Psychiatry Flashcards
What are the components of the Mental State Examination (MSE)
- Appearance
- Behaviour
- Cooperation and attitude
- Affect and Mood
- Affect is patients observed emotions
- Congruency - is the emotion appropriate?
- Range - broad (manic), flat, constricted (depressed)
- Reactivity - constricted, flat or blunted
- Mobility - changes to stimuli
- Mood - sustained emotion present over a long time
- Affect is patients observed emotions
- Speech
- Rate, volume, quantity, quality
- Thought form and content
- Form - how is it delivered
- Flow - linear, incoherent, tangential, circumstantial, derailment, flight of ideas
- Content
- Themes, preocuppations, overvalued ideas
- Ideations - self-harm, suicide, violent thoughts
- Delusions
- Posession - thought insertion, withdrawal, broadcasting
- Form - how is it delivered
- Perception
- hallucinations, illusions, derealisation, dissociation
- Cognition
- level of consciousness
- memory, concentration
- orientation
- Insight - awareness of their illness
- Judgement - ability to assess situations and act appropriately
- Risk - suicide, self-harm, homicide, relationships, finance, neglect
Symptoms of Depression (SIG E CAPS)
*Requires >=5 symptoms, for at least 2 weeks, with at least one of the symptoms being depressed mood or anhedonia
- Sleep disorders
- Interest loss
- Guilt/ worthlessness
- Energy depleted
- Concentration diminished
- Appetitie changes
- Psychomotor agitation
- Suicidal thoughts
What is the prevelance of depression in the community
- Lifetime prevelance of 20%
- Females > males (2:1)
- 5% of the population at any one time
- Peak onset in the 20s
What are some screening tools to assess depression
- PHQ-9
- DASS-21
- K-10
- Edinburgh depression score for postnatal depression
- Geriatric depression scale
Treatment for depression
First line
- SSRI’s (Selective Serotonin Reuptake Inhibitor)
- E.g. Sertraline (Zoloft), Citalopram (Clexa), Esclitopram (Lexapro), Paroxetine (paxil), Fluoxetine (Prozac)
- Modulation of the 5-HT transporter SERT
- SE – GI (nausea, diarrhea), Sexual (deceased libido), weight gain, fever
- SNRI’s (Selective Noradrenaline Reuptake Inhibitor)
- Venlafaxine (Effexor), Duoxetine
- Blocking of SERT and NA transporter (NAT)
- SE - Nausea, anorexia, constipation, dizzy, insomnia, dry mouth, sexual dysfunction, hypertension
- NaSSA (Noradrenaline Serotonin Specific Antidepressants)
- Mirtazapine
- Antagonism of inhibitory presynaptic alpha2-adrenoceptors on NA and 5-HT
- SE – weight gain, drowsy, dizzy, dry mouth, constipation
It may take 2-6 weeks to see a clinical response. if there is no initial or only a partial response then consider increasing the dose. If there is no or partial response consider switching to a different first line medication.
Second line
- RIMA (Reversible Inhibitor of Monoamine Oxidase A)
- E.g. Moclobemide
- Decreases interneuronal breakdown of NA and 5-HT
-
NRI (NA Reuptake Inhibitor)
* Reboxetine -
NDRI (NA Dopamine Reuptake Inhibitor)
* Bupropion
Third line
-
MAOI (Monoamine Oxidase Inhibitors)
* E.g. Selegiline (Zelpar), Phenelzine (Nardil), Tranylcypromine (:arnate) - TCA (Tricyclic Antidepressants)
- E.g. Amitryptyline (endep), Nortriptyline (allegron), Imipramine (tofranil)
- Negative allosteric modulators of NA and 5-HT transporters
- Many side effects, can be highly toxic, overdoses lethal
If psychosis is also present, then antipsychotics should be added to Tx
Other
-
Mood Stabilization Augmentation
* Lithium, sodium valproate, lamotrigine + SSRI & TCA -
ECT
* Response rate 50-80%
iii. CBT
What is dysthymia?
Symptoms of depression are present most of the day, for the majority of the days, lasting at least 2 years. It is less severe than MMD
Subtypes
- Pure dysthymia (low-grade chronic depression), without full criteria for major depression during the preceding 2 years
- Persistent Major depressive episode
- Intermittent major depressive episodes with current major depression
- Intermittent major depressive episodes without current major depressive disorder episode
Criteria
- Depressed mood for most of the day, more days than not for > 2 years
- Presence, while depressed of 2 or more of the following:
- Appetite Disorder
- Concentration deficit
- Hopelessness
- Energy deficit
- Worthlessness
- Sleep Disorder
- During 2 years patient hasn’t been without symptoms in criteria A and B for more than 2 months at a time
- Criteria for a major depressive disorder may be continuously present for 2 years
- There has never been a manic episode, a hypomanic episode, or criteria met for cyclothymic disorder
- Disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia
- The symptoms are not attributable to physiological effects of a substance
- Symptoms cause clinically significant distress or impairment in functioning
Difference between Premenstral Syndrome (PMS) and Premenstrual Dystrophic Disorder
PMS is characterized by cyclic, physical and behavioral symptoms occurring in the luteal phase of the normal menstrual cycle. Symptoms must not be present at other times through the cycle, must cause significant impairment and must not represent an exacerbation of another disorder. PMS is not classified as a mental illness.
Premenstrual Dysphoric Disorder (PMDD) is the more severe form of the disorder and classified as a mental illness in the DSM-5. The criteria for PMDD require that the woman experience at least 5 of 11 cognitive-affective, behavioural, and physical symptoms during the final week of the luteal phase that resolve with or near the onset of menses.
Treatment of PMS and Premenstrual Dystrophic Disorder
Fluoxetine (Lovan) - 2 weeks before period
What are the baby blues and how common is it?
Mother typically presents with mood swings ranging from elation to sadness, insomnia, tearfulness, crying spells, irritability, anxiety and decreased concentration. Symptoms develop within 2-3 days postnatal, peak on the fifth day and resolve within 2 weeks
It does NOT impact on the ability of the mother to function in ADLs or care for herself or the baby.
- Occurs in 30-80% of pregnancies (Very common)
- No treatment necessary
Define postpartum depression and risk factors
- Major depressive episode with onset in pregnancy or within 4 weeks of delivery
- 7-19% of women
Risk factors
- Psychosocial - stress, poor support, abuse, low SES
- Psychiatric - Hx depression, FHx, personality disorder
- Other - sleep deprivation, complicaitons of pregnancy, unwanted pregnancy, youn maternal age
Classifications of bipolar affective disorder
- Bipolar I: One or more manic episodes (lasting >=1 week) with or without major depressive episodes
- Bipolar II: One episode of hypomania + one episode of major depressive episode + no episodes of mania
Symptoms of Mania (DIGFAST)
Abnormally persistently elevated or irritable mood & increased goal-directed activity or energy. Lasting most of the day for at least 1 week, nearly every day. Includes greater than 3 of the following:
- Distractibility
- Indiscretion
- Grandiosity
- Flight of ideas
- Activity Increase
- Sleep deficit
- Talkativeness
*If psychotic symptoms are present, the episode is, by definition manic and not hypomanic
What makes an episode hypomanic as opposed to manic
- Most of the day for at least 4 consecutive days
- Same as symptoms for mania
- Episode is not severe enough to cause marked impairment in functioning
- No psychotic symptoms
Risk factors for Suicide attempt (SAD PERSONS)
- Sex (Male)
- Age (Older than 45)
- Depression
- Previous suicide attempt
- Ethanol abuse
- Rational thinking loss
- Sick (chonic disease)
- Organised plan (access to means)
- No spouse
- Social support lacking
5 Important questions regarding suicidal thoughts
- Ideation
- Intent
- Plan
- Access to means
- Previous attempt
Classification of Anxiety Disorders
- Generalized Anxiety Disorder
- Social Anxiety Disorder
- Panic Disorder
- Phobia
- Agoraphobia
- Separation Anxiety Disorder
- Selective Mutism
*PTSD and OCD
Risk factors for developing anxiety disorders
- Female sex
- Family history of mental health conditions
- Personality traits (behavioral inhibition)
- Perfectionist, timid, low self-esteem, inhibited, easily flustered, want to control everything
1. Physical illness - Diabetes, asthma, hypertension, health disease
1. Co-morbid mental health conditions - Mood disorders, substance use disorders
- Substance use
- Environmental and development factors
- Stress
- Smoking (risk for panic disorder and panic attacks)
- Psychological trauma, esp. during childhood
how many Australians have experienced Anxiety disorder in the past 12 months?
14.4%
Anxiety disorder is the most common class of mental disorders
higher rates in females (17.9%) vs males (10.8%)
Whats the difference between normal anxiety (stress) and abnormal anxiety?
Normal Anxiety:
- occurs in response to a stressful event
- can be beneficial to improve performance in stressful events
- goes away when the stimulus is removed
Abnormal anxiety:
- excessive and ongoing worry. Anxiety doesn’t subside when the stressor is removed. Anxiety may occur without an obvious cause, or may be disproportionate to a stressor.
- interferes with daily functioning
- causes significant physical and emotional distress
Symptoms of Generalized Anxiety Disorder
- Excessive anxiety and worry, occuring more days than not forat least 6 months, about a number of events or activites
- the individual finds it difficult to control the worry
- three of the following symptoms
- Worry
- Anxiety
- Tension in muscles
- Concentration difficulty
- Hyperarousal (irritable)
- Energy loss
- Restelessness
- Sleep disturbances
+ significant distress
+ no substance triggers
Screening tool used for generalised anxiety disorder and its questions
GAD-7
Over last 2 weeks, how often have you been bothered by any of the following symptoms
- Feeling nervous, anxious or on edge
- Not being able to stop or control worrying
- Worrying too much about different things
- Trouble relaxing
- Being so restless that it’s hard to sit still
- Becoming easily annoyed or irritable
- Feeling afraid as if something awful might happen
Treatment for GAD (Plus, what is CBT)
First line
-
CBT
* CBT can be used for anxiety or depression. It aims to help a person identify and challenge unhelpful thoughts and to learn practical self-help strategies. These strategies are designed to bring about positive and immediate changes in the person’s quality of life. CBT aims to show people how their thinking affects their mood and to teach them to think in a less negative way about life and themselves. It is based on the understanding that thinking negatively is a habit that, like any other habit, can be broken. - SNRI/ SSRI’s
- Buspirone (anxiolytic)
Benzodiazepines can be used until SSRIs take effect but should never be used for long-term management
What is Social anxiety Disorder and the treatment
-
SAD:
* Fear/anxiety out of proportion to a social situation where one may be scrutinized by others (e.g. meeting new people at a party, eating in public, using public restrooms) -
Performance-only SAD:
* Symptoms of fear/ anxiety restricted only to public speaking or performing in front of crowds - Cognitive Behavioral Therapy
- Pharmacology
- First line pharmacotherapy: SSRI/ SNRI
- No/ partial response to SSRI and no history of a substance - clonazepam (benzo)
- No/ partial response to SSRI and history of substance abuse - phenelzine (MAOI)
- For performance-only SAD: propanalol (beta-blocker)
DSM-5 criteria for Social anxiety disorder
- Marked fear or anxiety in one or more social or performance situations in which the person is exposed to possible scrutiny by others
- Fear that they will act in a way that will be humiliating, embarrassing, or they will be rejected by others
- Exposure to the feared social situation almost invariable provokes anxiety or panic attack
- Anticipatory anxiety
- Avoidance or fear interferes significantly with the person’s normal routine
- The duration of the symptoms must be at least 6 months
- Not due to substance or general medical conditions
What is agoraphobia?
Fear or anxiety about 2 or more of:
- Using public transport
- Being in open spaces
- Being in closed spaces
- Standing in line or being in a crowd
- Being outside the home alone
Patients fear or avoids these situations because escape may be difficult in the event of developing panic like symptoms, where fear and anxiety is out of proportion to the actual damage.
Symptoms of a Panic Disorder
Recurrent unexpected panic attacks with > 4 of the following symptoms:
STUDENTS FEAR THE 3 C’s
- Sweating
- Trembling
- Unsteadiness
- Depersonalisation/ derealisation
- Excessive heart rate/ palpitations
- Nausea
- Tingling
- SOB
- FEAR of dying
- Chest pain, chills, choking
1 months of anxiety about panic attacks with one of the following:
- persistent concern or worry about panic attacks
- significant maladaptive behaviour
Anxiety due to medical conditions
Physical Distress That Have Commonly Appeared Anxious
- Phaeochromocytoma
- Diabetes
- Temporal lobe epilepsy
- Hyperthyroidism
- Carcinoid (neuroendocrine tumours)
- Alcohol withdrawal
- Arrhythmias
DSM-5 classification of Post-traumatic Stress Disorder
- Experienced or observed event
- intrusions (e.g., flashbacks, intrusive images and sensory impressions, dreams/nightmares);
- Avoidance (e.g., avoiding people, situations, or circumstances resembling or associated with the event);
- Negative alterations in mood and cognition (e.g., feeling alienated from others, constricted affect, diminished interest in significant activities, distorted negative beliefs about oneself or the world, and inability to remember key features of the traumatic event);
- Alterations in arousal or reactivity (e.g., hypervigilance for threat, exaggerated startle response, irritability, difficulty concentrating, and sleep problems).
- Symptoms for greater than 1 month
- Significant distress or impaired function
Treatment of PTSD
Psychotherapy
- CBT (trauma focused, exposure therapy)
- Cognitive processing therapy
- Eye movement desensitization and reprocessing – recalling memories whilst watching finger move back and forth
Pharmacotherapy
- SSRI, SNRI (first line)
- Nightmares - Prazosin is effective for improving sleep
- Consider atypical antipsychotics for psychotic symptoms
- Benzodiazepines can be used for hyperarousal and anxiety, but monitored closely
How does acute stress disorder differ from PTSD
Characteristic symptoms same as PTSD, just lasts between 3 days to 1 month
What is adjustment disorder?
A maladaptive emotional or behavioural response to a stressor that lasts < 6 months following termination of the stressor. Symptoms such as stress, feeling sad, physical symptoms that occur because patients is having hard time coping. The reaction is stronger than expected for the type of event that occurred.
What are obsesions and compulsions
- Obsessions
- Recurrent and intrusive thoughts, ideas, impulses or images that are usually resisted by the person and are recognized as the product of their own mind and not imposed from outside
- Compulsions
- Repetitive behaviors in response to an obsession, to prevent discomfort or some dreaded event with which is not connected in a realistic way. The person generally recognizes that their behavior is excessive or unreasonable. Performing the action provides relief from anxiety caused by obsession
DSM-5 criteria for OCD
- Obsessions and/or compulsion
* Obsessions
- Recurrent/ persistent, intrusive thoughts, or urges that cause anxiety or distress
- Attempts to suppress these thoughts or urges
- Compulsions
- Repetitive behaviours or thoughts that the individual feels forced to perform by these obsessions
- Intentions to prevent or reduce anxiety, distress, or a dreaded event; behaviours are excessive or are not linked to the dreaded events at all
- Time-consuming, or resulting in significant distress/ impairment
- Not due to substance-use disorders or another medical condition
- Not due to another mental disorder (anxiety disorders, eating disorders)
Treatment for OCD
A combination of pharmacotherapy and psychotherapy has been proven effective in the treatment of OCD
- Cognitive Behavioural therapy
- Pharmacotherapy
- Antidepressants à SSRI (sertraline, fluoxetine)
- Alternatively, tricyclic antidepressants with serotonergic action (clomipramine)
- Atypical antipsychotics (quetiapine)
Clinical features of Schizophrenia (Including - positive symptoms, negative symptoms, cognitive symptoms and catatonia)
Schizophrenia tends to present initially with prodrome of negative symptoms (classically withdrawal) that precedes the positive psychotic symptoms (hallucinations and bizarre behaviours)
Positive symptoms of psychosis
-
Hallucinations
* A perceptual abnormality, in which sensory experiences occur in the absence of external stimuli - Delusions
Fixed, false beliefs that are not amenable to reason, despite evidence to the contrary
- Bizarre: impossibility of being true
- Non-bizarre: possibility of being true or consistent with patient’s culture
-
Illusions
* A perceptual abnormality, in which real external stimuli are misinterpreted - Disorganised thought and speech processes
- Loose associations – incoherent thinking expressed as illogical, sudden, and frequent topic changes
- Word salad
- Neologisms – creating of new words
- Flight of ideas
- Clang associations – use of words based on rhyme rather than meaning
- Circumstantial speech – non-linear thought expressed as a long-winded manner of explanation
- Tangential speech
- Thought-blocking
- Pressured speech
Negative symptoms of psychosis (the 5 A’s)
-
Flat affect
* Reduced or absent affective expression -
Avolition
* Reduced or absent ability to initiate purposeful activities -
Alogia
* Impoverished thinking that presents as reduced speech output or poverty of speech -
Anhedonia
* Inability to feel pleasure from activities -
Apathy
* Lack of emotion or concern, especially with regards to matters that are normally considered important
Cognitive symptoms
- Inattention
- Impaired memory
- Poor executive functioning
Mood symptoms - Depression
Catatonia – A behavioural syndrome characterized by abnormal movements and reactivity to the environment
- Retarded catatonia – immobility, posturing, negativism
- Excited catatonia – excessive, purposeless movement in both the upper and lower limbs, restlessness, impulsivitiy
- Malignant catatonia – fever, autonomic instability (tachycardia, tachypnea, abnormal BP and sweating), rigidity, and delirium (resembles neuroleptic malignant syndrome)
Criteria for schizophrenia
- >=2 of the following symptoms for >= 1 month (with at least one of the first 3)
- Delusions
- Hallucinations
- Disorganised speech
- Grossly disorganized or catatonic behavior
- Negative symptoms
- Symptoms must cause social, occupational or personal functional impairment
- Some sign of illness must persist for at least 6 months
- Schizoaffective disorder and mood disorder with psychotic features have been ruled out
- Symptoms must not be due to a medical or substance use disorder
- If there is a history of autism spectrum disorder or other communicating disorder beginning in childhood, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month
What are some other causes of depressive symptoms, and what investications would you consider performing?
Investigations
- TFTs – elevated TSH suggests hypothyroidism
- Metabolic panel
- FBC – anaemia can cause fatigue
- Serum B12 and folate
- 24-hour urinary cortisol – elevated levels suggest Cushing’s
- MRI, ANA, syphilis
Causes
- HIV/AIDS
- diabetes
- arthritis
- strokes
- brain disorders such as Parkinson’s disease, Huntington’s disease, multiple sclerosis, and Alzheimer’s disease
- metabolic conditions (e.g. vitamin B12 deficiency)
- autoimmune conditions (e.g., lupus and rheumatoid arthritis)
- viral or other infections (hepatitis, mononucleosis, herpes)
- back pain
- certain cancers (e.g., pancreatic)
- hypothyroidism
- anaemia
Causes and investigations for psychotic symptoms
- CT/ MRI – rule out dementia, brain tumour, traumatic brain injury
- EEG - Temporal lobe epilepsy
- Serum HIV enzyme-linked immunosorbest essay
- Serum rapid plasma regain test – rule out syphilis
- FBC
- WCC - infection (also do CRP): infections such as EBV, rabies, mumps, measles
- volume abnormalities in red cells can suggest vitamin deficiencies or increased alcohol intake
- LP – encephalitis
- Urea and electrolytes – Hypercalcemia
- LFTs – most drugs processed by liver, hepatic encephalopathy
- Urine drug screen and plasma drug level monitoring
- Antihistamine, Dextromethorphan, anticholinergic, dopamine agonist, corticosteroid, adrenergic, thyroid hormones, cocaine, cannabis, amphetamine, alcohol
- Endocrine disorders – TFTs, 24-hour urine cortisol, hyperparathyroidism
- Autoimmune disorders – SLE
- Metabolic disorders – Wilson’s disease – copper
- Chromosomal disorders – Klinefelter’s syndrome
- Prolactin
Causes
- Brain tumors
- Traumatic brain injury
- Epilepsy
- Autoimmune disorders
- Thyroid disease – hyperthyroidism
- Hyperparathyroidism
- Huntington’s disease
- CNS infection
- Multiple sclerosis
- Stroke
- Migraine
- Carbon monoxide poisoning
- Heavy metal poisoning
Treatment for schizophrenia
- Hospitalization if acutely psychotic
- General approach
- Acknowledge the patients emotional state
- Avoid validation of delusions or confronting patients about the delusional nature of their complaints
- Antipsychotic treatment
- Acute psychotic episodes - Short acting antipsychotics (olanzapine) +/- mood stabilizer (lithium, valproate)
- First-line treatment: second-generation antipsychotics (olanzapine, risperidone, quetiapine)
- Alternatively, first-generation antipsychotics (haloperidol, fluphenazine, chlorpromazine)
- Cloazapine for treatment-resistant schizophrenia
- Psychoeducation
- Patient, family and group psychosocial therapy and education
- CBT
- Supportive social measures
What is schizophreniform disorder?
Psychotic and residual symptoms lasting 1-6 months
(Schizophrenia lasts > 6 months)
What is breif psychotic disorder?
- Psychotic symptoms lasting > 1 day but < 1 month
- triggered by stressful symptoms
What is schizoaffective disorder?
- Features of schizophrenia AND a major mood disorder (depression or bipolar)
- psychosis must have been present for at least 2 weeks in the absence of any mood disturbance
- mood symptoms do not appear in the absence of psychosis
What is delusional disorder?
- >= 1 delusions with a duration of >=1 month and no other psychotic symptoms
- functioning is not markedly impaired and behaviour is not obviously bizarre or odd
- sympoms are not better explained by substance abue, ot other medical illness
What are some types of delusions?
- Persecutory – affected person fears they are being stalked, spied upon, obstructed, poisoned, conspired against or harassed
- Paranoid – belief one is being harmed or persecuted
- Grandiose – believe they are greater or more influential
- Referential delusions – e.g. radio talking to you
- Delusional jealousy – spouse or partner is being unfaithful
- Somatic delusion – thing something wrong with them
- Control passivity – someone else controls them or they control something
- Guilt delusions
- Nihilism – belief that life is meaningless
- Delusional parasitotis – parasites e.g. ice
- Shared delusion – folie a deux
- Erotomanic – someone else is in love with them (usually a famous person)
- Bizarre – refers to delusions that is implausible e.g. alien invasion
- Non-bizarre – delusion such as fear of being followed
- Mood congruent vs not mood congruent
What is a Mood disorder with psychotic features?
- meets criteria for a mood disorder
- psychotic features appear exclusively during manic or depressive episodes
- mood symptoms may be present in the absence of psychosis
Cluster A personality Disorders
- Paranoid personality disorder
- Schizoid personality disorder
- Schizotypal personality disorder
Paranoid Personality Disorder features
SUSPECT
- Suspects without bases that others are harming, exploiting or deceiving them
- Unforgiving
- Spousal infidelity suspected
- Perceives attacks on reputation that are not apparent to others
- Enemy or friend? Preoccupied with doubts of trust
- Confiding in others is feared
- Threats perceived in benign events
Schizoid Personality Disorder features
DISTANT
- Detached or flattened affect
- Indifferent to criticism or praise
- Sexual experiences of little interest
- Tasks done solitarily
- Absence of close friends
- Neither enjoys or desires close relationships
- Takes pleasure in few activities
Schizotypal personality disorder features
ME PECULIAR
- Magical thinking/ odd belief
- Experiences unusual perceptions
- Paranoid ideation
- Eccentric behavior/ appearance
- Constricted affect
- Unusual thinking and speech
- Lacks close friends
- Ideas of reference
- Anxiety in social situations
- Rule out psychotic disorder and pervasive developmental disorder
Cluster B personality disorders
- Antisocial personality disorder
- Bordeline (EUPD) disorder
- Histrionic peronality disorder
- Narcissistic personality disorder
Antisocial personality disorder features
CORRUPT
- Conformity to law lacking
- Obligations ignored
- Reckless disregard for safety of self or others
- Remorse lacking
- Underhanded (deceitful, lies, cons)
- Planning insufficient (impulsive)
- Temper
Borderline personality disorder features
IMPULSIVE
- Impulsive
- Moodiness
- Paranoia or dissociation under stress
- Unstable self-image
- Labile intense relationships
- Suicidal gestures
- Inappropriate anger
- Vulnerability to abandonment
- Emptiness – feelings
Histrionic personality disorder features
PRAISE ME
- Provocative behavior
- Relationships (considered more intimate than they are)
- Attention (uncomfortable when not center of attention)
- Influenced easily
- Style of speech (impressionistic, lacks detail)
- Emotions (rapidly shifting and shallow)
- Made up (physical appearance used to draw attention to self)
- Emotions exaggerated (theatrical)
Narcissistic personality disorder features
- Special (believes they are special and unique)
- Preoccupied with fantasies (unlimited success and power)
- Envious
- Entitlement
- Excessive admiration required
- Conceited
- Interpersonal exploitation
- Arrogant
- Lacks empathy
Cluster C personality disorders
- Avoidant personality disorder
- Dependent personality disorder
- Obsessive compulsive personality disorder
Avoidant personality disorder features
CRINGES
- Certainty of being liked required before willing to risk involvement
- Rejection possibility preoccupies thoughts
- Intimate relationships avoided
- New relationship avoided
- Gets around occupational activities that involve interpersonal contact
- Embarrassment potential prevents new activities
- Self-views as unappealing, inept, inferior
Dependent personality disorder features
RELIANCE
- Reassurance required for decisions
- Expressing disagreement difficulties (fear of loss of support or approval)
- Life responsibilities assumed by others
- Initiating projects difficult
- Alone (feels helpless and a sense of discomfort when alone)
- Nurturance (goes to excessive lengths to obtain nurturance and support)
- Companionship sought urgently when close relationship ends
- Exaggerated fears of being left to care for self
Obsessive compulsive personality disorder features
LAW FIRMS
- Loses point of activity
- Ability to complete tasks comprised by perfectionism
- Worthless objects (unable to discard)
- Friendships (and leisure activities) excluded due to preoccupation
- Inflexible, scrupulous, over conscientious
- Reluctance to delegate
- Miserly
- Stubborn
Treatment for personality disorders
- Psychoeducation, psychotherapy, dialectical behavior therapy, group therapy, and/ or cognitive therapy
- Symptomatic medical therapy
- Mood stabilizers – valproate, topiramate and lamotrigine
- Antipsychotics – especially for symptoms of delusion
- Antidepressants - SSRIs
What are the criteria for a substance use disorder
(Impaired control, Social impairment, Risky use, Pharmacological indicators)
Mild substance use if 3 of the following, moderate = 4-5, severe = 6+
- Impaired control
- Using substance in larger amounts and/ or for longer time than originally intended
- Repeated failed attempts to cut down
- Spending a great deal of time on substance related activities
- Social impairment
- Problems fulfilling work, school, family or social obligations
- Problems with interpersonal relationships directly related to substance use
- Reduced social and recreational activities
- Risky use
- Use in physically hazardous situations
- Use despite awareness of physical problems
-
Pharmacologic indicators
* Drug intolerance
* The need for individuals to continuously increase the dose of a substance to achieve the same desired effect
- Drug withdrawal
- Substance-dependent collection of symptoms that appear after cessation of prolonged heady drug use
What is the difference between dependence and addiction
Dependence
- Dependence specifically refers to a physical condition in which the body has adapted to the presence of a drug. If an individual with drug dependence stops taking that drug suddenly, that person will experience predictable and measurable symptoms, known as a withdrawal syndrome.
Addiction
- Addiction is an uncontrollable or overwhelming need to use a drug, and this compulsion is long-lasting and can return unexpectedly after a period of improvement.
What are the 3 questions involved in the Audit C screening for alcohol use disorder
Total of 5+ indicates increasing or higher risk, all on scale of 0-4
- How often do you have a drink containing alcohol?
- How many units of alcohol do you dirnk on a tyical day when you are drinking?
- How often have you had 6 or more units if female or 8 or more if male, on a single occassion in the last year?
Complications of alcohol use disorder
Acute
- Risky behavior endangering the patient such as
- Suicide, drowning, homicide, rape, abuse, vehicle accidents
- Aspiration of gastric contents
- Metabolic imbalances
- Hypothermia
- Seizures
Long-term
- Erosive gastritis
- Dilated cardiomyopathy
- Pancreatitis
- Cirrhosis
- Alcoholic liver disease
- Mood disturbance: anxiety, depression, irritability, aggression
- Vitamin deficiency: B1, B6, B9, B12
- Peripheral neuropathy
- Wernicke-Korsakoff
- Gout
In pregnancy – fetal alcohol syndrome
Investigations for alcohol use disorder
- Acute alcohol intoxication à breath alcohol level, BAC
- Chronic alcohol intoxication
- Liver damage – increased transaminase levels: GGT, ALT, AST (AST > ALT)
- Carbohydrate-deficient transferrin (CDT): CDT
- Malnutrition and bone marrow damage:
- decreases folic acid, vitamin B12, vitamin B1, vitamin B6, vitamin D, vitamin K
- FBC - anaemia, thrombocytopenia, MCV
- U&E
Treatment for alcohol use disorder
- Psychosocial support for cessation of alcohol use (e.g. alcoholics anonymous or another support group)
- Pharmacotherapy to promote alcohol cessation
- Block positive effects of alcohol: Administer naltrexone (blocks release of endogenous opioids post alcohol) , acamprosate or topiramate
- Create toxic reaction when alcohol ingested: administer disulfiram
- Ongoing vitamin supplementation
* Vitamin B1, B6, B12, folic acid
Haloperidol may worsen respiratory depression secondary to alcohol intoxication
Alcohol withdrawal symptoms
Cessation in alcohol use that has been heavy and prolonged
2 or more of the following develop few hours to several days after cessation
- Autonomic activity (sweating or tachycardia)
- Increased hand tremor
- Insomnia
- Nausea or vomiting
- Transient visual, tactile or auditory hallucinations or illusions
- Psychomotor agitation
- Anxiety
- Generalize tonic clonic seizures (onset 6-48 hours after last drink, if left untreated, risk of delirium tremens)
Treatment for alcohol withdrawal
- Frequent monitoring
- Fluid therapy and correction of electrolytes disturbances
- Pharmacotherapy
- IV benzodiazepines for control of psychomotor agitation – diazepam, lorazepam
- Cease benzos after 5-7 days
- Anticonvulsants – carbamazepine
- Antipsychotics – haloperidol, risperidone
- IV vitamin B1 (thiamine) as prophylaxis of Wernicke’s encephalopathy and peripheral neuropathy
- Antiemetic’s
- Control blood pressure and severe vegetative side affects
- Naltrexone
- May commence while still drinking, Start with ½ tab for 4 days, then single tablet (50mg) od
- Blocks reinforcement of pleasure effect of drinking
- Blocks opioid receptors
- Generally low side effects – mild nausea, headache, anxiet
- Non-addictive, no withdrawal
- Acamprosate (Campral)
- May commence while still drinking
- Non addictive, no withdrawal
- Mechanism: Glutamate pathways (stimulates inhibitroy GABA-ergic NT in the brain and antagonized the effects of excitatory amina acids, such as glutamate)
- Disulfiram
- Must be minimum 5 days alcohol free
- Inhibits acetaldehyde dehydrogenase – nausea, flushing, dizziness, palpitations
- Motivated patient, compliance improved if dosing supervised, often by a partner
- Caution – coexisting significant medical conditions, potentially toxic to liver
- Baclofen
- A selective GABAb receptor agonist – hence inhibitory role in CNS neuronal excitation
- Reduced anxiety, reduced craving for alcohol
- NNT = 7ish, NNH = 7ish, Not registered for use in alcohol relapse prevention
How long do you prescribe for?
Long enough for sustained change to become usual behavior: Mood disorder improved, Cravings absent or diminished – sense of control, Sense of self – improved esteem, hopefulness, Relationships recovered
Min 4 months, maybe 12 or 24 months
What is Wernicke-Korsakoff syndrome?
Thiamine deficiency.
Wernicke’s encephalopathy
Acute and reversible biochemical damage to the CNS as a result of thiamine depletion
Triad of symptoms
- opthalmoplegia (ocular disturbances)
- Changes in mental state (confusion)
- Ataxic gait
85% untreated progress to irreversible Korsacoff’s
Maximum recovery takes 1 year of abstinence
Korsacoff syndrome
Acute onset of severe memory impairment without any dysfunction in intellectual abilities: a manifestation of Wernicke’s. Damage primarily in Thalamus and Mammillary bodies.
Symptoms:
- Anterograde amnesia
- Retrograde amnesia
- Confabulation
- Minimal content in conversations
- Lack on insight
- Apathy
Treat with IV Thiamine
Mortality 10% in severe cases
Dramatic increase in death from causes such as infection
Symptoms of opioid intoxication
Opioid intoxication
- Altered mental status
- Bilateral miosis (pinpoint pupils)
- Respiratory depression
- Seizures
- Decreased bowel sounds
- Decreased heart rate and blood pressure
- Rhabdomyolysis
Treatment
- Acute airway management
- Administer opioid receptor antagonist: IV naloxone
- Management of complications (diazepam for seizure)
Opioid withdrawal symptoms and treatment
Opioid withdrawal
- Flu-like symptoms: rhinorrhea, chills, myalgia, arthralgia, leg cramps
- GI complaints: nausea, vomiting, abdominal pain, diarrhea, hyperactive bowel sounds
- Features of sympathetic hyperactivity: mydriasis, tachycardia, hypertension, hyperreflexia
- Features of CNS stimulation: insomnia, yawning, irritability, anxiety, agitation
Withdrawal symptom management
- Clonidine – helps ameliorate sympathetic system overdrive
- Metoclopramide/ odansetron – releif of nausea
- Loperamide – relief of GIT hypermotility
- Buscopan – relief of abdominal cramps
- Sedative – ameliorate the anxiety, agitation and distress. Insomnia management
Treatment of opioid substance use disorder
Provide a substitute opioid
- Methadone – full opioid agonist
- Buprenorphine – partial opioid agonist
Block the reinforcing effects of continual opiate use
- Naltrexone – mu receptor antagonist
Psychotherapy
- Motivational interviewing
- CBT, education, AA, group therapy, peer support
Personal harms from benzodiazepine misuse
- OD
- Disinhibition (aggression, high risk sexual encounters, shoplifting)
- Cognitive and memory impairment
- Abnormal sleep pattern with rebound insomnia
Treatment of benzodiazepine misuse
- Transfer to equivalent dose of diazepam
- Longer acting agents promote stable levels
- Prevent cycles of intoxication and withdrawal
- Caution if equivalent dose > 30mg diazepam
- Use a treatment agreement contract
- Rate of reduction
- Plan for managing emergent symptoms
- Reduce dose every 1 to 2 weeks
- For daily pickup – from daily to weekly
- Regular review with frequent reassurance, alternative coping strategies, maintain patient alliance
DSM-5 Classification for anorexia nervosa
- Significant deliberate reduction in body mass using strategies that include restrictive eating, purging, and excessive exercise
- Fear of weight gain motivates compensatory behavior that promotes weight loss, even if the patient already has low body weight
- Body image disturbance:
- Excessive concern about weight and body shape, despite being considerably underweight
- Lack of awareness of the seriousness of low body weight
Signs and symptoms of anorexia nervosa
- CNS – hypothermia, cortical pseudoatrophy with enlargement of subarachnoid space
- Endocrine
- Stress hormones (cortisol , adrenaline)
- Thyroid – euthyroid sick syndrome
- Secondary amenorrhoea (severe weight loss suppress the hypothalamic-pituitary-gonadal axis - hypogonatotropic hypogonadism)
- Electrolyte abnormality – hypokalaemia
- Heart - Bradycardia, hypotension, cardiac arrhythmias
- Bones – secondary osteoporosis and stress fracture
- Skin and hair: dry skin, wound healing disorders, hair loss
- Salivary glands – sialadenosis with dystrophy
- Dental status – caries due to frequent vomiting
- Blood – pancytopenia
Investigations in anorexia nervosa
- Electrolyte imbalances: increased potassium, sodium, chloride, increased bicarbonate (metabolic alkalosis)
- Glucose decreased
- Liver enzymes: increased AST/ ALT
- proteins: hypoproteinemia, hypoalbuminemia
- Blood count: pancytopenia
- TFTs
- ECG
- Bone density scan
Treatment of anorexia nervosa
Psychotherapy (first line)
- Cognitive Behavioral therapy
- Psychodynamic psychotherapy
Nutritional support
- Monitor weight gain and provide nutritional support; usually through oral intake
- Indications for hospitalization
- <70% ideal body weight or BMI < 15kg/m^2
- unstable vital signs - hypothermia (<35.5), bradycardia (<40bpm), hypotension or symptoms of lightheadedness
- acute medical complications (syncope, seizures, pancreatitis, liver failure)
- arrhythmia
- hypoglycaemia
- electrolyte disturbances
- severe refeeding syndrome
DSM-5 criteria for bulimia nervosa
All 5 criteria must be met:
- Binge eating
- Recurrent compulsive compensatory behavior to counteract weight gain
- Most frequently: self-induced vomiting after binge eating
- Laxative abuse
- Transient starvation periods
- Other weight loss measures
- Binge eating and inappropriate compensatory behavior both occur at least once a a week over a 3-month period
- Sense of self-worth pathologically influenced by perception of physical appearance (body weight and shape)
- Symptoms do not exclusively occur during an episode of anorexia nervosa
Complications of bulimia nervoa
Gastrointestinal tract
- Esophagitis and/or gastritis
- Poor dental status (e.g. perimylolysis)
- Salivary gland swelling (parotitis)
Metabolic imbalances
- ¯ potassium, ¯ sodium, ¯chlorine and ¯calcium
- blood pH
Skin
- Calluses on the knuckles (Russell’s sign)
- Dry skin and brittle nails
Cardiovascular symptoms
- Cardiac arrhythmias
- Hypotension
DSM-5 criteria for gender dysphoria in adults
An incongruence between a person’s experienced/ expressed gender and assigned gender over a period of at least 6 months, as manifested in >=2 of the following:
- Incongruence between one’s experienced/ expressed gender and primary and/ or secondary sex characteristics
- Strong desire to be rid of one’s primary and/ or secondary characteristics of the other gender
- Strong desire to the other gender
- Strong desire to be treated as the other gender
- Strong conviction that one has feelings and behaviors more typical of the other gender
+ clinically significant distress/ impairment in function
DSM-5 criteria for genito-pelvic pain/ penetration disorder
- Persistent or recurrent difficulty with >= 1 of the criteria below in women over a minimum period of 6 months:
- Vaginal penetration during sexual intercourse
- Severe vulvovaginal pain during vaginal intercourse or attempted penetration
- Severe anticipatory anxiety related to vulvovaginal or pelvic pain during attempted vaginal intercourse or attempted penetration
- Severe tightening of pelvic floor muscles during attempted vaginal penetration
- Causes significant distress to the individual
- Is not attributable to another mental illness, substance, significant relationship distress, or medical conditions
Treatment of penetration disorder
- Pelvic floor physical therapy: considered best initial treatment option
* Consists of a combination of modalities, as internal manual techniques, patient education, dilatation exercises, local tissue desensitization, and home exercises - Anxiolytic drugs – opioids, antidepressants, benzodiazepines
- Local botox injections for refractory cases
Erectile dysfunction causes
Organic
- Vascular – HTN, DM, CVD, hyperlipidemia
- Neurogenic – stroke, brain or spinal cord injury, dementia, Parkinson disease, multiple sclerosis
- Endocrine – hypogonadism, hyperprolactinemia, thyroid disorder
- Medications:
- Antihypertensives (beta-blockers, thiazide diuretics)
- Antidepressants (SSRIs)
- Dopamine agonists (antipsychotics)
- Iatrogenic – radical prostatectomy, pelvic radiation
- Trauma – pelvic fracture and urethral injury
- Alcohol abuse
Psychiatric
- Depression
- Anxiety (performance related)
- Trauma from prior experience
- Relationship issues
- Stress
DSM-5 criteria for erectile dysfunction
Treatment of erectile dysfunction
- Psychotherapy
- Counselling
- Sensate focus exercises for performance anxiety
- Medical therapy
- Phosphodiesterase-5 inhibitors – sildenafil, tadalafil
* Contraindicated in patients taking nitrates due to profound hypotension - Testosterone replacement if hypogonadism
- Intracavernous injection therapy with papaverine or alprostadil
- Mechanical
- Vacuum pump with penis ring
- Surgical
- Implantation of penile prosthesis – last resort
DSM-5 18 core items of ADHD classification
Presenting with 6 months or more of the following symptoms:
DSM 18 items (core phenotype)
- 9 inattentions (6 out of 9 items)
- Careless mistakes in schoolwork
- Sustain attention difficult
- Does not listen
- Not follow-through on instructions and fails to finish schoolwork
- Disorganized
- Avoid tasks that require mental effort
- Loses things
- Distracted by external stimuli
- Forgetful in doing daily activities e.g. chores
- 9 hyperactivity and impulsivity (6 out of 9 items)
- Fidgets
- Leaves seat when sitting expected
- Runs around or climbs in inappropriate situations
- Noisy – cant engage in activities quietly
- ‘on the go’ e.g. uncomfortable being still for extended time
- Talks excessively
- Blurts out answer before question completed
- Can’t wait e.g. in line
- Interrupt or intrudes other
- Several inattentive or hyperactive-impulse symptoms were present before 12 years of age
- Several symptoms present in two or more setting (home, school, work; friends; family; other activities)
- Symptoms interfere with, or reduce the quality of, social, academic or occupational functioning
- Symptoms don’t occur exclusively during a psychotic disorder, and are not better explained by another mental disorder e.g. mood, anxiety, dissociative, personality, substances)
Can be:
- ADHD predominantly inattentive (If inattention >= 6 out of 9)
- ADHD predominantly hyperactive/ impulsive (If hyperactivity >= 6 out of 9)
- ADHD combines (If both criteria >=6 out of 9)
In ADHD: Comborbidities is the norm, what are some differentials or comorbidities to screen for?
Either differentials, or comorbidity of:
- Learning disorder e,g, dyslexia
- IQ test, speech and language assessment, and also school attainment tests
- Language disorder
- Developmental coordination disorder
- Anxiety disorder, depression
- Autism Spectrum Disorder (ADI, ADOS)
- Tourette disorder and tic disorder
- OCD
- Oppositional defiant disorder
- Conduct disorder
Medical
- Hearing, vision problems
- Sleep, pain
- Foetal alcohol spectrum disorder
- Hyper/ Hypothyroidism
- PMS
DSM-5 Classification of Autism Spectrum Disorder
- Persistent deficits in social communication and social interaction across multiple contexts
- Deficits in social-emotional reciprocity, ranging, for example from abnormal social approach and failure of normal back and forth conversation; to failure to initiate interactions
- Deficits in nonverbal communication e.g. eye contact and body language
- Deficits in developing, maintaining and understanding relationships
- Restricted, repetitive patterns of behavior, interests or activities
- Stereotyped or repetitive motor movements, use of objects or speech
- Insistence on sameness, inflexible adherence to routines
- Highly restricted, fixated interests abnormal in intensity or focus
- Hyper- or hypo reactivity to sensory input or unusual interest in sensory aspects to environment
- Symptoms must be present in the early development period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learning strategies in later life)
- Symptoms cause clinically significant impairment in social, occupational or other important areas of current functioning
- These disturbances are not better explained by intellectual disability or global developmental delay. Intellectual disability and autism spectrum disorder frequent co-occur
Specify:
- With or without accompanying intellectual impairment
- With or without accompanying language impairment
- Associated with a known medical or genetic condition or environmental factor
- Associated with another neurodevelopmental, mental, or behavioral disorder
- With catatonia
Severity levels:
- Level 1 – Requiring support
- Level 2 – Requiring substantial support
- Level 3 – Requiring very substantial support
Treatment of ADHD
First-line treatment:
- Methylphenidate [Ritalin] (lower seizure threshold)
- Treatment for patients > 6yo, 5mg BD
- Dexamphetamine (epileptic subjects, non-responders)
- 5mg BD
Common side effects of stimulants: Increased BP, tachycardia, insomnia, dry mouth, sweating, headache, loss of appetite, nervousness, moodiness, tearfulness, stomach ache. Often short-lived and subside after 1-2 weeks. Rarer: hallucinations, mania, tics.
Second-line treatment:
- Atomoxetine 80mg-100mg
- start 20mg, then increase every 5/7 (20/7) and wait for 4/52 for response. Response rate: 1/3. s/e nausea, dry mouth, agitation, vivid dreams. Useful for anxious, panicky individuals
Treatment of Autism Spectrum Disorder
- Early behavior and educational management
- Competence training: social skills, communication skills
- Establishing clear and consistent structures
- Family support and counseling: e.g. parental education on interaction with the child and acceptance of his/her behavior
- Medical treatment
- SSRIs – repetitive stereotyped behavior, anxiety
- Antipsychotic drugs – aggression, self-injury
- Methylphenidate – ADHD
What is a conduct disorder
A repetitive persistent pattern of disruptive behavior for >= 12 months that violates basic rights of others or age-appropriate societal norms or rules.
DSM-5
- Aggression to people and animals
- Destruction of property
- Deceitfulness or theft
- Serious rule violation
- The disturbance in behavior significantly impairs social, academic, and/ or occupational functioning
Causes of Learning disabilities
Specific learning difficulties without generalized cognitive impairment
- Dyslexia
- Dyscalculia
- ADHD
- Specific language impairment
- Central auditory processing disorder
- Developmental co-ordination disorder/ dyspraxia
Genetic disorders
- Down Syndrome
* Chromosomal karyotype - Fragile X syndrome
- Learning and communication difficulties, hyperactivity and attention deficit, moto co-ordinaiton diffirulties
- DNA testing – fragile site on Xp27.3
- Tuberous sclerosis
- Seizures, variable cognitive impaitment, FHx, HTN, cardiac arrhythmia
- DNA test, CT brain
- Prader-Willi syndrome
- Turner Syndrome
- Autism spectrum disorder
Intra-uterine causes
- Intra-uterine Infections
* Rubella, toxoplasmosis, CMV - Fetal alcohol syndrome
- Teratogenic drugs
Perinatal causes
- Prematurity
- Perinatal hypoxia
CNS
- Bacterial meningitis
- Tumour
- Traumatic brain injury
- Hypoxia/ asphyxia
- Seizures
Endocrine
- Hypothyroidism
- Inborn errors of metabolism
Steps in a management plan for psychiatric patients
- Consider the context of the situation– Where to manage the patient? What is your role?
- Acute risk management
- Diagnostic clarification
- Management of acute symptoms - for each primary condition (Pharm and psychological)
- Psychosocial and other contributory factors
- Long term rehabilitation (Pharm and psychological)
Diagnostic clarification comprises of: History, MSE, physical examination and investigations. What investigations would you order and why?
- FBC
- Anemia can mimic depression
- Some drugs cause decreased WCC
- Infection can mimic delirium
- UEC
- Drugs metabolized by kidneys (if initiating drugs or if required for monitoring effects on kidney e.g. lithium)
- Hyponatramia can mimic depression
- LFTs
- Drugs metabolized by liver (e.g. if initiating drugs or if required for monitoring effects on liver e.g. anticonvulsants can cause deranged (increased) LFTs)
- Alcoholism/ cirrhosis
- TFTs – Increased can mimic anxiety, mania, irritability, decreased can mimic depression
- Drug levels (lithium, valproate for indications of compliance, toxicity, therapeutic range)
- bHCG – pregnancy
- Fasting BSL and fasting lipids – metabolic syndrome can be caused by drugs
- B12, folate – deficiency mimics depression, dementia, delirium
- Ca, Mg – parathyroid problems can mimic depression, delirium, psychosis, anxiety
- HSV, syphilis, hepatitis, HIV, Chlamydia/ Gonorrhea PCR – esp. IVDU patients
- Urine
- MCS – for UTI in older people – delirium
- Toxicology e.g. opiates, speed
- Imaging for patients with first episode psychosis and delirium
1. CT head to exclude SOL, SDH, atrophy - ECG – for possible drug side effects (cardiotoxic medications)
- EEG – temporal lobe encephalopathy (Wernicke’s encephalopathy), CJD, seizures (temporal lobe epilepsy)
Antidepressant classes, side effects, examples
*Note: all take 2-4 weeks to take effect
SSRI’s
- Sertraline (Zoloft) [50mg initial dose] , Citalopram, escitalopram (prosac) [10mg initial dose] , fluoxetine
- Increases extracellular seritonin by blocking reabsorption in the presynaptic cell
- Side effects:
- GI (N+V), Sexual (loss libido, ED), Weight gain, CNS (Insomnia, anxiety)
- Seretonin Syndrome, discontinue syndrome
SNRI’s
- Venlafaxine (Effexor) [37.5mg BD] Duloxetine
- Reversible, negative allosteric blocking of SERT and NA transporter on nerve terminals
- Side effects - same as SSRI’s (Except seretonin syndrome)
NaSSA (NA-serotonin specific antidepressant)
- Mirtazapine [15mg OD bedtime]
- Antagonism of inhibitory presynaptic alpha2-adrenoceptor on NA and 5-HT nerve terminals
- Side effects - dry mouth, consitpaiton, increased appetite, weight gain
Antipsychotic medications
Typical Antipsychotics
- Haloperidol [0.5-2mg orally 2-3 times a day for moderate], Chlorpromazine
- Block dopamine D2 receptor, hence they reduce dopaminergic neurotransmission in the four dopamine pathways (mesocortical pathway, mesolimbic pathway, nigrostriatal pathway, tuberoinfundibular pathway).
- Mesolimbic pathway - the dopamine theory postulates that positive symptoms such as delusions, hallucinations and thought disorder might be caused by an over activity of this pathway.
- Mesocortical pathway - part of the neurobiology of negative and cognitive symptoms.
- Note: Can worsen parkinson symptoms (nigrostriatal pathway)
- Side effects: Dry mouth, muscle stiffness, cramping, tremor, weight gain
- Adverse effects: Extrapyramidal symptoms (acute dyskinesia, parkinsonism, akathisia), QT prolongation, Neuroleptic malignant symdrome
Atypical Antipsychotics
- Olanzapine (metabolic syndrome + weight gain)
- Risperidone (postural hypotension)
- Clozapine (Agranulocytosis)
- Apiprazole (partial agonist)
- Quetiapine (sedation)
- MOA:
- All antipsychotics reduce dopaminergic neurotransmission.
Second generation antipsychotics have additional properties:
* 5-HT<sub>2A</sub> antagonism * some have 5-HT<sub>1A</sub> agonism * fast dissociation * 5HT2A antagonism can increase dopaminergic neurotransmission in the nigrostriatal pathway, reducing the risk of extrapyramidal symptoms. It could also theoretically improve negative and cognitive symptoms in schizophrenia by increasing dopamine release in the prefrontal cortex. * 5HT1A agonism would increase dopamine release in the prefrontal cortex and also reduce glutamate release.
- Apiprazole MOA:
- Aripiprazole is a partial agonist at D2 receptors.
- It may act as an antipsychotic by:
- Lowering dopaminergic neurotransmission in the mesolimbic pathway.
- Enhancing dopaminergic activity in the mesocortical pathway.
- It has a lower risk of EPS and hyperprolactinemia than other antipsychotics.
- Adverse effects
- Weight gain, metabolic syndrome, sedation, anticholinergic
- Lower rate of Extrapyramidal symptoms (Dyskinesia, akathisia, parkinsonism)
Mood stablizing drugs
- Lithium
- SE - GI (N+V), Neuro (tremor, headahce, vertigo), T wave inversion
- monitor - kidney function, thyroid, parathyroid, electrolytes
- Sodium Valproate
- Blockage of voltage dependent NA channels and increased levels of GABA
- SE - weight gain, N+V, drowsiness. Contraindicated in young females that can get pregnant
Benzodiazepines
- Diazepam (Valium) - 2-10mg 2-4 times per day
- Lorazepam, Midazolam, Clonazepam
- MOA - Enhance the effect of GABA at the GABA(A) receptor
- Indicated in anxiety, alcohol withdrawal
- Adverse effects - Parodoxical insomnia, restlessness, hyperexcitability. Dependence.
What is seritonin syndrome
A drug-related complication resulting from increased brain-stem serotonin activity, usually precipitated by the use of one or more serotonergic drugs:
- SSRI, SNRI, MAOI, Amphetamines, Metoclopramide, Odansetron, opioids, CNS stimulants
Symptoms
- Cognitive effects – headache, agitation, hypomania, mental confusion, hallucinations, coma
- Autonomic effects – shivering, sweating, hyperthermia, vasoconstriction, tachycardia, nausea, diarrhea, hypertension
- Somatic effects – myoclonus, hyperreflexia, clonus, tremor
Management
Discontinue serotonergic drugs immediately
Supportive care
- Antihypertensive, fluid replacement
- Benzodiazepines for sedation
- Cyproheptadine – 5-HT receptor antagonist – used for cases of serotonin syndrome that do not respond to supportive care.
- Cooling measures – ice packs, cold compress
What is neuroleptic maignant syndrome
Life threatening neurological disorder usually associated with antipsychotics. Blockade of dopamine receptor D2 leading to abnormal function of the basal ganglia and muscular symptoms. Atypical antipsychotics also affect serotonin, GABA and glutamate worsening the syndrome.
Symptoms
- F - fever
- E - encephalopathy (altered mental state)
- V - Vitals unstable (autonomic instability)
- E - Elevated enzymes - CK –> rhabdomyalosis
- R - Rigidity of muscles
Investigations
- CK increased, myoglobulinuria (rhabdo)
- Leukocytosis, increased transaminases
- Metabolic acidosis
Treatment
- discontinue antipsychotic
- Dantrolene (ryanodine receptor antagonist)
*
What is anticholinergic syndrome?
Inhibition of cholinergic neurotransmitters at muscarinic receptor sites following ingestion of certain medications:
- Anti-histamines
- Anti-Parkinson’s
- Atropine
- Anti-spasmodic
- Skeletal muscle relaxants
Symptoms
- Flushing, dry skin
- Mydriasis
- Altered mental state
- Fever
- Tachycardia and HTN
- Myoclonic jerking
- Urinary retention
- Dysrhythmias
- seizures
Antidepressant Discontinuation Syndrome definition
Symptoms that occur post rapid discontinuation of SSRIs or SNRIs
- Flue like illness
- Insomnia
- Nausea
- Imbalance
- Sensory disturbance
- Hyperarousal
What are the components of Cognitive Behavioural Therapy
CBT can be used for anxiety or depression. It aims to help a person identify and challenge unhelpful thoughts and to learn practical self-help strategies.
These strategies are designed to bring about positive and immediate changes in the person’s quality of life. CBT aims to show people how their thinking affects their mood and to teach them to think in a less negative way about life and themselves. It is based on the understanding that thinking negatively is a habit that, like any other habit, can be broken.
Motivational Interveiwing - Stages of change
Describe ECT
- Whilst under general anaesthesia (e.g. propofol) and a musclerelaxant (e.g. suxamethonium),electrodes placed on patient’s head and an electrical impulse is passed through the braincontinuously and this induces a generalised convulsive seizure. Therapeutic response iscorrelated with total seizure time. [from “psychiatry made ridiculously simple” book]
- Most troublesome S/E is short- term memory loss (hours to days) Other S/E: anaesthetics risk, headaches, myalgia
- Contraindications: increased ICP
- Indications
- Acute management of cases where the patient is not eating or drinking, or imminently suicidal < >Severe depression (especially melancholic) < >Catatonic schizophrenia < >Severe depression during pregnancy
What is Dialectical Behavioural therapy
Dialectical behaviour therapy (DBT) is a modified version of cognitive-behavioural therapy (CBT) designed to treat borderline personality disorder (BPD). It can also be used to treat other conditions, like suicidal behaviour, self-harm, substance use, post-traumatic stress disorder (PTSD), depression and eating disorders.
The term ‘dialectical’ means ‘working with opposites’. DBT uses seemingly opposing strategies of ‘acceptance’ and ‘change’. The therapist accepts you just as you are, but acknowledges the need for change in order for you to recover, move forward and reach your personal goals.
During a course of DBT, the therapist works with you to help you move away from a chaotic life and towards a life that you find personally meaningful and fulfilling.
DBT involves developing two sets of acceptance-oriented skills and two sets of change-oriented skills.
- Acceptance-oriented skills
- Mindfulness
* Focus your awareness on the present moment, acknowledge your thoughts, feelings, behaviors and bodily sensations - Distress tolerance
* Learn how to manage and cope during a crisis, and to tolerate distress when it is difficult or impossible to change situation - Change-oriented skills
- Emotional regulation
* Learning how to effectively manage your emotional experience, and not allow your emotions to manage you - Interpersonal effectiveness
* Learning assertiveness strategies to appropriately ask for what you want or need
Form 1a is a referral for examination by psychiatrist. Explain the criteria for inpatient treatment (all of which must be met) and its duration
Criteria for an inpatient treatment:
- The person has a mental illness requiring treatment
- Because of the mental illness there is a significant risk fo the health or safety of the person or to the safety of another person, or a significant or serious harm to the person or to another person
- the person does not demonstrate the capacity to make a decision about provision of treatment
- treatment in the community cannot reasonabily be provided to the person
- there is no alternative that would be less restrictive to the persons freedom of choice and mocement
Duration: referral must be made within 48 hours, referral remains in force for 72 hours
