Psychiatry - MSRA Study Notes PDF

REVIS A I R MS ON ON MS I R A REVIS MSRA MSRA STUDY NOTES Prepared By Dr. Marwa Harb Dr. Wessam Sabry Dr. Ahmed Helmy...

REVIS A I R MS ON ON MS I R A REVIS MSRA MSRA STUDY NOTES Prepared By Dr. Marwa Harb Dr. Wessam Sabry Dr. Ahmed Helmy Psychiatry Chapter Design By: Malak Yasser Index Sectioning Under the mental health act Thought disorders Psychosis Schizophrenia Hypomania vs. Mania Personality disorders Greif Seasonal Affect Disorders Depression Suicide Unexplained symptoms Genralized Anxiety dirosed Post-traumatic stress disorder Panic disorder Tremor Alcohol withdrawl Sleep paralysis Anroxia nervosa Psychopahramcology REVIS A I S MR ON ON MR I S A REVIS  Sectioning under the MH Act This is used for someone who will not be admitted voluntarily. Patients who are under the influence of alcohol or drugs are specifically excluded 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 Section 2 recommendation of 2 doctors One of the doctors should be 'approved' under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist) Admission for treatment for up to 6 months, can be renewed Section 3 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 if they are under a section 2 or 3 72 hour assessment order Used as an emergency, when a section 2 would involve an Section 4 unacceptable delay A GP and an AMHP or NR Often changed to a section 2 upon arrival at hospital A patient who is a voluntary patient in hospital can be legally Section 5(2) detained by a doctor for 72 hours Similar to section 5(2), allows a nurse to detain a patient who is Section 5(4) voluntarily in hospital for 6 hours REVIS A I S MR ON ON MR I S A REVIS  Supervised Community Treatment (Community Treatment Order) Can be used to recall a patient to hospital for treatment if they do Section 17a not comply with conditions of the order in the community, such as complying with medication A court order can be obtained to allow the police to break into a Section 135 property to remove a person to a Place of Safety Someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety Section 136 Can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged NOTES: Any person whose death occurs whilst under the mental health act, regardless of cause, must be reported to the coroner Therefore either yourself or the acute hospital doctors completing the certificate would not be the initial step. Although requiring reporting to the coroner a post mortem is not likely to occur. Old age cannot be used on a death certificate if the patient is under 80 years old. REVIS A I S MR ON ON MR I S A REVIS  Thought disorders The inability to answer a question without giving excessive, unnecessary detail. Circumstantiality However, return to the original point. Circumstantiality can be a sign of: anxiety disorders or hypomania Tangentiality Refers to wandering from a topic without returning to it. New word formations, which might include the combining of two Neologisms words. Associations are when ideas are related to each other only by the Clang fact they sound similar or rhyme. Describes completely incoherent speech where real words are Word salad strung together into nonsense sentences. Severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. Knight's move Also known as (loosening of associations or derailment) as there is thinking no apparent link between topics. It is a feature of schizophrenia. A feature of mania, is a thought disorder where there are leaps from one topic to another but with thoughts are linked sometimes Flight of ideas minimally and often by clanging (linking similar sounding words), punning or rhyming. It is the repetition of ideas or words despite an attempt to change Perseveration the topic. It is the repetition of someone else's speech, including the question Echolalia that was asked. REVIS A I S MR ON ON MR I S A REVIS  Wandering away from Tangentiality topic to topic without Neologisms New word formation returning Clang Words rhyming Word salad Incoherent speech Flight of Leap from topic to Perseveration Repetition of ideas ideas topic REVIS A I S MR ON ON MR I S A REVIS  Psychosis Psychosis is a term used to describe a person experiencing things differently from those around them. The peak age of first-episode psychosis is around 15-30 years. Psychotic features: Hallucinations (e.g. auditory) Delusions Thought disorganization: 1. Alogia: little information conveyed by speech 2. Tangentiality: answers diverge from topic 3. Clanging 4. Word salad: linking real words incoherently → nonsensical content Associated features: Agitation/aggression Neurocognitive impairment (e.g. in memory, attention or executive function) Depression Thoughts of self-harm Psychotic symptoms may occur in: Schizophrenia: the most common psychotic disorder Depression (psychotic depression, a subtype more common in elderly patients) Bipolar disorder Puerperal psychosis Brief psychotic disorder: where symptoms last less than a month Neurological conditions e.g. Parkinson's disease, Huntington's disease Prescribed drugs e.g. corticosteroids Certain illicit drugs e.g. cannabis, phencyclidine REVIS A I S MR ON ON MR I S A REVIS  Schizophrenia Mental illness characterized by psychosis. Risk factors: The strongest risk factor for schizophrenia is a positive family history (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 Its symptoms are split into positive and negative categories. Positive symptoms Negative symptoms Delusions: unswayable beliefs incongruent with reality Hallucinations: false perceptions in the absence of Social withdrawal stimuli Anhedonia (lack of interest in Thought disorders: pursuing activities) Insertion (the belief that their thoughts are Lack of emotion and flat someone else's/put in their mind by someone Incongruity/blunting of affect else) Alogia (poverty of speech) Withdrawal (the belief that thoughts are Avolition (poor motivation) removed from their mind) Broadcasting (the belief that others can their read thoughts) Other features of schizophrenia include: Impaired insight Neologisms: made-up words Catatonia REVIS A I S MR ON ON MR I S A REVIS Features: Schneider's first rank symptoms may be divided into: auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions: Auditory Two or more voices discussing the patient in the third person hallucinations of Thought echo a specific type Voices commenting on the patient's behaviour Thought insertion Thought Thought withdrawal disorders Thought broadcasting Bodily sensations being controlled by external influence Passivity Actions/impulses/feelings: experiences which are imposed on phenomena the individual or influenced by others A two stage process where first a normal object is perceived Delusional then secondly there is a sudden intense delusional insight into perceptions the objects meaning for the patient e.g. 'The traffic light is green therefore I am the King'. Factors associated with poor prognosis: strong family history gradual onset low IQ prodromal phase of social withdrawal lack of obvious precipitant Affect vs. Mood Affect is the current, observed emotional state of the patient (what you see), Mood is the more pervasive, predominant state over a longer period (what you ask about) REVIS A I S MR ON ON MR I S A REVIS  Hypomania vs. mania Mania Hypomania A lesser version of mania Lasts for at least 7 days Lasts for < 7 days, typically 3-4 days. Causes severe functional impairment in Can be high functioning and does not impair social and work setting functional capacity in social or work setting May require hospitalization due to risk UNLIKELY TO REQUIRE HOSPITALIZATION of harm to self or others May present with psychotic symptoms 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: characterized by rapid speech with frequent changes in topic based on associations, distractions or word play Poor attention Behavior Insomnia Loss of inhibitions: sexual promiscuity, overspending, risk-taking Increased appetite REVIS A I S MR ON ON MR I S A REVIS  Personality disorders Personality disorders may be defined as a series of maladaptive personality traits that interfere with normal function in life. It is thought that around 1 in 20 people have a personality disorder. They are typically categorised into three clusters: Cluster A: ' Cluster B: Cluster C: Odd or Eccentric' 'Dramatic, Emotional, or Erratic' 'Anxious and Fearful' Antisocial Obsessive- Paranoid Borderline (Emotionally Compulsive Schizoid Unstable) Avoidant Schizotypal Histrionic Dependent Narcissistic Cluster A: 'Odd or Eccentric' 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 REVIS A I S MR ON ON MR I S A REVIS 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 Cluster B: 'Dramatic, Emotional, or Erratic' Antisocial: Failure to conform to social norms with respect to lawful behaviours 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 the safety of self or others; Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations; Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another Borderline: also known as Emotionally Unstable 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 REVIS A I S MR ON ON MR I S A REVIS 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 Cluster C: 'Anxious and Fearful' 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 REVIS A I S MR ON ON MR I S A REVIS 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 due to fears of embarrassment Views self as inept and inferior to others Social isolation accompanied by a craving for social contact 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 Management: Personality disorders are difficult to treat and in the past have been considered 'untreatable' by definition.. However, a number of approaches have been shown to help patients, including: Psychological therapies: dialectical behaviour therapy Treatment of any coexisting psychiatric conditions REVIS A I S MR ON ON MR I S A REVIS  Grief reaction It is important to determine whether a patient is having a 'normal' grief reaction or is developing a more significant problem by understanding stages of grief Abnormal, or atypical, grief reactions are more likely to occur in women and if the death is sudden and unexpected. Other risk factors include: problematic relationship before death or if the patient has not much social support. Stages of grief ( 5 stages) 1. 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 2. Anger: this is commonly directed against other family members and medical professionals 3. Bargaining 4. Depression 5. Acceptance It should be noted that many patients will not go through all 5 stages. Features of atypical grief reactions include: Delayed grief Occur when more than 2 weeks passes before grieving begins Normal grief reactions may take up to and beyond 12 months& Prolonged grief can often last up to 6 months and present with both physical and psychological symptoms REVIS A I S MR ON ON MR I S A REVIS  Seasonal affective disorder Seasonal affective disorder (SAD) describes depression which occurs predominately around the winter months. Management: SAD should be treated the same way as depression 1. Begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration. 2. 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. REVIS A I S MR ON ON MR I S A REVIS  Depression New classification: Less severe depression More severe depression Previously termed subthreshold and Previously termed moderate and severe mild depression depression PHQ-9 score of < 16 PHQ-9 score of ≥ 16 NICE management of less severe depression: They recommend considering 'the least intrusive and least resource intensive treatment first'. It also recommends not routinely offering 'antidepressant medication as first-line treatment for less severe depression, unless that is the person's preference'. NICE management of more severe depression: A shared decision should be made. Electroconvulsive therapy Electroconvulsive therapy is a useful treatment option for patients with severe depression or refractory to medication (e.g. catatonia) those with psychotic symptoms. The only absolute contraindications is raised intracranial pressure. Short-term side-effects: Headache Nausea Short term memory impairment Memory loss of events prior to ECT Cardiac arrhythmia Long-term side-effects: Some patients report impaired memory REVIS A I S MR ON ON MR I S A REVIS  Treatment options in order of preference: Less severe depression More severe depression 1. a combination of individual cognitive behavioural therapy (CBT) and an antidepressant 2. individual CBT 1. guided self-help 3. individual behavioural activation (BA) 2. group cognitive behavioural therapy 4. antidepressant medication (CBT) 5. selective serotonin reuptake inhibitor 3. group behavioural activation (BA) (SSRI), or 4. individual CBT 6. serotonin-norepineph٨rine reuptake 5. individual BA inhibitor (SNRI), or 6. group exercise 7. another antidepressant if indicated based 7. group mindfulness and meditation on previous clinical and treatment history 8. interpersonal psychotherapy (IPT) 8. individual problem-solving 9. selective serotonin reuptake 9. counselling inhibitors (SSRIs) 10. short-term psychodynamic 10. counselling psychotherapy (STPP) 11. short-term psychodynamic 11. interpersonal psychotherapy (IPT) psychotherapy (STPP) 12. guided self-help 13. group exercise 14. ECT is indicated in life-threatening major depressive disorder, where catatonia in present REVIS A I S MR ON ON MR I S A REVIS  A 64-year-old woman presents as she is feeling down and sleeping poorly. After speaking to the patient and using a validated symptom measure you decide she has moderate depression. She has a past history of ischaemic heart disease and currently takes aspirin, ramipril and simvastatin. What is the most appropriate course of action? Stop aspirin, start sertraline Start venlafaxine Start sertraline + lansoprazole ✅️ Stop aspirin, start clopidrogrel + sertraline Start sertraline Explanation 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 ischemic heart disease. REVIS A I S MR ON ON MR I S A REVIS  Suicide Risk factors: The risk stratification of psychiatric patients into 'high', 'medium' or 'low risk' is common in clinical practice. Factors associated with increase 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: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. Family support Having children at home Religious belief REVIS A I S MR ON ON MR I S A REVIS  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 (symptoms =somatisation) Patient refuses to accept reassurance or negative test results Persistent belief in the presence of an underlying serious Illness anxiety disorder DISEASE, e.g. cancer (hypochondriasis) Patient again refuses to accept reassurance or negative test hypochondria = Cancer results Typically involves loss of motor or sensory function - +ve Hoover sign Maybe caused by stress Conversion disorder The patient doesn't consciously feign the symptoms (factitious (converted to stress) 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 The main symptoms of a dissociative disorder include feeling disconnected from yourself and the world around you, and memory gaps.) dissociation is a process of 'separating off' certain memories from normal consciousness Dissociative disorder 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 also known as Munchausen's syndrome Factitious disorder the intentional production of physical or psychological (Factitious is for fun) symptoms Malingering Fraudulent simulation or exaggeration of symptoms with the (Malingering is for money) intention of financial or other gain REVIS A I S MR ON ON MR I S A REVIS  Generalised anxiety disorder and panic disorder Anxiety is a common disorder that can present in multiple ways. Definition: An 'excessive worry about a number of different events associated with heightened tension.' NB. Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include hyperthyroidism, cardiac disease and medication-induced anxiety (NICE). Medications that may trigger anxiety: salbutamol theophylline corticosteroids antidepressants caffeine Management of generalised anxiety disorder (GAD): (step-wise approach) Step 1 Education about GAD + active monitoring Low-intensity psychological interventions (individual non-facilitated self-help Step 2 or individual guided self-help or psychoeducational groups) High-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. Sertraline should be considered the first-line SSRI If sertraline is ineffective, offer an alternative SSRI or SNRI Examples of SNRIs include duloxetine and venlafaxine Step 3 If the person cannot tolerate SSRIs or SNRIs Consider offering pregabalin For patients under the age of 30 years >> you should warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month Step 4 highly specialist input e.g. Multi agency teams REVIS A I S MR ON ON MR I S A REVIS Management of panic disorder: Step 1 recognition and diagnosis Treatment in primary care Either cognitive behavioural therapy or drug treatment Step 2 SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered Step 3 review and consideration of alternative treatments Step 4 review and referral to specialist mental health services Step 5 care in specialist mental health services REVIS A I S MR ON ON MR I S A REVIS  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. 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 Behavioral 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 Medical treatment: Drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then venlafaxine or SSRI such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used REVIS A I S MR ON ON MR I S A REVIS  Panic disorder For Panic disorder to be diagnosed symptoms have to be present for at least 1 month. Incidence: 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. 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. Risk factors for developing panic disorder: Living alone Early parental loss A history of abuse Poor educational history Urban living Management: SSRIs and CBT are the most commonly used therapies for Panic disorder. REVIS A I S MR ON ON MR I S A REVIS  Tremor Most important causes of tremor: Conditions Notes Resting, 'pill-rolling' tremor Bradykinesia Cog wheel Rigidity Flexed posture, short, shuffling steps Parkinsonism Micrographia 'Mask-like' face Depression & dementia are common NB. May be history of anti-psychotic use Postural tremor: worse if arms outstretched Improved by alcohol and rest Essential tremor Titubation NB. Often strong family history Anxiety History of depression Thyrotoxicosis Usual thyroid signs e.g. Weight loss, tachycardia, feeling hot etc Hepatic History of chronic liver disease encephalopathy Carbon dioxide History of chronic obstructive pulmonary disease retention Cerebellar Intention tremor disease Cerebellar signs e.g. Past-pointing, nystagmus etc Drug withdrawal Example: alcohol, opiates REVIS A I S MR ON ON MR I S A REVIS  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: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. NB. Lorazepam may be preferable in patients with hepatic failure. Mechanism: Typically given as part of a reducing dose protocol To mitigate this risk, either in a fixed-dose decreasing regimen as required per the patient's symptoms Other alternatives: Carbamazepine also effective in treatment of alcohol withdrawal Phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures REVIS A I S MR ON ON MR I S A REVIS  Sleep paralysis Overview: 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 REVIS A I S MR ON ON MR I S A REVIS  Anorexia nervosa Anorexia nervosa is associated with a number of characteristic clinical signs and physiological abnormalities Features: Reduced body mass index Bradycardia Hypotension Enlarged salivary glands Physiological abnormalities: Hypokalaemia Low FSH, LH, oestrogens and testosterone Low T3 Raised cortisol and growth hormone Impaired glucose tolerance Hypercholesterolaemia Hypercarotinaemia Remember In anorexia: Most things low G's and C's raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia REVIS A I S MR ON ON MR I S A REVIS  Psychopharmacology Selective serotonin reuptake inhibitors Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression. Citalopram and fluoxetine are currently the preferred SSRIs when an antidepressant is indicated 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. NB. Patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI. Adverse effects: 1-Gastrointestinal symptoms: are the most common side-effect Increased risk of gastrointestinal bleeding in patients taking SSRIs, thus PPI should be prescribed if a patient is also taking a NSAID Hyponatremia 2-Cardiac symptoms: 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: Fluoxetine and paroxetine have a higher propensity for drug interactions NSAIDs e.g. Aspirin : Do not normally offer SSRIs', but if given co-prescribe a proton pump inhibitor Warfarin / heparin: Better avoid SSRIs and consider mirtazapine Triptans: avoid SSRIs REVIS A I S MR ON ON MR I S A REVIS Monitoring the patient: Regular reviewing for all patients After 2 weeks of initiation For patients < 30 years or at they should be reviewed after 1 week increased risk of suicide they should continue on treatment for at least 6 If a patient makes a good response months after remission as this reduces the risk to antidepressant therapy of relapse. Discontinuation symptoms: When stopping a SSRI the dose should be gradually reduced over a 4 week period due to: Increased mood change Restlessness Difficulty sleeping Unsteadiness Sweating Gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting Paraesthesia Dizziness, electric shock NB. Paroxetine has a higher incidence of discontinuation symptoms. NB. This is not necessary with fluoxetine SSRIs and pregnancy: Use during the first trimester: gives a small increased risk of congenital heart defects Use during the third trimester: can result in PPH of the newborn NB. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester SSRI →1st line in depression In adolescent's& children → Fluoxetine ( doesn't need gradual withdrawal) Post MI → Sertraline REVIS A I S MR ON ON MR I S A REVIS  Antipsychotics Antipsychotics are a group of drugs used in the management of schizophrenia and other forms of psychosis, mania and agitation. They are usually divided into typical and atypical antipsychotics: Typical antipsychotics Atypical antipsychotics Dopamine D2 receptor Mechanism antagonists, blocking Act on a variety of receptors (D2, of action dopaminergic transmission in the D3, D4, 5-HT) mesolimbic pathways Extrapyramidal side-effects and Adverse Extrapyramidal side-effects and hyperprolactinaemia less effects hyperprolactinaemia common common Metabolic effects Clozapine Haloperidol Examples Risperidone Chlorpromazine Olanzapine Specific warnings when antipsychotics are used in elderly patients: Increased risk of stroke Increased risk of venous thromboembolism REVIS A I S MR ON ON MR I S A REVIS Extrapyramidal side-effects (EPSEs) Parkinsonism Acute dystonia Sustained muscle contraction (e.g. torticollis, oculogyric crisis)M maybe managed with procyclidine Akathisia (severe restlessness) Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, most common is chewing and pouting of jaw), may occur in 40% of patients, may be irreversible, Other side-effects: Aantimuscarinic: 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) REVIS A I S MR ON ON MR I S A REVIS  Extrapyramidal Syndromes A form of restlessness which will present as constant pacing up Akathisia and down, or the patient describing an inability to sit still. A side effect of antipsychotics that occurs after many years. It typically affects the face and involves repetitive, involuntary, Tardive dyskinesia writhing movements such as grimacing, tongue protrusion and lip smacking Mimics Parkinson's disease, such as bradykinesia, cogwheel Parkinsonism rigidity and shuffling gait. A symptom of mental illness and patients usually appear to be in a Catatonia stupor, maintain odd postures and appear awake but unresponsive to external stimuli. Oculogyric crisis It is a form of acute dystonic reaction. Signs can include : Eye pain An abnormal posture. Examination: Neck is fixed backwards and laterally Eyes are deviated upwards. Unable to control gaze. Tongue protrusion and jaw spasm. Treatment: is usually IV procyclidine and withdrawal of the causative medication. REVIS A I S MR ON ON MR I S A REVIS  Atypical antipsychotics Atypical antipsychotics should now be used first-line in patients with schizophrenia The main advantage of the atypical agents is a significant reduction in extrapyramidal side- effects. Examples of atypical antipsychotics: Clozapine: associated with agranulocytosis Olanzapine: higher risk of dyslipidemia and obesity Risperidone Quetiapine Amisulpride Aripiprazole: generally good side-effect profile, particularly for prolactin elevation Adverse effects of atypical antipsychotics: Weight gain especially with Olanzapine Agranulocytosis especially with Clozapine Hyperprolactinaemia Clozapine 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%) : Full blood count monitoring is therefore essential during treatment. 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 REVIS A I S MR ON ON MR I S A REVIS  Monitoring Antipsychotics The monitoring requires for patients taking antipsychotic medication are extensive. Test Frequency Full blood count (FBC), At the start of therapy urea and electrolytes Annually (U&E), liver function Clozapine requires much more frequent monitoring of tests (LFT) FBC (initially weekly) At the start of therapy Lipids, weight At 3 months Annually At the start of therapy Fasting blood glucose, At 6 months prolactin Annually Baseline Blood pressure frequently during dose titration Electrocardiogram Baseline Cardiovascular risk Annually assessment REVIS A I S MR ON ON MR I S A REVIS  Tricyclic antidepressants Tricyclic antidepressants (TCAs) are less commonly used 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. The primary mechanism by which TCAs exert their antidepressant effects is through the inhibition of the reuptake of neurotransmitters Serotonin (5-HT): This neurotransmitter has a pivotal role in mood regulation. Inhibition of its reuptake leads to increased concentrations in the synaptic cleft, enhancing serotonergic neurotransmission. Noradrenaline (NA): Similar to 5-HT, blocking the reuptake of NA increases its synaptic cleft concentration, intensifying noradrenergic neurotransmission As well as 5-HT and NA, tricyclics interact with number of other receptors that contribute to their side-effect profile: dry mouth Antagonism Antagonism of blurred vision Drowsiness of muscarinic histamine receptors constipation receptors urinary retention Antagonism of Postural Lengthening of QT interval adrenergic receptors hypotension Tricyclic antidepressants can cause overflow incontinence (anticholinergic effect) REVIS A I S MR ON ON MR I S A REVIS 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 Less sedative Amitriptyline Imipramine Clomipramine Lofepramine Dosulepin Nortriptyline Trazodone* Mirtazapine Mirtazapine is an antidepressant that works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters. Benefits: 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. Side effects: Sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite. Dosing: It is generally taken in the evening as it can be sedative. NB. Mirtazapine is generally more sedating at lower BNF doses (e.g. 15mg) than higher doses (e.g. 45mg) REVIS A I S MR ON ON MR I S A REVIS  Benzodiazepines Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels. Medical uses: Sedation Hypnotic Anxiolytic Anticonvulsant Muscle relaxant Tolerance: Patients commonly develop a tolerance and dependence to benzodiazepines, thus they are only prescribed for a short period of time (2-4 weeks). 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 Example of benzodiazepine: Alprazolam (Xanax®), chlordiazepoxide (Librium®), clorazepate (Tranxene®), diazepam (Valium®), halazepam (Paxipam®), lorzepam (Ativan®), oxazepam (Serax®), prazepam (Centrax®), and quazepam (Doral®). Clonazepam (Klonopin®), diazepam, and clorazepate Lorazepam belongs to the benzodiazepine class of drugs, also used in anaesthesia One of the side effects of this drug is that this can cause antero-grade amnesia. Def: Where memory recall and the creation of new memories is significantly impaired. REVIS A I S MR ON ON MR I S A REVIS 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 Withdrawal: 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 REVIS A I S MR ON ON MR I S A REVIS You review a 55-year-old woman who has become dependant on temazepam, which was initially prescribed as a hypnotic. She is keen to end her addiction to temazepam and asks for help. Her current dose is 20mg on. What is the most appropriate strategy? Switch to the equivalent zopiclone dose then slowly withdraw over the next 2 weeks Switch to the equivalent diazepam dose then slowly withdraw over the next 2 weeks Switch to the equivalent zopiclone dose then slowly withdraw over the next 2 months Switch to the equivalent diazepam dose then slowly withdraw over the next 2 months Explanation most appropriate strategy for this patient is to switch to the equivalent diazepam dose then slowly withdraw over the next 2 months. This approach is recommended because diazepam has a longer half-life than temazepam, which allows for a smoother and more gradual withdrawal process. Additionally, UK guidelines support using diazepam as the preferred benzodiazepine for withdrawal due to its long half-life and availability in lower doses, which facilitates gradual tapering. REVIS A I S MR ON ON MR I S A REVIS  Anticholinergic drugs Mechanism: inhibit effects of acetylcholine, neurotransmitter involved in muscle movement, heart rate regulation, learning and memory. Example: atropine and scopolamine Glutamate inhibitors Mechanism: It is an excitatory neurotransmitter in CNS and its inhibition would indeed result in reduced neuronal activity similar to enhancing GABA's effects. Drugs that do this are typically NMDA N-methyl-D-aspartate receptor antagonists like memantine used in Alzheimer's disease treatment. Noradrenaline (norepinephrine) inhibitors Used as antihypertensives or antidepressants such as beta-blockers or selective noradrenaline reuptake inhibitors (NARIs). Electroconvulsive therapy Indication: If all other treatments (CBT, anti-depressants) have failed If the situation is life threatening e.g. Patient not eating and drinking Severe psychotic depression Not talking Prognosis: People with mild depression, the majority end up to have a spontaneous recovery Average length of depression episode is 6-8 months Risk of recurrence: 50% after 1st episodes REVIS A I S MR ON ON MR I S A REVIS  Lithium Lithium is mood stabilising drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys. Mechanism of action: not fully understood, two theories: interferes with inositol triphosphate formation interferes with cAMP formation Adverse effects: nausea/vomiting, diarrhoea fine tremor nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus thyroid enlargement, may lead to hypothyroidism ECG: T wave flattening/inversion weight gain idiopathic intracranial hypertension leucocytosis hyperparathyroidism and resultant hypercalcaemia Monitoring of patients on lithium therapy: inadequate monitoring of patients taking lithium is common when checking lithium levels, the sample should be taken 12 hours post-dose after starting lithium levels should be performed weekly and after each dose change until concentrations are stable once established, lithium blood level should 'normally' be checked every 3 months after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable. thyroid and renal function should be checked every 6 months patients should be issued with an information booklet, alert card and record book REVIS A I S MR ON ON MR I S A REVIS  REVIS A R IO MS N MS N IO R A REVIS Design By Malak Yasser 01116331567 [email protected]