PSYCH Flashcards
(178 cards)
1
Q
What is in a MSE?
A
- Appearance and Behaviour
- Speech
- Mood and Affect
- Thoughts, Delusions, Perceptions and Hallucinations
- Cognition and Insight
2
Q
What would you comment on in Appearance and Behaviour?
A
- Appropriately dressed?
- Socially appropriate
- Eye contact
- Psychomotor agitation or retardation
3
Q
What would you comment on Speech?
A
Rate, rhythm, tone, volume
4
Q
What would you comment on for Mood and Affect?
A
Mood- how they say they are feeling in their own words
Affect- How they come across overall. Is their mood congruent with the conversation? Blunted? Flat?
5
Q
What would you comment on for Thoughts, Delusions, Perceptions and Hallucinations?
A
Content and form of thoughts
Thought disorder? Insertion? Withdrawal? Broadcasting?
Delusions? Persecutory or complimentary? Agency? Grandiose?
Perceptions? Illusions
Hallucinations? 2nd or 3rd person? Internal or external space? Visual,. Auditory or Tactile?
6
Q
What would you comment on about Cognition and Insight?
A
Are they orientated to time and place?- AMT?
Are they insightful to their illness, do they accept that they are ill?
7
Q
What is an illusion?
A
A misperception of a real external stimuli
8
Q
What is a hallucination?
A
Perceptions occurring in the absence of an external physical stimulus. Can be auditory, visual or olfactory
9
Q
What is a pseudo-hallucination?
A
Arise in the subjective inner space of the mind, not through of the external sensory organs
10
Q
What is meant by ‘over-valued idea’?
A
A false or exaggerated belief sustained beyond logic or reason
11
Q
What is a delusion?
A
A false, unshakeable idea which is out of keeping with the patients educational, cultural and social background; it is held with extraordinary conviction and certainty
12
Q
Give some examples of different types of delusions
A
- Persecutory
- Grandiose
- Self-referential
- Nihilistic (Cotard’s syndrome)
- Misidentification
- Religious
- Hypochondrial
13
Q
Give examples of types of thoughts patients may describe
A
- Thought insertion
- Thought withdrawal
- Thought broadcast
- Thought echo
- Thought block
14
Q
Define circumstantiality
A
Irrelevant wandering in conversation
15
Q
Define preservation
A
Repetition of a word, theme or action
16
Q
Define confabulation
A
Giving a false account to fill a gap in memory.
Often seen in dementia patients
17
Q
Define somatic passivity
A
The delusional belief that one is a passive recipient of bodily sensations from an external agency
18
Q
Define catatonia
A
Excited or inhibited motor activity in the absence of a mood disorder or neurological disease
19
Q
What is psychomotor retardation?
What conditions would it be present?
A
Slowing of thoughts and movements.
Seen in depression, Parksinson’s disease etc
20
Q
Describe incongruity of affect
A
Emotional response s that seem grossly out of tune with the situation or subject being discussed
21
Q
What is blunting of affect?
A
An absence of normal emotional responses
22
Q
What is depersonalisation?
A
Feelings of detachment from own’s body; the patient fells like a spectator of his own activities
23
Q
What is derealisation?
A
A sense of one’s surroundings lacking reality, surroundings may appear dull, grey, lifeless
24
Q
Describe dissociation
A
When a person feels disconnected from his/herself and/or their surroundings
25
What is obsession
A recurrent persistent thought, image or impulse; it remains despite efforts to resist
26
What is compulsion
Repetitive, purposeful behaviour accompanied by a subjective sense that it must be carried out despite the recognition of its senselessness and resistance
27
What is akathisia
Motor restlessness, ranging from anxiety to the inability to lie/sit still
28
What is projection
What is emotionally unacceptable in the self is unconsciously rejected and projected to others eg mother projects her anxiety onto her children claiming they are anxious instead
29
Give 3 signs/symptoms of mania
1. Pressured speech
2. Lots of projects/things going on
3. Delusions
4. Increased energy/activity
5. Overfamiliarity
6. Impulsivity
30
What are affective disorders
Illnesses which affect the way you feel and think
| Most common- depression and bipolar disorder
31
What are the 3 core symptoms of depression
1. Low mood
2. Anergia (Loss of energy)
3. Anhedonia (Loss of enjoyment)
32
Other symptoms of depression
1. Sleep disturbance
2. Change in appetite
3. Feelings of guilt and hopelessness
4. Suicidal thoughts
5. Lack of concentration and confidence
6. Change in sex drive
7. Agitation
8. Diurnal variation of mood
33
What is needed for a diagnosis of Depression?
2 core symptoms, everyday for at least 2 weeks- ICD10
MILD- 2 CORE + 2 MORE
MODERATE- 2 CORE + 3 MORE
SEVERE 3 CORE + 5 MORE
34
Signs of depression
1. Weight loss
2. Alteration of motor activity
3. Emotional reactions may change
4. Avoid eye contact
5. Speech slow and quiet
35
Investigations for Depression
- TFTs to rule out hypothyroidism
- Urine drug screen for ongoing substance misuse
- Medications review
36
Non-medical treatment of Depression
- Self help groups
- Guided self help
- Computerised CBT
- Individualised CBT
- Psychotherapy
37
Medical Treatment of Depression
- Antidepressants ( cont for 6 months after symptoms stop). Normally fluoxetine for <18s and sertraline for >18s
- For resistant depression- lithium, atypical antipsychotic, another antidepressant
- ECT in very severe depression
38
Symptoms of Bipolar Disorder
1. Increased energy
2. Pressured speech
3. Recklessness
4. Impaired judgement
5. Inflated self-esteem
6. Elevated mood
39
What is Bipolar I?
Mania and depression
40
What is Bipolar II?
Mild Hypomania and more episodes of Depression
41
What are the S&S of Hypomania?
>4 days
- elevated mood
- increased energy, talking
- poor conc
- mild reckless behaviour
- sociability
- ^ libido, confidence
- decreased need for sleep
- change in appetite
42
What are the S&S for Mania?
```
>1 week
Affecting daily functioning
- extreme uncontrollable elation
- overactivity
- pressure of speech
- impaired judgement
- extreme risk taking
- social disinhibition
- inflated self esteem
- psychotic symptoms
- insight often absent (they enjoy being manic usually)
```
43
Typical onset of Bipolar Disorder
Early 20s
44
What is needed for a diagnosis of Bipolar Disorder?
One episode of (hypo)mania
| History of 2 mood disorders
45
Causes of Bipolar Disorder and Risk Factors
- Post-partum female
- Substance misuse
- Chronic illness
- Past trauma/mental health problems
- Sleep deprivation
Genetic
46
MSE of someone with Bipolar Disorder
- May be flamboyantly dressed
- Difficult to interrupt
- Pressure speech
- Overactivity
- Usually Elated or angry or low
- Grandiose delusions
- Verbal associations
- Persecutory delusions
- Auditory hallucinations
- Cognition impaired, insight absent in mania
47
Treatment of Bipolar Disorder
```
Antipsychotics (haliperidol, olanzapine, quetiapine, risperdone)
Mood Stabilisers (Lithium, Sodium Valproate, Lamatogine, Carbamezapine)
BDZs short term
Psychoeducation, promoting social functioning
```
48
Antidepressants in Bipolar Disorder
- (fluoxetine) for depressive episodes- must be prescribed with mood stabiliser
- discontinue if manic
49
When is the onset of schizophrenia most typical?
2nd or 3rd decade
50
What is the cause of schizophrenia?
Dopamine excess
51
What are the first rank symptoms of schizophrenia?
1. Delusional perceptions
2. 3rd person hallucinations
3. Thought disorder (alienation)
4. Passivity Phenomena
52
What are 2nd rank symptoms of schizophrenia?
1. Delusion
2. 2nd person auditory hallucinations
3. Thought disorder
4. Negative symptoms
53
What are positive symptoms of schizophrenia?
- Delusions
- Hallucinations
- Formal Thought Disorder
- Passivity phenomena
- Lack of insight
- Mood disturbance
54
What are Negative symptoms of schizophrenia?
- Poverty of speech
- Flat affect
- Poor motivation
- Social withdrawal
- Lack of concerns for social conventions
- Blunting affect
- Self neglect
- Lack of insight
55
What are some cognitive symptoms of schizophrenia?
- Poor attention and memory
56
Investigations for schizophrenia
- Urine to rule out UTI delirium
- Urine drug screen
- CT to rule out organic neuro cause
- HIV if applicable
- Syphilis if applicable
- Check lipids, and ECG before starting antipsychotics
- Bloods: FBC, TFTs, U+Es, LFTs, CRP, fasting glucose
57
Diagnosis of schizophrenia
Need 2 1st rank symptoms for > 1month,
2 2nd rank for >1month.
At least 2 must be delusions/hallucinations or disorganised speech.
Must negatively impact life
58
Treatment for schizophrenia
- Typical antipsychotic (haliperidol, chlropromazine)
- Atypical antipsychotic (quetapine, olanzapine(~13.9kg weight gain 1yr), risperidone, aripriprazole, clozapine (last line- look out for constipation and agranulocytosis)
59
Name types of psychoses
1. Schizophrenia
2. Delusional disorder
3. Schizotypal disorder
4. Depressive psychosis
5. Manic psychosis
6. Organic psychosis
60
What is schizoaffective disorder?
Major depressive, manic or hypomanic episodes that come before or after psychotic symptoms. Mood overshadows psychotic symptoms
61
Describes some symptoms of BPD/(EUPD)
1. Emotional instability
2. Difficult, intense relationships
3. Feelings of emptiness
4. Impulsive
5. Self injurious behaviour
6. Fear of abandonment/rejection
62
Why might someone with Borderline Personality Disorder self-harm?
- Relieve psychic pain
- Express anger
- Reduce anxiety
- Feel in control
- Feel something when numb
- Communicate how they feel
They are much more likely to have a successful suicide attempt even though their intention was not to kill themselves, as they are impulsive and often make mistakes
63
Treatment for personality disorders
1. Psychological therapies- dialectal behaviour therapy
2. Structured clinical management
Medication is not mainstay
64
What are Cluster A PD?
- Paranoid PD
- Schizoid PD
- Schizotypal PD
65
What are Cluster B PD?
- Antisocial PD
- BPD (EUPD)
- Histrionic PD
- Narcissistic PD
66
What are Cluster C PD?
- Avoidant PD
- Dependant PD
- Obsessive Compulsive PD
67
What are some symptoms of PTSD?
- Nightmares
- Flashbacks
- Intrusive thoughts
- Avoidance of situations/environments
- Hyper vigilance
- Hyperarousal > trouble sleeping
- General instability
- Emotional outbursts
- Children often act out their memories in play
68
Diagnosis of PTSD
- Exposure to traumatic event
- Intrusive symptoms
- Recurrent, distressful, dissociative
- Avoidance of stimuli
- Negative changes in thoughts and feeling
- ^ Sensitivity to event
- Disturbances > 1mnth > distress in other areas of life
69
Treatment of PTSD
- 1st line- TF-CBT or eye movement desensitisation and reprocessing therapy (EDMR)
- 2nd line- SSRI or venlafaxine
70
What is delusional disorder?
> 1 delusion over >1 month, without meeting schizophrenia criteria
- Hallucinations can occur
affects day to day functioning
- Not caused by other condition/substance
71
Treatment of delusional disorder
- Anti-psychotics, anti-depressants, psychotherapy
72
What is psychotic depression
- When depression is accompanied by psychotic features
| - Only happens in major depressive episodes
73
What is postpartum depression
- Extreme sadness, decreased energy, anxiety, crying episode, irritability
- Onset 1wk-1mth
- Can negatively affect newborn
74
Treatment of postpartum depression
Antidepressants (for severe) - can have adverse effects on baby is breast feeding
75
What is postpartum psychosis
- Depressive or manic symptoms
- First rank symptoms of schizophrenia
- Emotional lability
76
Who is at risk for postpartum psychosis
- 1st time moms
- Previous psychosis
- Instrumental delivery
- FHx
77
Treatment for postpartum psychosis
- Hospitalise- baby stay with mom
- Antipsychotics
- ECT
78
What are the S&S for GAD?
- Unpleasant/fearful emotional state
- Bodily discomfort
- Palpitations, tachycardia, sweating, tremor, chest pain, N&V, abdo pain, dizzy, chills, hot flushes, feeling of choking
- Increased vigilance
- Sleeping difficulties
79
What are the risk factors for GAD?
- alcohol, BDZ, stimulants (withdrawal) , co-existing depression, FHx, child abuse, neglect, excessively pushy parents, life stresses, physical health problems
80
What assessment tools are used in GAD?
PHQ, GAD7
81
What physical health conditions can cause GAD?
- Hypothyroidism
- Phaechromocytoma
- Lung disease
- CHF
- Hypoglycaemia
82
Diagnosis of GAD
- Use PHQ, GAD7 tools
| - Excess anxiety and worry about >1 thing, for at least 3 weeks, difficult to control worry
83
Treatment for GAD
- CBT, Therapy
| - SSRIs(paroxetine), or SNRIs, pregabalin, BDZ(short term), BB(for physical s/e)
84
What is OCD?
- Obsessions (intrusive, unwelcome, unpleasant thoughts/images/doubts)
- Compulsions (repetitive, purposeful, physical or mental behaviour performed in response to obsession)
85
Causes or RF for OCD
- Genetics- FHx of OCD or tic disorder
- Parental over protection
- May occur after strep infection (PANDAS)
86
Symptoms of OCD
- Time consuming (>1 hr/day at least 2wks)
- Distressing and interfere with ADLs
- Avoidance of stimuli
87
Treatment of OCD
- Psychoeducation
- CBT, Exposure therapy
- SSRI (even if no depression)- fluoxetine
88
What is Somatisation Disorder?
- Physical symptoms without physical explanations
- Persistent >2 yrs
- More common in women
- GI and skin complaints most common
- Refuse to believe no organic cause
- Impact ADLs and family life
- Often results in needles ops
- Tx- rule out all possible causes
89
What is Conversion Disorder?
- Neurological SIGNS eg paralysis, weakness, amnesia
- Examination is inconsistent
- Patient not consciously faking it but no evidence of underlying pathology
90
What is described as alcohol abuse?
- Sufficient to cause physical, neurological, psychiatric or social damage
91
What is the recommended weekly alcohol intake?
14 units a week
| 10ml=1 unit
92
What is dependance?
The inability to control intake of a substance to which one is addicted. They also use the substance to avoid withdrawal.
93
What are the signs of alcohol abuse?
- CANT STOP
- Compulsion to drink
- Aware of harm but persists
- Neglect of other activities
- Tolerance of alcohol
- Stopping causes withdrawal
- Time preoccupied with alcohol
- Out of control use
- Persistent, futile wish to cut down
94
Investigations into alcohol abuse?
- CAGE screen- do they want to or are they
- Cut down?
- Annoyed by criticism?
- Guilty?
- Eye opener drink?
95
Treatment to alcohol dependance
- Motivational interviewing
- Psychological therapies
- Self help groups
- Prevention measures
96
What medication is used in alcohol withdrawal?
- Disulfram- blocks alcohol metabolism- gives s/e
- Acamprostate- reduce cravings
- Naltrexone - opioid receptor antagonist
97
What is involved in an alcohol detox?
- BDZ- prevent seizures and control withdrawal
- Rehydrate
- Thiamine (Pabrinex)
- Correct electrolytes
98
What is delirium tremens
- Acute confusional state secondary to alcohol withdrawal
- EMERGECNY
- Occurs 1-7 days after last drink (48-72hr peak)
- Clouding of consciousness, disorientation, amnesia from recent events , pscyhomotor agitation, tremors, hallucinations, fluctuations in severity hours, risk fo CV collapse
99
Treatment of delirium tremens
- Pabrinex
| - Lorazepam or antipsychotics (haloperidol or olanzapine)
100
What is Korsakoffs Psychosis?
- Short term memory loss and confabulation
| - Occurs in heavy drinkers due to thiamine def
101
Causes of Korsakoffs Psychosis?
- Heavy Drinkers
- Head injury
- Past anaesthesia
- Basal/temporal lobe encephalitis
- Carbon monoxide poisoning
- Anorexia
102
Treatment of Korsakoffs Psychosis
- Oral thiamine and multi vit
- Treat psychiatric comorbidities
- OT assessment
- Cognitive rehab
103
What is Wernickes Encephalopathy?
TRIAD-
- Confusion/intellectual impairment
- Ataxia
- Ophthalmoplegia (eye muscle paralysis) nystagmus
104
Treatment of Wernicke's Encephalopathy
- IV Pabrinex
- and Vit if high risk
- IMMEDIATE Tx
105
What is alcohol related dementia?
- Accounts fo 10% of dementia
- Generalised brain damage leading to cognitive decline
- Caused by alcohol XS
106
What are the symptoms of Behavioural and Psychological Symptoms of Dementia?
- Anxiety
- Depression
- Agitation
- Psychosis
- Disinhibition
107
Management of BPSD
- Rule out PINCH ME- - treatable causes
- Address underlying cause
- Educate
- OT
108
What is insomnia?
- 3 days a week for 1 month
- Trouble falling asleep
- Maintaing sleep
- Poor quality of sleep
109
Causes of insomnia
Fear, idiopathic, shift work, sleep related breathing disorder, REM disorder, depression, steroids
110
Treatment of insomnia
- Good sleep hygiene
- Sleep restriction
- Medication- zopiclone, zolpidem, zopeplon, mirtazapine, quetiapine, melatonin
111
What are S&S of Anorexia Nervosa?
- Dieting, denial, dread of weight gain, disturbed beliefs about weight, doesn't want help, dual effect- diet and overexercising/diuretics/laxatives, v. disinterested.socially withdrawn, decline in weight= rapid,
- Weight below 85% (<17.5 adults)
- Refusal to maintain normal
112
Physical signs of Anorexia Nervosa
- Dry skin
- Hypercarotenemia (yellow skin)
- Body hair
- Acrocyanosis
- Breast Atropy
- Swelling of parotid and submandibular glands
- Thinning hair
113
What happens to bloods in Anorexia Nervosa
- C and GH go up the rest go down
- Cortisol, Beta - Caratone, GH, Cholesterol up
- T3, glucose, oestrogen, testosterone, LH, FSH, phosphate down
114
Investigations in Anorexia Nervosa
- DXA (if underweight for a year)
- ECG - bradycardia, prolonged QT (if severe), T wave changes - hypokalaemia
- Squat test
115
What is MARISPAN
- Guidlines for management of people with anorexia nervosa
116
Treatment for Anorexia Nervosa
- CAHMS- anorexia based family therapy
- CBT- 2nd line
adult
- CBT-ED
- MANTRA (Maudsley anorexia nervosa treatment for adults)
- SSCM (specialist supportive clinical management)
- food diary
- SSRI - fluoxetine
117
What is Bulimia Nervosa
- Binge eating followed by intentional vomiting or other purgative behaviours like laxative or diuretics or exercising
118
What changes happen in Bulimia Nervosa due to vomiting
- Metabolic alkalosis on ECG
- Low Cl- - loss to stomach
- ECG- hypokalaemia
119
Features of Bulimia Nervosa
- Recurrent binge eating
- Lack of control during episode
- Recurrent compensatory behaviours
- Once a week for 3 months
- Self evaluation- by body and shape
120
Give some examples of opiates
- Codeine
- Diamorphine
- Loperamide
- Methadone
- Dihydrocodeine
- Morphine
- Fentanyl
- Heroin
- Oxycodone
- Tramadol
121
Symptoms of an opiate overdose
- Acute= drowsiness, resp depression > resp acidosis (retain co2), hypotension, tachycardia, pin point pupils
- Chronic- constipation
122
Treatment of opiate overdose
- ABCDE
- naloxone IV if coma or resp depression ( IM if shit veins)
- Oral activated charcoal if have ingested a load ( Nacetylcysteine)
123
Heroin withdrawal symptoms
- Goose flesh (piloerection)
- Pupil dilation
- Yawning
- Sweating
- Abdo cramps
- Insomnia
124
What is Munchausen's Syndrome?
- A mental illness where someone fakes an illness
| - Can be be proxy, where they fake it for someone else
125
What to look out for in Muchausens
- Previous PD diagnosis
- Usually physical symptology - extend to pain not flex
- Sometimes psychiatric symptoms
- Multiple A&E presentations
- Frequent admissions
- Multiple surgical procedures
- Multiple aliases, no fixed address
- When discovered- self discharge
126
What are the symptoms of ADHD?
- Inattentiveness
- Hyperactivity
- Impulsiveness
- Restlessness
- Poor concentration
127
Treatment of ADHD
- Methylphenidate (Ritalin)- need to monitor growth
| - Psychotherapy
128
What are some risk factors for Down's Syndrome?
- ^ Maternal age
- Previous child with Down's
- If mother has Down's
129
What are some features of those with Down's Syndrome?
- Flat occiput
- Oblique Palpebral fissures
- Smooth mouth
- High arched palate
- Broad hands
- Single Palmar transverse crease
-
130
What problems are associated with Down's Syndrome
- Learning difficulties
- Autistic traits
- High risk developing Alzheimers
- Hypothyroidism
- Complete AVSD
131
What is Charles-Bonnet Syndrome?
- Complete visual hallucinations in person with partial or severe blindness (macular degeneration diabetic retinopathy)
- Patients understood hallucination are not real and often have insight
132
What are the triad of Autistic Spectrum Disorder features?
- Impaired social interaction
- Speech and language disorder
- Imposition of routines- ritualistic and repetitive behaviour
133
What are some other symptoms of ASD?
- Poor eye contact
- Failure to develop relationships
- Abnormal playing/communication
- Restricted interests or activities
- Abnormal gaze
- Motor tics
134
What is the difference between Autism and Apsergers?
- Aspergers has milder social features and near normal speech development
135
What is Fragile X syndrome?
- X linked dominant, inherited disorder
- More common in males
- Large head and ears, poor eye contact, abnormal speech, hypersensitivity to touch, auditory and visual stimuli, hand flapping and hand biting
- Autism associated
136
Tourette's
- Genetic association
- Environmental factors- stress, gestational/perinatal insults, fatigue, PANDAS
- Often co-morbid with OCD, ADHD, depression, anxiety, learning difficulties, ASD, migraines
137
Treatment of Tourette's
- educate, liaise, reduce caffeine intake, reduce stress, consider meds if severe
(antipsychotics, alpha adrenergic)
138
What principles underly the Mental Health Act?
1. Respect for the patients' wishes and feelings
2. Minimise restrictions on liberty
3. public safety
4. Patient well-being and safety
5. Involving patients in planning, developing an delivering care
139
Section 2 -
Purpose: Assessment, treatment can be given without consent
Duration: 28 days, can't be renewed
Professionals involved: 2 doctors (one S12), AMHP
Evidence needed: a) suffering from a mental disorder that needs to be detained, b) obtained for own health or safety of them or others
140
Section 3 -
Purpose: Treatment
Duration: 6 months, can be renewed
Professionals involved: 2 doctors, AMHP
Evidence- a), b), c) appropriate treatment must be available
141
Section 4 -
Purpose: Emergency order
Duration: 72 hours (when waiting for 2nd doctor would lead to delay)
Professionals involved: 1 doctor and 1 AMHP
Evidence: a), b), d) not enough time for 2nd doctor to attend
142
Section 5(4) -
Purpose: for a patient already admitted but wants to leave
Duration: 6 hours, can't be coercively treated
Professionals: Nurse holding power until doctor attends
143
Section 5(2) -
Purpose: for a patient already admitted but wants to leave
Duration: 72 hours, can't coercively treated
Professionals: Doctors holding power
Allows for a section 2 or 3 assessment
144
Section 135/136 -
- Police sections
136- Person suspected having mental disorder in public
135- Needs court order to access patients home to move them
To a place of safety (psych unit/ police cell)
Further assessment?- need section 2 or 3
145
Why should Lithium be used with care?
- Lithium has a narrow therapeutic range which can lead to renal failure
- Risk of lithium toxicity
- Monitor- check weekly at first, once blood levels are stable, every 3 months, 12 hours after last dose
- Interactions: thiazide diuretics, NSAIDs, ACEi, SSRI, Alcohol- can alter lithium (drowsiness) - can drink in moderation 1-2 units a day
146
What is Lithium used for?
- 1st line for bipolar disorder
- Mood stabiliser
- Works by decreasing aggressive or self harming behaviour
147
Side effects of Lithium
- GI disturbance
- Polyuria
- Polydipsia
- Weight gain
- Hypothyroidism
148
What happens in lithium toxicity?
- Coarse tremor, ataxia, hyperreflexia, LOC, muscle weakness, blurred vision, N&V
- Avoid thiazide diuretics as can cause
- Tx- stomach pumping, IV fluids, vital sign monitoring
149
Alternatives to lithium for Bipolar Disorder: Sodium Valproate
- Sodium Valproate, takes shorter time to work than lithium. Used short term when rapid mood stabilisation needed. s/e- GI upset, agitation, confusion. Risk- teratogenic > liver toxicity. Interactions - can potentiate antipsychotic effects, smoking cessation required
150
Other alternatives to Lithium for Bipolar Disorder
- Carbamazepine (treat mania if SV and lithium do not work, used in rapid cycling and manic depression)
- Lamotrigine (in conjunction with valproate- targets depressive episodes)
- Phenytoin
151
What are Benzodiazepines used for
Insomnia= temazepam, lorazepam
Agitation= lorazepam (often IM)
Panic disorder= diazepam, alprazolam, short term only. in combo with antidepressants
GAD- lorazepam, diazepam for somatic Sx
152
Side effects of BDZs and risks
- Drowsiness, calming effect/euphoria, confusion, unsteadiness, muscle weakness
Risks- ^ risk abuse and dependance. Avoid in PD.
Interactions with opioids
153
What is buspirone used for?
GAD
- safer than BDZs and less s/e. 4 weeks onset of action, safer long term
s/e- N, dizziness, headaches, fatigue, confusion
Risks- drowsiness
Contraindications- alcohol, MAOIs
154
Give some examples of 1st gen antipsychotics
Chlorpromazine- s/e- anti-adrenergic s/e, sedation, anti-muscarinic effects, avoid in postural hypotension
Flupentixol and Zuclopenthixol- anti-dopimingeric s/e, available as depot
Haloperidol- PO or IM
155
What are some risks of antipsychotics?
High risk of long QT, need ECG before starting and every 6 months
Low therapeutic window
Higher risk for EPSEs
156
Give some examples of 2nd gen antipsychotics
- Olanzapine
- Quetiapine
- Aripriprazole
- Clozapine
157
Side effects of Olanzapine
- PO, Depot, IM
- Mean weight gain 13.9kg
- Sedation
- Anticholinergic side effects- Constipation, urinary retention, blurred vision, dry mouth, cognitive impairment
158
Side effects of Quetiapine
Anticholinergic side effects. Less cardiac side effects
| Often used first line
159
Side effects of Aripriprazole
Partial agonist so wider therapeutic window
No anticholinergic effects
Akathisia common
160
Side effects of Clozapine
- Only use if 2 don't work
- Agranulocytosis (MONITOR)
- Hypersalivaiton
- Constipation- biggest killer
- Weight gain
161
How do antipsychotic work
- Dopamine antagonist
162
Extra Pyramidal Side Effects from antipsychotics
(in time order)
- Acute dystonia- Tx procyclidine 10mg IV
- Parkinsonism - tremor, rigidity, bradykinesia, 1wk after initiation. Tx- Reduce antimuscarinic
- Akathisia- restlessness >1mnth after initiation. Tx- propranolol + BDZs
- Tardive dyskinesia- slow movements (lip smacking) sudden, involuntary and irreversible
163
What is Neuroepileptic Syndrome
- Caused by dopamine antagonists
- Tremor, muscle cramps, fever, autonomic instability, delirium, muscle rigidity, bradykinesia
- Raised CK- can progress to rhabdomyolysis
- slower onset (days-wks)
- Idiosyncratic but increased risk in dementia with Lewy body
- Tx- DA agonists eg Bromocriptine (resolution days-wks)
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What are SSRIs used for
1st line depression (selective serotonin reuptake inhibitor)
- Fluoxetine- 1st line depression <18, OCD, bulimia
- Sertraline- 1st line depression > 18 , OCD, PTSD
- Paroxetine- depression, anxiety, OCD, panic disorder, PTSD, GAD. Wean off- flu like symptoms, Unsafe in pregnancy
- Citalopram- depression, panic disorder- s/e QT prolongation
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When to stop antidepressants
- Continue for 6 months after symptoms stop
| If stopped abruptly > irritable, headache, insomnia
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Side effects of SSRI
- Decreased sexual function
- GI upset
- N, D
- Headache
- Insomnia
- (LOTS OF anticholinergic effects)
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Risks, interactions of SSRIs
- Contraindicated if had manic episode, cant use with MAOIs,
- Citalopram can cause QT prolongation
- Serotonin syndrome
Monitor- weekly initially as increase suicidal thoughts at start
- Interactions: BB, alcohol, anticonvulsants, lithium,, methadone, MAOIs, smoking, warfarin
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Alarm bells with SSRIs
- Hyponatraemia, GI bleeding, serotonin syndrome, neuromuscular hyperactivity (hyperreflexia, clonus, tremor, myoclonus). autonomic dysfunction (tachycardia, BP changes, hyperthermia, diaphoresis, shivering, D), altered mental state (agitation, confusion, mania)
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What is serotonin syndrome
- within 24 hours of starting a serotonin agonist
| - Hyperactivity, tremor, clonus, reflexes
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Treatment of serotonin syndrome
- BDZs, cryptoheptadine
| - resolution 24hrs
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What are TCAs used for
- More severe depression- reserved for after SSRIs
- inhibits reuptake of serotonin and noradrenaline and dopamine
- Amitriptyline, clomiprmaine, imipramine
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Side effects of TCAs
- Anticholinergic (dry mouth, blurred vision, constipation, drowsiness, confusion)
- Adrenergic (drowsiness, postural hypotension)
- 5HT2 (decreased sexual dysfunction)
- Antihistaminergic (drowsiness, weight gain)
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MAOI
- Used for treatment resistant depression
- Avoid cheese, alcohol, avocado (dietary tyramine)
s/e- weight gain, insomnia, postural hypotension, anxiety, ankle oedema
risks- hepatotoxicity, HTN crisi,
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SNRIs
- Serotonin and noradrenaline reuptake inhibitor
- Depression, GAD
- venlafaxine, duloextine
- s/e- N, GI upset, constipation, loss of appetite, dry mouth, dizziness, agitation, insomnia, sexual dysfunction, headache, nervousness, sweating
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NASSA
- depression with insomnia
- Mirtazapine
- Generally less GI s/e and less sexual dysfunction
has anxiolytic effect
- s/e - sedation, weight gain, tremor, myoclonus, N, GI upset
risk- agranulocytosis, liver toxicity, jaundice
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What is ECT used for?
- Major depression or bipolar or catatnoia or severe mania that doesn't respond to other treatment
- brief electrical stimulation of brain under anaesthesia
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Stimulants
- eg methylphenidate
- used to treat ADHD
-s/e- aggression, anxiety, decreased appetite, mood disturbance
risk- avoid abrupt withdrawal
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Hypnotics
Z drugs
- zopiclone, zolpidem and zaleplon
- insomnia which hasn't improved without drugs. never 1st line
s/e- drowsiness, GI upset
