Psychiatry Flashcards
Paranoid Personality Disorder - characteristics?
Suspicious, mistrustful
Holds grudges
Entitled to more rights
Schizoid personality disorder
Detached, aloof, no interest in friends or sex
Schizotypal
Eccentric, odd beliefs
BPD/EUPD
Impulsive, feelings of ‘emptiness’, unstable, fear of abandonment
Narcissistic
Grandiose…
Antisocial
Antisocial, disregard for feelings of others, lack sense of responsibility
Histrionic
Theatrical, dramatic, seductive, self-harm
Anankastic
Obsessive compulsive, rigid, stubborn, perfectionist
Dependent
Dependent on others to make decision, need constant reassurance
Anxious avoidant
Persistent anxiety, sensitive to rejection, avoid relationships unless acceptance is guaranteed
SSRIs
SSRIs - sertraline (safest in cardiac disease), citalopram (prolongs QT), fluoxetine (adolescents)
First line for depression
Side-effects: Nausea and Vomiting, GI Bleeding, Initial worsening of anxiety/suicidal ideation - because they work on your motivation before they work on your mood, hence more likely to act out suicide
Contra-indications - Warfarin/heparin; NSAIDs (give with PPi)
Coming off SSRI - discontinuation syndrome (NV, Diarh, Insomnia - Paroxetine because short half life). Hence take off slowly over 4 weeks.
Serotonin Syndrome
Serotonin syndrome is a potentially life-threatening syndrome that is precipitated by the use of serotonergic drugs and overactivation of both the peripheral and central postsynaptic 5HT-1A and, most notably, 5HT-2A receptors. This syndrome consists of a combination of mental status changes, neuromuscular hyperactivity, and autonomic hyperactivity.
More likely with Fluoxetine because long half life
SNRIs
Serotonin-Adrenaline reuptake inhibitor
Venlafaxine
Duloxetine
SEs - Loss of appetite/weight
Fatigue
NV
Reduced libido
TCA antidepressants
Amitriptyline (Neuropathic pain)
Clomipramine (OCD)
Donepezil (palliative for Alzheimers)
SEs
Can’t see, can’t pee, can’t spit, can’t shit and drowsiness
NaSSAs - Noradrenergic and Specific Serotonergic antidepressants
Block a2 adrenoceptors and specific serotonergic receptor
Mirtazapine
Weight gain
Sleepiness
Constipation
Dry mouth
MAOIs
Monamine oxidase inhibitor
prevents breakdown of monoamine neurotransmitters (last line - consultant choice)
Serotonin, melatonin, adrenaline, noad
Hydrazine
Isocarboxazid
Nialamide
Tyramine cheese reaction - pt needs to avoid things with Tyramine such as animal livers, cheese, fortified wine
Increased tyramine. Increased Norad. a1 receptor, vasoconstriction = hypertensive crisis
Treatment for hypertensive crisis
hydralazine/sodium nitroprusside
Depression core symptoms
Symptoms:
1) Low mood
2) Anhedonia
3) Low energy
- Cognitive (Reduced concentration, negativity, guilt, suicidal ideation)
Beck’s Triad: -ive thoughts about self, world, future
- Biological (mood variation - diurnal, worse in the morning; EMW; loss of libido)
+/- Psychotic symptoms:
- 2nd person auditory hallucinations
- Hypochondriacal, guilt, nihilistic, persecutory delusions
Differentials for depression
Anaemia
Thyroid
Hypercalcaemia ("Painful stones, abdominal groans and psychic moans")
LFTs
U&Es
Precipitating factors
Steroids and Long term conditions
Diagnosis of depression vs diagnosis of mania duration
> 2 wks depression
>1 wks mania
Treatment of Mania
Acute mania: Olanzapine, Risperidone, Quietiapine
Mood stabilisers:
Sodium Valproate
Lithium
Lamotrigine
Carmazapine (linked to benzos)
Note: Quetiapine is first line because of risks with Lithium
Lithium SEs
Lithium Toxicity
Lethargy/leucocytosis Intentional tremor Teratogenicity Hypothyroidism Insipidus Urine excess/renal failure Metalic taste
Toxicity – can be fatal
• Confusion, coarse tremor, nausea and vomiting, ataxia and seizures
- Treated with supportive measures – dialysis if necessary
- Potential for toxicity increases with dehydration – advise to drink lots of water in hot climates
About to start pt on Lithium, what tests
Baseline U&Es, LFTs, TFTs, Pregnancy, ECG
Not metabolised, just excreted by kidneys - hence need to make sure kidneys are accurately excreting to maintain therapeutic dose
Monitor 12 hour after first dose
Weekly for 4 weeks until therapeutic dose achieved
3 monthly
Every 6 months monitor U&Es
Every year TFTs
Causes of psychosis
Non organic: Schizophrenia, Schizotypal disorder, Schizoaffective disorder, Acute psychotic episode, Delusional disorder
Organic: Dementia, Delirium, Huntington’s disease, Endocrine or hypocalcaemia, Syphilis, Drug-induced (Cannibis)
Classification of depression
Mild 2 core + 2 others
Moderate 2 core + 3-4 others
Severe 3 core + others
RISK takes you straight to severe
Antipsychotics
Typical: Haloperidol, Chlorpromazine
Atypical: Olanzapine, Risperidone, Quetiapine, Aripiprazole, CLOZAPINE
Block D2 receptor
Also have other effects:
Serotonergic - help affective symptoms
Antihistaminergic - sedative
Antiadrenergic - postural hypotension, tachycardia
Anticholinergic - Can’t see,pee,spit,shit
Antipsychotics
Typical: Haloperidol, Chlorpromazine
Atypical: Olanzapine, Risperidone, Quetiapine, Aripiprazole, CLOZAPINE
Block D2 receptor
Extra-pyramidal side effects
Parkinsonism - tremor, rigidity, bradykinesia
Akathisia
Dystonia (+ Oculogyric crisis)
Tardive dyskinesia
Dopaminergic pathways and side effect profile of antipsychotic
Mesolimbic pathway - positive symptoms of schizo
Mesocortical - negative “”
Nigrostriatal pathway (EPS and TD)
Tuberoinfundibular - hyperprolactinaemia
What can be given to reduce extra-pyramidal side effects of antipsychotics?
Procyclidine
Anti-cholinergic
Metoclopramide
Odansatron
Cyclizine
Dopamine antagonist
Serotonin antagonist
?
SEs of antipsychotics except clozapine
Weight gain - metabolic syndrome - increased bp, incr lipids and glucose, increased abdominal circumference
Hyperprolactinaemia - Dec. libido, amenorrhoea, gynaecomastia, dec. bone density
Clozapine SEs
Should be used in schizophrenia after two other antipsychotics have not worked
• Significant potential for agranulocytosis (severe leukopenia): therefore close monitoring of FBC: weekly for first 18 weeks then fortnightly then monthly.
• Significant potential for gastrointestinal hypomobility: constipation, potentially fatal bowel obstruction.
• Other side-effects include hypersalivation and urinary incontinence.
• Dose titrated slowly upward over two weeks and vital signs monitored due to potential for autonomic dysregulation
Neuroleptic Malignant Syndrome
• Rare, life-threatening reaction to antipsychotics
• Fever, confusion, muscle rigidity, sweating, autonomic instability
• Death usually due to:
• Rhabdomyolysis, renal failure, seizures
• Risk factors include:
• High potency dopamine antagonists (typical antipsychotics) in antipsychotic
naive, high doses, young men • Treatment:
• Emergency referral to A&E; stop antipsychotics; fluid resuscitation; reduce temperature
Benzos
Most typically used are diazepam (long half-life) and lorazepam (shorter half-life)
• Bind to GABA receptors to potentiate the effect of GABA and therefore reduce the excitability of neurones.
• Therefore they are positive allosteric modulators of GABA receptor
• Significant potential for tolerance and dependence
• Significant potential for misuse
• Use very cautiously and for no more than six weeks
• Occasionally cause paradoxical disinhibition
Pregabalin
Binds to voltage gated calcium channels in neurones
• Increases extra-cellular amounts of the enzyme responsible for synthesis of GABA and therefore increases GABA concentrations in the brain
• Reduces neuronal activity (i.e. is a CNS depressant)
• Used in anxiety, neuropathic pain and epilepsy
• Less potential for misuse and dependence (and tolerance) than benzodiazepines – but still misused – nickname “Budweisers”
• BNF says short term use – often used indefinitely
• Causes sedation and can cause weight gain
Benzo alternative
OD treatment
Positive allosteric modulator of GABA
Zopiclone, Zolpidem
OD of benzo: Flumazenil
Lamotrigine
Has a potential to cause Steven Johnson’s Syndrome
Aspirin give to children - bad…
Reye’s (Reye) syndrome is a rare but serious condition that causes swelling in the liver and brain. Reye’s syndrome most often affects children and teenagers recovering from a viral infection, most commonly the flu or chickenpox.
