Psychiatry Flashcards
Phenomenology
See other deck
Serotonin syndrome
increased serotonin in synapses
MAOIs, SNRIs, SSRIs, St John’s wort, MDMA, cocaine, LSD
SS Px
Sx onset <6hrs of taking drug
Autonomic hyperactivity
- HTN, high temp, tachycardia, sweaty, diarrhoea, mydriasis
Neuromuscular abnormality
- tremor, clonus, ocular clonus, hypertonicity, hyperreflexia
Mental status changes
- anxiety, agitation, confusion, coma
SS Ix
- clinical dx
- bloods, in FBC, U/E, CK, tox screen, culture, LFTs, ?CT head, ?LP
SS Mx
- consider activated charcoal, IV fluids, benzos
- cyproheptadine - serotonin antagonist
- ICU / sedation + paralysis if severe
Neuroleptic malignant syndrome (NMS)
- life-threatening reaction to antipsychotics
- ?caused by D2 receptor blockade / dopamine depletion
NMS Px
- <10d of starting med
- severe rigidity
- fever
- altered mental state
- autonomic dysfunction - tachycardia, BP up/down, tremor, incontinence, sweating, salivation
- oculogyric crises, seizures, chorea
NMS Ix
- bloods - eg FBC, U/E, Ca, ABG, LFTs, CK, coag, urinary drug screen
- ?CT head, ?LP
NMS Mx
- agitation - benzos
- stop antipsychotic
- bromocriptine / amantadine - DA agonists
- dantrolene - muscle relaxant
- consider ECT
Rapid tranquilisation
Idk see guidelines
Try oral first
IM / IV lorazepam
Consider haloperidol, promethazine….
Delirium
Acute reversible confusional state
Delirium causes
PINCH ME
Pain
Infection
Nutrition
Constipation
Hydration
Medication
Environment
Delirium Px
Hyperactive - inappropriate behaviour, hallucinations, agitation, restlessness, wandering, aggression
Hypoactive - lethargy, reduced concentration and appetite, appear quiet + withdrawn
Mixed
Delirium Ix
- Full examination, check for head injury
- AMTS / MMSE / ACE-III
- bloods - FBC, U/E, LFTs, coag, B12/folate, glucose, cultures, TFTs, bone profile
- urinalysis if sx of UTI
- CXR, CT head
Delirium Mx
- tx cause
- supportive mx
- loraz / halo if agitated
- STOPP-START criteria for medication review
Depression
low mood, loss of interest / pleasure
RFs
F>M, PMHx, significant physical illness, other mental health problems, psychosocial problems, bullying, homelessness etc
Depression Px
Core sx
- low mood
- anhedonia
Associated sx
- too much/little sleep
- change in appetite / weight
- fatigue, low energy
- agitation, slow movts
- poor conc, indecisiveness
- feel worthless / guilty
- suicidal thoughts / acts
Other sx
- headache, GI upset, loss of libido, catatonia, psychotic sx
- elderly - agitation, confusion, decline in normal function
- children - irritable, withdrawn, decline in school performance
Depression Dx
- sx present >2wks
- not secondary to alcohol, drugs, medication, bereavement
- all must include low mood / anhedonia
sub-threshold - 2-5 sx
mild - 5 sx - minor functional impairment
moderate - >5sx - varying impairment
severe - >5 sx - marked impairment +/- psychosis
Depression Ix
- Hx, MSE
- PHQ-9, HADS, BDI-II
- Bloods - FBC, U/E, LFTs, TFTs, B12/folate, ESR, glucose, bone profile, Mg
- consider toxicology, thyroid ABs, ANA, dex suppression test, syphilis, LP, CT/MRI head
- risk assessment
- SAD PERSONS
Depression Mx
- CBT, IAPT
- SSRIs - sertraline, fluoxetine, citalopram
- Pregnancy - sert, cit
- SNRIs - duloxetine, venlafaxine
- TCA - sedating (amitriptyline, clomipramine), non-sedating (imipramine, lofepramine)
- A2 antagonist - mirtazpine
- MAOi - isocarboxazid, phenelzine sulfate - don’t eat tyramine food/drink (cheese, yoghurt, liver) -> HTN crisis
- continue tx for 6mo after sx remission before gradual reduction
Dysthymic disorder
- chronic >2yrs low grade depressive sx
Px - depressive sx
Mx - SSRI, TCA, CBT
Seasonal affective disorder
- seasonal pattern to recurrent depressive episodes
Px - depressive sx during same time each year
Mx - light therapy, SSRIs
Bipolar affective disorder (BAD)
2+ episodes of disturbed mood (over months), with 1+ episode of hypomania / mania / mixed - with depression
BAD types
Type 1 - major depression + mania
Type 2 - major depression + hypomania
Cyclothymia - minor depression + hypomania (>2yrs)
BAD Px
Mania - abnormally + persistently elevated mood - >1wk, cause hospital admission, impair function
- elevated mood / self-esteem, take risks, over-familiar, increased energy, reduced attention
- thought disorder - pressure of thought / speech, flight of ideas, word salad
- Psychotic sx - delusions (eg grandiosity), hallucinations, violent behaviours, catatonia, loss of insight
Hypomania - mild form of mania
- mildly increased mood, no psychosis
- reduced sleep, sociable, more energy
Depressive phase
- low mood, low energy, anhedonia, negative thoughts, general depressive sx
BAD Ix
- Hx, MSE
- risk assessment
- bloods
- CT / MRI head
BAD Mx
Acute manic episode
- benzos - lorazepam
- antipsychotic - olanzapine / quetiapine (1st line), haloperidol / risperidone
Depressive episode
- SSRI - fluoxetine
- use antipsychotic also
- if manic, stop anti-depressant
Maintenance
- lithium
- also carbamazepine, lamotrigine, valproate
- ECT
Psychotherapy
- psychoeducation
- CBT
- IPT - interpersonal psychotherapy
- support groups
Lithium
- mood stabiliser
- therapeutic index 0.5-1.0mmol/L
- takes ~3wks to reach max effect
- take dose at night
- usually 800-1200mg, 2g max dose
Lithium monitoring
Before - BMI, bloods (FBC - leucocytosis, U/E, TFTs, calcium, PTH, Mg) ECG, pregnancy, goitre
Monitor levels every 5d until stable dose (12hrs post dose)
Every 3mo - lithium levels, eGFR
Every 6mo - TFTs, BMI, S/E review
Lithium S/Es
Hypothyroidism
Teratogenic - Ebstein’s anomaly
Cardiac impairment
Renal impairment
Tremor, sedation, lethargy, hair loss, polyuria, polydipsia, wt gain, confusion
Passmed:
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia
CI
- pregnancy, breastfeeding
- renal drugs - diuretics, ACEi, ARBs, CCBs, NSAIDs
Lithium toxicity
Can be from OD, or reduced excretion - dehydration, low renal function, infections, drug interactions
Lithium toxicity Px
- anorexia, N+V+D, drowsiness, restlessness, dysarthria, dizzy, ataxia, incoordination, twitching, tremor
- excessive thirst / urination
- hyperreflexia, convulsions, collapse, coma, seizures
- renal failure, dehydration, circulatory collapse, hypokalaemia
Passmed:
coarse tremor (a fine tremor is seen in therapeutic levels)
hyperreflexia
acute confusion
polyuria
seizure
coma
Lithium toxicity Ix
- serum lithium levels
- U/Es, renal function
- ECG - T wave inversion, sinus node dysfunction, SA block, PR prolongation, QT prolongation, VT, STEMI, HB
Lithium toxicity Mx
- stop lithium
- stop diuretics
- fluids
- haemodialysis
Electroconvulsive therapy (ECT)
- for catatonia, prolonged / severe mania, severe depression
- CI - raised ICP
- Short term S/Es - headache, nausea, short term memory impairment, memory loss, cardiac arrhythmias
- Long-term S/Es - impaired memory
- if on SSRI, reduce dose prior
Schizophrenia
Most common form of psychosis - splitting of thoughts / loss of contact with reality
- underactivity of mesocortical pathway and relative overactivity of mesolimbic pathway (both dopaminergic systems)
Schizophrenia types
Paranoid - delusions / hallucinations
Hebephrenic - speech + behaviour
Simple - -ve sx
Residual - -ve sx after +ve
Catatonic - psychomotor features
Undifferentiated - no specific sx
Schizophrenia RFs
- peaks 2-3rd decade and middle age
- FHx
- prem, urban areas, migration, trauma, abuse, cerebral injury, substance misuse
Schizophrenia Px
1st rank sx - need >1
- thought disorder (insertion, withdrawal, broadcast)
- passivity
- 3rd person auditory hallucinations
- delusional perceptions
2nd rank sx
- delusions
- 2nd person auditory hallucinations
- other hallucinations
- negative sx
- catatonia
Schizophrenia +ve/-ve sx
Positive sx
- auditory hallucinations
- delusions - fake, unshakeable belief
- catatonia
- thought disorder
- tangentiality, loosening of association
- speech disorder, eg pressured, word salad
- passivity
Negative sx
- avolition
- anhedonia
- asocial
- blunting / incongruity of affect
- low speech
- depression, self-neglect
Schizophrenia Ix
- Hx / MSE
- neuro exam
- CT / MRI head
- Bloods
- Urine toxicology
Schizophrenia Mx
- oral antipsychotics - risperidone / olanzapine
- depot - slow release IM antipsychotic
- Benzos for acute aggression
- CBT, family therapy, art therapy, lifestyle changes
- ECT
- CVD risk modification
Schizoaffective disorder
- mood disorder + schizophrenia
Manic - mania + psychosis
Depressive - depression + psychosis
Mixed - mania + depression + psychosis
Px
Combination of mania, depression, psychosis
Ix
- Hx/ MSE
- Bloods, imaging etc
Mx
- antipsychotics, antidepressants, CBT, social interventions
Psychotic depression
- severe depression + delusions + hallucinations (false perception w/o external stimulus)
Mx
- CBT, antidepressants, antipsychotics
GAD Mx - NICE stepwise care model
- all dx, suspected GAD
- education
- monitor - No improvement after 1.
- low intensity CBT
- individual / guided self-help groups
- psychoeducational groups - no response to 2. / marked functional impairment
- high intensity CBT +/- sertraline / other SSRIs, SNRIs, pregabalin - complex, refractory, self-neglect, self-harm
- specialist
- CBT + SSRI
- propranolol - for autonomic sx
Generalised anxiety disorder (GAD)
Excessive worry / apprehension >6mo - leading to significant distress / functional impairment
GAD Px
- Need >3 associated sx for dx
Mental
- apprehensive, nervous, frightened, rumination, depersonalisation, impaired conc, irritable…
Physical
- tach, palpitations, SOB, sweaty, N+V, dizzy, fatigue, diarrhoea, etc….
GAD Ix
- H/E
- GAD-7 questionnaire
- Exclude organic cause - eg thyroid, cardiac, meds
Panic disorder
- recurrent, episodic, severe panic attacks
Px
- sx peak in 10 mins
- discrete episodes of intense fear
PANICS Disorder:
- Palpitations
- Abdominal distress
- Numbness / nausea
- Intense fear of death
- Choking / chest pain
- Sweating / shaking / SOB
- Depersonalisation / derealisation
Ix
- r/o organic, H/E, GAD-7 (r/o GAD)
- ECG
Mx
- CBT
- SSRI - sertraline
- If giving TCA - imipramine
Phobias
- excessive / unreasonable sx of anxiety due to specific triggers
- eg arachnophobia, social phobia, agorophobia
Mx
- exposure therapy
- CBT, psychoeducation, relaxation training
- Meds - SSRIs, SNRIs, benzos may help to engage pt in exposure
Obsessive compulsive disorder (OCD)
- chronic condition of thoughts (obsessions) + acts (compulsions) -> significant distress / impairment
Obsessions - involuntary intense thoughts, recurrent, recognised as from own mind (active, whereas schizo is passive)
Compulsions - repetitive physical / mental acts in response to obsession, anxiety / stress if not performed
OCD Dx
- presence of obsessions / compulsions / both
- most days for >2wks
- know it’s from pts mind
- time consuming, causes significant distress / impairment
- > 1 event of failure to resist obsession
- obsession unpleasantly repetitive
OCD Ix
Assess risk, impact on self
OCD Mx
- Exposure and Response prevention (ERP)
- CBT, psychotherapy
- SSRIs, clomipramine (TCA) 2nd line
- antipsychotics
Adjustment disorder
- difficulty adapting to stressor
- onset <1mo of stressor, resolves in 6mo
- therapy / support
Acute stress reaction
- transient response to exceptional stress / trauma, <1hr of event, occurs in <4wks after event, sx resolve in 3d
Px
- initial daze, tunnel vision, fight/flight, panic, hyperarousal
Mx
- trauma-focused CBT
- maybe EMDR
- BBs for sx
Post-traumatic stress disorder (PTSD)
- severe psychological disturbance following traumatic stressor
- sx develop >4wks, last >1mo, cause distress / impairment
- cPTSD - more severe circumstances
PTSD Px
Intrusion - eg flashbacks, nightmares
Avoidance - avoid triggers
Hyperarousal - hypervigilant, irritable, reckless
Mood - emotional numbing, feel estranged
- depression, substance misuse, anger
PTSD Ix
- Hx, MSE
- Trauma screening questionnaire (TSQ)
PTSD Mx
- trauma-focused CBT
- Eye movt desensitisation and reprocessing (EMDR)
- SSRI, venlafaxine, risperidone if severe
- zopiclone for sleep
Anorexia nervosa
low BMI, fear of fatness, extreme dieting
Anorexia nervosa Px
- low bodyweight, restrictive eating, over-exercise, diuretics, laxatives
- amenorrhoea, constipation, dysphagia, fatigue, faint, puberty delay
- brady, low BP, peripheral oedema, gaunt face
- fail sit-up / squat test
Anorexia nervosa Ix
- Bloods
- DEXA if <18yo
- ECG, assess risk
- MARSIPAN checklist
Anorexia nervosa Mx
- CBT-ED
- MANTRA - Maudsley Anorexia Nervosa Tx for Adults
- SSCM - specialist supportive clinical mx
- Family therapy <18yo
- admit if unwell, oral / IV supplements, bisphosphonates - use MARSIPAN
Anorexia nervosa Cx
- low K, P, Mg, Cl, BM, high cholesterol
- high cortisol, GH, low T3/4, low sex hormones
- pancreatitis, ECG changes, HF, low HR/BP
- osteoporosis, renal stones, AKI, CKD
- infertility, infections….
Refeeding syndrome
- metabolic cx of refeeding after prolonged starvation
- when starved - body turns from carb to fat/protein metabolism - drop in circulating insulin (low carb), decrease in IC electrolytes (phosphate)
- when refeeding - carb levels rise, insulin increases, phosphate cellular uptake increases
- low serum phosphate
- low thiamine (co-enzyme in carb metabolism)
- salt + water retention
Refeeding syndrome Px
- low K, Mg, phosp
- high BM, encephalopathy (Wernicke-Korsakoff)
- arrhythmias, HF, PO, rhabdo, seizures, death
Refeeding syndrome Mx
- prevention - high-dose pabrinex, refeed slowly
- dietician involvement
- correct electrolytes
- phosphate supplementation
Bulimia nervosa
Eating disorder characterised by binges + wt loss behaviours
Bulimia Px
- binge eating
- vomiting / laxatives, fasting, excessive exercise
- irregular periods
- bloating, lethargy, reflux, abdo pain, sore throat
- swollen salivary glands
- dental erosion
- Russel’s sign - calluses on back of hand
Bulimia Ix
- bloods - low K (check U/E)
Bulimia Mx
- CBT-ED
- family therapy (bulimia focused)
Personality disorders
- series of maladaptive personality traits that interfere with normal function in life
- Dx >18yo
Cluster A - weird
- paranoid
- schizotypal
- schizoid
Cluster B - wild
- antisocial
- EUPD / BPD
- histrionic
- narcissistic
Cluster C - worried
- avoidant / anxious
- obsessive-compulsive (anankastic)
- dependant
Ix
- Hx, MSE
- personality diagnostic questionnaire (PDQ-IV)
- Minnesota multiphasic personality inventory
- consider CT / MRI head
- risk assessment
Mx
- Tx sx - antidepressants, mood stabilisers
- Dialectical behavioural therapy (DBT)
- Mentalisation-based therapy
- CBT / psychodynamic therapy
Paranoid
paranoid, doubts loyalty, relationships suffer, hypersensitive, perceives attacks
Schizoid
cold, detached, doesn’t want close relationships, loner, reduced sex drive, few interests
Schizotypal
odd beliefs, ideas of reference, paranoid, eccentric, lack of close friends, odd speech, magical thinking, inappropriate affect
Antisocial
cold, rule-breaker, non-conformer to social rules, deceptive, aggressive, can’t maintain relationships
EUPD
unstable, intense emotions, insecure, self-damaging, impulsive, suicidal
Histrionic
centre of attention, inappropriate sexual seductiveness, shallow, egocentric, dramatic, manipulative
Narcissistic
cold, arrogant, self-centred, takes advantage, egotistical, power-seeking, lack of empathy
Obsessive-compulsive
Obsessive, meticulous, unwilling to delegate, pedantic, perfectionist, inflexible
Avoidant
Anxious, timid, socially withdrawn (but crave interaction), insecure, fear of rejection
Dependant
fear of abandonment, lack of self-confidence, clingy, needs others to take responsibility, lack of initiative, can’t disagree
Autism spectrum disorder (ASD)
Developmental disorder of:
- impairments in social interaction / communication
- restricted interests / rigid behaviours
association with epilepsy, ADHD, LDs
Multifactorial causes
ASD Px
- sx emerge 1-2yo, initially - language delay, lack of response to name, limited eye contact
A - antisocial
- lack of eye contact, delay smiling, can’t read non-verbal cues, not playing
B - behaviour
- rituals, stereotyped behaviour, fixed routines, restricted food
C - communication
- delay in language development, lack of non-verbal cues
ASD Ix
- ASD tools - eg CHAT, ADI-R, DISCO
- Dx after 2-3yo
- refer to ASD team
- full developmental assessment, hearing tests, karyotyping
ASD Mx
Bio - tx co-existing conditions, melatonin, antipsychotics
Psycho - education, CBT, SSRIs
Social - educational interventions, play-based tx, behaviour modifications
Attention deficit hyperactivity disorder (ADHD)
Inattention / hyperactivity / impulsivity that interferes with functioning / development
ADHD Px
Inattentive - not paying attention, easily distracted
Hyperactive/impulsive - fidgets, leaves seat, blurts out etc
Can be inattentive / hyperactive / combined
ADHD DSM-5 Dx
- sx <12yo
- present in 2+ settings, eg school + home
- interfere with functioning
- no schizo / psychosis
ADHD Ix
- by specialist psychiatrist / paediatrician
- clinical / psychosocial assessment
- rating scales, determine impact of sx on life
- TFTs
ADHD Mx
- ADHD-focused support, diet + exercise
- CBT
- 10 week watch and wait
Drug therapy seen as last resort and only in those over 5 years old
- Methylphenidate (ritalin) - S/Es abdo pain, nausea, dyspepsia- in children weight and height every 6 months
- 2nd line - lisdexamfetamine, dexamfetamine- in those who can’t tolerate lis side effects
- All drugs - cardiotoxic (rpt ECGs), monitor height/weight every 6mo
Alcohol misuse
- drinking out of control
- recommended levels <14units/wk
- 1 unit = %ABV x volume (L)
Alcohol misuse Ix
CAGE - yes to 2 - excessive drinking
- felt like you should cut down?
- people annoyed?
- feel bad / guilty?
- eye opener - drink in morning?
AUDIT - Alcohol Use Disorders Identification Test
FAST - Fast Alcohol Screening Test
SADQ - Severity of Alcohol Dependence Questionnaire
- examination - ?withdrawal, hepatomegaly, ascites, ascites, Wernicke-Korsakoff syndrome
- Bloods - FBC, clotting, U/E, LFTs, alcohol level
Alcohol misuse Mx
- CBT, behavioural therapies, motivational interviewing
- Acamprosate - reduces cravings
- Naltrexone - reduces pleasurable effects of alcohol
- Disulfiram - causes unpleasant sx when drinking
- Nalmefene - reduce alcohol consumption
Acute alcohol withdrawal
- after not drinking
- mild sx 6-8hrs after, moderate/severe ~48hrs later
- thought to be from low inhibitory GABA, increased NMDA glutamate transmission
Alcohol withdrawal Px
- insomnia, fatigue, anorexia
- tremor, anxiety, N+V, headache, sweating, palpitations
- hallucinations - after 12-24hrs
- seizures - after 24-48hrs
- delirium tremens - after 48-72hrs
Alcohol withdrawal Ix
- Hx
- CIWA-Ar score - Clinical Institute withdrawal Assessment for Alcohol scale (revised) - >10 = benzos
- Bloods - FBC, U/E, LFTs, coag, bone profile, Mg, phosph, BM
Alcohol withdrawal Mx
Benzos
- reducing dose chlordiazepoxide over 5-7d
- diazepam
- Lorazepam preferred in patients with liver cirrosis/hepatic failure
- pabrinex - thiamine
- IV fluids
- antiemetics
- refer to alcohol liaison team
Delirium tremens
- Acute confusional state - hyperadrenergic
Px
- 24-72hrs after last drink
- hallucinations, confusion, delusions, severe agitation, seizures
- tachy, increased RR, hyperthermia, sweaty, tremor, mydriasis
Ix
- Bloods
- CT head
- CXR
Mx
- A-E
- Sedation - benzos
- pabrinex
Wernicke-Korsakoff syndrome
- thiamine (B1) deficiency
- Triad - confusion + ataxia + ophthalmoplegia
- Wernicke encephalopathy untreated -> Korsakoff syndrome
Px
- Double vision, eye movt abnormalities, eyelid drooping, unsteady walking, loss of memory, hallucinations
- abnormal reflexes, polyneuropathy, nystagmus, BP low, low temp, tachycardic
- confabulation, memory loss
- encephalopathy - 2/4 of thiamine deficiency, oculomotor abnormalities, cerebellar dysfunction, altered mental state
Ix
- Bloods, CT head, LP
Mx
- IV pabrinex - Wernicke’s
- PO thiamine + multivitamins for 2yrs - Korsakoff’s syndrome
Opioid misuse
Sx of withdrawal
- 6-24hrs after last dose, lasts 5-7d
- sweaty, dilated pupils, increased HR, high BP, watering eyes/nose, abdo pain, N+V, tremor, cramps
OD Mx
- naloxone
Dependence Mx
- methadone / buprenorphine as detox - monitor compliance with urinalysis
- lofexidine - sx relief in withdrawal
- naltrexone - aids abstinence
Mental health act
Legislation that defines how patients who won’t be admitted voluntarily may be detained (sectioned) for tx
- must not be under influence of drugs / alcohol
- need to have mental disorder - disorder / disability of mind
Section 2
- assessment
- 28d, unrenewable
- 2 Drs (one S12), 1 AMHP (approved mental health professional)
Section 3
- treatment
- 6mo, renewable
- 2 Drs, 1 AMHP
Section 4
- emergency order
- 72hrs
- only in urgent necessity where wait for S2 is too long
- 1 Dr, 1 AMHP
Section 5(2)
- pt admitted but trying to leave
- Drs holding power
- 72hrs - allow time for section 2/3 assessment
- can be coercively treated
Section 5(4)
- pt already admitted, wanting to leave
- Nurses’ holding power
- 6hrs
- cannot be coercively treated
Section 135/136
- police sections
- S135 - police remove person from home - need court order
- S136 - police remove from public place
- 24hrs, MHA assessment needed
- take to place of safety - psych ward / police cell
SSRIs
- block serotonin transporters
- sertraline, citalopram, fluoxetine, paroxetine
Indications
- depression, GAD, PTSD, ED, OCD
- sertraline fewest drug interactions
- Fluoxetine - for adolescents
- sertraline post-MI
- once started, review after 2wks / 1wk if <30 or high suicide risk
- continue for >6mo after sx resolve
SSRIs Adverse Effects
- long QT (citalopram)
- GI sx - N+V+D
- GI bleed - if taking NSAID + SSRI, add PPI
- sexual dysfunction
- SIADH -> hyponatraemia
- irritable, insomnia, anxiety, increased suicide risk
SSRIs drug interactions
- NSAIDs - give PPI
- Warfarin / heparin / aspirin - avoid SSRI, consider mirtazapine
- Triptans - avoid - SS risk
- MAOIs - SS risk
SSRI stopping
- gradually reduce over 4wks (not necessary with fluoxetine)
Discontinuation sx
- mood change, restless, difficulty sleeping, unsteady, sweaty, abdo pain, D+V, paraesthesia
SSRIs in pregnancy
- risk vs benefit
- congenital heart defect risk in 1st trim
- pulm HTN risk in 3rd trim
- paroxetine - risk of congenital malformations
SNRIs
- duloxetine, venlafaxine
- block serotonin + noradrenaline reuptake inhibitors
Indications
- major depressive disorder, GAD, social anxiety disorder, panic disorder….
- Increased NAd -> HTN, CV sx
TCAs
- sedative - amitriptyline, clomipramine, dosulepin, trazodone
- less sedative - imipramine, lofepramine, nortriptyline
TCA choice
- low dose amitriptyline - neuropathic pain, tension/migraine prophylaxis
- lofepramine - lower risk of toxicity in OD
- amitriptyline / dosulepin - most dangerous in OD
S/Es
- anticholinergic - blurred vision, urinary retention, dry mouth, constipation
- A1 adrenergic antagonism - orthostatic hypotension
- Antihistamine (H1) - sedation
- OD, seizures
- QT prolongation
MAOIs - monoamine oxidase inhibitors
- phenelzine, isocarboxazid (A+B), selegiline (B)
- serotonin + NAd are metabolised by monoamine oxidase in presynaptic cell
- Type A - prevent serotonin breakdown
- Type B - prevent dopamine breakdown (good for Parkinson’s)
Adverse effects
- SS risk if used with another antidepressant
- Food interaction - avoid tyramine foods (cheese, pickled herring, Bovril, Oxo, marmite, broad beans) - leads to hypertensive crisis (headache, tremor, HTN)
- Anticholinergic
Atypical antidepressants
- mirtazapine, bupropion
- mirtazapine - blocks A2 adrenergic receptors - increases appetite, causes sedation (take in evening) - fewer S/Es - good for older pts
1st gen antipsychotics (typical)
- haloperidol, chlorpromazine
- antagonise D2 receptors
S/Es
- hyperprolactinaemia, long QT, EPSEs
2nd gen antipsychotics (atypical)
- clozapine, olanzapine, risperidone, quetiapine, aripiprazole
- antagonise D2 + serotonin receptors - lower EPSEs / prolactin - but wider S/E profile
- aripiprazole - most tolerable S/Es
- clozapine - for tx-resistant schizophrenia - agranulocytosis - weekly FBCs for 18wks, then monthly bloods, myocarditis risk - regular ECGs, reduced seizure threshold, smoking reduces efficacy (smokers need higher dose)
- also wt gain, high lipids, sedation, orthostatic hypotension, long QT
General S/Es antipsychotics
- stroke / VTE risk in elderly
- antimuscarinic - can’t pee…
- galactorrhoea
- reduced seizure threshold
- long QT
- NMS
Antipsychotics monitoring
- FBC, U/E, LFTs annually (clozapine weekly FBC to start)
- lipids, weight gain, fasting BM, prolactin, BP, ECG, CV risk assessment
Pseudoparkinsonism
- parkinson-like sx - stooped posture, shuffling gait, rigidity, bradykinesia, tremors at rest, pill-rolling motion
Mx
- procyclidine / amantadine - anticholinergics
Acute dystonia
- abnormal involuntary muscle tone - spasms, twisting / repetitive movts, cramps
- facial grimacing
- oculogyric crisis
- muscle spasms of tongue, face, neck, back
Mx
- procyclidine
- oculogyric crisis - clonazepam (BZD) second line
Akasthisia
- restlessness, affects voluntary movt
- trouble standing still, pace floor, rocking back and forth
Mx
- Beta blocker
Tardive dyskinesia
- slower onset, continuous smooth involuntary movts
- choreoathetoid movts - sucking, smacking movts of lips, chewing motions
- involuntary movts of body / extremities
Mx
- tetrabenazine - anti-chorea
Benzos
- enhance GABA - increase frequency / duration of chloride channels
- sedation, hypnotic, anxiolytic
- withdrawal - insomnia, irritable, anxiety, tremor
- flumazenil - benzo reversal, but seizure risk
Z-drugs
- non-benzo hypnotics
- zopiclone
- increased falls risk in elderly
Barbituates
- eg phenobarbitol
- sedative hypnotics
