phase 3a phoebe barrett and natasha hussain the peer teaching society is not liable for false or...

Phase 3a

Phoebe Barrett and Natasha Hussain

Psychiatry

The Peer Teaching Society is not liable for false or misleading information…

• We will ask you lots of questions

Psychiatry ClassificationBehavioural

Developmental

E.g. Learning disorders and pervasive developmental disorders (autism/ADHD)

E.g. Eating disordersPersonality disordersPsychosexual disorders

Mental Illness

OrganicFunctional

Organic Substance abuse

E.g. DeliriumDementiaHypothyroidism

Psychoses(loss of contact with reality)

Neuroses(severe “normal” experience)

Schizophrenia

Mood disordersBipolar, depression, mania

Anxiety Phobias

Psych emergencies

Acute dystonic reactionNeuroleptic Malignant SyndromeLithium toxicity

Developmental

Mental Illness

OrganicFunctional

Schizophrenia

Anxiety Phobias

Psych emergencies

• What is it?

(1) Schizophrenia

• A psychotic mental illness characterised by ≥ 1 month of a number of certain symptoms

• What are the symptoms of schizophrenia? (at least 8)

Schizophrenia symptoms•Thought echo/insertion/broadcast/withdrawal or breaks in train of thought/knight’s move thinking

•Delusions of control/influence/passivity (+ passivity phenomenon)

•Auditory hallucinations (3rd person, running commentary)

•Persistent delusions e.g. Religious/super power

•Catatonic behaviour

•Negative symptoms: poverty of speech, blunting of affect, lack of volition, socially withdrawn

What are the purple ones?

• Who gets schizophrenia and what the are main risk factors for getting it?

• Adolescents/young adults, both sexes get it (men it occurs earlier)

• RF – heavy cannabis/skunk use, FH, complications in pregnancy, severe maternal malnutrition

• What investigations might you do to rule out organic pathology

(name investigation or a differential you are trying to rule out)

• Bloods – FBC, U&E, LFTs, TFTs, glucose, Calcium, cortisol

• Drug and alcohol screen• ECG• Urine dipstick/MSU• CT/MRI head

• Treatment of schizophrenia?

• Anti psychotics (typicals v atypicals?)• Benzodiazepines• Procyclidine (why?)• Plus talking therapies, family therapy,

education, CBT, social/housing/community support

Typical anti-psychotics Atypical anti-psychotics

Old school Newer

Worse side effect profile Still some pretty bad side effects

E.g. Haloperidol, cholpromazine E.g. Olanzapine, clozapine, risperidone, aripiprazole

So what are these side effects?(at least 6)

• P - ↑ prolactin and extra-Pyramidal side effects (EPSEs)

• S – sexual dysfunction• Y – You get fat• C – CV effects - ↑ HR, BP changes, arrhymias, QT

prolongation• H – Hyperglycaemia and Diabetes• O – other – Anti-muscarinic side effects e.g. Dry eyes,

mouth, constipation -Bad withdrawal if stopped

“PSYCHO”

• Acute dystonic reaction• Akathisia• Parkinsonism• Tardive dyskinesia

Extra-pyramidal side effects

What are they?

Developmental

Mental Illness

OrganicFunctional

Schizophrenia

Anxiety Phobias

Psych emergencies

• What is it?

Neuroleptic Malignant Syndrome

• Severe motor/mental/autonomic dysfunction• ↑ temp• Muscle rigidity• Unstable BP, ↑ HR, ↑ sweating• Dysphagia• Mutism• Urinary incontinence

A rare, life threatening reaction to anti-psychotics (or can be to anti-depressants or anti-convulsants) within first 10/7 Tx

High mortality

Developmental

Mental Illness

OrganicFunctional

Schizophrenia

Anxiety Phobias

Psych emergencies

• Depression– Antidepressant therapy– ! Serotonin syndrome

• Mania and bipolar affective disorder– Mood stabilisers– ! Lithium toxicity

(2) Mood Disorders

What classification system can we use?

What are the symptoms of depression?= 3 core ones

At least 2 of these, every day, for 2 weeks

Depression

• D Depressed mood• E Energy ↓ = ‘ANERGIA’• P Pleasure, interest and enjoyment ↓ = ‘ANHEDONIA’• R Retardation (psychomotor) – N.B. atypically

agitation• E Eating changes: ↓appetite and weight – ↑in

atypical• S Sleep disturbance (EMW)• S Suicidal/self harm thoughts• I I’m a failure • O Only me to blame • N No concentration or attentionThe Peer Teaching Society is not liable for false or misleading information…

Symptoms

Which are biological? Cognitive?

Can they exhibit psychotic features?Delusions? Hallucinations?

Depression

Neurological DegenerativeIdiopathic/iatrogenicCongenitalEndocrine

VascularInfectiveTrauma/environmentalAutoimmuneMetabolicInflammatoryNeoplastic (+heam)

Peer Teaching Society is not liable for false or misleading information…

Surgical Sieve

+ PSYCH!!

• Psych – schizophrenia, anxiety, PND, hypoactive delirium etc!

• Neuro – encephalitic disorder, PD, dementia, MS (CSF, brain imaging, MMSE)

• Iatrogenic (drugs);– Anticonvulsants, antipsychotics, anabolic steroids– Beta blockers,– Contraceptives (progesterone), CCBs, corticosteroids– Drugs for PD, e.g. levadopa

DD and Ix

• Endocrine;• Hypoglycaemia - glucose• Hypothyroid (hyper in anxiety) - TFTs• Cushing’s - cortisol• HyperPTH (high calcium) - PTH/ Ca and phosphate

levels• Vascular - CVD - Cholesterol• Infective - post viral, Lyme disease, neurosyphilis, AIDs

and other chronic – bloods, virology

DD and Ix

• Trauma – bleeds? - imaging• Environmental;

• Alcoholism, MCV, LFTs (gamma GT)• Drugs such as cannabis, benzodiazepines,

amphetamines - urine• Autoimmune – SLE - ANA, ESR, anti dsDNA• Neoplastic – SOL - imaging• Haem – anaemia - FBC, vit B12/folate

DD and Ix

Depression Tools

How can you diagnose depression and assess severity?

Can you ‘screen’?What is the criteria used re: screening?

• Mild– Low intensity psychological interventions: self help/ telephone

sessions/group CBT, exercise classes• Moderate

– More intense psychological interventions – individual CBT, counselling, interpersonal therapy

– + Antidepressant drugs • Severe

– Intensive psych treatments– Drugs– ECT in emergency– ? Antipsychotics

Treatment

• SE: hypertensive crisis if eat cheese!• E.g: phenelzine• Action: block monoamine oxidase enzyme = x

breakdown of monoamine neurotransmitters dopamine, serotonin and norepinephrine

• Answer: MAOIs– Use in treatment of drug resistant/atypical

depression

Antidepressants Quiz!

• SE: – Anticholinergic: dry mouth, blurred vision,

constipation, urinary retention, postural hypotension, drowsiness, sweating

• E.g: clomipramine• Answer: TCAs • Can help with poor sleep• Problems: cardiotoxic in overdose• ECG changes??

• SE: GI bleeds, dyspepsia• E.g: paroxetine• Action: inhibit reuptake of serotonin by

presynaptic cells • Pros: less cardiotoxic and safer in overdose

than TCAs first line drugs• Answer: SSRIs• ?Why not in children & adolescents?

• SNRIs;– E.g. duloxetine, S/E: anticholinergic– Also used in OCD, ADHD, anxiety

• Trazadone – sedating, good for anxiety• Mirtazapine – increases appetite and is

anxiolytic

Other antidepressants

Which drugs can cause this?Symptoms include;- Agitation/restlessness- Hyperpyrexia - Tachycardia- Hypertension- Loss of co-ordination- Myoclonus- Rigidity- Coma

Treatment – withdrawal of causative drug(s), benzodiazapine, cyproheptadine

Serotonin (5HT) Syndrome

When is depression unipolar?

When is it part of bipolar affective disorder?

Mood Disorders

How would you describe somebody with mania?

Cardinal feature?

• Appearance/behaviour– Psychomotor overactivity – little sleep, distracted– ? Brightly coloured, mismatched clothing – Increased appetite and libido

• Mood and affect– Usually elated – Congruous

• Speech – Uninterruptable/pressured, rapid

• Perception– May have delusions of persecution or grandiose – mood congruent

• Thoughts– Flight of ideas, hallucinations (usually auditory)

• Cognition• Insight

– Often absent The Peer Teaching Society is not liable for false or misleading information…

ManiaDifferentials?- Substance abuse – esp. amphetamines,

cocaine- Schizophrenia - Personality disorders

• Co-ordinated care• Rapid access to support in crisis• ?Hospitalisation – MHA• Psychological care – education, promoting

social funtioning etc• Medication • Annual reviews

Management

- Anti-manic drugs (prophylaxis);- Lithium- Valproate- Carbamazapine - Lamotrigine

- Atypical antipsychotics – olanzapine, apiprazole, quetiapine, risperidone

- ? Rapid tranquilisation

Mania Treatment

- Treat depression- ?Rapid cycling

- Treat mania

Bipolar Affective Disorder

• Monitor– Lithium levels;

• 12 hours after administration• Weekly until levels stable after initiation/dose change• Then every 3/12

– U&E – baseline and every 6/12– TFTs – every 6/12

N.B. Pregnancy test prior – Ebstein’s anomaly

Avoid diuretics!

Lithium

EARLY• Mild diuresis• FINE tremor• Dry mouth• Metallic taste

LATE• Weight gain• Hypothyroidism• Hypokalaemia• Oedema

TOXICITY• Blurred vision• COARSE tremor• Muscle weakness• Ataxia• N and V• Hyper-reflexia• Circulatory failure• Oliguria• Seizures • Coma

Lithium SEs & Toxicity

Treatment;– Supportive – Stop lithium dose and recheck levels– IV fluids/encourage diuresis (monitor fluid

balance)– Monitor U&Es– Consider dialysis– Treat seizures

If mild, generous amounts of sodium salts and fluid will reverse toxicity

Lithium

Developmental

Mental Illness

OrganicFunctional

Schizophrenia

Anxiety Phobias

Psych emergencies

Questions?

phase 3a phoebe barrett and natasha hussain the peer teaching society is not liable for false or...

symptoms of schizophrenia

learning disorders

number of certain symptoms

commentarypersistent

severe maternal malnutrition

phoebe barrett

train of thoughtknights

poverty of speech

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