Psychiatry Flashcards
Antidepressant classes
SSRIs
SNRI/Dual acting agents
1st gen: TCA and MAOi
Multimodal agents
MX of OCD
Lifestyle - cut down caffeine, alch, drugs, smoking, incr exercise, activity scheduling etc
Psychotherapy: psychoeducatin, Exposure and response prevention therapy, cognitive therapy, relaxation therapy
Meds
High dose SSRIs
Medication for GAD
Venlafaxine (SNRI/dual uptake inhibitor)
Benzodiazepines
Buspirone
Broad management of different severity of depression
○ Sadness: reassurance, psychotherapy
○ Mild depression: psychotherapy
○ Moderate depression: psychotherapy +/- medication
○ Severe depression: medication + psychotherapy +/- ECT
○ Psychotic depression: medication +/- antipsychotic/ECT
Side effects of TCAs
Seizures and cardiotoxicity (arrhythmias) - lethal in overdose!
Anti-cholinergic (anti-slud) side-effects
Adrenergic block -> hypotension
Sedation and weight gain (anti-histamine)
Side effects of MAOi
Seizures and cardiotoxicity
Anti-cholinergic side effects
Adrenergic block (hypotension)
Sedation and weight gain (anti-histamine)
The Cheese Effect due to build up of tyramine following ingestion of cheese, red wine, choc, vegemite etc
What is the Cheese Effect
Build up of tyramine resulting in toxicity following ingestion of cheese, red wine, choc, vegemite etc because tyramine is ALSO broken down by MAO
Results in Incr BP, stiff neck, sweating, N&V, occipital headache
Examples of dual uptake inhibitors
How do they work
When do you use these ?
Block reuptake of serotonin at low doses and NA at higher doses
= SNRIs
Venlafaxine, Duloxetine, Desvenlafaxine
2nd line, in SSRI non-responders .
How does Mirtazepine work?
What effects does it has - what is it’s use?
It is a multimodal agent
- alpha2 antagonist w indirect effects on serotonin, NA, histamine (H1R)
Anti-anxiety and sedation
Use at night, low dose, in conjunction with another antidepressant
Classes of anxiety meds
Benzodiazepines
Buspirone
Antidepressants (SSRIs, SNRIs, TCA, MAOi)
Beta blockers
Meds for panic disorder
TCA, MAOi, SSRIs
Benzodiazepines
Meds for phobias
SSRIs
Meds for PTSD
SSRIs
Indications for benzodiazepines
GAD
Panic attacks - rapid alleviation
Sleep
Risks/side effects of benzodiazepines
Behavioural disinhibition Psychomotor impairment Cognitive impairment Rebound insomnia Withdrawal phenomena (for short term use only; taper dose at end of therapy)
Buspirone
- how does it act
- indications
- benefits
- side effects
Serotonin partial agonists w some D2 antagonism
Indications: mild-mod GAD only (efficacy similar to benzos but not for panic disorder)
No/Low abuse potential or withdrawal phenomena
SE: Drowsiness, dizziness, headache, nausea, restlessness
Which symptoms of schizophrenia respond to medication, which don’t tend to?
Positive symptoms respond well; negative and cognitive SX don’t
What is the recommended treatment time for schizophrenic patients with antipsychotics
Optimal therapy takes 6 weeks, then swap to lower ‘maintenance dose’
College suggests treatment for 2-5 years, then stop and reassess
With a second episode after this, need indefinite tx -> high risk of relapse w non-compliance
Treatment ‘resistant’ if have failed 2 doses over 8 years -> next step is to trial Clozapine (req strict haematological monitoring due to risk of agranulocytosis)
Side effects of antipsychotics
Extrapyramidal parkinsonian-like SX
- Bradykinesia
- Tremor
- Rigidity
Tardive dyskinesia
Postural hypotension
Metabolic syndrome (olanzapine and clozapine)
Falls risk
Hyperprolactinatemia
Examples of atypical antipyshotics
Olanzapine
Risperidone
Clozapine
Side-Effects of atypical antipsychotics
EPS
Weight gain -> T2DM and CVD
Postural hypotension
Anticholinergic effects
Sedation, insomnia, agitation
Cardiotoxicity
Neuroleptic malignant syndrome
What are the extreme risks of Clozapine?
Agranulocytosis, so need strict haematological monitoring - weekly for first 18 months, then monthly
-> Neutropenia
Cardiomyopathy/myocarditis/arrhyhmias
Bowel ileus -> obstruction
What are the symptoms neuroleptic malignant syndrome?
What causes it?
Serum marker for this?
Mx?
Muscular rigidity, fever, altered consciousness, autonomic dysfunction, labile BP
Side-effect of atypical antipsychotics (1% incidence but 20% mortality)
Raised CPK (creatinine phosphokinase)
Mx - dantrolene or bromocryptine(DA agonist) + supportive + cease antipsychotic +/- ICU
Classes of mood stabiliser for bipolar disease
Lithium
Anticonvulsants
Atypical antipsychotics
Examples of anticonvulsants for bipolar disease
Sodium valproate
Lamotrigine
Carbamazepine
Indictions for Lithium
- Schizophrenia and schizoaffective disorder
- Bipolar and unipolar depression as prophylaxis/mood stabiliser
- hypomanic episodes
- Acute depressed episodes as 3rd line after antidepressants and ECT
- Augmentation of antidepressants in case of treatment resistance
What must be done before starting Lithium?
Medical HX and physical exam to establish baseline
Biochemical screening:
- TFTs (every 6 months)
- UEC (Serum creatinine every 6mo)
as Li affects kidney and thyroid function
How is lithium excreted and what does this mean you have to be careful with?
Really excreted so take care with impaired renal function
Side effects of Lithium
Polyuria, polydipsia Weight gain Memory problems Sexual dysfunction Metallic taste
What do you have to be careful with for lamotrigine?
Steven Johnson syndrome (Severe drug reaction)
Potentially lethal to stop drugs immediately
Sodium Valproate contrainidications
Liver disease
Pregnancy (passes into pregnancy)
Side effects of sodium valproate
Thinned hair Facial flushing, skin rashes Anaemia Slurred speech Weight gain Ataxia Lethargy Nausea, diarrhoea, stomach cramps 50% women get irregular menses
What is CBT?
○ Interpretation of events (not the event itself) drives our emotional state - but this is an automated response for most people -> unhelpful thinking patterns (ex: catastrophisation of events, overestimation of risk)
§ Unhelpful thinking patterns are responses that produce distress
§ CHALLENGING unhelpful thinking patterns
Non-pharmacological management of depression/anxiety/insomnia etc
Exercise
Diet (?omega 3 fatty acids)
Men’s sheds etc
Activity scheduling
Relaxation exercises (breathing control, progressive muscle relaxation, cognitive slowing/mindfulness)
Graded exposure (for phobias)
Motivational interviewing (for behavioural change)
ECT
Transmagnetic stimulation
CBT Problem solving thinking Interpersonal therapy Supportive psychotherapy Psychoeducation
Indications for ECT
Major depressive disorder or episode
Bipolar - Mania
Clonidine-resistant schizophrenia or schizoaffective disorder
Side effects of ECT
Cognitive (amnesia, post-octal confusion, persistent memory disturbance)
Headache, muscle aches
Nausea
Diagnosis of depression
2 definition symptoms must occur for at least 2 weeks
- Depressed mood (pervasive and diurnal)
- Anhedonia (unable to experience pleasure)
Sleep disturbance (terminal insomia/early morning waking) Anergia Anorexia Psychomotor agitation or retardation Negative thought content - feelings of worthlessness, guilt - suicidal ideation, recurrent thoughts of death, suicidal plan/attemps - hopelessness - nihilism - Depersonalisation, derealisation
Risk factors for suicidality
Insomnia/sleep deprivation Weight/appetite loss Feelings of worthlessness, guilt and hopelessness Thoughts of death Impulsive/agressive personality traits Early phase of recovery
Features of psychotic depression
Delusions: of guilt, self-criticism, poverty, hyperchondrial, nihilism etc (often mood congruent)
Auditory hallucinations - mood congruent
Catatonia
What medical conditions present w depression as a prodrome?
Endocrine - hypothyroid, Cushings, Addisons, HypoCa/HypoMg
Cancers (small cell lung cancer, pancreatic; paraneoplastic phenomena)
SLE
MS
HIV
What neuro conditions can present w depression
Post-stroke Parkinsons Dementia Intracerebral neoplasia ABI, trauma
Drugs assoc w depression
Steroids Propanolol GABA-ergic drugs (ex: alcohol) Chemotherapy agents, IFN OCP
What is melancholic depression?
Severe depression with MARKED psychomotor retardation OR agitation (as main SX)
How does depression often start out?
Starts w changes in sleep/energy with other changes accumulating over time
What are you concerned about with postpartum depression?
Attachment issues
Infanticide
How does depression in the following subgroups present:
- children
- teens
- elderly
Children: Enuresis, encopresis, school refusal, behavioural problems
Teens: substance use or antisocial behaviour
Elderly: Withdrawal, constipation, weight los, anhedonia, agitation
Management of depression
Psychological therapy
- problem-solving therapy
- CBT
- Interpersonal or family therapy
Lifestyle (diet, exercise, sleep, reduce alcohol and illicit drugs)
Pharmacotherapy
- start w SSRI
- SNRI (enlafaxine or duloxetine) or Mirtazepine 2nd line
- TCA 3rd line, or 2nd line if melancholic-type
- Lithium or atypical antipsychotics as augmenting agents
ECT for melancholic, psychotic, puerperal, bipolar depression or in cases of prominent suicidality or poor oral intake
Risk factors for Bipolar
Genetics
Head injury and organic CNS disease
AIDs
Triggers - childbirth, spring and summer (trigger mania), circadian rhythm disruptions (trigger mania)
Symptoms of mania
Elevated and/or irritable mood (incongrous to life circumstances)
Grandiosity, increased self esteem
Increased talkativeness
Decr need for sleep
Flight of ideas, tangentiality, pressured speech
Distractibility
Impulsive (incr spending, gambling, regret)
Increased social activities
Risk taking behaviour and sexual activities (run ins w police common)
+/- psychotic features (delusions often of grandiosity, religious, sexual)
Hypomania vs mania
Hypomania SX for 2-4 days + can keep it together in daily life
Mania - SX >1 week and impacts on life and relationships
Natural history of bipolar
Usually begins in adolescence as an atypical, brief episode of depression.
Depression comes first, then 1st manic episode follows around ~5 years later
3x more time spent in depressed than manic states
Management of bipolar
Mood stabilisation (Li or anticonvulsant) and Quetiapine as 1st line
2nd line - atypical antipsychotics
Antidepressants secondary to mood stabilisers in depression (start go slow because don’t want to trigger a manic episode!)
Benzos as an adjunct for treating mania w marked hyperarousal
Clozapine for treatment-resistant cases
ECT for severe/intractable mania and depression
Psychological
- psychoeducation
- family, marital and interpersonal therapy
- relaxation exercises/stress management
Lifestyle
- regular exercise, decr alcohol and drugs
dysthymia
Proposed personality type characterised by:
○ Chronic low-grade depressive-type state
○ Brooding, self-critical, lacking confidence, pessimistic, tired easily, sluggish, bound to routine, shy, sensitive etc individual
Cyclothymia
Proposed personality type characterised by:
○ Moods swing between short periods of mild depression and hypomania, an elevated mood. The low and high mood swings never reach the severity or duration of major depressive or full mania episodes.
Hyperthymia
Proposed personality type characterised by:
○ Relentlessly cheerful throughout life
What are pseudo hallucinations vs true hallucinations?
Pseudo: recognised by patient as unreal (voices coming from inside head - recognised by patient as not coming from an external stimulus; or seeing something that ‘seemed like a dream’)
-> grief,
True: voices coming from external source (ex in the room around you)
-> Schizofrenia
DDX for psychosis
Psychotic disorders (schizophrenia, schizoaffective disorder, delusional disorder, brief psychotic disorder)
Personality disorder (schizoid, schizotypal)
Mood disorders (severe depression w psychosis, bipolar w psychotic features)
Drug-induced or withdrawal
Organic pathology
Causes of delirium
Pervasive developmental disorders (autism, aspergers’s etc)
What are Schneider’s “first rank” symptoms
Classic positive symptoms of Schizophrenia
Auditory hallucinations
- third person
- running commentary
- audible thoughts
Delusional phenomena (red traffic light = world is doomed)
Passivity phenomena of
- Behaviours (puppet/their behaviours are controlled by external source)
- Thoughts (thought insertion, withdrawal and broadcast)
Psychotic disorders
- Brief psychotic disorder (>1day and <1month) Often associated with a stressful life event
- Schizophreniform disorder (symptoms for >1mo but <6mo)
- Schizophrenia (Symptoms for >6mo)
- Drug induced psychosis (main presentation due to drugs)
- Schizoaffective disorder
- Delusional disorder (delusions but no other positive symptoms)
Schizophrenia common co-morbidities
Depression
Anxiety disorders
PTSD
Substance abuse (alcohol, cannabis most commonly)
Physical (CV risk factors elected w Clozapine, olanzapine, sedentary lifestyles, poor diet -> Obesity, HTN, diabetes, HTN); higher cancer mortality)
Management of schizophrenia
Early intervention and multidisciplinary care
Manage co-morbidities (depression, anxiety, substance abuse risk management plans for suicidality) and physical health
Lifestyle - exercise, social activities, hobbies
Dietician and food diary - manage SE of clozapine
Social work and OT - vocation help
- employment, volunteering
Pharmacotherapy
- atypical antipsychotics (low dose for elderly)
- Clozapine for non or under-responders to 2 trials antipsychotics
Psychological
- CBT for persistent delusions/hallucinations non-responsive to meds
- social skills training workshops
- cognitive remediation to enhance cognitive function
- psychoeducation and support for family
- family therapy and IPT
Features of schizophrenia
Positive symptoms (delusions, hallucinations-commonly auditory)
Negative symptoms (anhedonia, affect bluntening/restriction, avolition, alogia/poverty of speech, social withdrawal)
Disorganisation (speech, behaviour; inappropriate affect)
Thought disorder
- tangentiality
- circumstantially
- clanging/rhyming
- neologicism (making up new words)
- punning
Cognitive deficits (attention, memory, executive functioning, verbal fluency, social and work functioning)
Mood symptoms (agression, depression//anxiety, suicidality)
Flat vs blunted affect
Flat (awareness but little capacity for emotional response) = Depression
Blunted (loss of awareness/empathy/sensitivity for an emotional event) = psychosis
Aetiology of schizophrenia
Genetics
Environment
Neurodevelopment
Altered neural chemistry and structural pathology in brain (neuronal migration, brain vol, ventricular vol)
Egodystonic vs egosyntonic and example of a mental illness that characterises
Ego-syntonic refers to instincts or ideas that are acceptable to the self; that are compatible with one’s values and ways of thinking. They are consistent with one’s fundamental personality and beliefs.
ex: Anorexia
Ego-dystonic refers to thoughts, impulses, and behaviors that are felt to be repugnant, distressing, unacceptable or inconsistent with one’s self-concept.
ex: OCD
Psychopathology of obsessions in OCD
Egodystonic thoughts Recurrent Intrusive Cause distress Recognised as abnormal and UNWANTED (at least initially)
Psychopathogy of compulsions in OCD
Ritual performed to reduce or neutralise the distress of obsessions in OCD
May be mental or physical actions
When does OCD usually develop?
Usually develops in adolescence (although they may not present for decades after)
If it develops later in life, you think of it coming as secondary to depression or substance misuse
What drug-drug interaction do you have to be wary of due to risk of serotonin syndrome
Tramadol and SSRIs can be a bad combination -> risk of serotonin syndrome
SSRIs + Li, MAOi, tryptophan
What are specific risks of SSRIs in elderly people?
Serotonin syndrome - interaction w tramadol
Hyponatraemia due to SiADH
Gastric bleeding
Relapse vs recurrence
Relapse - patient is in partial remission and develops another episode of depression
Recurrence - patient is in full remission and then have another episode of symptoms
Health monitoring of atypical antipsychotics
BMI (weight, height) BP Weight circumference BSL and lipids Smoking and alcohol use assessment
What is tardive dyskinesia
Side effect of typical antipsychotics
Continuous Involuntary movements of tongue, cheeks, lips, facial muscles. only absent in sleep.
Acute management of mania
Antipsychotics
+/- Mood stabilisers
+/- Benzodiazepines
Then mood stabilisers once they have been stabilised.
When would you not use Li as a mood stabiliser?
Family planning/fertile ages
Pregnancy
Breastfeeding
Children, elderly - lower doses and close monitoring required
Effect of clozapine on OCD . Treatment
Can make latent OCD worse or trigger OCD
Features of serotonin syndrome
Tremor, hyperreflexia, myoclonus muscle tremor, rigidity Agitation, irritability, confused Hyperthermia Tachycardia, arrhythmias HTN Sweating Fever
Mx - supportive, stop psychotropic medication, serotonin R antagonist
Risk factors for drug-drug interactions
Elderly and debilitated
Medically ill treated w many drugs
Renal or liver disease
Treatment w potent isoenzyme inhibitors
Features of Steven Johnson syndrome
Rash Fever Sore throat General malaise Conjunctivitis Mucosal vesicular lesions
Antidepressant discontinuation syndrome features
Withdrawal SX from sudden cessation of psychotropic drug, esp venlafaxine
Dizziness Tiredness Headache Depression Anxiety Insomnia Nausea Diarrhoea Emotional lability Poor concentration Flu-like symptoms Paraesthesia Visual disturbance
When does anxiety become pathological?
Excessive
No longer ADAPTIVE
Disruptive to person’s life and daily functioning
In response to situations which shouldn’t normally be anxiety producing
Components of anxiety
Cognitive
- Thoughts of worry and stress to do with the future
- Fear of losing control
- Inability to concentrate
+/- racing thoughts, feeling of impending doom
Physical
- Fight or flight response/adrenergic bodily arousal (tachycardia, chest pain, tachypnoea, dyspnoea, sweating, tremor, nausea, butterflies, paraesthesia, diarrhoea, derealisation/depersonalisation)
- Muscle tension (pain, stiffness, tremor)
- Difficulty sleeping
- Restless, irritable
- Increased startle responses
- Avoidance of situations assoc w anxiety
- Difficulty concentrating
- Nervous energy
Classifications of anxiety
- GAD - chronic worry about a lot of things all the time. Long-standing and non-specific
- Panic disorder - recurrent panic attacks; feeling of impending doom/death, sudden onset, settles after a while, tachypnoea, tachycardia, chest tightness, nausea
- Phobia - focused fear and anxiety on one thing ie snakes, spiders, sharks, blood, infection, claustrophobia
- assoc w panic attacks in these situations
- anxiety assoc w anticipation of these things and avoidance
- PTSD - following a traumatic/stressful precipitant, flashbacks/nightmares assoc w trigger, avoidance, sleep disturbance; >1mo SX ; SX onset often delayed
- Acute stress disorder if sx onset immediately after event and end within a month.
- “do you find you have to check things repetitively? Or become troubled if things aren’t neat and organised?”
- Social anxiety disorder/social phobia - fear of social situations, worry about what people are saying/thinking about them
- Agoraphobia - fear of being in a social setting that they can’t leave from (shopping centre, que in supermarket, public transport etc) -> assoc w panic attacks in these situations
Elements of stress-related disorders
Exposure to serious threat event + TRIAD
- Recurrent intrusive memories (flashbacks, nightmares) of event assoc w trigger
- Avoidance of things assoc w event
- Hyperarousal, hyper vigilance, startle reflexes
Sleep difficulties
Components of OCD
Obsessional thoughts/images/impulses +/- compulsive rituals to reduce the distress of the obsessional thought
Recurrent, intrusive phenomena
Lead to anxiety and distress
Resisted at the beginning but in chronic state they start to accept their obsessions as true -> delusions
Organic DDX for anxiety
Organic:
- CNS - tumours, migraine/encephalitis
- Arrhythmias
- Pulm insufficiency
- Hyperthyroid
- Hypoglycaemia
- Cushing’s disease
- Carcinoid tumour
- Pheochromocytoma
INTOXICATION -stimulants, meds, alcohol, caffeine
WITHDRAWAL
Adjustment disorder (ft of anxiety and depression)
What is Panic disorder
Recurrent/habitual reoccurrence of panic attacks
No clear organic cause and no predictable precipitant
Often assoc w inter panic anxiety and avoidance behaviour
Management of panic disorder
Lifestyle (exercise, relaxation therapy, decr substances and caffeine)
Psychoeducation
CBT
Meds
- SSRIs
- Benzos to attenuate an acute attack (short period of treatment only)
what is agoraphobia?
Management
Fear of situations in which the individual feels trapped
- supermarkets
- heavy traffic
- public transport etc
MX:
- lifestyle (exercise, relaxation therapy, decr substances and caffeine)
- psychoeducation
- exposure/response therapy
- SSRIs or SNRIs if required
What is exposure/response therapy?
Mapping fears, behaviours and avoidances
Help the patient tackle these fears in a structured hierarchical way (Start w something easy then move onto next hardest step etc)
- used for phobias, agoraphobias
Mx of GAD
Lifestyle:
- Exercise
- Decr caffeine, alcohol and drugs
- Relaxation techniques
Psychotherapy:
- Psychoeducation
- Problem solving therapy or CBT
+/- SSRIs or SNRIs (help w comordbid depression)
Organic causes of psychiatric disorders
Delirium (any case) Dementia ABI CVD Epilepsy Infectious diseases Neoplasia Demyelinating disease HD Autoimmune diseases Endocrine and metabolic disorders
What is delirium?
Syndrome characterised by
Fluctuating level of consciousness
Acute onset of
- cognitive sx
- psychotic sx
- altered arousal (incr or decr)
- sleep cycle reversal
Causes of delerium
Prescribed drugs
Alcohol/substance intoxication and withdrawal
Medical conditions - post-op hypoxia, febrile illness, sepsis, organ failure, hypoglycaemia, dehydration and electrolyte imbalance, constipation, burns, major trauma
Neurological conditions - epilepsy post-ictal, head injury, space occupying lesion, encephalitis
Criteria for anorexia
DECR INTAKE
- Restriction of energy (caloric) intake relative to requirements
FEAR
- Intense fear of gaining weight/becoming fat
DISTORTED BODY IMAGE
- See selves as fat when they are actually very thin
Types of anorexia
Restrictive (no recurrent episodes of binging/purging. dieting, fasting, excessive exercise as means of weight loss)
Binge-eating/purging (recurrent episodes of binging/purging in last 3 months. Self-induced vomiting, use of laxatives, diuretics, enemas etc)
Risk factors for anorexia
Family
- eating disorders
- parental obesity
- restrictive dieting
- concerns about eating, appearance, weight
Personal HX
- body dissatisfaction
- childhood obesity
- restrictive dieting
- early menarche
- depression
- substance abuse or dependence
- OCD
- Social anxiety
- adverse life events
Personal Traits
- perfectionist, obsessional
- low self-esteem
- female
- occupation (model)
DSM criteria for Bulimia
Recurrent episodes of binging
Recurrent compensatory behaviour to prevent weight gain
The above 2 things occur at least once a week for 3 months
NOT fitting criteria for anorexia
Physical parameters for hospital admission
Bradycardia (HR<50)
Hypotension (90/60 with a postural drop of >20)
BMI <14or hospital admission
temp <35.5
Hypoglycaemia
Electrolyte imbalance (low K, Mg, Phosphate)
Several days of no oral intake
Petechial rash and Plt/bone marrow suppression
Psych parameters for psych admission
Needing supervision - can’t be managed or trusted in community
Active suicidal plan
Other psych. comorbidities requiring admission
Severe family problems
Signs and complications of anorexia nervosa
Emaciated frame Psychomotor retardation Stupor Easy bruising Cyanosis, anaemia infection proximal myopathy (squat)
Lanugo hair to insulate due to hypothermia
Parotid swelling from vomiting
Poor dentition from vomiting and lack of Ca
Fractures, osteoporosis from lack of Ca
Angular stomatitis from lack of Fe, B12
Dry skin, loss of skin turgor from dehydration
Russell’s sign (erosion of knuckles from acid)
Brittle nails
Clubbing
Cold hands
Bradycardia
Arrhythmia
Hypotensive w postural drop
Signs and complications of anorexia nervosa
Emaciated frame Psychomotor retardation Stupor Easy bruising Cyanosis, anaemia infection proximal myopathy (squat)
Lanugo hair to insulate due to hypothermia
Parotid swelling from vomiting
Poor dentition from vomiting and lack of Ca
Fractures, osteoporosis from lack of Ca
Angular stomatitis from lack of Fe, B12
Dry skin, loss of skin turgor from dehydration
Russell’s sign (erosion of knuckles from acid)
Brittle nails
Clubbing`
Cold hands
Bradycardia
Arrhythmia
Hypotensive w postural drop
2 important investigations to order w anorexia
UEC and CMP (K, Mg, PO4)
ECG
Pathophys refeeding syndrome
- Low carb intake -> low insulin secretion -> fat catabolism -> FFA and ketones used over glucose
- In severe starvation, Mg/K/PO4 stores are depleted whilst serum levels are maintained
- Refeeding -> CHO metabolism -> incr insulin stimulates PO4/K/Mg into cells -> fall in serum concentration
Occurs within 3-4 days of refeeding
What is somatic symptom disorder
KEY: Multiple symptoms, multiple systems, concurrently, with no underlying physical cause
CRITERIA:
- A history of multiple physical complaints/SX
beginning before 30 years of age that
occur over a period of several years (>6mo) and
result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning
- After inappropriate investigation, each of the SX cannot be explained by a known general medical condition or the direct effects of a substance (medication or drug of abuse)
- When there is a related general medical condition, the physical complains or resulting functional impairment are in excess of what would be expected form Hx/Ex/Ix
- SX are not intentionally produced or feigned
DDX somatic SX disorder
Illness anxiety disorder (intense worry about illness rather than SX)
Delusional disorder (somatic type- belief in delusional intensity i.e. not open to reasoning/reassurance)
Body dysmorphic disorder (excessive concern about perceived defect)
Depressive disorder with somatisation (look for core depressive SX like low mood, anhedonia etc)
GAD (general worries other than health)
Panic disorder (anxiety in acute episodes compared to persistent SX with SSD)
What is conversion disorder?
Motor (paralysis or functional gait disorders) or sensory (blindness) deficits or non-epileptic seizures suggesting a neurological or medical cause but for which no physical explanation can be found
Psychological factors are assumed to be associated with the SX or deficit because the initiation or exacerbation of the SX or deficit is preceded by conflicts or other stressors
SX or deficit isn’t
○ Intentionally produced or feigned
○ Causes significant distress or impairment
○ After appropriate investigation, can’t be fully explained by general medical condition or affect of a substance
What is factitious disorder?
Intentional production or feigning of physical or psychological signs and symptoms
Motivation for behaviour is to assume the sick role (obtain the sympathy and special attention given to people who are truly medically ill)
No external incentives for the behaviour (economic gain, avoid legal responsibility, improving physical well-being etc), as in malingering, are absent
What is factitious disorder associated with?
Associated with
- disturbed early attachments (emotional neglect, loss, abuse)
- Cluster B personality
- early illness and hospitalisation in childhood
- Women > Men
- Health professionals
What is illness anxiety disorder and how does this differ from somatic symptom disorder?
Illness anxiety disorder = hypochondriasis
Preoccupation with fears of having, or the idea that one has, a serious physical disease based on person’s misinterpretation of normal bodily symptoms leading to seeking medical help, but failing to be reassured by negative medical examination and tests.
- Often focused on a specific disease
- May or may not actually have any physical SX
Duration >=6 months
Causes significant distress/impairment in life functioning
DSM5 definition of personality disorder
Personality disorder - Enduring over time - Inflexible and rigid (hard to change these people because they don’t have insight) - Manifests over multiple situations - Detrimental to self and others - Started in childhood, stable and long duration - Also effects ○ Cognition/perception ○ Affect ○ Impulse control ○ Interpersonal functioning
DSM5 criteria for BPD
I DESPAIRR’ - SYNDROME (need around 3 of these)
- Identity disturbances (confused w sexual, gender identity, as a person etc) - Dissociation - mind feels disconnected from body - Emptiness (feel empty and lonely even in a crowd of friends nad family) - Suicidal, self-injurious behaviour - Paranoid ideation (mistrust in relationships due to past traumatic events) - Abandonment (feel of real or imagined abandonment/rejection etc - extremely sensitive) - Impulsivity (self injurious behaviours, shopping sprees, unstable relationships, alcohol and drug use, promiscuity) - Rocky on-off relationships - Rage (inability to regulate emotions - anxiety, depression, rage)
Ego defence mechanisms in BPD
Splitting: Idolisation (best person) and devaluing (worst person in the world)
Projection: - projecting difficult, unconscious feelings onto the surgeon
Mainstays of treatment for BPD
PSYCHOTHERAPY: Dialectical behavioural therapy to help regulate emotions Mindfulness ACT Interpersonal/group therapy
+ Risk management plan in place
MEDICATIONS
used in MX in context of comorbid mood disorder and psychosis which they are prone to developing.
- Quetiapine and/or SSRI or benzo to take edge of anxiety
Cluster A, B and C disorders
Cluster A “weird”: Schizoid (aloof), paranoid (accusatory), schizotypal (awkward) personality disorder
Cluster B “wild”: BPD, antisocial, Narcissistic
Cluster C “worried”: avoidant, dependent, obsessive-compulsive
Common comorbid psych problems with personality disorders
Substance abuse Bipolar w cluster B Depressive disorders Schizophrenia w cluster A Anxiety w cluster C
Schizoid vs Schizotypical PD
Schizotypal (typal -> thinking) : weird thinking and behaviour (magical thoughts, ideas of reference etc) . Don’t want to be alone, but often are because they have trouble maintaining relationships due to odd thinking and lack of insight.
Schizoid (oid -> ODD) individuals simply feel no desire to form relationships, because they see no point in sharing their time with others.
-DISTANT
Narcissistic vs antisocial PD
NPD: pervasive pattern of grandiosity, need for admiration, and lack of empathy for others
ASPD: pervasive pattern of disregard for and violation of rights of others, often in criminal justice system
What is malingering?
Faking SX for external rewards (medication, money, time off work etc)
Explain the physical symptoms of a panic attack
Cycle of anxiety:
- Thoughts (something terrible will happen and i will not be able to cope)
- > - Feelings (of apprehension, tension, fearfulness)
- > - Physical symptoms (tachycardia, palpitations, flushing, dry mouth, diarrhoea, urinary freq, sweating, fatigue, tremor, chest tightness etc)
- > 1. (experiencing SX leads to avoidance -> anticipatory anxiety -> further catastrophic thoughts)
Hyperventilation in itself leads to hypocapnoea (blowing off CO2) which leads to feelings on anxiety
Investigations as a part of routine initial assessment
FBE, UEC, LFTs, TFTs
Lipids, BSL
Weight, height, BP
Urine drug screen
+/- EEG, CT or MRI if organic aetiology suspected
+/- CXR, ECG if suggested by clinical picture
DDX depression
Primary depression Bipolar Adjustment disorder Comorbid depression Organic aetiology
Define: delusion
Fixed, unshakable beliefs, unamenable to reason
Impossible and unreasonable
Cannot be challenged
Out of keeping with education, cultural, social background
Examples of common types of obsessions and accompanying compulsions (OCD)
- Contamination fears -> cleanliness rituals
- Obsessional doubt -> compulsive checking
- Order -> ordering, rearranging
- Aggressive impulses -> checking safety of others
- Sexual impulses -> mental rituals
What might visual hallucinations be more likely to be caused by?
Organic pathology
Alcoholic hallucinosis
Drug intoxication
What Qs to ask to enquire about a patient’s insight?
▪ Do you think you are unwell? ▪ Do you know in what way you are ill? ▪ Early warning sign/relapse awareness ▪ Do they know how they became ill? ▪ Compliance
DDX OCD
depressive disorder (can present w obsessions and compulsions)
SCZ (in early phase obsessional SX can be common, and thought insertion can appear similar to an obsession although in this case the individual is only recognising the thoughts as their own)
Cluster C personality disorder (high level perfectionism, obsession w rules and details)
DDX PTSD
Acute stress disorder (sx last <1mo following stressful event)
Adjustment disorder (reaction to a change in life circumstances rather than to a specific stressful event)
Depression
Panic disorder
GAD
High risk anxiety
Panic attacks + depression
DDX low mood after birth
◦ Postpartum blues - 80% experience this but should only last a few days, in first week after birth
◦ Adjustment problems/disorders (Difficulty bonding with child - feelings of guild, sadness etc)
◦ Postpartum depression (Develops between 1 month and up after birth of baby)
Impact of mental illness in pregnancy on
- Pregnancy
- Baby itself
Impact on pregnancy
▪ Poor self care
▪ Quality of maternal care
▪ Less likely to attend antenatal appointments
▪ Smoking, alch
▪ Incr risk of spontaneous abortion, pre-eclampsia, gestatonal HTN etc
Impact on baby ▪ Developmental delay ▪ Lower IQ ▪ ADHD ▪ Impaired language ▪ Impaired emotional development
Medications CI in breastfeeding
◦ Fluoxetine (infant jitteriness)- other SSRIs ok
◦ TCAs - low level in breast milk
◦ Anticonvulsants
◦ Clozapine (Risk-agranulocytosis)
◦ Li only If severely necessary - affects thyroid (need close monitoring of infant and serum levels)
◦ Short-acting benzos ok for short course (avoid long-acting agents)
Risk of Lithium use in pregnancy
Epstein’s anomaly (neural tube defect) in the infant
Use of medications for mental illness in pregnancy (safe vs unsafe)
SSRIs (Sertraline is safe)
ANtivconvulsnat - Lamotrigine is safe (sodium valproate is not)
2nd gen atypical antipsychotics safe (1st gen not)
ECT safe
Li not safe
TCAs not safe
DSM 5 criteria for SCZ
A) At least 2 of the following, present most of the time for at least one month
- Hallucinations
- Delusions
- Disorganised speech
- Disorganised or catatonic behaviour
- Neg SX
B) Social/occupational disruption
C) Continuous signs of disturbance persist for at least 6 months
DA hypothesis of Schizophrenia
- mesolimbic pathway involves DA - overactivity of this results in positive SX
- mesocortical pathway involves DA - overactivity results in negative SX, hypoactivity, cognitive impairment
- blocking nigrostriatal pathway incidentally w antipsychotics causes movement disorders (parkinsonian SX)
- blocking tuberoinfundibulnar pathway (inhibits prolactin release) w antipsychotics causes hyperprolactinaemia as a SE
Requirements for the MHA
▪ must be deemed to be mentally unwell (disturbance in mood, thought, perception etc)
▪ requiring immediate treatment
▪ risk to self/health or others
•
▪ if you aren’t sure you can detain them for a max of 72 hours = inpatient assessment order
▪ compulsory treatment as an inpatient or at a community mental health service - can occur for 28 days until they must have a tribunal hearing
Criteria for involuntary admission
Person appears to have a mental illness
Person at imminent danger to self or others (or risk of deterioration)
Appropriate treatment available at site
This is the least restrictive method available
Person is incapable of providing informed consent or is unwilling to do so
3 orders under MHA to know about
Assessment order - by any medical condition
- transfer to psych facility within 72 hours, once there lasts 24 hours but can be extended up to 72 hours.
Temporary treatment oder - by a psychiatrist
Treatment order
- up to 6 mo inpatient or 12 mo outpatient
DSM alcohol use disorder
Alcohol is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
Craving, or a strong desire or urge to use alcohol.
Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
Recurrent alcohol use in situations in which it is physically hazardous.
Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect b) A markedly diminished effect with continued use of the same amount of alcohol.
Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol (refer to criteria A and B of the criteria set for alcohol withdrawal) b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
