Psychiatry Quick Revision Notes PDF

PSYCHIATRY QUICK REVISION NOTES BASICS OF PSYCHIATRY related thalamic and cortical areas) 2. Control/regulation - Frontal lobeQ COMPONENTS OF MSE (MENTAL...

PSYCHIATRY QUICK REVISION NOTES BASICS OF PSYCHIATRY related thalamic and cortical areas) 2. Control/regulation - Frontal lobeQ COMPONENTS OF MSE (MENTAL B. Perception - STATUS EXAMINATION) Perception involves receiving information and MSE- The clinical examination in psychiatry is called processing it. Two important disturbances of as MSE (mental status examination) perception are: A. Mood and Affect - Both terms 1. Illusions: ‘False perception of a real object’. reflect ‘emotions’ E.g, A man mistakes a rope for a snake and gets frightened.Q Mood- Sustained (long-term) and internal emotional state 2. Hallucinations: ‘False perception in the absence of any object or stimulus’ E.g. A man saw a snake on Affect- Short-lived and external expression of the ground when there was nothing there. internal emotions that can be observedQ The terms ‘affect’ and ‘mood’ are used Properties of hallucinations: interchangeably 1. Occur in the absence of any sensory or perceptual stimulus. Abnormalities of affect and mood- 2. Are as vivid (clear or detailed) as true perceptions. 1. Euphoria- Excessive happiness without any reason. In mania/hypomania 3. Are experienced in the outer objective space. E.g. A patient with auditory hallucinations reported 2. Dysphoria (dysphoric mood) - Irritability (In that the voices are coming from outside, such as mania) from the wall or outside the house. 3. Labile mood or emotional lability - Excessive 4. Are not under the wilful control of the patient. variations in the mood without any apparent reason. The patient can neither start the hallucinations E.g.- A man starts crying and then starts laughing nor can he stop them. the next moment, without any apparent reason. In mania Pseudohallucinations fulfil the other criteria but are experienced in the ‘inner and subjective space’. E.g. 4. Affective flattening (flat affect, emotional A patient with auditory pseudohallucinations reported blunting, blunt affect): Lack of emotional response. that the voices are originating from within his mind In schizophreniaQ and not from outside.Q 5. Anhedonia-Loss of capacity to experience pleasure in activities that were previously pleasurable. Can Specific hallucinations: be seen in depression, and schizophrenia.Q 1. Hypnagogic hallucination- While ‘’going to sleep”. In Neuroanatomy of emotions narcolepsy. 2. Hypnopompic hallucination - While getting up from 1. Generation- Limbic system ((hippocampus, sleep. In narcolepsy amygdala, hypothalamus, cingulate gyrus and 152 Cerebellum Quick Revision Notes 3. Reflex hallucinations - Stimulus in one modality b. Loosening of association: Loss of connection produces hallucinations in another modality. E.g. between components of the same thought. “Whenever I see a tube light (stimulus- visual c. Incoherence (Word salad): Complete lack modality), I start hearing the voice of Deepika of organization that makes the thought Padukone” (hallucination- auditory modality). It’s incomprehensible and impossible to understand. a morbid variety of synesthesia (syn=combination, aesthesia=sensations). Seen in cannabis and d. Neologism: Coining of a new word whose lysergic acid diethyl amide (LSD) intoxication.Q derivation cannot be understood. For example, a patient used the word “tintintapa” for a pen. 4. Phantob limb hallucinations- Sensations felt after amputation, in the body part which was removed 3. Disorders of content:Q Delusion is a disorder of during amputation. the content of thought. Delusion is: 5. Third person auditory hallucination- The patient a. A false belief hears atleast ‘two voices’ which discuss or argue b. Firm, fixed, and unshakeable (continues despite about the patient in the third person. Referring evidence against it) the patient as “He/She/Him/Her” c. Unexplained by social and cultural background C. Thought Types of delusions: The terms “cognition” and “thought” are often used interchangeably. The disturbances of “thought” can Delusion of persecution: The most commonQ be further subdivided into: type of delusion. The patient believes that he is being harmed. For example, “My family members 1. Disorders of the stream (flow) of thought: The want to kill me and take away my property.” stream of thought basically refers to the speed and continuity of thinking. The abnormalities Delusion of reference: The patient believes include: that neutral events happening around him are somehow related to him. For example, “Doctor, a. Flight of Ideas: Thoughts follow each other the tube light in your room has a camera fitted rapidly, and the connection between successive which is recording me.” thoughts appears to be due to chance factors such as rhyming. For example, a patient said, “I Delusion of grandeur/grandiosity: The patient live in Delhi, I like eating jelly, my cat has a big believes that he has some special power/role/ belly.” This is seen in mania. identity. For example, “I am so powerful that I can push a train with my bare hands.” b. Perseveration: Repetition of the same response beyond the point of relevance. For example: Delusion of love (erotomania, de Clerembault syndrome, fantasy lover syndrome):Q Patients Q. What is your name? develop a false belief that someone is in love Ans: Mahesh Kumar with them. For example, a rickshaw puller who had never left his town claimed that Katrina Q. Where do you live? Kaif is in love with him and was forced to marry Ans: Mahesh Kumar some other guy by big producers. Q. How many children do you have? Delusion of infidelity (morbid jealousy, pathological jealousy, Othello syndrome): The Ans: Mahesh Kumar patient has a false belief that the partner/ 2. Disorders of form: The form of thought refers to spouse is having an affair. the organization of thinking/association between Delusion of guilt: The patient develops guilt thoughts. In disorders of the form of thought or at a delusional level. The patient may claim “formal thought disorders,” there is a disturbance that he is an evil person and has committed in the organization of thinking. The important unpardonable sins. Usually seen in patients with formal thought disorders include: severe depression. a. Derailment:Q Loss of connection between Nihilistic delusion (delusion of negation, Cotard successive thoughts. syndrome): Patients may deny the existence of  153 Psychiatry their body, their mind, or the world in general. repeat them back. For example, a patient with severe depression –– The test begins with a single digit and claimed that all his internal organs have rotted. gradually progresses to longer sequences Delusion of enormity: The patient believes (e.g. two-digit, three-digit, etc.) until the that their action will cause a catastrophe. At patient is unable to accurately repeat the times, patients with the delusion of negation numbers. also develop delusion of enormity. For example, –– An inability to repeat at least five digits a patient said, “I cannot urinate because if I indicates defective attention. urinate, there will be floods all around the world. If I sneeze, the world will blow away.” –– E.g. If the examiner says 1,4,2,6,9; the patient should be able to repeat and say Delusion of misidentification (misidentification 1,4,2,6,9. syndrome):Q –– A variation is the digit backward test, where a. Capgras syndrome (Delusion of doubles): if the examiner says 1,4,2,6,9; the patient is The patient believes that a familiar person supposed to say 9,6,2,4,1, can also be used. has been replaced by a “similar-looking stranger.” –– Digit repetition test (digit forward test) is Close Person Got Replaced By A Stranger preferred over digit backward test. b. Fregoli syndrome:Q The patient believes 2. Concentration - Ability to sustain attention for a that a familiar person is changing the longer duration. physical appearance and disguising as a –– Tested using Serial Seven Subtraction Test stranger. And that multiple different in which the patient is asked to serially appearances can be taken by this person. subtract 7s from 100 (100, 93, 86, 79….) Familiar person giving goli 3. Memory · Three different types of memory-. –– Immediate memory/Working memory 4. Disorders of Possession: –– For intervals of seconds. Tested using In disturbances of possession of thought, the patient the digit repetition test or serial seven may believe that someone is manipulating or interfering subtraction test. with their thoughts. Alternatively, they may feel that they have lost control over their thoughts. –– Recent memory - For minutes, hours or days. Tested using 24-hour recall method. Thought insertion: “My neighbor is putting thoughts in my mind.” –– Remote memory- For years, tested by asking for both personal information and historical Thought withdrawal: “My neighbor withdrew/ events. E.g.: Which school did you go to? stole thoughts from my mind.” When did India win the world cup? Thought broadcast: The patient experiences Clinical relevance- Dementia affects recent memory that thoughts are escaping his mind, and others first and remote memory in later stages. can access them. 4. Judgement- Ability to take the right decision Obsessions:Q A thought comes repeatedly into according to the situation. Three types of the patient’s mind against his will. judgments are there- D. Higher mental functions a. Test judgment: Here, a test situation is given, and the patient is asked to give the appropriate 1. Attention- Ability to attend to a specific stimulus response in that situation. The commonly asked without getting distracted. question is what would the patient do if he sees –– Tested using the Digit Repetition Test (also a “house on fire” and the response is evaluated. known as the Digit Span Test). 5. Insight: Insight is defined as the ‘awareness of –– During the test, the examiner recites a series the illness’. Insight is rated on a five-point scale: of numbers, and the patient is required to –– Grade 1: Absent insight (e.g. ‘I don’t have any 154 Cerebellum Quick Revision Notes problem) –– Dopamine and serotonin hypothesis –– Grade 2: Some awareness of being sick but ƒƒ Excessive levels of dopamine & serotonin denying it at the same time (e.g., At times, cause schizophrenia I hear some voices, but there is no illness) Genetic factors –– Grade 3: Awareness of being sick but –– DiGeorge syndrome (22q11.2 deletion, attributing the symptoms to external or velocardiofacial syndrome) physical factors. (e.g., Yes, I hear voices, and it is because my neighbours have installed a ƒƒ 30% develop schizophrenia by the time hidden speaker to trouble me) they reach adulthood –– Grade 4: Intellectual Insight, awareness of SYMPTOMS illness without any accompanying changes in behaviour. e.g., I know I have schizophrenia, Positive symptoms (Or psychotic symptoms) but I don’t want to take any medicines or –– Delusions -- M/C is delusion of persecution treatments. –– Hallucinations -- M/C - auditory hallucinations, –– Grade 5: Emotional Insight, awareness of 2nd M/C - visual hallucinations illness along with the accompanying changes in the behaviour. It’s the highest level of –– Neurobiology- Dopamine excess in the insight. e.g. I have schizophrenia, and I want mesolimbic tract (ventral tegmental area to take regular medications to prevent any to nucleus accumbens) leads to positive relapses. symptoms. –– Both these positive symptoms respond well to CLASSIFICATORY SYSTEMS medicationsQ A. ICD-11 (International Classification of Diseases, –– Good prognostic factor 11th edition): Published by WHO Negative symptoms B. DSM-5-TR (Diagnostic and statistical manual of –– Avolition - Loss of drive for goal-directed mental disorders, text revision) - Published by activities American Psychiatric Association –– Anhedonia -Lack of pleasure in previously pleasurable activities SCHIZOPHRENIA AND OTHER –– Asociality -Lack of social interaction PRIMARY PSYCHOTIC DISORDERS –– Affective flattening (Or emotional blunting) HISTORY - Lack of emotional response –– Neurobiology- Decreased dopamine in the Epidemiology mesocortical tract (Ventral tegmental area Lifetime prevalence: 1% to the prefrontal cortex) results in negative Equally prevalent in men and women; however, symptoms. the onset of illness is earlier in males and later –– Respond poorly to medications in females –– Poor prognostic factors Age of onset- adolescence and young adulthood (15-24 years) Disorganization symptoms –– Disorganized behaviour (odd & socially ETIOLOGY & PATHOGENESIS inappropriate behaviour) Neurotransmitter hypothesis –– Disorganized speech and thinking (Formal Thought Disorders) –– Dopamine hypothesis –– Inappropriate affect ƒƒ Excessive levels of dopamine cause schizophrenia Motor symptoms (Catatonic symptoms/  155 Psychiatry symptoms of conation) attempt suicide Motor symptoms include –– M/C cause of premature & unnatural death in –– Stupor- A state of extreme inactivity schizophrenia. or immobility (akinesis) & minimal Risk factors for suicide in a patient with responsiveness. schizophrenia- –– Waxy flexibility Q - It is the feeling of plastic –– Presence of a major depressive episode resistance that the examiner experiences (similar to what is experienced while –– Increased symptoms (esp. command bending a wax candle) while making a passive hallucinations, delusion of persecution) movement on the patient. –– Early in course of illness, immediately after –– Posturing- Maintenance of a posture for a admission or discharge long period of time –– Young males, comorbid substance abuse, –– Echolalia - Repetition of speech unemployed –– Echopraxia- Repetition of behaviour –– At times paradoxical (Fewer negative symptoms, less affect disturbances) –– Grimacing - Maintenance of odd facial expressions Duration Criteria –– Ambitendency- Inability to decide the motor According to DSM-5, for the diagnosis of movements schizophrenia, the total duration of illness –– Stereotypy - Spontaneous, repetition of odd should be at least six months. purposeless movements According to ICD-11, the duration criterion of –– Mannerisms- Spontaneous repetition of ICD-11 is one month and not six months. semi-purposeful movements, done in an exaggerated manner. TREATMENT –– PerseverationQ - Induced movement, Antipsychotics are the mainstay of treatment repeated beyond the point of relevance. in schizophrenia It is suggestive of organic brain disorder. Two special types of perseveration Duration of treatment. For first episode, at least one year of treatment needs to be given. Suicide and violence For more than one episodes, atleast 5 years of –– 10% of patients with schizophrenia die by treatment is recommended.Q suicide (DSM-5 figure: 5-6%) Typical antipsychotics and atypical –– 20%-50% of patients with schizophrenia antipsychotics Typical (FGA) Atypical (SGA) Mechanism D2 antagonism D2 and 5HT2 antagonism Effective against Positive symptoms Positive and Negative symptoms Extrapyramidal symptoms & More Less hyperprolactinemia Metabolic side effects Less More 156 Cerebellum Quick Revision Notes Typical antipsychotics (First generation Acute akathisia antipsychotics)- –– Commonest side effect of antipsychotics Classification according to chemical groups- –– Characterised by an inner sense of Phenothiazines-Chlorpromazine, restlessness along with objective signs of trifluoperazine, thioridazine, prochlorperazine, restlessness such as fidgeting of legs, pacing triflupromazine, fluphenazine, perphenazine around, and inability to sit or stand in one place for a long time Thioxanthenes- Thiothixene, flupenthixol –– DOC - PropranololQ Butyrophenones- Haloperidol, droperidol, –– Anticholinergics, benzodiazepines can also be penfluridol used. Miscellaneous- Pimozide, loxapine, molindone Tardive dyskinesia Side effects –– The term ‘tardive’ means long-term and A. Movement disorders (or extrapyramidal side dyskinesia means abnormal movements effects or EPS)Q –– Develops after long-term treatment with –– Caused by the blockade of dopamine antipsychotics receptors in the nigrostriatal tract (neural –– Can present with involuntary movement of pathway from substantia nigra to striatum) jaw (chewing movements), lips (pouting, –– More common with typical antipsychotics puckering, smacking) or extremities than atypical antipsychotics –– Choreiform (rapid, jerky, nonrepetitive) or –– More common with parenteral administration athetoid movement (slow, sinusoid) than oral administration –– Rabbit syndrome - Rhythmic motions of the Drug-induced parkinsonism mouth along a vertical planeQ –– Symptoms: Tremors (3-6 Hz), Rigidity, –– Cause- Long term use of antipsychotics and Bradykinesia accompanying blockade of D2 receptors results in D2 receptors up-regulation –– Prophylaxis - Anticholinergics (E.g. along with postsynaptic dopamine receptor trihexyphenidyl, diphenhydramine etc) supersensitivity.Q –– Treatment - Anticholinergics (E.g. –– Treatment- Shift to second generation trihexyphenidyl, diphenhydramine etc), shift antipsychotics, Use of Valbenazine, to second generation antipsychotics. Tetrabenazine, and Deutetrabenazine. Acute dystonia Neuroleptic malignant syndrome –– Symptoms - Sudden contraction of a muscle –– Symptoms - Muscle rigidity, elevated group resulting in symptoms like torticollis, temperature (greater than 38°C), and trismus (contraction of jaw muscles), increased CPK (creatine phosphokinase) levels. deviation of eyeballs (oculogyric crisis due –– Other symptoms- diaphoresis, tremors, to contraction of extraocular muscles), confusion, autonomic disturbances, liver laryngospasm, etc enzyme elevation and leukocytosis. –– Earliest side effect of antipsychoticsQ –– Pathophysiology- D2 blockade in- –– More common in young males ƒƒ Corpus striatum causes muscle rigidity –– Treatment - Parenteral anticholinergics (e.g. that generates heat. i.m. promethazine) ƒƒ Hypothalamus interferes with heat –– Prophylaxis - Anticholinergics (E.g. regulation trihexyphenidyl, diphenhydramine etc) ƒƒ Spinal neurons causes autonomic disturbances  157 Psychiatry ƒƒ Muscle injury causes an increase in CPK Clozapine levels Treatment-resistant schizophrenia (TRS)- ƒƒ Continuing muscle damage can cause Lack of response to at least two different myoglobinuria and renal failure. antipsychotics, including at least one second- –– Treatment- Withdraw antipsychotic, generation antipsychotic, given in adequate adequate hydration, dantrolene is the drug of dosage and for an adequate duration (at least choice, dopamine agonists like bromocriptine 4-6 weeks) and amantadine can be used too. Clozapine is the drug of choice (DOC) in TRS. –– How to restart the antipsychotics? - Keep the Unique mechanism of action- More affinity for patient antipsychotic-free for 2 weeks, then D4 than D2, hence causes minimal EPS. start with second-generation antipsychotics. Antipsychotic that causes max weight gain B. Endocrine side effects Clozapine is the only antipsychotic with Blockade of dopamine receptors in antisuicide property the tuberoinfundibular tract causes hyperprolactinemia (remember dopamine Side effects of clozapine inhibits prolactin secretion) Life-threatening: Agranulocytosis Symptoms- Galactorrhoea, menstrual (idiosyncratic), myocarditis (idiosyncratic), disturbances in females, Sexual dysfunction, seizures (dose-dependent) low libido in males Sedation (most common), sialorrhea Atypical antipsychotics (Second Syncope, hypotension, tachycardia, nausea, generation antipsychotics) vomiting Clozapine, olanzapine Weight gain, anticholinergic side effects Risperidone, paliperidone, iloperidone Due to the possibility of agranulocytosis, when a patient is on clozapine, ANC and TLC monitoring is Quetiapine, ziprasidone, aripiprazole required. The regime of monitoring- Sertindole, zotepine, lurasidone –– First 6 months- Once a week Asenapine, amisulpride –– Next 6 months- Once in two weeks Newer ones - Brexpiprazole, cariprazine, –– After 1 year- Once in four weeks, till pimavanserin clozapine is continued Side effects of atypical antipsychotics Stop clozapine, if WBC2 hrs earlier than the usual waking time) –– Serotonin, norepinephrine and dopamine Reduced latency of REM sleep deficiency Sleep is usually decreased but may be increased too PSYCHOLOGICAL THEORIES OF DEPRESSION Duration Criterion Of Depression- 2 WeeksQ Cognitive theory of depression- Given by Aaron Specifiers Beck –– Negative thoughts have a central role in the In addition to the above-mentioned symptoms, the development of depression. patient may have other special features which are called ‘specifiers’. These include- –– Three negative thoughts are particularly important ( Beck’s cognitive triad)Q Psychotic symptoms/features (psychotic depression) ƒƒ Negative view of self (ideas of worthlessness) –– Presence of delusions/hallucinations ƒƒ Negative view of environment (ideas of Atypical features (atypical depression)Q helplessness) –– Reversed biological features (Increased ƒƒ Negative view of the future (ideas of appetite, weight and sleep) hopelessness) –– Mood reactivity present (mood improves with positive events) Treatment –– Leaden paralysis (subjective feeling of Pharmacotherapy heaviness of limbs and difficulty in moving Psychotherapy them) Other somatic treatments –– Extreme sensitivity to interpersonal rejection 160 Cerebellum Quick Revision Notes Pharmacotherapy –– Hyperprolactinemia (mostly with amoxapine) Antidepressants are chosen on the basis of TCA toxicity their side effect profile TCAs have a narrow therapeutic index First line- SSRIs are the first line due to better The following are the signs & symptoms of side effect profile TCA toxicity Onset of action- In 1-2 weeksQ –– CVS - hypotension, tachycardia, chest pain Maximum therapeutic effect- In 4-6 weeks –– CNS - altered sensorium, respiratory depression, convulsions Antidepressants –– ANS - dry mouth, blurred vision, urinary 1. Tricyclic and tetracyclic antidepressants (TCAs) retention Mechanism of action- Block serotonin & –– Metabolic acidosis (due to tissue hypoxia) norepinephrine reuptake transporters and hence increase the levels of serotonin and –– ECG changes- prolonged PR, QRS and QT norepinephrine. interval, AV block, right axis deviation Following drugs are TCAs Management of TCA toxicity –– Imipramine, desipramine, trimipramine –– If QRS > 100 ms, serum alkalinization using i.v. sodium bicarbonate is the mainstay of –– Amitriptyline, nortriptyline, protriptyline treatment –– Amoxapine, doxepin, maprotiline, –– Gastric lavage and activated charcoal can clomipramine be administered immediately after the Clomipramine- most serotonin-selective TCA overdosage. Desipramine- most norepinephrine selective TCA 2. Selective serotonin reuptake inhibitors (SSRIs) Mechanism of action- Act by blocking the Side effects of TCAs reuptake of serotonin. SSRIs do not have Due to muscarinic receptors blockade problematic side effects seen with TCAs. (anticholinergic side effects)Q SSRIs include fluoxetine, fluvoxamine, –– Constipation, urinary retention, dry mouth, citalopram, escitalopram, sertraline, paroxetine blurred vision, decreased sweating, delirium & vilazodone –– Can cause acute angle closure glaucoma Side effects of SSRIs –– Benign prostatic hyperplasia –– Gastrointestinal- nausea (most common),Q diarrhoea, constipation (more common with Due to alpha-adrenergic receptors blockade, paroxetine), anorexia cardiac sodium channel blockade –– Sexual side- Most common long-term side –– Postural hypotension effects, include low libido, delayed orgasm, –– QT prolongation and poor erection. The side effect of delayed orgasm is useful in patients with premature –– Tachycardia, rarely hypertension ejaculation (PME), hence SSRIs are often Other side effects used for the management of PME.Q –– Sedation (due to H1 blockade) –– CNS- anxiety, insomnia, sedation, vivid –– Weight gain dreams, sweating, seizures, emotional blunting, extrapyramidal side effects. –– Tremors –– QTc prolongation –– Seizures (due to excessive serotonin & norepinephrine receptors blockade) –– Anticholinergic side effects  161 Psychiatry –– Haematological - Platelet aggregation, –– NSSA (noradrenergic & specific serotonergic hyponatremia antidepressant) –– Weight gain –– Central α2 antagonism (increases norepinephrine and serotonin) Vortioxetine- A novel antidepressant with a unique mechanism of action that includes- –– Antagonism of 5HT2 and 5HT3 receptors –– Blockade of the reuptake of serotonin –– Side effects- sedation, wt gain and vivid dreams –– Agonism at 5HT1A, partial agonism at 5HT1B, antagonism at 5HT3, 5HT1D and 5HT7 –– Minimal sexual side effect Q receptors. Bupropion Q 3. Serotonin-norepinephrine reuptake inhibitors –– NDRI (norepinephrine dopamine reuptake (SNRIs) inhibitor) Mechanism of action- Blockade of the reuptake –– Side effects- insomnia, restlessness, of both serotonin and norepinephrine seizures SNRIs include venlafaxine, desvenlafaxine, –– Minimal risk of sexual side effects, weight duloxetine, milnacipran, levomilnacipran gain or sedationQ Some studies have found that SNRIs are more Antipsychotics effective than SSRIs in the management of severe depression. –– Use in the presence of psychotic features Side effect profile is similar to SSRIs. In –– Also for augmentation of antidepressants addition, SNRIs can cause anticholinergic side Psychotherapy effects and hypertension.Q Cognitive behavioural therapy (CBT)- Most Discontinuation syndrome commonly used psychotherapy in depression.Q Most effective and with the best evidence in Due to the sudden discontinuation of patients with depression antidepressants –– Focussed on fixing automatic negative Most commonly associated with venlafaxine, thoughts and cognitive distortions paroxetine and fluvoxamine –– As effective as antidepressants in mild The patient presents with the following depression symptoms (Mnemonic- FINISH) –– In pregnant and lactating women with –– F - Flu-like symptoms (fatigue, aches etc) mild depression, CBT is preferred over –– I - Insomnia antidepressants –– N - Nausea Other somatic therapies –– I - Imbalance (vertigo) 1. Electroconvulsive therapy (ECT)- First-line –– S - Sensory disturbances (paraesthesia) treatment in cases of - –– H - Hyperarousal (anxiety, irritability) Depression with suicide risk 4. Atypical antidepressants Depression with stupor Trazodone & nefazodone In patients with depression with psychotic symptoms or who are intolerant to antidepressants, ECT can be –– Mechanism of action- SARI (5HT2A and 5HT2C antagonism and reuptake inhibition) considered. –– Important side effect of trazodone - 2. Repetitive Transcranial magnetic stimulation priapism Q (rTMS) Mirtazapine Uses rapidly changing magnetic fields to produce small electric currents (known as eddy 162 Cerebellum Quick Revision Notes currents) in superficial cortical neurons. A - Activity levels increased Approved as a treatment modality in major F - Flight of ideas depressive disorder. A - Abnormally increased levels of activity/energy Non-convulsive, no anaesthesia required S - Sleep decreased (decreased need for sleep) (e.g. Other important diagnoses patient feels refreshed after 2 hours of sleep) T - Talkativeness (Overtalkativeness) 1. Recurrent depressive disorder- History of more than one depressive episode. G - Grandiose ideas and increased self-esteem (Increased self-confidence, maybe boastful, and may 2. Dysthymia (Dysthymic disorder)- Depressive make big claims) symptoms for more than 2 years; symptoms are not severe enough to make a diagnosis of even D - Distractibility mild depressive episode (subsyndromal depressive P - Painful consequences (involvement in activities with symptoms > 2yrs) potentially painful consequences like making foolish 3. Double depression- Depressive episode investments) superimposed over dysthymia. Duration criterion: At least 7 daysQ MOOD DISORDERS (BIPOLAR SPECIFIERS DISORDERS) Bipolar type I - Mania/Mixed + Depression Psychotic symptoms –– Even a single manic/mixed episode is enough Presence of delusions/hallucinations to make the diagnosis of Bipolar type I Hypomania disorder, however, most of these patients experience depressive episodes too. Symptoms- Similar to manic symptoms Bipolar type II - Hypomania + Depression Severity- Symptoms are the same but not as severe as in mania –– It is characterised by atleast one episode of hypomania and depression each Impairment- Less impairment in comparison to mania EPIDEMIOLOGY Duration- Atleast 4 daysQ Lifetime prevalence of Bipolar I- 1% Rapid cycling in bipolar disorders Sex ratio Four or more episodes in one year –– Bipolar I - Roughly equal (1.1:1) –– Bipolar II- More common in women TREATMENT OF BIPOLAR Mean age of onset DISORDER –– Bipolar I - 18 yrs 1. Acute manic episode or mixed episode For less severe symptoms, monotherapy with –– Bipolar II - Mid 20s mood stabilisers or atypical antipsychotics can Suicide rate in bipolar disorder- 4-19% be usedQ –– Mood stabiliser monotherapy (Lithium, SYMPTOMS OF MANIA Valproate/Divalproex, Carbamazepine) (MNEMONIC- MY ASIA FAST –– Atypical antipsychotic monotherapy GDP) For severe symptoms, a combination of mood M - Mood elevation (undue excessive happiness) or stabilisers and antipsychotics are preferred. irritable mood If in the exam, you are asked the DOC for  163 Psychiatry acute mania or severe mania, and you have to Therapeutic drug monitoring for lithium pick one class of drug, antipsychotics is the Lithium has a narrow therapeutic index. Following better answer. However, for the same question, are the effective serum concentration of lithium- if a combination of mood stabilisers and antipsychotics is one of the options, go for it. For acute mania- 1.0-1.2 mEq/L In presence of psychotic symptoms, For maintenance treatment- 0.4-0.8 mEq/L antipsychotics should be added to the treatment Lithium toxicity is usually seen when levels regime. are > 1.5 mEq/L; however, toxicity should be For mixed episodes - Valproate > Lithium suspected in the presence of relevant signs and symptoms irrespective of serum lithium 2. Acute depression (bipolar depression) levels. The following are first line treatments for acute Monitoring of serum lithium levels should be depression in a patient with bipolar disorder- done after 12 hours of the last dose. So if the –– Mood stabilisers (Lithium, lamotrigine). patient took the lithium at 9 pm at night, the According to American Psychiatric blood sample should be taken at 9 am in the Association (APA) guidelines, the first-line morning to measure the serum lithium levels. pharmacological treatment is the initiation of either lithium or lamotrigine. Side effects of lithium –– Olanzapine + Fluoxetine A. Neurological side effects –– Quetiapine Postural tremors (DOC- beta blockers)Q A combination of mood stabilisers + Lack of spontaneity (memory disturbances, antidepressants, can also be used, but in slowness of thinking) general antidepressants are avoided in a patient Raised ICT and peripheral neuropathy with bipolar disorder to avoid the risk of ‘manic switch’ B. Endocrine side effects Electroconvulsive therapy becomes the Hypothyroidism preferred modality in cases of high suicide risk. Rarely hyperthyroidism, hyperparathyroidism Concept of a manic switch- A patient with C. Renal side effects depressive symptoms, when prescribed an antidepressant, may switch from depression Most common is polyuria with secondary to mania. This is more likely to happen, if an polydipsia. Lithium interferes with the action underlying diagnosis of bipolar disorder was of ADH (antidiuretic hormone), resulting in missed, and the patient was treated with polyuria.Q antidepressants without adding the cover of May progress to Diabetes insipidus mood stabilisers. In case of a ‘manic switch’, stop the antidepressant, and start a mood Management of lithium-induced polyuria- Potassium-sparing diuretics like Amiloride, and stabiliser/antipsychotic. triamterene. Amiloride blocks the entry of Lithium lithium into the principal cell of collecting ducts by blocking the Na+ epithelial channels. Lithium Is a monovalent cation like Na+, and the body uses these Na+ epithelial channels to enter the handles lithium the way it handles Na+ collecting ducts. Lithium is rapid and completely absorbed after Thiazides can also be used for the management oral intake. of lithium-induced polyuria. Thiazides work Doesn’t bind to plasma proteins, not metabolised, by inducing hypovolemia, which in turn results and is excreted unchanged through the kidney. in increased proximal sodium and water reabsorption and decreasing water delivery to ADH sensitive collecting ducts & reducing urine output. 164 Cerebellum Quick Revision Notes Rare side effects- Nephrotic syndrome, renal –– Muscle fasciculations, increased DTR, tubular acidosis, interstitial fibrosis. convulsions, impaired consciousness, death D. Dermatological side effects Management of lithium toxicity Acne, psoriasis (worsening), hair loss, rashes Stop lithium E. Nausea, vomiting, wt gain, leukocytosis Correct dehydration F. Teratogenic side effect- Ebstein’s anomaly Use of sodium polystyrene sulphonate or Mnemonic of side effects of lithium (LITHIUM Q polyethylene glycol (to remove unabsorbed WASHER) lithium from GI). Activated charcoal is not useful L- Leukocytosis Hemodialysis, in severe cases.Q Usually, when I- Increased urination, polydipsia s.lithium levels are more than 3.5mEq/dl, but T- Tremors, clinical symptoms are given more importance than serum lithium levels. H- Hypothyroidism, hyperthyroidism, Hyperparathyroidism PREGNANCY AND MOOD I - Interstitial fibrosis STABILISERS U- Upset stomach (nausea, vomiting) Lithium M- Mother (ebstein’s anomaly) –– Can cause ebstein’s anomaly, ASD and VSD W- Weight gain –– Hence, high resolution ultrasound and A - Acne echocardiography is recommended in 6th and 18th week of pregnancy S - Psoriasis, Spontaneity (lack) –– Chances of lithium toxicity increase with H- Hairfall hypovolemia, chances may increase during E- ECG changes (T wave flattening or inversion) delivery/in postpartum period if there is excessive bleeding, R- Rash, Rental tubular acidosis Valproate Lithium toxicity –– Most teratogenic, use of valproate in Remember the body deals with lithium, the way it pregnancy must be avoided deals with sodium. –– High risk of NTD (neural tube defect in the Hence anything which causes hypovolemia or baby) if valproate is used hyponatremia would lead to increased sodium –– Child may have low IQ if mother using reabsorption in the kidney, and it would also result in valproate during the pregnancy increased lithium reabsorption, increasing the chances of lithium toxicity. Carbamazepine Low dietary intake, use of diuretics and –– Teratogenic, but not as much as valproate diarrhoea, increase the risk of lithium toxicity. –– Can cause NTD in the child Lithium has a low therapeutic index, and serum –– Can cause hemorrhagic disease in both lithium levels > 1.5mEq/dl increase the risk of mother as well as the child toxicity. –– In case carbamazepine is used in pregnancy, Symptoms of lithium toxicity- prophylactic vitamin K injections should be given to mother to prevent hemorrhagic GI symptoms- Abdominal pain, vomiting disease CNS symptoms Lamotrigine –– Coarse tremors, ataxia, dysarthria –– Considered safer than lithium, valproate and  165 Psychiatry carbamazepine 3. Postpartum psychosis AntipsychoticsQ Onset is within 2-3 weeks of delivery –– Much more safer than mood stabilisers, also Symptoms- Initial symptoms include tearfulness, effective. If a pregnant female develops a insomnia, and lability manic episode, chose antipsychotics over Later delusions (e.g baby is dead, didn’t give mood stabilisers. birth to child) and hallucinations develop. Psychiatric aspects of pregnancy There is a risk of harm to self or the baby. In some cases, the baby has to be separated from 1. Postpartum blues (baby blues)Q the mother to prevent harm to the baby. Seen in 30-75% of females after childbirth Postpartum psychosis is basically an episode Transient symptoms like tearfulness, sadness, of bipolar disorder, triggered by the stress of mood lability and sleep disturbances (basically child birth mild depressive symptoms) Mostly recovery is complete Onset is in 3-5 days of delivery In 50% of cases, the episode happens after Symptoms last for days to weeks delivery of the first child; in 50% cases, another perinatal complication is there, in 50% cases Support to mother is enough for resolution of there is a family history of mood disorders. symptoms 2/3rd of patients have another episode in the Diagnosis should be made on the basis of next 1 year symptoms, do not give too much importance to the onset of symptoms while solving the MCQs Treatment - Antipsychotics with lithium; antidepressants may be added if required. 2. Postpartum depression More severe depressive symptoms are present SUICIDE in comparison to postpartum blues. Suicide rate in India- 12 per lakh of the DSM-5 uses the diagnosis of “Depressive population (2021 data) episode with peripartum onset” for this clinical Method- Most common method of dying by condition. suicide is hanging, followed by the use of poisons Seen in 10-15% of females post delivery, CSF levels of 5 HIAA (5 hydroxyindoleacetic Symptom onset is within 3 months of acid) are inversely related with the suicide risk. delivery Remember, 5 HIAA is a metabolite of serotonin. Symptoms- Sadness, tearfulness, lability, sleep disturbances, anhedonia, suicidal thoughts/ Causes thoughts of harming baby, guilt Depression (most common cause of suicide) As is clear, the symptoms are more severe, and Schizophrenia that should be the basis of making the diagnosis. Alcohol dependence Often patients have a history of mood disorder, Borderline personality and antisocial personality and family h/o mood disorders is also often disorder present There is an increased risk of future depressive Risk factors of suicideQ episodes if a patient has a post partum Previous suicide attempt (most important risk depression episode. factor) Treatment - Pharmacotherapy and Signs of suicidal intent (e.g. writing a suicide psychotherapy. Treated along the lines of note, transferring money into the accounts of depression. relatives) 166 Cerebellum Quick Revision Notes Hopelessness All anxiety disorders are more common in Male sex females than males. Age> 45 years A. PANIC DISORDER Substance abuse Panic attack- It’s an acute attack of intense Delusions/Hallucinations anxiety, with a ‘feeling of impending doom’. Divorced, separated Patient may feel that ‘he is having a heart attack’, ‘he is about to die’, or that ‘he is about Unemployed to go crazy’.Q Chronic illness Usually panic attacks resolve in 20-30 minutes Family history of suicide Symptoms of a panic attack- Palpitations, Poor social support choking sensations, chest pain, dizziness, depersonalisation, derealisation H/o sexual abuse Panic disorder is characterised by recurrent Some related terms and unexpected panic attacks Copycat suicide- Instances have been reported Treatment where adolescents from the same social group die by suicide in succession. This phenomenon, A combination of pharmacotherapy and known as copycat suicide, occurs when one psychotherapy is preferred. person’s suicide influences the actions of PharmacotherapyQ others. –– Benzodiazepines (short term, tapered and Paradoxical suicideQ- Paradoxical suicide: In stopped) & SSRIs (long term) certain cases, a person with depression might die by suicide while their symptoms show signs Psychotherapy of improvement after beginning antidepressant –– Cognitive behavioural therapy (CBT) treatment. This is referred to as paradoxical suicide, as it occurs when symptoms have already started to improve. The hypothesis is that a B. SPECIFIC PHOBIAS depressed individual may not have the energy Phobia is defined as a strong, persistent & to act on suicidal thoughts initially; however, as irrational fear of an object or a situation. their condition begins to improve, their energy Common types of phobias levels increase before their suicidal thoughts subside. This creates a window of time during Nyctophobia Dark which the person has regained energy but still Acrophobia Heights experiences suicidal thoughts, and it is within Claustrophobia Closed spaces this window that they may die by suicide. Ailurophobia Cats ANXIETY OR FEAR RELATED Cynophobia Dogs DISORDERS Mysophobia Germs or dirt Pyrophobia Fire SYMPTOMS OF ANXIETY Xenophobia Strangers Sweating, tremors, restlessness, tachycardia, Thanatophobia Death mydriasis Hydrophobia Water –– Increased urinary frequency, diarrhoea –– Hyperreflexia, cold clammy skin Treatment –– Feeling of nervousness Pharmacotherapy  167 Psychiatry –– Benzodiazepines (short term, tapered and E. SELECTIVE MUTISM stopped) & SSRIs (long term) More common in children and is comparatively –– Beta blockers can be used less common in adolescents/adults. –– Psychotherapy- Behavioural therapy is the Characterised by a consistent failure to speak preferred psychotherapy for patients with in one or more specific social situations (usually specific phobias. the school setting) while speaking fluently in other more familiar situations, such as at home. C. GENERALISED ANXIETY Treatment- SSRIs and CBT (cognitive DISORDER behavioural therapy). Characterised by excessive worries and anxiety about minor and everyday issues; hence the OBSESSIVE-COMPULSIVE & patient is almost always anxious (the term RELATED DISORDERS ‘free-floating anxiety is used to describe this persistent anxiety)Q A. OBSESSIVE COMPULSIVE In addition, there are somatic symptoms of DISORDER anxiety such as Obsessive compulsive disorder (OCD) is –– Restlessness, easy fatigue, muscle tension characterised by obsessions and compulsions –– Poor concentration, insomnia, irritability Obsessions are- Treatment- –– Recurrent, intrusive thoughts, images or impulses, which cause anxiety (e.g. a –– Pharmacotherapy- Benzodiazepines (short repetitive thought that ‘my hands are term, tapered and stopped) & SSRIs (long unclean’)Q term). –– Patient considers them as a product of their –– Psychotherapy- CBT own mind (D/d thought insertion)- Patient considers ‘obsessions’ as his own thoughts, D. SEPARATION ANXIETY whereas a patient with thought insertion DISORDER says that ‘someone is inserting thoughts in the mind’ More common in children and is comparatively less common in adolescents/adults. –– Patient finds them excessive, irrational and senseless, at some time during the illness Characterised by a persistent and excessive (D/d delusions) - Patient with obsessions fear of separation from prominent attachment usually doesnt believe in the obsessive figures (such as parents), which manifests in thoughts that he gets, whereas a patient the form of reluctance to go to school, work, with delusion believes in the content of or away from home, or sleep in a separate room delusion. If separation happens, the child may experience –– Patient tries to resist or neutralize them physical symptoms such as abdominal pain or headache. Compulsions are Fear that something bad will happen to the –– Repetitive behaviours / mental acts attachment figures or to self, in case of performed in response to obsessions separation –– They reduce anxiety temporarily Treatment- SSRIs and CBT (cognitive –– E.g. The patient who repeatedly gets the behavioural therapy). thought that ‘my hands are unclean’ washes his hands despite knowing that they are not unclean. This washing of hands is a ‘compulsion’. 168 Cerebellum Quick Revision Notes Both obsessions and compulsions are ego- Magical thinking- Just because they thought dystonic (thoughts/behaviours which are not about an event, it will occur in reality. E.g. A agreeable to self, i.e., unwanted thoughts/ patient would repeatedly have a thought, “If behaviours) Q I do not knock on the door three times, the mother will die” Duration criterion for making the diagnosis - 2 weeks Most common obsession- Obsession with contamination. Lifetime prevalence: 2-3%, more common in females Most common compulsion- Compulsion of washing. Most common comorbidity with OCD is depression Treatment Etiology A combination of pharmacotherapy and psychotherapy gives better results Neurotransmitter- Primarily caused by serotonergic dysfunction Pharmacotherapy Circuit involved- Dysfunction in the cortico- –– SSRIs and clomipramine (first-line striato-thalamico-cortical tract (a neural treatment) circuit that starts in the orbitofrontal cortex –– Antipsychotics (used for augmentation) and anterior cingulate cortex, and projects to the striatum, from the striatum to the thalamus –– Li, Valproate, carbamazepine, venlafaxine and back to the cortex) has been hypothesized (can be used) to be responsible for the development of OCD. Psychotherapy Symptom patterns –– Exposure and response prevention (kind of CBT/BT)- Therapy of choiceQ Q Obsession of contamination with compulsion of washing and avoidance- This is the most common presentation of OCD wherein patients have an B. HOARDING DISORDER obsession of contamination (e.g., the thought Characterised by an inability to discard things, that hands are contaminated with dirt) followed that are of little or no value & fear of losing by compulsion of washing something important Pathological doubt with compulsions of checking- In DSM-5 and ICD-11, hoarding disorder has This is the second most common pattern where been made a separate diagnosis, earlier it was patients have obsessions of doubt followed considered as a type of OCD by compulsions of checking. For example, a housewife would have repeated doubts about Treatment- SSRIs and CBT whether she locked the door properly and would Exposure and response prevention is not so repeatedly check it. effective in the management of hoarding Intrusive thoughts (usually with mental disorder. compulsions)- The third most common pattern is characterized by repetitive, intrusive C. BODY DYSMORPHIC DISORDER thoughts without any apparent compulsions. These obsessive thoughts often revolve around Characterised by a preoccupation with an themes of religion, aggression, or sexuality and imagined defect in the physical appearance. often cause significant guilt and distress in the If a slight physical anomaly is present, the patient. concern regarding it is clearly excessive. Symmetry or precision with compulsion of There are repetitive behaviours such as mirror slowness- In this fourth most common pattern, checking or repeatedly asking others about the patients have an extreme need for symmetry or ‘physical anomaly’ precision along with the compulsion of slowness. Usually, the preoccupation is about hair, nose  169 Psychiatry or skin repetitive events that involve exposure to actual/threatened death, serious injury or Treatment- SSRIs and CBT sexual violence to self or others E.g.-Trauma such as earthquake/ floods, wars, D. BODY FOCUSSED REPETITIVE murder, rape, serious accidents etc. BEHAVIOUR DISORDER- Clinical symptoms of PTSD It is characterised by repetitive actions –– Intrusion symptoms such as directed at the integument (skin, hair) and the inability to stop them. It includes- ƒƒ Flashbacks (patient may feel as if the traumatic event is happening again and –– Trichotillomania- It is characterised by- may also act as if he is in the middle of ƒƒ Repetitive hair pulling, resulting in hair the traumatic event loss. ƒƒ Vivid memories of the trauma, nightmares ƒƒ Patients have an impulse to pull out their about the trauma hair and try to resist it –– Avoidance of situations that remind of the ƒƒ But the feeling of tension increases, trauma driving them to engage in hair-pulling –– Arousal symptoms such as hypervigilance ƒƒ The act brings a sense of relief and, at (a state of excessive alertness) and times, pleasure exaggerated startle response ƒƒ A subset of patients chew or swallow the –– Other symptoms such as emotional numbing, hair they pull (trichophagy) emotional detachment and anhedonia ƒƒ Trichophagy may lead to complications such –– To make the diagnosis of PTSD, the as trichobezoars (hairball accumulation in symptoms should be present for more than the intestine), intestinal blockages, and one month. malnutrition. –– Excoriation disorderQ - It is characterised Treatment of PTSD by- SSRIs (drug of choice)Q ƒƒ Repetitive picking of the skin resulting in CBT (treatment of choice) skin lesions Eye movements desensitisation and reprocessing ƒƒ The impulse, increasing tension and the (EMDR)- A technique that has been developed feeling of relief/pleasure is similar to for the management of PTSD. what happens in trichotillomania. Treatment B. ADJUSTMENT DISORDERS SSRIs and Behavioural therapy (e.g. habit reversal May develop after traumatic events which are technique, in which the patient learns to identify and critical but not uncommon in the course of life be aware of the urge that precedes hair pulling and E.g. Relationship issues, change of job, migration, then replaces the act of hair-pulling with some other death of a loved one voluntary acts such as making a fist) Symptoms- Presents with anxiety and depressive symptoms, but the symptoms are not severe TRAUMA AND STRESSOR enough to make the diagnosis of depression or RELATED DISORDERS an anxiety disorder. Adjustment disorder and depression: If after A. POST TRAUMATIC STRESS a traumatic event, the symptoms are severe enough to make the diagnosis of depression, DISORDER (PTSD) the diagnosis of depression should be given Follows a significant traumatic event or preference over the diagnosis of adjustment 170 Cerebellum Quick Revision Notes disorder/ C. Conversion disorder (ICD-11 Treatment-Psychotherapy is the treatment of uses the term ‘Dissociative neurological choice for adjustment disorder. Supportive symptom disorder’) psychotherapy is often used. Pharmacological Patients present with symptoms suggestive of treatment is symptomatic, i.e. depends on the motor, sensory or cognitive deficits; however, type of symptoms. no neurological cause can be found. Also, the symptoms do not conform to the SOMATIC SYMPTOMS & RELATED anatomical and physiological principles DISORDERS (SOMATOFORM Patients may have ‘la belle indifference’, which DISORDERS) is a lack of concern for the symptoms. E.g. A patient with sudden onset loss of vision in an A. SOMATIC SYMPTOM eye may appear unconcerned with her symptom. DISORDER (ICD-11 USES THE An important d/d of conversion disorder is TERM ‘BODILY DISTRESS acute intermittent porphyria. DISORDER’) More common in females Characterised by the presence of one or more somatic symptoms, in the past the term, DISSOCIATIVE DISORDERS medically unexplained symptoms (MUS), was Characterised by dissociation. Dissociation is a used as the cause of the symptom could not be disruption in normally integrated functions of found. memory, identity, perception, consciousness Patients present with excessive thoughts (too and motor behaviour. much worried about the symptom),Q excessive The symptoms are unconscious, which means, feelings (too high anxiety about the symptoms) the patient doesnt deliberately produce the and excessive behaviours (​​ excessive time, symptoms (unlike factitious disorders and and energy spent visiting multiple doctors and malingering) getting unnecessary tests done) in relation to the somatic symptoms. Onset is usually associated with a stressor. B. ILLNESS ANXIETY TYPES OF DISSOCIATIVE DISORDER (HYPOCHONDRIASIS) DISORDERS Characterised by a preoccupation with having or Dissociative amnesiaQ acquiring a serious physical illness –– Sudden loss of autobiographical memory or The preoccupation persists despite normal personal memory (usually for a traumatic investigations and medical reassurances event) Excessive thoughts, feelings and behaviours are associated with the preoccupation. Dissociative identity disorder (Multiple personality disorder) A patient with somatic symptom disorder is preoccupied with the symptoms, whereas It is characterised by the presence of two or a patient with an illness anxiety disorder is more personalities (or “personality states” or preoccupied with the idea of having a serious ‘alters’) in an individual, out of which, only one is illness. E.g. A patient with somatic symptoms evident at a time. disorder may be preoccupied with the symptom Usually, the different personalities are of ‘abdominal bloating’ whereas a patient with completely unaware of each other’s existence. illness anxiety disorder/hypochondriasis would be preoccupied with the idea of having ‘stomach cancer’.  171 Psychiatry Depersonalization/derealization –– Disturbances of consciousness, disorder –– Disorientation to time, place and person, Depersonalisation is characterised by feelings –– Hallucinations (most commonly visual) of unreality or detachment from oneself or one’s body –– Surgery or infections may trigger delirium tremens The patients feel “as if”Q they have changed, although find it difficult to describe what exactly has changed Alcohol induced neurocognitive disorders The patients frequently report that they feel as if they were detached from their bodies and These are amnestic disorders characterised by were watching themselves as if a movie is going disturbances in short term memory. They include- on. A. Wernicke’s encephalopathy- Acute complication Depersonalisation is often accompanied by of thiamine deficiency. derealisation, in which the patient experiences Symptoms- Mnemonic GOAQ “as if” the world is unreal. –– G: Global confusion Reality testing is intact; in other words, the patient during the episode realises that, in –– O: Ophthalmoplegia (6th nerve palsy > 3rd reality, nothing has changed; they are just nerve palsy) feeling like that. –– A: Ataxia SUBSTANCE-RELATED AND Cause- Thiamine deficiency ADDICTIVE DISORDERS Treatment- High dose of parenteral thiamine. Ophthalmoplegia responds first to the TERMINOLOGY treatment, ataxia doesnt improve completely in Tolerance- Increasing amounts of a substance almost 50% of cases. are required to get the desired effect B. Korsakoff syndrome- Chronic complication of Withdrawal symptoms: Typical symptoms that thiamine deficiency. develop when the substance intake is reduced or stopped. Symptoms –– Anterograde amnesia (inability to form new ALCOHOL memories) > retrograde amnesia (inability to recall old memories) Alcohol withdrawal –– Confabulations (making of false stories to fill Symptoms that develop after cessation of memory gaps, which is unintentional) alcohol intake Cause- Thiamine deficiency After 6-8 hours: Tremors (most common, coarse tremors),Q nausea, vomiting, anxiety, Treatment - Oral thiamine for around 3–12 hypertension, mydriasis months After 12-24 hours: Alcoholic hallucinosis Prognosis is guarded (hallucinations without any disturbances of In Wernicke’s korsakoff syndrome, the consciousness) neuropathological lesions are usually symmetrical After 24-48 hours: Alcohol withdrawal and involve mammillary bodies. Other sites involved seizures. Usually generalised and tonic-clonic. include the thalamus, hypothalamus, midbrain, pons, Patients have more than one seizure in a short medulla, fornix and cerebellum. span, hence often called, cluster seizures. Treatment After 48-72 hours: Delirium tremens. Characterised byQ A. Detoxification- Focuses primarily on managing the withdrawal symptoms 172 Cerebellum Quick Revision Notes Benzodiazepines are considered the drug of Opioid intoxication choice for the management of alcohol withdrawal Symptoms of opioid intoxication In presence of liver damage- short-acting benzodiazepines, such as oxazepam or –– Euphoria, initial euphoria followed by a period lorazepam, are preferred of sedation (nodding off) Role of carbamazepine- Can be used to –– Slow respiration, hypothermia, hypotension, manage alcohol withdrawal. bradycardia, pinpoint pupil, cyanosis Thiamine administration- Alcohol-dependent Overdosage patients are often deficient in thiamine –– Can be lethal by causing respiratory due to poor intake and absorption. Thiamine depression must be administered before giving glucose, to prevent the precipitation of Wernicke’s –– DOC- i.v. naloxone (opioid antagonist)Q encephalopathy. Opioid withdrawalQ For delirium tremens- Intravenous Opioid withdrawal presents with a flu-like benzodiazepines are the drugs of choice, syndrome, with the following symptoms parenteral thiamine (and other B vitamins) must be administered, and antipsychotics can –– Lacrimation, rhinorrhea, sweating, diarrhoea be used to manage hallucinations and agitation. –– Yawning and piloerection B. Maintenance of abstinence (relapse prevention)- –– Mydriasis Follows detoxification; the goal is to prevent the –– Body ache and insomnia patient from relapsing to alcohol use –– Hypertension, anxiety, tachycardia Pharmacological agent –– Anticraving agents- Help decrease the Treatment craving for alcohol. The preferred are Detoxification- Focuses primarily on managing naltrexone and acamprosate. Others include the withdrawal symptoms. topiramate, baclofen, and serotonergic agents like fluoxetine –– Long-acting opioids like methadone (preferred) or dextropropoxyphene are used –– Deterrent agents (aversive agents)- Disulfiram, acts by inhibiting the enzyme Maintenance of abstinence aldehyde dehydrogenase leading to the –– Opioid substitution therapyQ- methadone, accumulation of acetaldehyde after alcohol buprenorphine. Harm reduction approach as consumption. This results in an unpleasant the patient is shifted from more harmful reaction called as ‘disulfiram ethanol