Psychiatry Flashcards
Anti-psychotics side effects
Extra pyramidal side-effects Hyperprolactinaemia Metabolic Anticholinergic Seizures VTE and/in the elderly Neuroleptic malignant syndrome Arrhythmias bracket (haloperidol Prolonged QT interval)
Typical versus atypical antipsychotics
Typical = Dopamine antagonists non-selective
Chlorpromazine, Haloperidol, Flupentixol Decanoate
- Cheap, effective
- EPSE’s greater and difficult to reverse
Typical equals more selective dopamine antagonists and other chemical messengers e.g. serotonin
Quetiapine, aripiprazole, Risperidone, Olanzapine, Amisulprimide
- Less EPSEs
- Greater metabolic side effects - but more reversible
Effects of dopamine in schizophrenia
Excess dopamine in the Mesolimbic pathways equals positive symptoms
Reduced dopamine in the mesocortical pathways equals negative symptoms
Clozapine side effects
Monitoring (bloods?)
Same as other antipsychotics but additionally Annulus psychosis granulocytosis Seizures Myocarditis Lacrimation Sedation Postural hypotension (when giving)
STOPPING SMOKING INCREASES CLOZAPINE LEVELS
Weekly for 18 weeks
Fortnightly for the rest of the year
Monthly
Features of substance dependency
What is substance misuse
Tolerance Dependency Compulsions Salience Narrowing of repertoire Constant use despite home Difficult controlling use Reinstatement
Misuse = Pattern of use causing psychological/physical dame
Alcohol units
10 in a bottle of wine
Three in a glass of wine
Three in a pint
40 in a bottle of spirits
Delirium tremens presents
Management
72 HOURS INTO ABSTINENCE. DT = Day Three
= life threatening
[1] Mental - Tactile and visual hallucinations (typically feeling bugs crawling on skin and seeing young men) - Confusion - Disorientation - Paranoia [2] Neurological - Seizures - Cerebellar signs (DANISH: ataxia, decreased coordination etc) - Severe vomiting [3] Cardiovascular - Tachycardia (most sensitive sign) - Unstable blood pressure
Management Benzo (short acting) e.g. lorazepine reducine regime \+ Parenteral thiamine \+ Admit \+ Fluids + electrolytes
CIWA to assess severity of withdrawal symptoms
Wernicke vs Korsakoff
Werknick's encephalopathy = COAT Confusion Opthalmoplgia Ataxia Thiamine required to REVERSE
Korsakoff syndrome = RACK Retrogrades amnesia Anterograde amnesia Confabulation Korsakoff IRREVERSIBLE
Alcohol side effects
BIOLOGICAL
Liver: Hepatitis, cirrhosis –> ascites, hepatic encephalopathy
GI: Pancreatitis, oesophageal varices, peptic ulcers
Neuro: Peripheral neuropathy, seizures, dementia
Cancers: Bowel, breast, liver
CVS: HTN and cardiomyoptahy
Head injur: Risk of subdural haematoma
Fetal alcohol syndrome
PSYCHOLOGICAL
Depression, anxiety, self harm, suicide risk
Amnesia (blackouts)
Cognitive impairment (Korsakoff syndrome)
Alcoholic hallucinations
SOCIAL
Unemployment, poor performance/attendance at work
Domestic violence, separation, divorce
Children have increased risk of neglect/abuse/conduct disorder
Investigations for alcohol
Management for alcohol (specifics)
AUDIT = dependency
CIWA-AR tool = dependency
FBC, LFTs, UDS, hepatitis screen (IVDU)
Referral to drugs and substance miss use clinic. Involve partner/family
- Assess and repair: motivation to change and motivational interviewing
- Detox
- Relapse prevention
- Rehabilitation
Detox
- Pabrinex (give in GP too)
- Long acting benzo (Chlordiazepoxide)
- In patient if : Dependent at home, previous failed, withdrawal fits, comorbid psych/medical illness
Relapse prevention
- Psychological = CBT, group therapy,
- Medical = Disulfiram (blocks aldehyde dehydrogenase); Acamprosate (Enhances GABA transmission –> reduces cravings); Naltrexone (Blocks Opiod receptors –> reduces cravings)
- Social = Alcoholics anonymous, day programmes, groups
Opiates
Examples
Intoxication presentation
Withdraw presentation
Heroin (diamorphine, brown, smack, H), dihydrocodeine, morphine, pethidine, codeine
Act on receptors on brain and spinal cord that are normally acted on by endogenous endorphins (brains natural pain killers)
Intoxication = ARMED C Analgesia Respiratory + CNS depression --> seizures + death Miosis Euphoria Drowsy Constipation
Withdrawal = AFTER 6 HOURS of Abstinence
Everything runs: diarrhoea, nausea and vomiting, lacrimation, rhinorrhoea
Flu like symptoms: fever stomach cramps aching joints
Call turkey: Sweating Dilated Peoples, piloerection
Dysphoria, insomnia, agitation, yawning
IV drug use complications
Local
- Abscess
- Cellulitis
- DVT
- Emboli
Systemic
- Septicaemia
- Infective endocarditis
- Blood borne infections
- Increased risk of overdose
Opiates management
Overdose = NALOXONE
Referral to drugs and substance miss use clinic. Involve partner/family
- Assess and repair: motivation to change and motivational interviewing
- Detox
- Relapse prevention
- Rehabilitation
HARM REDUCTION - advise on needles, vaccination, testing for infection, free condoms, GUM clinic. FBC, LFTs, GUM.
Detox (12 wks in community or 4 in hospital)
- Methadone (full agonist) or Burepronorphine (partial agonist)
+ Adjuncts:
- Loperamide
- Metoclopramide
- Non-opiate pain killers
Relapse prevention
- Can use naltrexone (opiate antagonist)
Rehab
- SMART recovery, narcotics anonymous
Opiate effects in pregnancy
Low birth weight IUGR Premature SIDS Neonatal abstinence syndrome Developmental delay
Management
- Methadone maintenance
Sedatives
Examples
Uses
Intoxication + Withdrawal picture
Increase inhibitory Effect of GABA
Uses - Sedation - hypnotic - anxiolytic - anticonvulsants - muscle relaxant MAX 2-4 WEEKS
Intoxication
- Sedation
- Slurred speech
- Ataxia
- Stupor
- Coma
Withdrwal
- Just like alcohol.
- Withdraw by 1/8 every fortnight to prevent withdrawa syndrome = Insomnia, irritable, anxiety, tremor, loss off appetite, tinnitus, perspiration, perceptual disturbances, seizures
UDS lengths it can detect drugs for
Heroine (2d) Amphetamine (2d) Cocaine (5-7d) Methadone (7d) Cannabis (up to 1month)
Stimulants
MOA
Examples
Intoxication
Withdrawal
MOA: Potentiate effects of neurotransmitters DA, NA, 5HT
Cocaine, amphetamines, MDMA
Intoxication
- Euphoria, less sleep needed, risky behaviour
- Arrythmias, HTN, stroke
- Anxiety, panic, psychosis
Withdrawal
- Depression, lethargy
Rx: HARM REDUCTION - short term benzo for anxiety
Cocaine - formication
Ecstasy - chatty, empathy, closeness, withdrawal = lethargy
Cocaine in pregnancy
Teratogenic IUGR PLACENTA abruption + vasa praevia Preterm Stillborn SIDS
Cannabis
THC acts on receptors in the brain
Intoxication
- Relaxation, euphoria –> anxiety, paranoia, panic
- Perceptual disturbance (slows down time), hunger, N&V, dry mouth, tachy
Withdrawal
- Nothing specific
Complications
- Psychosis, schizophrenia
- Smoking, Ca if smoking
In pregnancy - IUGR, tobacco use
Hx for substance use
TRAP
- Type
- Route
- Amount
- Pattern
Dependency symptoms
- Compulsions
- Tolerance
- Salience
- Withdrawal symptoms
- Narrowing of repertoire
- Re-instatement
- Use despite harm
Past use
- Current substance
- Other substances
Future use
- “what are you worried about”
Frontotemporal dementia
Asymmetric frontal/anterior temporal lobe atrophy
40-60yos; sporadic; death in 5-10yrs
Disinhibition, inattention, antisocial, personality changes, apathy, akinesia, withdrawal, memory loss and disorientation
LOSE INSIGHT EARLY
3 types:
1) Frontotemporal dementia: Promnent disinhibition and personality change
2) Semantic dementia: progressive loss of understanding of verbal and visual meaning
3) progressive non-fluent aphasia: naming difficulties –> mutism
Picks disease = accumulation of Pick bodies (hyperphosphorylated Tau) in substantia nira
HIV dementia
In 10% of HIV patients
Direct effect of virus on brain
Years after infection
- Cognitive function
- Energy and libido
- Incontinence and ataxia
MRI: Diagnostic - atrophy and diffuse white matter signal change
Huntington’s disease
CAG repeat in huntington gene (Chr 4) depositis of Huntington protein, atrophy of basal ganglia and thalamus, mostly frontal (ATROPHY OF CAUDATE NUCLEUS)
Mid adulthood, AD, anticipation :(
Personality and behaviour changes Mood (depression, irritability, euphoria) Subcortical dementia (late onset) Chorea Wide based gait Seuzyres Insight maintained in early years
Dx: Clinical, MRI: caudate nucleus atrophy, EEG: flat, genetic testing
Supportive management, death within 15yrs
Delerium
Risk factors
Acute and transient state of global brain dysfunction with clouding of consicousness
Sudden onset with fluctation throughout the day
Disorientated, poor attention and short term memorhy
Mood changes may dominate
Illusions/hallucinations common (visual usually)
Speech/sleep disturbance
Behavioural changes: Either hyperactive or hypoactive
Risk factors
- Old age
- Pre-existing physical/mental health illness (esp dementia)
- Subtance misuse
- Polypharmacy
Must check PAIN FLUID INTAKE CONSTIPATION URINARY RETENTION
Delirium aetiology
Investigations
Trauma (head) Hypoxia Infective Metabolic Endocrine (hypoglycaemia) Nutritional (Wenickes) CNS pathology Drugs and alcohol Medication e.g. anticholinergics, opiates
Physical exam. Check medications UDS Bloods: FBC, U&Es, glucose, LFTs, Ca CVS/RS: SaO2, CXR, ECG Septic screen Consider imaging, blood cultures, CSF etc.
Delirium management
TREAT CAUSE
- Avoid constipation, urinary retention, dehydration and pain
Tell them who they are, who you are, where they are. Involve family/friends
Behavioural management
- Reorientate - clocks, calendars, lighting
- Sensory problems - glasses, hearing aids
- Minimise changes + calm environent
Involve family and friends, tell
Med
- Small nocturnal benzodiazepine MAY promote sleep and help correct sleep-wake cycle
- If distressed, a risk to others or self AND DE-ESCALATION NOT WORKED - short term <1 week) haloperidol
Consider referral to psych or old age
Prevention
- Good sleep, as above, minimal moves in hospital
Some pts never return to pre-morbid level - can take weeks/months
Higher mortality
Longer admissions
Higher re-admission rates
Dementia
General picture
Acquired, chronic progressive cognitive impairment impacting on ADLs
- normal consciousness
- > 6months!
Beginning - forgetful and anxiety/depressiom Then disorientation in order - Time - Place - Person Towards the end - Unable to carry out ADL - Thinking and language impoverished - Mood and personality severely affected
Dementia
Aetiology
Pathology
Acquired, chronic progressive cognitive impairment impacting on ADLs
- normal consciousness
- > 6months!
Aetiology
Age, female
Genetic mutations: PSEN 1/2 And APP and trisomy 21
Asking factors
Low IQ
Head injury: CTE (American football, boxing)
Pathology
- Widespread cortical atrophy
- beta-amyloid plaques
- Neurofibrillary tangles of town
- Cerebral amyloid angiopathy
- Loss of cholinergic neurons
Alzheimer’s key features + management
Amnesia: recent memories first memories
Aphasia: word finding problems
Apraxia: difficulty with coordinating tasks e.g. dressing
Management
Memory clinic referral
ACh esterase inhibitors
– Donepazil: reversible
– Rivastigmine: Short half life of April as patch
– Galantamine: Like donepazil but extra actions
NMDAR inhibitors
– Memantine: Used for mod/severe Alzheimer;s
PSYCHO SOCIAL
HIPPOCAMPAL ATROPHY
Vascular dementia presentation
Management
Stepwise progression with each infarct
- Patchy if various patches e.g. personality/areas of cognition spared
- Neuro signs e.g. hemiparesis (contralateral motor cortex infarct) or aphasia (receptive - Wernicke’s; expressive - Broca/s)
LACUNAR LESIONS
Death in 5yrs due to IHD/stroke
DO NOT USE DEMENTIA DRUGS
- Statins
- Anti-hypertensives
- Smoking + weight advise
- Aspirin
- Clopidogrel
- Warfarin
- Diabetes meds
PSYCHO SOCIAL
Lewy body dementia
Lewy bodies (composed on alpha synuclein and ubiquitin)
- In PD: In substantia nigra –> motor symptoms
- In LBD: In cyngulate gyrus and neocortes –> dementia
1) FLUCTUATING confusion with marked changes in alertness
- easy to confuse with delerium but cannot start haloperidol due to extreme neuroleptic sensitivity in LBD
2) Vivid visual hallucinations
3) Spontaneous parkinsonian signs
Anti-cholinesterase drugs side effects
Donepazil, Rivastimine if MMSE >12/30
SE: S alivation L acrimation U rinary inc D efacation G I upset E mesis
MS
Inflammation and demyelination at different sites/times within CNS white matter tracts
RELAPSING AND REMITTING
Triad
1) Scanning speech
2) Intention tremor/Incontinence/Internuclear opthalmoplegia
3) Nystagmus
50% have depression and mania is common
Treat as primary depression
Anxiety symptoms
Psychological – Fears and worries – poor concentration – irritability – insomnia
Motor symptoms
– restless and fidgety
– on edge
Neuromuscular Headaches – muscle aches – trauma – dizzy – Tinnitus
GI – dry mouth swallowing difficulty – nausea – butterflies - Flatulence – frequent or loose nations
CVS
– chest discomfort
– palpitations
Respiratory
– difficulty breathing
– tight chest
Genitourinary
– urinary frequency
– erectile dysfunction
– amenorrhoea
OCD diagnosis
> /= 1hr/day of symptoms
or
Interfering with life
Obsessions = Recurrent intrusive thoughts despite resistance. KNOWS irrational and their own
Compulsions = repeated, serotyped behaviour an seemingly purposeless
- May have no link to obsession
Do the Yale brown obsessive compulsive compulsive scale
Panic disorder diagnosis
Intermittent out of the blue
Sudden and extreme panic attacks. 4 or more of:
- Sweating
- Trembling
- Palpitations
- Chest pain
- SOB feeling
- Choking feeling
- Nausea or abdo distress
- Dizzy/lightheaded
- Fear of losing control or going crazy
- Fear of dying
- Numbness or tingling
- Chills or hot flushes
Dx:
Recurrent unexpected panic attacks
At least 1 attack followed by 1 month or more of of 1 or omore of:
- Persistent Worry about having another attack
– worry about the attack consequences
– significant change in behaviour related to the attacks
Agoraphobia
20-30yos
Core fear: Open spaces, away from ‘safe space’, fear of not being able to leave situations
MUST BE 2 situations. >/= 6 months
e. g.
- Travelling
- Supermarkets
- Large crowds
- Parks
Social phobia
Late teens. Male=Female
Core fear: Scrutiny by others and embarrassed in public.
Large crowds usually ok but not small events e.g. dinner parties
Sometimes specific problems e.g. eating/ fear of embarrassing symptoms
PTSD
Management
Hyperarousal - can’t relax, hypervigilant, insomnia, poor conc
Re-experiencing - flashbacks, nightmares, intrusive mems
Avoidance - Avoiding reminders of the event
Decreased interests and powerful emotions
Co-morbidities
- Depression and anxiety
- Alcohol use
Active monitoring for 1 month
Trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then paroxetine or mirtazapine are recommended
Depression
Aetiology
Core symptoms:
Low mood
Anhedonia
Anergia
At least 2 for 2 weeks
Becks model of depression:
- worthless, helpless, hopeless
- Self, world, future
Cognitive symptoms
- Guilt, pessimistic
- Poor concentration and memory
- Thinking may feel slowed
Biological symptoms
- Sleep altered: insomnia, early waking (2h before)
- Appetite for food and sex suppressed –> weight loss and relationship strain
- Physical symptoms of constipation, aches, pains may occur
Psychotic symptoms (if severe)
- Auditory hallucinations (derogatory) or rarely visual
- Nihilistic delusions - rotting, guilt themes etc.
- Guilt can progress to delusion, believing they have committed a crime
Depression
Aetiology
Hypothesis
Physical illness: Cushings, hypothyroid, MS, hyperPTH
Medications: beta blockers, anti-HTN, cocaine, steroids
FH of depression or BPAD
Adverse childhood events
Life events
- Death of close relative, divorce/separation, jail term
Vulnerability factors
- Unemployment, lack of confiding relationships, lower socioeconomic status and social isolation
Monamine hypothesis = Depression is deficiency in brain monamine neurotransmitters:
- Serotonin: Sleep, Appetite, Mood, Memory
- Noradrenaline: Mood, Energy
- Dopamine: Psychomotor activity
Depression prevalence
Lifetime risk ~ 15%
Point prevalence ~ 8%
Female 2 x risk
Age of onset
- F: 40
- M: 60-70s
Subtypes of depression
SAD:
Lower mood in winter. Usually reserved symptoms of overeating and sleeping
Atypical depression:
Reserved biological symptoms and may retain mood reactivity
Agitated depression:
Depression with psychomotor agitation instead of retardation e.g. restlessness, pacing, hand wringing
Depressive stupor:
Psychomotor retardation so profound that person grinds to a halt
Masked depression:
Doesn’t present with low mood; maintain a cheerful exterior
Somatic syndrome:
>/= 4 biological symptoms of depression
Pseudo-dementia:
Depression affecting memory so badly that patient appears to have dementia
- NB dementia itself can begin with affective change
Depression investigations
Screening questions - in last 2 weeks:
1) Feeling down, depressed or hopeless?
2) Little interest or pleasure in doing things?
Collateral hx Physical examination Depression screening tools: PHQ9, HADS Bloods: TFTs, FBC, Glucose or HbA1c Rating scaled to measure severity or monitor response: BDI
CT/MRI ONLY if cerebral pathology suspected
SSRIs
Side effects
Length of treatment
Fluoxetine, Sertraline, Paroxetine, Fluvoxamine, Citalopram, Escitalopram
Initial Side effects:
- Nausea, Vomiting
- Appetite and weight change
- Anxiety and agitation
Persistent side effects:
- Blurred vision
- Insomnia, tremor, dizziness
- Headache
- Sweating
- Lower seizure threshold
- Hyponatraemia
- Some degree of sexual dysfunction
1st choice in depression generally.
Continue at least 6 months after no longer depressed
- reduces relapse
- not associated with addiction
Explain onset delayed and outline major side effects
2 YEARS IF RECURRENT DEPRESSION
When to avoid antidepressants
Hypomania or mania
DON’T DRINK
Don’t kneed to avoid but be cautious in epilepsy
Choice of antidepressant in patients with cardiac conditions
Sertraline post MI
Citalopram/Escitalopram prolong the QT interval so shouldn’t be used in those with
- long QT
- Know pre-existing QT prolongation
- Other meds that in combination prolong the QT
Antidepressant choice for children
Fluoxetine is the drug of choice
