Psychiatry Flashcards
Alcohol withdrawal
Mechanism
chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
Features
symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
peak incidence of seizures at 36 hours
peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Management
patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
first-line: benzodiazepines e.g. chlordiazepoxide. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
carbamazepine also effective in treatment of alcohol withdrawal
phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
GABA is an inhibitory neurotransmitter which means it decreases brain activity and produces calming effects when levels are elevated. This is increased during alcohol consumption and causes the classic symptoms of drunkenness.
Glutamate is an excitatory neurotransmitter, meaning it increases brain activity and acts as a sort of natural stimulant. This is decreased during alcohol consumption, causing the body to slow down on a physiological level.
When a person consumes alcohol, the brain acts as if there is more GABA and less glutamate present. If the person continues to drink to excess on a regular basis, the brain produces less GABA and more glutamate in an attempt to restore normal brain chemistry. If they then quit drinking there is a rebound effect. The brain is still producing less GABA than is needed without alcohol and more glutamate, so when the alcohol is taken out of the picture the brain then acts as if there is a shortage of GABA and a surplus of glutamate. This gives the person withdrawal symptoms.
Anorexia nervosa: features
Anorexia nervosa is associated with a number of characteristic clinical signs and physiological abnormalities which are summarised below
Anorexia features
most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Features
reduced body mass index
bradycardia
hypotension
enlarged salivary glands
Physiological abnormalities
hypokalaemia
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3
Antipsychotics
Antipsychotics act as dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways. Conventional antipsychotics are associated with problematic extrapyramidal side-effects which has led to the development of atypical antipsychotics such as clozapine
Extrapyramidal side-effects (EPSEs)
Parkinsonism
acute dystonia: sustained muscle contraction (e.g. torticollis, oculogyric crisis)
akathisia (severe restlessness)
tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
EPSEs may be managed with procyclidine
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism
Other side-effects
antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin
may result in galactorrhoea
due to inhibition of the dopaminergic tuberoinfundibular pathway
impaired glucose tolerance
neuroleptic malignant syndrome: pyrexia, muscle stiffness
reduced seizure threshold (greater with atypicals)
prolonged QT interval (particularly haloperidol)
Atypical antipsychotics
Atypical antipsychotics should now be used first-line in patients with schizophrenia, according to 2005 NICE guidelines. The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects.
Adverse effects of atypical antipsychotics
weight gain
clozapine is associated with agranulocytosis (see below)
hyperprolactinaemia
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism
Examples of atypical antipsychotics
clozapine
olanzapine: higher risk of dyslipidemia and obesity
risperidone
quetiapine
amisulpride
aripiprazole: generally good side-effect profile, particularly for prolactin elevation
Clozapine
Clozapine, one of the first atypical agents to be developed, carries a significant risk of agranulocytosis and full blood count monitoring is therefore essential during treatment. For this reason, clozapine should only be used in patients resistant to other antipsychotic medication. The BNF states:
Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.
Adverse effects of clozapine
agranulocytosis (1%), neutropaenia (3%)
reduced seizure threshold - can induce seizures in up to 3% of patients
constipation
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation
Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.
Antipsychotics can cause an acute dystonic reaction, an important form of which is an oculogyric crisis
Important for meLess important
The patient is experiencing an oculogyric crisis, a form of acute dystonic reaction. Other signs can include tongue protrusion and jaw spasm.
Treatment is usually IV procyclidine and withdrawal of the causative medication.
Akathisia is a form of restlessness which will present as constant pacing up and down, or the patient describing an inability to sit still.
Tardive dyskinesia is a side effect of antipsychotics that occurs after many years. It typically affects the face and involves repetitive, involuntary, writhing movements such as grimacing, tongue protrusion and lip smacking.
Parkinsonism is the general term for side effects of antipsychotics that mimic Parkinson’s disease, such as bradykinesia, cogwheel rigidity and shuffling gait.
Catatonia is a symptom of mental illness and patients usually appear to be in a stupor, maintain odd postures and appear awake but unresponsive to external stimuli.
An ECG is required at baseline for patients commenced on antipsychotic medications
An ECG should also be offered if:
Specified in the summary of product characteristics (SPC)
Cardiovascular risk identified e.g. high BP
Personal history of cardiovascular disease
Service user is being admitted as an inpatient
Olanzapine is a second-generation antipsychotic. QT prolongation is a recognised complication of taking antipsychotic medications. The main reason for doing an ECG in this particular patient is that she is an inpatient.
Benzodiazepines
Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels. They therefore are used for a variety of purposes:
sedation
hypnotic
anxiolytic
anticonvulsant
muscle relaxant
Patients commonly develop a tolerance and dependence to benzodiazepines and care should therefore be exercised on prescribing these drugs. The Committee on Safety of Medicines advises that benzodiazepines are only prescribed for a short period of time (2-4 weeks).
The BNF gives advice on how to withdraw a benzodiazepine. The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight. A suggested protocol for patients experiencing difficulty is given:
switch patients to the equivalent dose of diazepam
reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
time needed for withdrawal can vary from 4 weeks to a year or more
If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug. Features include:
insomnia
irritability
anxiety
tremor
loss of appetite
tinnitus
perspiration
perceptual disturbances
seizures
GABAA drugs
benzodiazipines increase the frequency of chloride channels
barbiturates increase the duration of chloride channel opening
Frequently Bend - During Barbeque
…or…
Barbidurates increase duration & Frendodiazepines increase frequency
Lorazepam belongs to the benzodiazepine class of drugs. One of the side effects of this drug is that this can cause anterograde amnesia. Where memory recall and the creation of new memories is significantly impaired. Lorazepam is also used in anaesthesia. Citalopram is an SSRI which causes some side effects such as tiredness and sleepiness but not amnesia. Ramipril is an ACE inhibitor which has an important side effect of a dry cough. The side effect most commonly associated with nitrofurantoin is haemolytic anaemia.
Syndromes
Cotard syndrome
Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.
Cotard syndrome is associated with severe depression and psychotic disorders
Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of a higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes.
Capgras delusion is the belief that friends or family members have been replaced by an identical looking imposter.
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Depression: screening and assessment
Screening
The following two questions can be used to screen for depression
‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’
A ‘yes’ answer to either of the above should prompt a more in depth assessment.
Assessment
There are many tools to assess the degree of depression including the Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9).
Hospital Anxiety and Depression (HAD) scale
consists of 14 questions, 7 for anxiety and 7 for depression
each item is scored from 0-3
produces a score out of 21 for both anxiety and depression
severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly
Patient Health Questionnaire (PHQ-9)
asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm
depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe
NICE use the DSM-IV criteria to grade depression:
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate, or indecisiveness nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Subthreshold depressive symptoms
Fewer than 5 symptoms
Mild depression
Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment
Moderate depression
Symptoms or functional impairment are between ‘mild’ and ‘severe’
Severe depression
Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms
Depression: management of unresponsive, moderate and severe depression
NICE produced updated guidelines in 2009 on the management of depression in primary and secondary care. Patients are classified according to the severity of the depression and whether they have an underlying chronic physical health problem.
Please note that due to the length of the ‘quick’ reference guide the following is a summary and we would advise you follow the link for more detail.
Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression
For these patients NICE recommends an antidepressant (normally a selective serotonin reuptake inhibitor, SSRI)
The following ‘high-intensity psychological interventions’ may be useful:
Individual CBT
Delivery
typically 16-20 sessions over 3-4 months
consider 3-4 follow-up sessions over the next 3-6 months
for moderate or severe depression, consider 2 sessions per week for the first 2-3 weeks
Interpersonal therapy (IPT)
Delivery
typically 16-20 sessions over 3-4 months
for severe depression, consider 2 sessions per week for the first 2-3 weeks
Behavioural activation
Delivery
typically 16-20 sessions over 3-4 months
consider 3-4 follow-up sessions over the next 3-6 months
for moderate or severe depression, consider 2 sessions per week for the first 3-4 weeks
Behavioural couples therapy
Delivery
typically 15-20 sessions over 5-6 months
For people who decline the options above, consider:
counselling for people with persistent subthreshold depressive symptoms or mild to moderate depression; offer 6-10 sessions over 8-12 weeks
short-term psychodynamic psychotherapy for people with mild to moderate depression; offer 16-20 sessions over 4-6 months
For patients with chronic physical health problems the following should be offered:
group-based CBT
individual CBT
Grief reaction
It is normal for people to feel sadness and grief following the death of a loved one and this does not necessarily need to be medicalised. However, having some understanding of the potential stages a person may go through whilst grieving can help determine whether a patient is having a ‘normal’ grief reaction or is developing a more significant problem.
One of the most popular models of grief divides it into 5 stages.
Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
Anger: this is commonly directed against other family members and medical professionals
Bargaining
Depression
Acceptance
It should be noted that many patients will not go through all 5 stages.
Abnormal, or atypical, grief reactions are more likely to occur in women and if the death is sudden and unexpected. Other risk factors include a problematic relationship before death or if the patient has not much social support.
Features of atypical grief reactions include:
delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
Seasonal affective disorder
Seasonal affective disorder (SAD) describes depression which occurs predominately around the winter months. SAD should be treated the same way as depression, therefore as per the NICE guidelines for mild depression, you would begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration. Following this an SSRI can be given if needed. In seasonal affective disorder, you should not give the patient sleeping tablets as this can make the symptoms worse. Finally, the evidence for light therapy is limited and as such it is not routinely recommended.
This question tests your ability to assess and manage a patient who is suicidal. This gentleman has multiple risk factors: His gender, past history of depression, recently separated and with a stated future intent.
In this situation you need to act appropriately. The best team to assess and manage this cases are the CRISIS team, who will be able to assess and manage this patient as a matter of urgency.
With regards to the other options:
A transfer to the Emergency Department would simply delay the referral to the crisis team, and is not the best option.
CAMH are the child and adolescent mental health team and would not be appropriate in this setting.
It would not be your professional remit to instigate relationship counselling.
The patient has too many risk factors to allow for discharge without psychiatric assessment.
ECT is indicated in life-threatening major depressive disorder, where catatonia in present
Importance: 94
ECT is indicated in life-threatening major depressive disorder, where catatonia in present.
The patient is presenting with life-threatening major depression as evidenced by her severe dehydration, suicide risk and catatonia.
Whilst she has never received any psychiatric medication before, an SSRI such as citalopram (even if augmented) is not appropriate given the degree of her illness - ECT will provide quicker results.
Hypomania vs. mania
Mania
Lasts for at least 7 days - Causes severe functional impairment in social and work setting
May require hospitalization due to risk of harm to self or others
May present with psychotic symptoms
Hypomania
A lesser version of mania
Lasts for < 7 days, typically 3-4 days. Can be high functioning and does not impair functional capacity in social or work setting
Unlikely to require hospitalization
Does not exhibit any psychotic symptoms
Therefore, the length of symptoms, severity and presence of psychotic symptoms (e.g. delusions of grandeur, auditory hallucinations) helps differentiates mania from hypomania.
The following symptoms are common to both hypomania and mania
Mood
predominately elevated
irritable
Speech and thought
pressured
flight of ideas: characterised by rapid speech with frequent changes in topic based on associations, distractions or word play
poor attention
Behaviour
insomnia
loss of inhibitions: sexual promiscuity, overspending, risk-taking
increased appetite
Hypomania is characterised by elevated mood, pressured speech and flight of ideas but without psychotic symptoms
Panic disorder
For Panic disorder to be diagnosed symptoms have to be present for at least 1 month. The prevalence of panic attacks is around 7-9%, the prevalence of panic disorder is 1.5-2.5%. It is twice as common in females than in males. There are two peaks of onset from ages 15-24 and 45-54. SSRIs and CBT are the most commonly used therapies for Panic disorder.
Living alone, early parental loss, a history of abuse, poor educational history and urban living are risk factors for developing panic disorder. There is a 40% prevalence seen in 1st degree relatives of those with panic disorder and it generally follows a chronic, mild and stable course in 50% of patients.
A panic attack is a discrete period of intense fear or discomfort developing abruptly and peaking within 10 minutes. It is characterised by palpitations, sweating, trembling, shortness of breath, choking sensations, nausea, abdominal distress, dizziness, fear of control or ‘going crazy’, fear of dying, tingling sensations, numbness and chills or hot flushes. Derealisation and depersonalisation may also be seen. Recurrent attacks with fear of having another attack and worry about the implications of another attack suggest a diagnosis of panic disorder.
The most frequently used pharmacological interventions used in panic disorder are SSRIs and TCAs. Paroxetine (3) is an SSRI. There is no role for the use of antipsychotics (1, 4, 5) in panic disorder. Short-acting benzodiazepines such as lorazepam reduce the frequency and intensity of panic attacks but carry a high risk of dependence therefore are not recommended. Venlafaxine (2) is an SNRI.
Personality disorders
Disorder
Features
Antisocial
Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
More common in men;
Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
Impulsiveness or failure to plan ahead;
Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
Reckless disregard for safety of self or others;
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
Avoidant
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
Unwillingness to be involved unless certain of being liked
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks doe to fears of embarrassment
Views self as inept and inferior to others
Social isolation accompanied by a craving for social contact
Borderline
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
Dependent
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
Histrionic
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are
Narcissistic
Grandiose sense of self importance
Preoccupation with fantasies of unlimited success, power, or beauty
Sense of entitlement
Taking advantage of others to achieve own needs
Lack of empathy
Excessive need for admiration
Chronic envy
Arrogant and haughty attitude
Obsessive-compulsive
Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Demonstrates perfectionism that hampers with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare time activities
Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
Paranoid
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
Unwarranted tendency to perceive attacks on their character
Schizoid
Indifference to praise and criticism
Preference for solitary activities
Lack of interest in sexual interactions
Lack of desire for companionship
Emotional coldness
Few interests
Few friends or confidants other than family
Schizotypal
Ideas of reference (differ from delusions in that some insight is retained)
Odd beliefs and magical thinking
Unusual perceptual disturbances
Paranoid ideation and suspiciousness
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
Odd speech without being incoherent
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example, a major disaster or childhood sexual abuse. It encompasses what became known as ‘shell shock’ following the first world war. One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one month.
Features
re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
avoidance: avoiding people, situations or circumstances resembling or associated with the event
hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
emotional numbing - lack of ability to experience feelings, feeling detached
from other people
depression
drug or alcohol misuse
anger
unexplained physical symptoms
Management
following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
watchful waiting may be used for mild symptoms lasting less than 4 weeks
military personnel have access to treatment provided by the armed forces
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 venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used
Schizophrenia: epidemiology
The strongest risk factor for developing a psychotic disorder (including schizophrenia) is family history. Having a parent with schizophrenia leads to a relative risk (RR) of 7.5.
Risk of developing schizophrenia
monozygotic twin has schizophrenia = 50%
parent has schizophrenia = 10-15%
sibling has schizophrenia = 10%
no relatives with schizophrenia = 1%
Other selected risk factors for psychotic disorders include:
Black Caribbean ethnicity - RR 5.4
Migration - RR 2.9
Urban environment- RR 2.4
Cannabis use - RR 1.4
Schizophrenia: prognostic indicators
Factors associated with poor prognosis
strong family history
gradual onset
low IQ
premorbid history of social withdrawal
lack of obvious precipitant
Schizophrenia: features
Schneider’s first rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions:
Auditory hallucinations of a specific type:
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient’s behaviour
Thought disorder*:
thought insertion
thought withdrawal
thought broadcasting
Passivity phenomena:
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Delusional perceptions
a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.
Other features of schizophrenia include
impaired insight
incongruity/blunting of affect (inappropriate emotion for circumstances)
decreased speech
neologisms: made-up words
catatonia
negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)
*occasionally referred to as thought alienation
Treatment resistant schizophrenia, as the name suggests, is notoriously difficult to control. One of the most effective drugs is called clozapine, an atypical antipsychotic.
This is not a first line medication and should only be initiated if there is a lack of clinical improvement following sequential use of at least two antipsychotics for 6-8 weeks, with at least one of these antipsychotics being from the atypical class.
Whilst a very effective medication, there are a number of serious side effects including, but not limited to, the following:
weight gain
excessive salivation
agranulocytosis
neutropenia
myocarditis
arrhythmias
In the case of the above patient, your concern would be that he is suffering from myocarditis and given his underlying psychiatric condition it would be likely that he was on clozapine.
Schizophrenia: management
NICE published guidelines on the management of schizophrenia in 2009.
Key points:
oral atypical antipsychotics are first-line
cognitive behavioural therapy should be offered to all patients
close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
Agranulocytosis/neutropenia is a life-threatening side effect of clozapine - monitor FBC
Important for meLess important
The most important complication of clozapine therapy to exclude is agranulocytosis. Weight gain is common in patients taking an antipsychotic
Atypical antipsychotics
Atypical antipsychotics should now be used first-line in patients with schizophrenia, according to 2005 NICE guidelines. The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects.
Adverse effects of atypical antipsychotics
weight gain
clozapine is associated with agranulocytosis (see below)
hyperprolactinaemia
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism
Examples of atypical antipsychotics
clozapine
olanzapine: higher risk of dyslipidemia and obesity
risperidone
quetiapine
amisulpride
aripiprazole: generally good side-effect profile, particularly for prolactin elevation
Sectioning under the Mental Health Act
This is used for someone over the age of 16 years who will not be admitted voluntarily. Patients who are under the influence of alcohol or drugs are specifically excluded
Section 2
admission for assessment for up to 28 days, not renewable
an Approved Mental Health Professional (AMHP) or rarely the nearest relative (NR) makes the application on the recommendation of 2 doctors
one of the doctors should be ‘approved’ under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist)
treatment can be given against a patient’s wishes
Section 3
admission for treatment for up to 6 months, can be renewed
AMHP along with 2 doctors, both of which must have seen the patient within the past 24 hours
treatment can be given against a patient’s wishes
Section 4
72 hour assessment order
used as an emergency, when a section 2 would involve an unacceptable delay
a GP and an AMHP or NR
often changed to a section 2 upon arrival at hospital
Section 5(2)
a patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours
Section 5(4)
similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours
Section 17a
Supervised Community Treatment (Community Treatment Order)
can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication
Section 135
a court order can be obtained to allow the police to break into a property to remove a person to a Place of Safety
Section 136
someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged
Section 136 is used by the police to bring people who could be displaying signs of mental illness presenting a risk to themselves or others to place of safety.
It lasts up to 24 hours, to allow time for a Mental Health Act Assessment to be arranged. It can in exceptional circumstances be extended by a further 12 hours.
It can only be used for someone in a public place, not in their own property or someone else’s property - for this section 135 is required.
It does not permit treatment against someone’s will.
A safe place includes a hospital, the person’s home or a friend’s home or, if there is no other option, a police station.
A community treatment order (CTO)
A community treatment order (CTO) can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication
Importance: 26
Section 17a, otherwise known as a Community Treatment Order (CTO), is a Section of the Mental Health Act. It is used if a patient has been an inpatient in hospital and allows them to be treated at home with some conditions put in place by the responsible clinician (RC) - this is usually the inpatient consultant alongside an Approved Mental Health Professional (AMHP). The team need to show that the patient will not be able to manage their mental health without the use of a CTO, and that their mental health will deteriorate if they stop treatment in the community.
Conditions include things that are necessary to prevent risk to the patient or others. These can include taking medication, where they live or maintaining engagement with their community team(s).
If the conditions are not met, the consultant can recall the patient back to the hospital. For this to happen the patient must require treatment in hospital, and there must be significant risks to the patient or others should they not be recalled.
The recall lasts for up to 72 hours, after which the patient can be discharged back to the community or detained again under the original Section.
Treatment can be given without consent under a CTO.
A CTO lasts for up to 6 months and can be renewed.
Selective serotonin reuptake inhibitors
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression.
citalopram (although see below re: QT interval) and fluoxetine are currently the preferred SSRIs
sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants
SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of choice when an antidepressant is indicated
Adverse effects
gastrointestinal symptoms are the most common side-effect
there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
fluoxetine and paroxetine have a higher propensity for drug interactions
Citalopram and the QT interval
the Medicines and Healthcare products Regulatory Agency (MHRA) released a warning on the use of citalopram in 2011
it advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment
Interactions
NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin: see above
triptans - increased risk of serotonin syndrome
monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
SSRIs and pregnancy
- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
SSRI: side-effects
SSRI + NSAID = GI bleeding risk - give a PPI
There is an increased incidence of gastrointestinal bleeding when aspirin / NSAIDs are combined with selective serotonin reuptake inhibitors. This patient should therefore also be offered a proton pump inhibitor such as lansoprazole. It would be inappropriate to stop aspirin in a patient with a history of ischaemic heart disease.
Note the use of sertraline in this patient, the first-choice SSRI in patients with a history of
SSRI: side-effects
Adverse effects
gastrointestinal symptoms are the most common side-effect
there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
hyponatraemia
patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
fluoxetine and paroxetine have a higher propensity for drug interactions
Citalopram and the QT interval
the Medicines and Healthcare products Regulatory Agency (MHRA) released a warning on the use of citalopram in 2011
it advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment
Interactions
NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin: see above
triptans: avoid SSRIs
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
cardiovascular disease.
Mirtazapine
Mirtazapine is generally more sedating at lower BNF doses (e.g. 15mg) than higher doses (e.g. 45mg)
Important for meLess important
Mirtazapine is an atypical antidepressant which is also useful as a sedative and appetite stimulant. It has effects on many different receptor types. Its sedating effects via antagonism of H1 receptors at 15mg tend to be outweighed by antagonism at 5-HT2a and 5-HT2c receptors leading to more wakefulness at higher doses (i.e. 30 - 45mg).
Mirtazapine
Mirtazapine is an antidepressant that works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters.
Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in older people who may be affected more or be taking other medications. Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.
It is generally taken in the evening as it can be sedative.
Sleep paralysis
Sleep paralysis
Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognised in a wide variety of cultures
Features
paralysis - this occurs after waking up or shortly before falling asleep
hallucinations - images or speaking that appear during the paralysis
Management
if troublesome clonazepam may be used
Suicide: risk factors
Suicide: risk factors
The risk stratification of psychiatric patients into ‘high’, ‘medium’ or ‘low risk’ is common in clinical practice. Questions based on a patient’s suicide risk are therefore often seen. However, it should be noted that there is a paucity of evidence addressing the positive predictive value of individual risk factors. An interesting review in the BMJ (BMJ 2017;359:j4627) concluded that ‘there is no evidence that these assessments can usefully guide decision making’ and noted that 50% of suicides occur in patients deemed ‘low risk’.
Whilst the evidence base is relatively weak, there are a number of factors shown to be associated with an increased risk of suicide
male sex (hazard ratio (HR) approximately 2.0)
history of deliberate self-harm (HR 1.7)
alcohol or drug misuse (HR 1.6)
history of mental illness
depression
schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide
history of chronic disease
advancing age
unemployment or social isolation/living alone
being unmarried, divorced or widowed
If a patient has actually attempted suicide, there are a number of factors associated with an increased risk of completed suicide at a future date:
efforts to avoid discovery
planning
leaving a written note
final acts such as sorting out finances
violent method
Protective factors
There are, of course, factors which reduce the risk of a patient committing suicide. These include
family support
having children at home
religious belief
Thought disorders
Thought disorders
Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return the original point.
Tangentiality refers to wandering from a topic without returning to it.
Neoligisms are new word formations, which might include the combining of two words.
Clang associations are when ideas are related to each other only by the fact they sound similar or rhyme.
Word salad is completely incoherent speech where real words are strung together into nonsense sentences.
Knight’s move thinking is a severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia.
Flight of ideas, a feature of mania, is thought disorder where there are leaps from one topic to another but with discernible links between them.
Perseveration is the repetition of ideas or words despite an attempt to change the topic.
Echolalia is the repetition of someone else’s speech, including the question that was asked.
Generalised anxiety disorder
Management
SSRI anti-depressants
buspirone (5-HT1A partial agonist)
beta-blockers
benzodiazepines: use longer acting preparations e.g. diazepam, clonazepam
cognitive behaviour therapy
Tricyclic antidepressants
Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-effects and toxicity in overdose. They are however used widely in the treatment of neuropathic pain, where smaller doses are typically required.
Common side-effects
drowsiness
dry mouth
blurred vision
constipation
urinary retention
lengthening of QT interval
Choice of tricyclic
low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
lofepramine has a lower incidence of toxicity in overdose
amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose
More sedative
Amitriptyline
Clomipramine
Dosulepin
Trazodone*
Less sedative
Imipramine
Lofepramine
Nortriptyline
*trazodone is technically a ‘tricyclic-related antidepressant’
Unexplained symptoms
There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:
Somatisation disorder
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
Hypochondrial disorder
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
Conversion disorder
typically involves loss of motor or sensory function
the patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
Dissociative disorder
dissociation is a process of ‘separating off’ certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
Factitious disorder
also known as Munchausen’s syndrome
the intentional production of physical or psychological symptoms
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
