psychiatry Flashcards
What are the characteristics features of a pervasive developmental disorder?
the presence from early life of differences & delay in social-communicative
development associated with restricted patterns of interest or behaviour. This
definition applies to disorders such as Childhood Autism, Atypical Autism, Rett’s
syndrome, Childhood Disintegrative Disorder & Asperger’s Syndrome. Pervasive
developmental disorder is analogous with autistic spectrum disorders.
Criteria for Childhood Autism (ICD-10, WHO 1992)
the presence of and/or
impaired development that is manifest before the age of three years, and by the
characteristic type of abnormal functioning in all three areas of social interaction,
communication, and restricted, repetitive behaviour.
criterial for adjustment disorder
state of subjective distress and emotional disturbance,
usually interfering with social functioning and performance, and arising in the period of
adaptation to a significant life change or to the consequences of a stressful event
What factors influence the symptoms in cases of somatisation.
Prev med experience and beliefs
Personality
Social circumstances
Prevailing mental state
Ddx medically unexplained symptoms.
Somatic dist if mood or psychotic illness
Hypochondriasis
Somatoform disorder - somatization, conversion, psychogenic pain disorder
Body dysmorphic d
Feigned illness
Factitious
Malingering
Do pts with factitious disorder have an awareness
Yes
What med works for body dysmorphic
Ssri
Diff between briquets and somatization
Briquets are shifters between systems
Somatizers are narrow simple lots detail
About how many pts with major depression only report somatic symptoms to gp
69%
Hypochondriacs are concerned with _____ where as somatisers are concerned with _______
Hypochondriacs are concerned with disease_ where as somatisers are concerned with symptoms
Conversion disorder presents with
Small no symptoms
Often just 1
1 organ system - typically CNS
Dissociative disorder presents with
Psychological symps?… Like amnesia..?..
What medical illnesses might mimic somatization disorder?
Sle ms sarcoidosis etc!
What proportion of pts wuth somatization disorder will experiemce an additional psychiatric disorder at some point
2/3
Depression and anx most common
Also substance abuse
What percent of hypochondriacs meet criteria for anxiety or depressive disorder?
50%
Prevalence and prognosis of somatization disorder?
Prev: 0.5%
75% improve over time
choosing anti depressants: 3 things to think about when assessing likely tolerability:
- anticipated adverse events (ses and discontinuation symps)
- potential interactions with concom meds and illnesses
- persons perception of the efficacy they have already taken
big problem with ssris?
bleeding.. thus prescribe ppi if on nsaids or aspirin
which ssri is ass with discontinuation symps very early if stopped
paroxetine has very short half life
which 2 antidepressants are ass with greater risk from od?
tcas and venlafaxine
give a patient info on how antidepressants should be taken
- Keep in touch with your doctor in the first few weeks. With some of the older Tricyclic drugs it’s best to start on a lower dose and work upwards over the next couple of weeks. If you don’t go back to the doctor and have the dose increased, you could end up taking too little. You usually don’t have to do this with the SSRI tablets. The dose you start with is usually the dose you carry on with. It doesn’t help to increase the dose above the recommended levels.
- Try not to be put off if you get some side-effects. Many of them wear off in a few days. Don’t stop the tablets unless the side-effects really are unpleasant. If they are, get an urgent appointment to see your doctor. If you feel worse it is important to tell your doctor so that he can decide if the medicines are right for you. Your doctor will also want to know if you get increased feelings of restlessness or agitation.
- Take them every day - if you don’t, they won’t work.
- Wait for them to work. They don’t work straight away. Most people find that they take 1-2 weeks to start working and maybe up to 6 weeks to give their full effect.
- Persevere - stopping too early is the commonest reason for people not getting better and for the depression to return.
- Try not to drink alcohol. Alcohol on its own can make your depression worse, but it can also make you slow and drowsy if you are taking antidepressants. This can lead to problems with driving - or with anything you need to concentrate on.
- Keep them out of the reach of children.
- Tempted to take an overdose? Tell your doctor as soon as possible and give your tablets to someone else to keep for you.
- Tell your doctor about any major changes in how you feel when the dose of antidepressant is changed
5 BIG THINGS TO TELL SOMEONE STARTING ON ANTIDEPRESSANTS
- not addictive
- not known to have major long term adverse events
- delayed onset of action 10-14 days
- should be continued for at least 6 months after symptom resolution
- don’t stop abruptly coz of discontinuation symptoms (NB PAROXETINE AND VENLAFAXINE!)
WHATS AN ADEQUATE TRIAL OF ANTIDEPS
6 weeks during full compliance and therapeutic doses!
how do TCAs work and main se’s ?
Block reuptake of NA AND 5HT!
Unwanted effects due to:
blocking muscarinic cholinergic receptors (dry mouth, dry eyes, urinary retention, blurred vision, constipation, attentional probs)
by blocking alpha one adrenergic receptors: (ortho hypotension, dizziness)
histaminic 1 blockage: sedation and weight gain
sodium channel block! ( arrhythmias, seizures)
maois work by?
irreversibly blocking MAO-A!!!!
thus you can build up monoamines and lead to hypertensive crisis!
be careful with what you eat
phenelzine is an example
SSRIs work by..? and se’s?
blocking re uptake of 5ht and also block 5ht1-a autoreceptors thus increase serotonins availability!
MINIMAL EFFECTS on hista, alpha, musc, and negligible effects on NA thus safe in OD!!!!
NAUSEA AND VOM
BLEEDING
SEX DYSFN
EARLY AGITATION
MIRTAZAPINE IS AN EXAMPLE OF A
NASSA! na and specific serotonin anti dep
block alpha 2 !!!
increases release of NA AND 5HT
PROBLEM? block H1 : WEIGHT GAIN AND SEDATION!!!!!
buproprion is an example of a
NDRI
which anti depressants need to be escalated in their doses in order to minimise propensity for adverse effects
venlafaxine duloxetine mirtazapine and tcas
what neurochemical effects seen at what doses of venlafaxine?
<150 : 5HT
200 : 5HT AND NA
300 : 5HT NA DA
what are the risk of further episodes of depression with treatment discontinuation?
risk is determined by previous episode frequency relapse rates of 50% after 1 episode 70 after 2 >90 after 3 or more episodes
options for treatment resistant depression?
increase dose change agent or class augment with mood stabiliser ect combo anti dep tz augment with t3 or antipsych use MAOI esp if hypersomnia, hyperphagia, reversed DMV
name all the somatic symptoms?
loss of interest or pleasure waking 2 hrs or more earlier than usual worse depression in morning psychomotor retardation or agitation loss of appetitie with >5% weight loss loss of libido
whats bipolar 1
at least 1 manic episode with or without an episode of depression
whats bipolar 2
one or more depressive episodes with at least one hypomanic episode and not any manic or mixed episodes!
what % of pts don’t benefit adequately from antidepressants?
30-40%
what do you check in pre lithium work up?
u + e, cr clearance, tfts, ECG
how do you start lithium?
commence at 400mg NOCTE
check plasma level after 7d and then every 7 d after each dose change!
recommended level is 0.4mmol/L in unipolar dep and 0.6mmol/L in bipolar illness with higher levels to treat mania
assess levels 12 hrs after last dose
how do you monitor lithium?
check lithium every 3 months and TFTS and U + E every 6 months. gradually u can check lithium levels every 6 months too!
weight check regularly
advise to discuss pregnancy
reduce slowly over 2 months if gonna stop - risk of ‘rebound psychosis’ if stopped too quickly!
tell pt on lithium to look out for:
neuro signs, dizziness, ataxia, tremor, vomiting, double vision, decreasing consciousness
consider ECT for…
severe life threatening depression and when a rapid response is required or when other tx have failed
indications for ECT:
depression with
- severe bio disturbance (eating drinking psychomotor retardation)
- high risk self harm or harm others
- dep with psychotic symptms
and mania schizoaffective catatonia neuroleptic malignant syndrome
how often ECT is given
twice or three times/wk
with a total of 6-12 treatments for depressive illness
discontinuation symptoms of paroxetine or venlafaxine?
dysphoria
agitation
sweating
restless
what are the se’s of typical antipsychotics?
dystonia
parkinsonism
tardive dyskinesia
akithesia
clozapine se’s
AGRANULOCYTOSIS 32/100,000 in the first 18 weeks
metabolic stuff: weight gain, dyslipidemia, glucose regulation off!
anticholinergic effects
siallhorrhea, tachycardia
counsel someone on starting antipsychotic:
many diff antipsychs that are effective all have se's cant predict who will develop se's will monitor closely if you do develop ses we can change dose or drug
restless feeling (akathisia)
stiffness in arms or legs
tremor
involuntary movements affecting muscles of face neck or limbs - this is less common with newer antipsychs but let doc know!!
weight gain, hyperglycemia, diabetes, raised cholesterol, esp with newer drugs (thus imp to monitor health)
can take tab every day or some come in injection every 2-4 wks
alcohol and illicit drugs can interfere and make worse
if become unwell - mental health team
Misdiagnosis of major illnesses in somatizers?
<10%
Name all the abnormal forms of thought
Intrusive recollections Obsessional thought Overvalued idea Delusion Ruminations
Whats an obsessional thought?
Recurring Intrusive Unwanted Unpleasurable Distressing Anxiogenic
Ego dystonic
Sense of compulsion
Features of an overvalued idea
Unreasonable in intensity and conviction
Undesirable in context of background/personality/culturwl/religion
Insight maintained NOT SHAKEABLE
RECOGNISE OTHERS SEE THEM AS UNREASONABLE
turn up an over valued idea? —–DELUSION!
