phase 3a phoebe barrett and natasha hussain the peer teaching society is not liable for false or...
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Phase 3a
Phoebe Barrett and Natasha Hussain
Psychiatry
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• We will ask you lots of questions
The Peer Teaching Society is not liable for false or misleading information…
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
OCD
Psych emergencies
Acute dystonic reactionNeuroleptic Malignant SyndromeLithium toxicity
The Peer Teaching Society is not liable for false or misleading information…
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
OCD
Psych emergencies
Acute dystonic reactionNeuroleptic Malignant SyndromeLithium toxicity
The Peer Teaching Society is not liable for false or misleading information…
• What is it?
(1) Schizophrenia
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• A psychotic mental illness characterised by ≥ 1 month of a number of certain symptoms
• What are the symptoms of schizophrenia? (at least 8)
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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•Negative symptoms: poverty of speech, blunting of affect, lack of volition, socially withdrawn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?
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• Who gets schizophrenia and what the are main risk factors for getting it?
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• Adolescents/young adults, both sexes get it (men it occurs earlier)
• RF – heavy cannabis/skunk use, FH, complications in pregnancy, severe maternal malnutrition
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• What investigations might you do to rule out organic pathology
(name investigation or a differential you are trying to rule out)
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• Bloods – FBC, U&E, LFTs, TFTs, glucose, Calcium, cortisol
• Drug and alcohol screen• ECG• Urine dipstick/MSU• CT/MRI head
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• Treatment of schizophrenia?
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• Anti psychotics (typicals v atypicals?)• Benzodiazepines• Procyclidine (why?)• Plus talking therapies, family therapy,
education, CBT, social/housing/community support
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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)
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• 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”
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• Acute dystonic reaction• Akathisia• Parkinsonism• Tardive dyskinesia
Extra-pyramidal side effects
What are they?
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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
OCD
Psych emergencies
Acute dystonic reactionNeuroleptic Malignant SyndromeLithium toxicity
The Peer Teaching Society is not liable for false or misleading information…
• What is it?
Neuroleptic Malignant Syndrome
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• 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
The Peer Teaching Society is not liable for false or misleading information…
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
OCD
Psych emergencies
Acute dystonic reactionNeuroleptic Malignant SyndromeLithium toxicity
• Depression– Antidepressant therapy– ! Serotonin syndrome
• Mania and bipolar affective disorder– Mood stabilisers– ! Lithium toxicity
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(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
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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?
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Depression
Neurological DegenerativeIdiopathic/iatrogenicCongenitalEndocrine
VascularInfectiveTrauma/environmentalAutoimmuneMetabolicInflammatoryNeoplastic (+heam)
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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
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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
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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
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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
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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
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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??
Antidepressants Quiz!
• 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?
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Antidepressants Quiz!
• SNRIs;– E.g. duloxetine, S/E: anticholinergic– Also used in OCD, ADHD, anxiety
• Trazadone – sedating, good for anxiety• Mirtazapine – increases appetite and is
anxiolytic
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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
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Serotonin (5HT) Syndrome
When is depression unipolar?
When is it part of bipolar affective disorder?
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Mood Disorders
How would you describe somebody with mania?
Cardinal feature?
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Mania
• 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…
Mania
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ManiaDifferentials?- Substance abuse – esp. amphetamines,
cocaine- Schizophrenia - Personality disorders
RFs?
• Co-ordinated care• Rapid access to support in crisis• ?Hospitalisation – MHA• Psychological care – education, promoting
social funtioning etc• Medication • Annual reviews
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Management
- Anti-manic drugs (prophylaxis);- Lithium- Valproate- Carbamazapine - Lamotrigine
- Atypical antipsychotics – olanzapine, apiprazole, quetiapine, risperidone
- ? Rapid tranquilisation
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Mania Treatment
- Treat depression- ?Rapid cycling
- Treat mania
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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
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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
The Peer Teaching Society is not liable for false or misleading information…
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
OCD
Psych emergencies
Acute dystonic reactionNeuroleptic Malignant SyndromeLithium toxicity
The Peer Teaching Society is not liable for false or misleading information…
Questions?