Psychiatric Management Flashcards
(99 cards)
1
Q
Common receptor effects of adrenergic
A
Sweating Tremor Headaches Nausea Dizziness
2
Q
Common muscarinic (acetylcholine) receptor effects
A
Dry mouth, difficulty swallowing, thirst
Difficulty urinating, urinary retention
Hot flushed skin, dry skin
3
Q
Common histamine receptor effects
A
Dry mouth
Drowsiness
Dizziness
N+V
4
Q
Features of antidepressants
A
Work on serotonin activity - increase activity at post synaptic receptors Most of their effect in 2-3 weeks Most commonly used = SSRIs - SNRIs - Mirtazapine - Tricyclics - MAOIs
5
Q
Method of action of SSRIs
A
Selective Serotonin Reuptake Inhibitors
- increase serotonin activity by reducing the presynaptic reuptake of serotonin after release
- more serotonin sits in nerve junction
- leads to down regulation of post-synaptic receptors
6
Q
Side effects of SSRIs
A
Sense of restlessness and agitation on induction - countered by use of benzodiazepines
Nausea and GI disturbance
Headache
Weight change
Sexual dysfunction
Uncommon
- bleeding - due to serotonin receptors on GI tract and platelets
- suicidal ideation particularly teenagers and early 20s - due to increased motivation before increased optimism
7
Q
Examples of SSRIs
A
Sertraline - safest in cardiac disease
Citalopram/Escitalopram - careful of QTc prolongation
Fluoxetine - watch out for serotonin syndrome when switching
Paroxetine - watch out for discontinuation syndrome
8
Q
Method of action of SNRIs
A
Serotonin and Noradrenaline Reuptake Inhibitors
- bind to noradrenaline and serotonin reuptake inhibitors
- leads to down regulation of post-synaptic receptors
Evidence base for use in neuropathic pain also
9
Q
Side effects for SNRIs
A
Sedation
Nausea
Sexual dysfunction
10
Q
Types of SNRIs
A
Duloxetine - low dose range
Venlafaxine - more efficacious and can go to a higher dose
- caution with higher doses in heart disease
11
Q
Method of action of Mirtazapine
A
Acts as 5HT-2 and 5HT-3 serotonin receptor antagonist Strong H1 (histamine) activity -> sedation
12
Q
Side effects of mirtazapine
A
Sedation
Weight gain
13
Q
Features of tricyclic antidepressants
A
Reasonably effective - useful for those who do not responds to SSRIs Newer tricyclics (lofepramine and nortriptyline) tolerated better than older tricyclics (amitriptyline) Used at low doses for neuropathic pain
14
Q
Side effects of tricyclic antidepressants
A
Muscarinic and histamine effects
Can be fatal in overdose - QTc prolongation and arrhythmias
15
Q
Features of MAOIs
A
Monoamine Oxidase Inhibitors
- MAOI-A - work more on serotonin
- MAOI-B - work more on dopamine
Possibly more effective for atypical depression
16
Q
Types of MAOIs
A
Irreversible = more dangerous - phenelzine - isocarboxazid Reversible = less dangerous - moclobamide - tranylcypromine
17
Q
Considerations of MAOIs
A
Significant and dangerous interaction with other drugs
Potential for tyramine reaction leading to hypertensive crisis - avoid chees, pickled meats, wine
If changing to another antidepressant needs a washout period - up to 6 weeks
18
Q
Features of vortioxetine
A
Serotonergic activity
Effective
Well tolerated - common side effect is nausea but less severe
Evidence for improvement in difficult to treat cognitive symptoms
19
Q
Considerations when choosing an antidepressant
A
What has been used before
Was it effective/tolerated
Are there particular symptoms or co-morbidities to address
- weight loss and insomnia = mirtazapine
- neuropathic pain = SSRIs
In new cases start with an SSRI unless major weight loss and insomnia - consider mirtazapine
20
Q
Considerations for increasing/switching antidepressant
A
Don't need to wait 4 weeks to have idea about effectiveness For depression - if no benefit then switch - if partial effect then increase dose For anxiety - consider increasing dose If struggling with side effects - may get better in couple of weeks - switch is cannot stand
21
Q
Define discontinuation syndrome
A
Group of symptoms occur when antidepressant stopped
- antidepressants not addictive
Influenced by half life - shorter half life = bigger problem
22
Q
Features of discontinuation syndrome
A
Sweating Shakes Agitation Insomnia Headaches Irritability Nausea Vomiting Paraesthesia Clonus
23
Q
How to prevent discontinuation syndrome
A
Go slow
- can alternate days of taking or snap tablets in half
Sometimes worth switching to Fluoxetine and reducing
Paroxetine and venlafaxine trickiest
24
Q
Define serotonin syndrome
A
Symptoms caused by excess serotonin
- risk when starting another antidepressant after fluoxetine
25
Features of serotonin syndrome
Cognitive
- headaches, agitation, hypomania, confusions, coma
Autonomic
- shivering, sweating, hyperthermia, tachycardia, nausea and diarrhoea
Somatic
- myoclonus, hyper-reflexia and tremor
26
Treatment of serotonin syndrome
Supportive
- fluids
- monitoring
27
Method of action of antipsychotics
Reduce level of dopamine activity as D2 receptors antagonists
- target pathways = mesocortical and mesolimbic
- unwanted pathways = nigrostriatal (movement) and tuberoinfundibular (hypothalamic-pituitary-adrenal axis)
28
Classes of antipsychotics
Typical
- older
- more likely to cause extra-pyramidal side effects
- bind to more muscarinic and histaminic receptors
Atypical
- more serotonergic activity
- more likely to cause diabetes and dyslipidaemia
29
Examples of antipsychotics
```
Typical
- haloperidol
- flupenthixol
- zuclopenthixol
- chlorpromazine
- sulpride
Atypical
- clozapine
- olanzapine
- risperidone
- quetiapine
- amisulpride
- aripirazole - partial D2 agonist
```
30
Side effects of antipsychotics
```
Sedation
Weight gain
QTc prolongation
Typical
- extra-pyramidal
- bradykinesia
- muscle stiffness and tremor
- tardive dyskinesia
- akathisia
- dizziness
- sexual dysfunction
Atypical
- weight gain
- dyslipidaemia and diabetes
```
31
Monitoring required for antipsychotics
```
Baseline
- FBC, lipids, LFTs, HbA1c, weight, ECG, BP and pulse
Weekly
- weight
Others at 3 months then yearly
```
32
Features of clozapine
D2 antagonist and 5HT-2 antagonist
Most efficacious antipsychotic
Improvements can continue for several months
Used in schizophrenia after at least 2 other antipsychotics failed
Dose titrated slowly upward over 2 weeks and vital signs monitored due to potential for autonomic dyregulation
33
Side effects of clozapine
Agranulocytosis
- close monitoring of FBC - weekly for first 18 weeks then fortnightly then monthly
Gastrointestinal hypomobility
- constipation and potentially fatal bowel obstruction
Hypersalivation
Urinary incontinence
34
Treatment of clozapine induced agranulocytosis
Stop clozapine
Stop other marrow supressing drugs - sodium valproate
Avoid other antipsychotics for a couple of weeks where possible - if needed aripiprazole
Contact consultant haematologist
Avoid sources of infection - consider broad spec abx
Lithium - increased WCC and neutrophil count
Granulocyte colony-stimulating factor - injection
35
Define neuroleptic malignant syndrome
Rare, life-threatening reaction to antipsychotics
36
Features of neuroleptic malignant syndrome
```
Fever
Confusion
Muscle rigidity
Sweating
Autonomic instability
Death due to
- rhabdomyolysis
- renal failure
- seizures
```
37
Risk factor for neuroleptic malignant syndrome
High potency dopamine antagonists (typical antipsychotics)
Antipsychotic naïve patients
High doses
Young men
38
Treatment for neuroleptic malignant syndrome
Emergency referral to A&E
Stop antipsychotics
Fluid resuscitation
Reduced temperature
39
Treatment for extra pyramidal side effects of antipsychotics
Anticholinergics
- Ratio of dopamine: acetylcholine in nigrostriatal pathway more important than absolute quantities
- If too much acetylcholine in relation to dopamine - reduce acetylcholine activity
- not effective for tardive dyskinesia
40
Examples of anticholinergics
Procyclidine - potential for misuse
Benztropine
Trihexyphenidyl
41
Define acute dystonia
Sustained, often painful, muscular spasms producing twisted abnormal postures
42
Features of acute dystonia
Neck, tongue, jaw, oculogyric crisis (neck arched and eyes roles back)
50% cases in first 48 hours, 90% in first 5 days
43
Treatment of acute dystonia
```
Stop antipsychotic
Administer IM or IV anticholinergics
- procyclidine
Continue for 1-2 days after dystonia
Consider long-term prophylactic
```
44
Types of anxiolytics
Reduce anxiety
- beta-blockers
- benzodiazepines
- pregabalin
- antidepressants
45
Method of action of beta-blockers
Reduce autonomic nervous system activation
| - bio-psycho feedback
46
Consideration for beta-blockers
Most commonly used = propranolol
Contraindicated in asthma
Limited effectiveness for enduring anxiety disorders
47
Method of action of benzodiazepines
Bind to GABA receptors to potentiate effect of GABA
- reduce excitability of neurones
- positive allosteric modulators of GABA receptors
48
Features of benzodiazepines
```
Most commonly used
- diazepam - long half-life
- lorazepam - short half-life
Significant potential for
- tolerance
- dependence
- misuse
Use for no more than 6 weeks
Occasionally cause paradoxical disinhibition
```
49
Method of action of pregabalin
Binds to voltage gated calcium channels in neurones
Increases extra-cellular amounts of enzyme responsible for synthesis of GABA
- increases GABA concentrations in brain
Reduces neuronal activity
50
Features of pregabalin
Used in anxiety, neuropathic pain and epilepsy
Less potential for misuse and dependence than benzodiazepines
BNF says short term use
Causes sedation and weight gain
51
Antidepressants for anxiety
Most commonly SSRIs
- similar doses
- doses for OCD higher
52
Types of hypnotics (sleeping tablets)
```
Benzodiazepines
- temazepam
- lormetazepam
- nitrazepam
Nonbenzodiazepines
- act in similar way - positive allosteric modulators
- zopiclone
- zolpidem
```
53
Features of hypnotics
Significant potential for misuse, dependence and rebound insomnia
Use for only 2 weeks and take only 5 out of 7 days each week
54
Features of mood stabilisers
```
Used to treat bipolar mood disorder
Groups
- lithium
- anticonvulsants
- second generation (atypical) antipsychotics
```
55
Features of lithium
Most effective mood stabiliser
MOA unknown
Narrow therapeutic window - 3 monthly serum lithium levels
Excreted by kidneys
Reduces suicide - licence for reduction of self-harm
56
Side effects of lithium
```
GI disturbance
Metallic taste
Dry mouth
Fine tremor
Polydipsia
Polyuria
Weight gain
Long term effects
- hypothyroidism - reversible
- renal impairment - irreversible
- need annual U&Es and LFTs
```
57
Features of lithium toxicity
```
Confusion
Coarse tremor
N+V
Ataxia
Seizures
```
58
Treatment for lithium toxicity
Supportive - fluids
| Dialysis if needed
59
Risk factors for lithium toxicity
```
Dehydration - advise to drink lots of water in hot climates
Drug interactions
- NSAIDs
- Loop diuretics
- ACE inhibitors
```
60
Use of atypical antipsychotics in bipolar
Quetiapine - 1st line for bipolar
| Doses and monitoring same for psychosis
61
Use of anticonvulsants as mood stabilisers
Various modes of action - GABA receptors, calcium channels and sodium channels
Most common
- Sodium valproate - avoid in women in child bearing age due to teratogenicity, check LFTs before and soon after starting
- Carbamazepine
- Lamotrigine - potential for Stevens Johnson Syndrome
- Pregabalin
62
Side effects of anticonvulsants
Sedation
Weight gain
Thrombocytopenia - check FBC
63
Drugs used for cognitive symptoms in dementia
Do not prolong life or slow neurodegenerative changes
- improve cognitive and emotional/behavioural symptoms
Acetylcholinesterase inhibitors
Memantine
64
Method of action of cholinesterase inhibitors
Inhibit breakdown of acetylcholine
- increase levels of acetylcholine in brain
Alzheimer's associated with lower levels of activity in cholinergic system
65
Uses of cholinesterase inhibitors in dementia
Used in Alzheimer's for cognitive and neuropsychiatric symptoms
Indicated in mild to moderate dementia only
66
Side effects of cholinesterase inhibitors
```
Nausea
Diarrhoea
Vomiting
Insomnia
Muscle cramps
Anorexia
Muscle cramps
Anorexia
Bradaycardia
```
67
Monitoring for cholinesterase inhibitors
Pulse check at every appointment
| ECG before starting
68
Examples of chonisterse inhibitors
Donepezil
Galantamine
Rivastigmine - given as patch - good for concordance and less GI side effect
69
Features of Memantine
Glutamine (NMDA) receptor antagonist -> lower neuronal excitability
Used in moderate to severe Alzheimer's
- agitated/challenging behaviour
Generally well tolerated if initiated slowly
No specific monitoring needed
70
Side effects of memantine
Headache
Drowsiness
Insomnia
Nausea
71
Drugs used in ADD and ADHD
Most treatments are CNS stimulants
- potential for misuse and dependency
- monitor weight, height and pulse in children
- Methylphenidate
- most commonly prescribed
- given as combination of immediate and sustained release
- Dextroamphetamine
Atomoxetine
- noradrenaline re-uptake inhibitor
- used according to patient preference, unable to tolerate stimulants or previous drug dependence
72
Framework of psychological therapies
Type A - psychological treatment as integral part of mental health care
Type B - eclectic psychological therapy and counselling
Type C - formal psychotherapies
73
Types of formal psychotherapies available
CBT - cognitive-behaviour therapy
Psychoanalytic/psychodynamic therapies
Systemic and family therapy
74
Define transference
Unconscious transfer of feeling and attitudes from the past into the therapist
- being seen through eyes of the past
75
Uses of psychodynamic therapy
```
Recurrent and chronic inter-personal difficulties
Contribute to management of
- personality disorders
- depression
- eating disorders
- anxiety
```
76
Uses of CBT
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Depression
Anxiety states - phobias, OCD, GAD, panic, PTSD
Eating disorders
Sexual dysfunction
Insomnia
```
77
Features of CBT
Based on learning theory
Thoughts, feelings, actions and physical symptoms all connected - changing one can affect others
Unhelpful thinking leads to unhelpful behaviours
78
Five areas model of CBT
```
Life situation, relationships and practical problems
Altered thinking
Altered emotions
Altered physical feelings/symptoms
Altered behaviour or activity levels
```
79
Features of psychodynamic psychotherapy
Evolution of conscious understanding primarily by interpreting what the patient does and says during a session
Addresses issues of transference and psychological defence mechanisms
80
What is psychotherapy
Systematic use of a relationship between a patient and therapist to produce changes in feelings, cognition and behaviour
81
Uses of psychodynamic psychotherapy
Recurrent and chronic inter-personal difficulties
Psychological conflict or alienation
Contribute to management of
- personality disorders, depression, eating disorders
82
Use of interpersonal therapy
Depression
83
Features of interpersonal therapy
Uses link between onset of depressive symptoms and current interpersonal problems as a focus for treatment
84
Features of family/systemic therapeis
Target system that generates problematic behaviour
| - suggestion, emphasising positive values
85
Uses of family therapies
Intervention for children
Eating disorders
Adjunctive treatment in schizophrenia
86
Aim of CBT
Help individuals to identify and challenge their automatic negative thoughts and then modify any abnormal underlying core beliefs
87
Define selective abstraction
Focusing on one minor aspect rather than the bigger picture
88
Define all or nothing
Thinking of things in all or nothing terms
89
Define magnification/minimization
Over or under estimating the importance of an event
90
Define catastrophic thinking
Anticipating the worst possible outcome of an event
91
Define overgeneralisation
Anticipating the worst possible outcome of an event
92
Define arbitrary interference
Coming to a conclusion in the absence of any evidence to support it
93
Features of relaxation training
Stress-related and anxiety disorders
Patient is asked to use muscle relaxation during times of stress or anxiety
Patient learns to put themselves in situations where they feel relaxed
94
Features of systemic desensitisation
Phobic anxiety disorders
| Individual gradually exposed to hierarchy of anxiety-producing situations
95
Features of flooding
Patient rapidly being exposed to phobic object
96
Exposure and response prevention features
Anxiety disorders - OCD and phobias
Patient repeatedly exposed to the situation that causes them anxiety and prevented from performing their compulsive actions
97
Features of behavioural activation
Depressive illness
Patient avoid doing certain things as they feel they will not enjoy them or fear of failure
Involves making realistic and achievable plans to carry out activities and then gradually increased amount of activity
98
Indications of psychodynamic therapy
```
Dissociative disorders
Somatoform disorders
Psychosexual disorders
Certain personality disorders
Chronic dysthymia
Recurrent depression
```
99
Rationale of psychodynamic therapy
Childhood experiences, past unresolved conflicts and relationships significantly influence individuals current situation
