agitation
Schizophrenia
DX
- 2 Sx ((at least ONE POSITIVE sx))
- for at least 6 months
symptoms rarely have an acute onset. Instead, there is often a prodromal state followed by a progressive worsening of the symptoms
SCHIZOPHRENIA
Psychosis
definition
- Psychosis is a loss of contact with reality - loss of insight into the fact that one is mentally ill
- Some people with psychosis have false beliefs that can best be described as fearfulness and suspiciousness (paranoia);
- They may have vague fears or complaints about others controlling their lives, but many describe consistent suspicions of very specific, elaborate, and persistent plots against THEM. Very often, these beliefs are directed at family members or friends.
SCHIZOPHRENIA - Delusions definition
false beliefs that are inconsistent with patient’s background and cannot be corrected by reasoning (result of an illness or illness process)
SCHIZOPHRENIA - Hallucinations definition
false perceptions in the absence of any external stimuli (e.g. auditory, visual) - no one else feels them
SCHIZOPHRENIA - Illusions definition
misperceptions of genuine stimuli, a specific form of sensory distortion because:
- individuals have been deliberately misled (e.g. by a magician);
- if their attention is diminished (e.g. delirium, fatigue, boredom or laziness)
- there is a lack of visual clarity (e.g. dim lighting, semi-darkness, fog)
- if they are intensely aroused by fear, passion or depression.
Some people have vivid imaginations and may see faces or figures in ordinary environmental features such as clouds, tree trunks, rock formations etc. This is quite common in children and is not considered
Schizophrenia
POSITIVE Sx
(should not be present, but are)
‘HD BS’
- Hallucinations (auditory most common)
- Delusions (paranoid or persecutory)
- Thought Disorganisation = Behaviour (disorganised) + Speech (disorganised)
Schizophrenia
features of the auditory hallucination
- comes from OUTSIDE of the head (as opposed to inside)
- RIGHT side
- commentary between speakers (as opposed to one voice)
- mix of male and female voices
- intermittent (rather than continuous)
Person will find specific REDUCING BEHAVIOURS (e.g. listening to radio/watching TV/talk to others very loud, wear headphones)
Person may seen reacting to what the voices are telling them (“RESPONDING TO INTERNAL STIMULI”)
SCHIZOPHRENIA
examples of Disorganised Behaviour
- Motor perseveration (repeating same motions over and over)
- echopraxia (copying someone’s movements)
- Catatonia
SCHIZOPHRENIA
examples of Disorganised Speech
- clang association ( words based on its sound/
phonetics, like rhyming, rather than the actual meaning) - neologism
- echolalia
- perseveration (say the same word repeatedly w/o a purpose)
- word salad (non-sense words)
- concrete thinking (inability to think in abstract terms)
- loosening association (Rapidly shifting from topic to topic, with no connection
between one thought and the next) - Circumstantiality - an inability to answer a question without unnecessary and excessive detail
Schizophrenia
NEGATIVE Sx
(‘should be present but aren’t’)
The 5 A’s
- Affect (flat/blunted)
- Ambivalence/Avolition (difficulty making decisions/executing commands/poverty of thoughts)
- Alogia (decreased or even absent speech)
- Anhedonia
- Asociality (social withdrawal)
Schizophrenia EPIDEMIOLOGY/PROGNOSIS
- incidence general population 1/100 (1%)
- men more affected than women 3/2 (1.5x)
- earlier in men (18-25) than for in women (25-35)
- men tend to exhibit more severe form and worse outcome
- earlier onset
- chances of recurrence after first episode (90% - similar to bipolar disorder)
- SUICIDE: when it occurs, tends to happen in early stages when the insight is still preserved
- negative symptoms are least likely to respond to medication.
Schizophrenia - RISK FACTORS
- Monozygotic twin** 50%** chance of developing
- Dizygotic twin has a 15% chance.
- There is 48% chance if both parents are affected
- There is 12 -13% chance if one birth parent is affected
- There is increased risk with advanced paternal age, where the parent was aged over 55
- Winter birth
- Foetal hypoxia (Pre-eclampsia and emergency c-section)
- use of illicit drugs (cannabis, amphetamines, cocaine, LSD)
- Urban areas
- stressful life experiences/migrants
- physical/sexual abuse in childhood
Schizophrenia - Symptoms and different age groups
YOUNG PATIENTS (15-35 yo)
- spontaneous remission more common
- requires higher doses
- more likely to have “negative symptoms”
LATE ONSET (> 40-45 yo)
- less likely to remit spontaneously
- respond to lower doses
- persecutory delusions is most common symptom, along with accusative or abusive auditory hallucinations
- less likely to have thought disorder and negative symptoms
> 60 yo
- less likely to remit spontaneously
- visual hallucinations
- less likely to have thought disorder and negative symptoms
SCHIZOPHRENIA
Early signs suggestive of evolving psychosis in teenagers
- Irritability or depressed mood (FIRST)
-
Deteriorating social or school function
– Withdrawal from friends and family
– A drop in performance at school - Increase in suspisciouesness
- Hypervigilance
- Ideas of reference and unsual rhoughts
- Trouble sleeping
- Lack of motivation
- Strange behavior
- Sudden and bizarre changes in emotions
- Severe problems in making and keeping friends
- Difficulty speaking, writing, focusing or managing simple tasks.
SCHIZOPHRENIA timeline DDx
- Brief Psychotic disorder: > 1 day & < 1 month
- Schizophreniform Disorder: > 1m & < 6 m
- Schizoaffective Disorder
SCHIZOPHRENIA vs Schizoaffective Disorder
HATS:
- H: HALF or more of the time ill must be spent with mood sx
- A: psychotic sx must occur ALONE (i.e. w/o mood sx)
- T: psychotic sx must occur TOGETHER (i.e during an episode of mood disorder)
- S: exclude effect of SUBSTANCES or other medical conditions
SCHIZOPHRENIA vs BPD
- stable or improving level of disfunction after early adulthood (as opposed to progressive decline over time seen in Schizophrenia)
- affect instability of BPD involves rapidly emotional shifting (as opposed to weeks to months changes)
- psychotic sx tend to be an sign of distress (experienced during times os stress)
- Auditory hallucinations- if present - are described as inside (as opposed to outside) and vague/unclear (as opposed to clear/vivid)
SCHIZOPHRENIA vs Dementia
Demented patients usually have:
- late onset
- lack of prior psychiatric sx or signs
- match average population in social milestones (school, work, marriage)
- visual hallucinations
- loss of recall of learnt information and visuospatial ability (schizophrenic patients have these intact)
SCHIZOPHRENIA
Secondary causes of acute-onset psychosis in children & adolescents
- Metabolic/electrolyte disturbances
- Urea cycle disorders
- Acute intermittent porphyria
- Wilson disease
- Renal/liver failure
- Hypoglycemia
- Sodium/calcium/magnesium disturbances
- SLE
- Thyroiditis
Capgras syndrome
- Also called delusional misidentification syndrome
- Disorder in which a person believes that an identical-looking has replaced a friend, spouse, parent, or other close family member impostor
- commonly occurs in patients with paranoid schizophrenia,
dementia and brain injury
Cotard Syndrome
patient believes they have lost important body parts, blood, internal organs, or even their soul
- prevalent in schizophrenia, bipolar disorder, non-dominant temporo-parietal lesions and migraine.
Ekbom syndrome
Delusional infestation with parasites or worms in schizophrenic patients
≠
Willis-Ekbom disease (WED); Witmaack-Ekbom syndrome or Restless leg syndrome (RLS) is characterised by a ‘compulsive’ restlessness or need to move the legs, often associated with paraesthesiae or dysaesthesiae. Symptoms at rest or disturbing sleep, quickly but temporarily relieved by standing and walking, with nocturnal worsening of symptoms.
https://litfl.com/karl-axel-ekbom/
FOLIE a DEUX
Shared psychotic disorder
Delusion developing in a person in close relationship with another person who has an established delusion (more common in mother-daughter or sister-sister relationships)
Dominant person and submissive or
dependent person in the relationship is clearly established.
Delusion similar in content.
HAPPENS IN FAMILIES – GROUPS OF PEOPLE
– example is a cult.
Treatment:
biggest challenge is getting the pair (or system) to accept the need for treatment.
FIRST STEP IS to separate the person or people with the secondary disorder from the person with the primary disorder, as the secondary’s delusions often don’t persist following separation.
Atypical antipsychotics aripiprazole and quetiapine most effective
Schizophrenia
first-episode psychosis treatment
- Amisulpride
OR
- Aripiprazole
OR
- Olanzapine
OR
- Paliperidone
OR
- Quetiapine
OR
- Risperidone
OR
- Ziprasidone
Schizophrenia
Interventions additional to medication to prevent relapse and improve outcome
- monitor for adverse drug effects
- Shared-care programs
- cognitive behavioural therapies (eg medication compliance therapy, motivational interviewing for substance abuse, coping strategies enhancement, symptom control interventions)
- cognitive remediation for cognitive deficits, social skills programs, supported employment programs, accommodation and disability support options, education and training assistance, and social interventions to combat isolation
- Manage comorbidities
- monitor substance use
- Maintain physical health and target cardiovascular risk factors
- Work with family/carers
- Carer assistance programs
Schizophrenia
period that requires symptoms to respond to treatment
- Agitation = settles within days
- Positive symptoms = may require several weeks, but some treatment response can be expected early (ie within 1 to 2 weeks of starting an antipsychotic)
- Negative symptoms of schizophrenia are
responsive to antipsychotics, but less so than positive symptoms
Schizophrenia
How long to wait before reevaluating if prescribed medication is working in a schizophrenic patient?
3 weeks
- Increase dose of the initial medication first,
- wait until 4-6 weeks
after 4-6 weeks
1 change to an alternate SGA, preferably (depending on positive/negative symptoms)
OR
2 change to FGA:
Haloperidol
OR
Chlorpromazine
SCHIZOPHRENIA
switchover regimen for antipsychotics
crossover phase of at least 1 to 2 weeks
Schizophrenia
Treatment duration
- 2 years (Following a first psychotic episode)
- ONLY if there has been full remission
Indefinite continuation of maintenance therapy is required for the majority of people with schizophrenia.
Schizophrenia
drug tapering regime
- the antipsychotic can be cautiously tapered and discontinued over a period of at least 3 months.
- monitor for early warning signs of relapse during this process and for a further 12 months after drug cessation.
- If relapse occurs after cessation of maintenance therapy, longer-term treatment (ie at least 5 years) is required.
Schizophrenia
Main reason for relapse
drug discontinuation due to poor concordance
Schizophrenia
Risk factors for relapse
- poor insight into the purpose of medication
- psychosocial stressors
- substance use (alcohol, cannabis, amphetamines more common)
- premature lowering of the dose
- discontinuation of antipsychotic treatment
Schizophrenia
Treatment Relapse Mx
- commencing a depot antipsychotic
- initiation of proceedings for involuntary community treatment
Schizophrenia
Treatment-resistant first step
identify any reasons for treatment resistance:
- Is the diagnosis correct?
- assess treatment concordance
- Have possible underlying medical causes been identified and treated?
- Is the patient reacting adversely to a current medication?
- Have the drug dose and duration of administration been adequate?
- assess abuse of alcohol and other drugs (eg cannabis, amphetamines)
- Could an interacting drug be compromising the response?
- Urine drug screening may be indicated, but this only identifies recent use and does not constitute a diagnosis of drug abuse or dependence,
Schizophrenia
Treatment Resistance definition
- reasons in step one excluded
PLUS
- drug trial of 6 to 12 weeks’ duration on optimal doses of at least TWO different antipsychotics
Schizophrenia
drug of choice for treatment resistance
Clozapine
Schizophrenia
Management of clozapine failure
- augmenting strategies: (no drug has demonstrated to be the best)
– amisulpride VO
– haloperidol VO
– lamotrigine VO
– omega-3 fatty acids (in particular formulations high in eicosapentaenoic acid) 2 to 3
- A trial of adjunctive ECT should be considered
(However, the relapse rate is high after ceasing an acute course of ECT)
Schizophrenia
Indications for the use of Clozapine
- severe and persistent positive and/or negative sx
- persistent or frequently recurrent suicidal ideation and/or behaviours
- severe and persistent EPS (eg tardive dyskinesia)
- marked aggressive behaviour
- severe comorbid substance abuse.
Schizophrenia
Mx of negative symptoms
(if not improved with first-line therapy)
Change to:
1 Amisulpride
OR
1 Clozapine
OR
1 a SGA other than clozapine
PLUS
an antidepressant (fluoxetine preferred)
OR
2 clozapine (
PLUS
an antidepressant (fluoxetine preferred)
OR
2 clozapine
PLUS
Lamotrigine
Hyperactive Delirium
Patients with hyperactive delirium demonstrate features of restlessness, agitation and hyper-vigilance. They often experience hallucinations and delusions but have no insight.
Lewy Body Dementia
Dementia with Lewy Bodies is characterised: -impaired cognition
- fluctuating levels of awareness and attention
- Parkinsonism (ataxic gait)
- visual hallucinations
- sleep disorders
- tend to lack insight into the visual hallucinations
Behavioural emergencies
recommended methods necessary to gain control (from least invasive)
- verbal de-escalation and early negotiation
(including the offer of VO medication) - ‘show of force’
(involves having a sufficient number of staff visibly backing up the clinician who is attempting to
negotiate with the patient) - physical restraintv (immobilisation)
- chemical restraint
NOTE: when weapons are involved or there is a high likelihood of extreme violence), security staff and/or police will be required to disarm and restrain the patient.
BEHAVIOURAL EMERGENCIES
What are the two types of treatment outcomes
-Tranquillisation
= defined here as a state of calmness (ie not showing anxiety, anger or other emotions)
-Sedation
= defined here as a state of rousable drowsiness.
BEHAVIOURAL EMERGENCIES
Oral Medication options
-
Diazepam VO
(preferred in drug withdrawal and stimulant intoxication) -
Olanzapine VO
(preferred in acute psychosis)
BEHAVIOURAL EMERGENCIES
Intravenous medication option
Q.3.374
-
DIAZEPAM IV
OR - MIDAZOLAM IV
If patient tolerant to benzodiazepine or if failure of first-line benzdiazepine USE: (in combiantion or single)
-
HALOPERIDOL IV
OR - OLANZAPINE IV
If combination therapy is considered appropriate, each drug should be administered separately (ie do not combine drugs in the same syringe)
BEHAVIOURAL EMERGENCIES
Intravenous medication option
- MIDAZOLAM IM
If patient tolerant to benzodiazepine or if failure of first-line benzdiazepine USE: (in combiantion or single)
-
HALOPERIDOL IM
OR - OLANZAPINE IM
Diazepam is not recommended for intramuscular injection as absorption is poor and erratic.
ANXIETY DISORDERS
Generalised Anxiety Disorder (GAD) Dx
Excessive anxiety/worry occurring on most days for at least 6 months (“chronic”)
Associated with 3 or more of the 6 symptoms.
ANXIETY DISORDERS
Generalised Anxiety Disorder (GAD) Sx
“MISERA-ble”
M - Muscle tension
I - Irritability
S - Sleep (decreased)
E - Energy (easy fatigue)
R - Restlessness, feeling keyed up, on the edge
A - Attention (Mind going blank or difficulty concentrating)
Not due to medical/ substance abuse/other
psychiatric disorders.
ANXIETY DISORDERS
Generalised Anxiety Disorder (GAD) Mx
**Therapy CBT/SPS **(structured problem solving) - should always be first-line treatment
If severe or CBT ineffective after 3 months,
then SSRI can be introduced.
(SSRIs are decreased and ceased if patient is
symptom free for 6 months)
Other options
- Buspirone - anxiolytic
- Benzodiazepines (short term of 2 weeks
and tapered over next 2 weeks; although it
has a more rapid effect it can easily lead to
physical dependence and should not be
used as long-term treatment)
- SNRI
- Beta blockers (PROPANOLOL) - if associated palpitation, tremors, for performance-only subtype
Individuals with performance-only social anxiety disorder do not fear nonperformance social situations and are not socially avoidant in general.
The pharmacologic treatment of performance-only social anxiety disorder includes as-needed beta blockers or benzodiazepines rather than maintenance medication.
- Beta blockers (eg, propranolol) on an as-needed basis help control the associated autonomic response (eg, tremors, tachycardia, diaphoresis).
- Due to their addictive potential, benzodiazepines (eg, diazepam, lorazepam) are generally avoided in patients with a personal or family history of substance use disorder. In addition, they are not preferred
when performance could be impaired by sedation and cognitive side effects (eg, giving a presentation, as in this case)
ANXIETY DISORDERS
Panic Attack Dx
- Intense ACUTE fear or discomfort
- in which 4 or more symptoms develop abruptly
- reaches a peak in 5-10 minutes (crescendo-decrescendo pattern)
ANXIETY DISORDERS
**Panic Attack **
Sx
STUDENTS Fear C’s
S - Sweating
T - Trembling - shaking
U - Unsteadiness or Dizziness/Faintness
D - Derealisation/depersonalisation/
dissociation
E - Elevated HR (Tachycardia/Palpitations)
N - Nausea
T - Tingling (Paresthesia)
S - Shortness of breath/ smothering sensation
FEAR - Fear of dying, Fear of loosing control or going crazy
C’S
= Choking feeling
= Chills - hot flushes
= Chest pain/tightness
ANXIETY DISORDERS
*Panic Disorder *
Dx
1/6 people with panic attacks will develop panic disorder
Panic Disorder results from anxiety about having future panic attacks that impact one’s ability to lead a normal life
“SURP-rise”
S - Sudden (without a trigger)
U - Unexpected
R - Recurrent
P - Panic attacks
Rise anxiety
Not associated with substance abuse
ANXIETY DISORDERS
*Panic Attack/Disorder *
Mx
FIRST: exclude medical condition. (acute
MI, asthma, thyrotoxicosis).
At the time of attack:
- slow breathing technique (if
hyperventilating)
- distraction methods
- benzodiazepines
** Treatment to prevent further attack**
- CBT (stress management, exposure and
desensitisation)
- avoid caffeine
if Psychotherapy is not working
- SSRI or buspirone.
- should be used in conjunction with CBT
ANXIETY DISORDERS
Agoraphobia
It is generally a specific coping mechanism that arises in response to having panic attacks/disorder where one begins to avoid going out at all preferring to stay in the safety of their own home (become housebound) where they feel less vulnerable to panic attacks - however, it can occur alone
it develops in about 1/4 of people with Panic Disorder (it is a marker of severe Panic Disorder
ANXIETY DISORDERS
Social Phobia/ Social Anxiety Disorder
Persistent fear of interpersonal rejection
Affected individuals avoid social or performance situations in fear they’ll embarrass themselves or be judged as anxious or stupid
ANXIETY DISORDERS
Disorders that often present with anxiety as chief complaint and their differences
- OCD (obsessional thoughts)
- Somatisation ( anxiety to physical sx)
- PTSD (re-experiencing trauma)
ANXIETY DISORDERS
Medical conditions that often present as anxiety
Pheochromocytoma (rare)
Diabetes Mellitus
(Hypoglycaemia is the commonest underlying organic cause of anxiety symptoms)
Arrhythmias (Paroxysmal supraventricular tachycardias)
Temporal epilepsy
Hyperthyroidism
Alcohol withdrawal
Drug intoxication or withdrawal
NOTE:
Carcinoid does not cause anxiety.
Carcinoma of the bronchus and hyperparathyroidism are more likely to present with depression.
OCD
Definition of Compulsion
Compulsive behaviours are:
- repetitive actions driven by anxiety or distress;
- They often serve as a coping mechanism to alleviate stress or prevent a feared event or situation through a repeated behaviour
- Associated with negative reinforcer (taking something - ie anxiety - away)
≠
Impulsive behaviour are:
- spontaneous actions performed without forethought or consideration of the consequences
- These behaviours are driven by immediate desires
- Associated with positive reinforcer ( often meaning is pleasurable)
OCD
Are patients egosyntonic or ego-dystonic with how they view their disorder?
Ego-dystonic = recognise one’s intrusive thoughts are not reflective (discordant) of their true desires (insight is preserved)
OCD
Clinical features
- obsessive thoughts and compulsive rituals
- Compulsions are “repetitive purposeful”, “intentional” behaviours conducted to prevent an adverse outcome
- While OBSESSIONS are REQUIRED for the diagnosis, COMPULSIONS are OPTIONAL (not everyone with obsessions will develop compulsions; however, everyone with compulsions will have obsessions)
- Obsessions:
Recurrent, intrusive, anxiety-provoking thoughts, urges, or images - Compulsions
Response to obsessions with repeated behaviors or mental acts. Behaviors not connected realistically with preventing feared event
OCD
Obsessive thoughts characteristics
“I MURDER”
I - Intrusive
M - Mind-based (not thought insertion)
U - Unwanted
R - Resistant
D - Distressing
E - Ego-dystonic
R - Recurrent
- Time-consuming (>1 hr/day) or causing significant distress or impairment
OCD
Epidemiology
- Men and women are “EQUALY” affected
- once of symptoms often during childhood or young adulthood (< age of 20-30)
OCD
Mx
optimal management always include a combination of both:
CBT **(ERP = exposure & response prevention) **
\+
SSRI
NOTE: Alcohol makes OCD symptoms feel better for a while, however, it is not recommended as a therapy due to the risk of alcohol abuse
NOTE: “CLOMIPRAMINE” is a TCA and can be used as a second-line alternative if CBT+SSRI have failed or in more severe cases of OCD
NOTE Neurosurgery (i.e cynguloctomy) is reserver for severe/refractory cases
SINGLE THERAPY IS NOT EFFECTIVE IN CBT - combination therapy is always the first line treatment
Risks of developing Obsessive Compulsive Disorder
- Anxiety
- Depression
- Alcohol or substance misuse
- Eating disorders
- Body dysmorphic disorders
- Chronic physical health problems (skin problems due to excessive hand washing)
BODY DYSMORPHIC DISORDER
Key features
“FIX ME DOC”
FIX - Fixation on perceived flaw
M - Medical care-seeking
E - Ego-Syntonic
D - Disabling
O - Obsessive thoughts
C - Compulsive behaviours
BODY DYSMORPHIC DISORDER
patients are ego-syntonic or ego-dystonic with how they view their disorder?
Ego-syntonic
Patient does not admit that their fears and preoccupations are extreme or excessive
BODY DYSMORPHIC DISORDER Mx
CBT ± SSRI
Comorbid conditions found with BDD
- Anxiety
- Social Phobia
- OCD
- Delusional disorder
- Alcohol or substance misuse
GENDER DYPHORIA (GD)
Clinical features
- Experiences persistent (>6 months) incongruence between assigned & felt gender
- Desires to be another gender
- Dislikes own anatomy, desires sexual traits of another gender
- discomfort with the development of unwanted secondary sexual characteristics.
- Believes feelings/reactions are of another gender
- Feels significant distress/impairment
GENDER DYPHORIA (GD)
Management
- Assessment of safety
- Support; psychotherapy (individual, family)
- Referral to specialist Gender identity-affirming care services (medical & mental health multidisciplinary)
HYPOCHONDRIASIS Dx
vs
Illness Anxiety Disorder
fears and symptoms persist for ≥ 6 months
HYPOCHONDRIASIS
features
- Preoccupation with or fear of having (as opposed to getting) a serious disease, despite medical reassurance, leading to significant distress/impairment.
- often present with a (self)-diagnosis
- Ego-syntonic (involuntary/non-volitional & unconsciously)
- Often involves history of prior physical disease.
HYPOCHONDRIASIS Mx
- group therapy ± SSRI
- schedule regular appointments with the patient’s primary caregiver (if existing)
Difference between Hypochondriasis & Somatisation
Hypochondriasis:
patient presents with a diagnosis
focus on the disease, not a particular symptom
failure to respond to reassurance
Somatisation: - presents with a variety of unexplained sx - primary focus of preoccupation/concern with the symptoms themselves
HOARDING DISORDER
Management
CBT and SSRI
nonetheless, patient usually don’t respond well
HOARDING DISORDER
Define Diogenes syndrome
- squalor and decline in personal hygiene
- sometimes hoarding useless items
- significant frontal lobe impairment
PTSD
Signs & Symptoms
“TRAUMA”
T - Trauma core
R - Re-experiencing core
A - Arousal core
U - Unable to function
M - Month ( present > 4 weeks)
A - Avoidance core
PTSD
Trauma features
Must be:
- life-threatening
- actual or threatened physical and/or sexual violence
- secondary exposure to a traumatic event (such as about a spouse or family member) also qualifies
NOTE: other non-life-threatening events such as harassment and non-violent bullying do not “qualify” as trauma per DSM-5 (despite these being distressing and resulting in S/S indistinguishable from PTSD) and ADJUSTMENT DISORDER with ANXIOUS MOOD should be considered
PTSD
Arousal phenomenon
Persistent (chronic) and generalised
- Hyper-arousal State:
increased anxiety and awareness - hyper-vigilance:
constant scanning of their environment for
clues to the presence of danger - MISERA-ble = MUSCLE tension, IRRITABILITY, trouble with SLEEP, low ENERGY, RESTLESSNESS, inability to pay ATTENTION (poor concentration and memory) to non-trauma related stimuli
PTSD
Duration
Symptoms must be present for at least 1 month
NOTE: it does not necessarily mean that symptoms have to present in the first month after the trauma occurs (delayed onset is more characteristic)
ACUTE: symptoms last < 3 months
CHRONIC: symptoms last > 3 months
DELAYED ONSET: Sx appear at least 6 months
after traumatic event
**PTSD **
vs
ACUTE STRESS DISORDER
When the core trauma-related symptoms have not yet reached ONE month in length
NOTE: the presence of ASD immediately following a traumatic event does not rule in later development of PTSD, nor does its absence rule it out
NOTE: the presence of ASD immediately following a traumatic event does not rule in later development of PTSD, nor does its absence rule it out
PTSD
Avoidance features
– physical avoidance (people, places, things)
– Psychological avoidance (emotional numbing)
an attempt to self-protect against strong negative
emotions; however, interferes with ability to
experience positive emotions such as joy (flattening
affect), satisfaction, love (detachment from others)
PTSD
Risk factors
- alcohol and drug abuse
- previous history of depression
- previous history of sexual abuse.
- Victims of domestic violence
PTSD
Features that predict a higher chance of having PTSD one year from the incident
- the intentional nature of the trauma
(eg sexual abuse/rape/assassination attempt) - Experiencing the trauma alone
- lack of social support network
- presence of at least one pre-trauma psychiatric diagnosis
NOTE: Onset of symptoms soon after the traumatic event (ie ACUTE DISTRESS DISORDER)
PTSD Mx
- CBT (FIRST-LINE TREATMENT)
- trauma-based psychotherapy, crisis
intervention therapy, - EMDR (eye movement desensitisation and
reprocessing therapy)
- trauma-based psychotherapy, crisis
- Life-style modifications (sleep hygiene,
relaxation techniques)
NEXT STEP
- If not responding, then SSRI (it does not help specifically with either sleep or nightmares)
PTDS
Initial response to an acutely traumatised state
- provide a comforting and consoling presence
- to listen empathically
Most people following traumatic events recover spontaneously without specific psychological interventions
NOTE:
the current consensus is that debriefing is not clinically
indicated as an immediate intervention and may even be harmful.
ADJUSTMENT DISORDER
with ANXIOUS MOOD or DEPRESSIVE MOOD
features:
Diagnostic criteria:
onset of anxiety/depression symptoms within 3 months of identifiable psychosocial stressor(s)
which:
- are time-limited (Once the stressor or its consequences have terminated, the symptoms do not persist for more than 6 months)
- Aren’t severe enough to meet criteria for MDD or GAD and incurs in response to as stress that isn’t life-threatening or violent enough to be trauma
- are in excess of normal expectations of reaction to the stressor(s)
- are not due to another identifiable mental disorder
- are not part of a continuing pattern of overreaction to stress impair social or occupational functioning.
- Significant impairment in social,
occupational, or other important areas of
functioning
ADJUSTMENT DISORDERS
Mx
- primary interventions = psychological supportive therapy including counselling, relaxation, problem solving, stress management, and (CBT)
- short-term pharmacotherapy (usually < 2 wks) with BZ = if the symptoms are severe, if significant impairment of functioning and there is inadequate response to psychological interventions.
NOTE: Most drugs used to treat anxiety (ie [SSRIs]) take a number of weeks to produce an effect, thus in this situation the use of a BZP may be appropriate
NOTE: Intermittent use, on occasional days when there is a severe exacerbation of anxiety, may suffice and is preferable to continuous treatment.
ADDICTION/SUBSTANCE ABUSE
overall pattern
- Repeated use
- Reinforcers (Positive)
- Repercussions (Njuegative)
ADDICTION/SUBSTANCE ABUSE
vs
OCD
Compulsive vs. Impulsive:
The primary difference between compulsive and impulsive behaviours lies in their motivation and execution.
- Compulsive behaviours stem from an internal drive to alleviate the fear and anxiety triggered by obsessive thoughts
- Impulsive behaviours are spontaneous and often driven by desires.
ADDICTION/SUBSTANCE ABUSE
‘Tobacco’
The stages of intervention
the 5As framework
— ask (about smoking)
— assess (motivation & nicotine dependence)
— advise (to quit)
— assist (with cessation)
— arrange follow-up
ADDICTION/SUBSTANCE ABUSE
‘Tobacco’
Nicotine dependence levels
— high dependence
— moderate dependence
— low-to-moderate dependence
— low dependency
ADDICTION/SUBSTANCE ABUSE
‘Tobacco’
Nicotine HIGH Dependence
waking at night to smoke
or
smoking within the first 5 minutes after waking
= usually smokes > 30 cigarettes daily
ADDICTION/SUBSTANCE ABUSE
‘Tobacco’
Nicotine MODERATE Dependence levels
smoking within 30 minutes after waking
= usually smokes 20- 30 cigarettes daily
ADDICTION/SUBSTANCE ABUSE
‘Tobacco’
Nicotine LOW-TO- MODERATE Dependence levels
not needing to smoke within the first 30 minutes after waking
usually smokes 10-20 cigarettes daily
ADDICTION/SUBSTANCE ABUSE
‘Tobacco’
Nicotine LOW Dependence levels
not needing to smoke in the 1st hour after waking
usually smokes < 10 cigarettes daily.
ADDICTION/SUBSTANCE ABUSE
‘Tobacco’
When to intervene for stopping smoking with pharmacotherapy
Recommended for:
- moderately to highly nicotine-dependent smokers
&
- who express an interest in quitting
ADDICTION/SUBSTANCE ABUSE
“Tobacco’
Interventions for smoking cessation
Best results are usually achieved when pharmacotherapy is combined with counselling and support
ADDICTION/SUBSTANCE ABUSE
‘Tobacco’
Smoking cessation First-line pharmacotherapy options
- Nicotine Replacement Therapy (NRT)
- Varenicline
- Bupropion
ADDICTION/SUBSTANCE ABUSE
‘Tobacco’
NRT
indications/suitability
– Combination NRT (ie patch and oral form) preferred
(*Combination NRT is as effective as varenicline and more effective than single types of NRT.)
- can be used by people with cardiovascular disease (Caution is advised for people in hospital for acute cardiovascular events, but NRT can be used under medical supervision if the alternative is active smoking.)
- NRT may be considered in women who are pregnant if they were unsuccessful in stopping smoking without pharmacotherapy. If NRT is used, the benefits and risks should be explained carefully to the patient by a suitably qualified health professional. The clinician supervising the pregnancy should also be consulted.
- NRT (ie patch, intermittent) is considered an option for breastfeeding mothers. Infant exposure to nicotine can be reduced further by taking intermittent NRT immediately after breastfeeding.
- cannot be used in children aged < 12 years
ADDICTION/SUBSTANCE ABUSE
‘Tobacco’
Varenicline
indications/suitability
- The most effective single-form pharmacotherapy for smoking cessation
- not recommended for pregnant and breastfeeding women, nor for adolescents.
- causes nausea in 30% of patients
- requires caution in CKD patients
ADDICTION/SUBSTANCE ABUSE
‘Tobacco’
Bupropion
indication/suitability
- less effective than varenicline for smoking cessation.
- contraindicated in patients with a history of seizures, eating disorders and those taking monoamine oxidase inhibitors
- not recommended for women who are pregnant or breastfeeding
- Should be used with caution in people taking medications that can lower seizure threshold (eg antidepressants, antimalarials, oral hypoglycaemic agents)
ADDICTION/SUBSTANCE ABUSE
“Alcohol Use Disorder”
CAGE questionnaire in Alcohol Use Disorder (AUD):
“YES” to 2 or more is a POSITIVE screen:
C - CUT
Have you ever felt you should Cut down on your drinking?
A - ANNOYED
Have people Annoyed you by criticising your drinking?
G - GUILTY
Have you ever felt bad or Guilty about your drinking?
E - Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (Eye-opener)
ADDICTION/SUBSTANCE ABUSE
“Alcohol Use Disorder”
Overdose/Intoxication
Mx
Treatment of intoxication and overdose is supportive and symptomatic, with careful monitoring of:
- BAC
- airway
- level of consciousness and responsiveness
- oxygen saturation
- hypoglycaemia and metabolic acidosis
- Alcoholic Hallucinations
Stimulants should not be given.
ADDICTION/SUBSTANCE ABUSE
“Alcohol Use Disorder”
“ACUTE Alcohol withdrawal syndrome”
Symptoms usually appear within 6-24 hours of the last consumption of alcohol (BAC ≤ 0.1%). can last up to 72 hours
The signs and symptoms may be grouped into three major classes: autonomic, gastrointestinal, and CNS changes that represent manifestations of sympathetic hyperactivity.
AUTONOMIC:
- Sweating
- Fever
- Tachycardia
- Hypertension
- Tremor
GASTROINTESTINAL:
- nausea and vomiting
- Dyspepsia
- Anorexia
CNS
- Anxiety
- agitation
- Delusions/Hallucinations
- Insomnia and vivid dreams
- Seizures (occasionally - 5% - observed, grand mal type = generalised, not focal)
LAB
- ↑ GGT
- ↑ AST/ALT RATIO
Seizures is the hallmark feature of Acute Alcohol Withdrawal (in contrast to Delirium Tremens which normally does not present with seizures) and the most concerning intercurrence
ADDICTION/SUBSTANCE ABUSE
“Acute Alcohol withdrawal” Mx
- Diazepam VO
– Oxazepam VO (if liver disease) - Thiamine (IM or IV)
- AVOID antipsychotics (which lower seizure threshold).
If hallucinations are not responding to Benzodiazepines alone, add:
- Olanzapine VO
other meaures include:
- Nursing in well-lit and quiet environment
- Monitoring for and treating hypoglycaemia
- Rehydration
- High calorie high carbohydrate diet,
ADDICTION/SUBSTANCE ABUSE
Alcoholic Hallucinosis vs DTs
Alcoholic Hallucinosis
* develop 6 - 24 hours of the last drink
* typically persist for up to 72 hours
* transient visual, auditory hallucinations
* Usually benign
* Associated with Alcohol intoxication
DTs
* occurs 24-72 hours after stopping/significantly reducing alcohol consumption
* Autonomic instability (↑ BP, ↑ HR)
* Usual course is 3 days, but persist for up to 14 days
* Associated with withdrawal
ADDICTION/SUBSTANCE ABUSE
“Delirium Tremens (DTs)” Ddx
Delirium tremens is a diagnosis by exclusion, so before commencing treatment, screen for other factors contributing to delirium, in particular:
- subdural haematoma
- head injury
- Wernicke’s encephalopathy
- hepatic encephalopathy
- hypoxia
- sepsis
- metabolic disturbances
- intoxication with or withdrawal from other drugs
ADDICTION/SUBSTANCE ABUSE
Benzodiazepines use & intercurrent illness
- IV Diazepam should be avoided if possible.
– Onset of action isn’t much faster than with
VO
– there is a greater likelihood of causing
severe adverse effects such as respiratory
depression.
– If an injection is necessary, it must not be
diluted and it must be given slowly over
several minutes to minimise the risk of
respiratory depression or arrest. Close
cardiorespiratory monitoring is essential. - If Severe liver disease
– Oxazepam VO - Severe chronic airflow limitation
Use benzodiazepines with caution and with
close monitoring.
– Midazolam IV
or
– Short acting Benzodiazepine = Temazepam
or Oxazepam
