Phase 3A Bukky Olaitan and Rolla Ibrahim The Peer Teaching Society is not liable for false or misleading information…

Phase 3A

Bukky Olaitan and Rolla Ibrahim

Psychiatry (Part 1)

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

• Psychotic disorders – schizophrenia and Treatments

• - Mood disorders – e.g. mania, depression, bipolar disorder and Treatments

• Quick note on non-pharmacological treatments

• - Psychiatric emergencies


Contents


Introduction


Diagnostic Hierarchy

• Chronological– Predisposing factors - predispose a person to being vulnerable to

suffering from a psychiatric disorder. Examples include the person’s genetic makeup, obstetric complications, and his or her personality

– Precipitating factors - arise just before a psychiatric disorder starts and appear to have precipitated it e.g life events such as involvement in traumatic incident, bereavement

– Perpetuating factors – Cause psychiatric disorder to continue, e.g social withdrawal (often a result of psychiatric disorders)

• Multifactorial – Genetic, biochemical and neurotransmitter changes, psychological, infections, psychosocial stressors, personality and psychodynamic

Aetiology


• Physical– Pharmacotherapy (drug treatment – antipsychotic

aka neuroleptics)– ECT– Phototherapy (light therapy)

• Psychological

• Psychosocial

Treatments



• Major psychotic disorder• Lifelong condition – chronic or relapsing

remitting• 1% of population will be diagnosed at some

point in their lives, prevalence is 200 per 100 000

• Multifactorial• Subtypes

Schizophrenia


• Multifactorial – Genetic, social and environmental, associated with some drugs e.g cannabis

• Risk Factors – Family history; intrauterine and perinatal conditions e.g premature birth or v. low birthweight; social isolation, migrants; abnormal family interactions e.g overly critical parents; delayed neuromuscular development

Aetiology of Schizophrenia


• Main clinical features– Change in Thinking – Change in perception (hallucination)– Blunted or inappropriate affect– Decreased level of social functioning

Schizophrenia Features


• Auditory hallucinations– Thought Echo– Second Person– Third Person

• Thought Alienation– Thought Withdrawal– Thought Insertion– Thought broadcasting

• Made feelings, impulses or actions – may feel like hypnosis• Somatic Passivity• Delusional Perception

Schneider’s First Rank Symptoms


• Other persistent delusions• Other persistent hallucinations• Thought disorders – e.g thought blocking,

neologisms• Catatonic behavior – Waxy flexibility; stupor;

excitement; posturing; negativism• Negative Symptoms

Other Symptoms of Schizophrenia


• Chronic schizophrenia• Usually later stages• Apathy• Poverty of speech• Lack of drive• Blunted or incongruous affect• Results in social withdrawal and lowered social

performance

Negative Symptoms of Schizophrenia


• Positive Symptoms (Acute schizophrenia)– Hallucinations– Delusions– Thought Disorders

• Negative Symptoms (Chronic schizophrenia)– Poverty of speech– Affective blunting– Lack of volition– Socially withdrawn


Symptoms overview

• Appearance & behaviour – may show self neglect, restlessness or odd, or lack of movements, and odd appearance(e.g. hair / makeup / clothes)

• Speech – Tangential speech – one though is unrelated to the next. Often neologisms, may be incoherent, jumps from subject to subject.

• Mood – suspicious, may often seem deep in though and perplexed/confused

• Thoughts – delusions,though disorder, persecutory• Perceptions – hallucinations – most commonly auditory• Cognition – poor attention span and concentration, unshakable

beliefs (‘concrete thinking’)

Schizophrenia mental state exam

• Paranoid – Well formed delusions and hallucinations (most common)

• Hebephrenic – Delusions and hallucinations fleeting or fragmented– Irresponsible and unpredictable behaviour; – Shallow and inappropriate affect; – Prominent thought disorder.

• Catatonic – Prominent psychomotor disturbance e.g mutism, waxy flexibility etc

• Simple – Slow onset, mainly negative symptoms, few positive, poor functioning, diagnosis

often made in retrospect.• Residual or Chronic

– Preceded by one of above types. Characterised by negative symptoms

Schizophrenia subtypes


• If presenting for first time. Mainly to rule out any organic cause (remember hierarchy!)– further information– urea and electrolytes, full blood count, thyroid function tests,

liver function tests– a screen for illicit drugs, if psycho active substance use is

suspected as a cause– vitamin B12 and folate levels– syphilitic serology– EEG (the symptoms may be caused by complex partial seizures

of the temporal lobe)– CT scan (if clinically indicated).

Investigations


Antipsychotic drugs


Typical Antipsychotics – Postsynaptic blockade of dopamine D2 receptors in CNS,. Antidopaminergic action on mesolimbic system is required effect – responsible for antipsychotic activity.

Atypical Antipsychotics – Act on other dopaminergic receptors (not D2) and sertotonergic receptors (5HT). E.g clozapine (beware neutropenia and agranulacytosis)


Side effects of chlorpromazine (EPSE not shown)

04/01/2010© The University of Sheffield / Department of Marketing and

Communications21

• Depot antipsychotic drugs

Risperidone, Haloperidol

• Side effects:

Extrapyramidal effects Anti-dopaminergic action on basal ganglia


Communications22

EPSE Extrapyramidal side effects

• Acute Dystonia• Akathisia• Parkinsoninan syndrome• Tardive dyskinesia


Communications23

Acute Dystonia

• Occurs early stages treatment • Severe rigidity • Torticollis, tongue protrusion

• Treatment: - procyclidine

24

Akathisia

• Unpleasant feeling of physical restlessness • Occurs first 2 weeks of treatment

• Treatment: beta blockers & benzodiazepines


Communications25

Parkinsoninan syndrome

• Bradykinesia• Expressionless face • Coarse tremors • Festinant gait

Treatment: procyclidine, change antipsychotic


Communications26

Tardive dyskinesia • Chewing • Sucking movements • Choreoathetoid movements

Treatment:Limit the long term use of antipsychotics Atypical agents


Communications27

Other side effects of antipsychotic drugs

Sedation Postural hypotension

Dry mouth Urinary hesitancy and retention

Constipation Blurred vision

Cardiac conduction: prolonged QT & T wave flatting

Depression


Communications28

Specific side effects

Weight gain: Olanzapine

Clozapine and Olanzapine: increased risk of type II DM

Sexual dysfunction due to increased prolactin

Lower seizure threshold

Clozapine - leucopoenia, agranulocytosis, myocarditits and myopathy


Communications29

Neuroleptic Malignant Syndrome Rare but serious disorder

Onset first 10 days of treatmentSevere motor, mental and autonomic dysfunction

Generalised muscular hypertonicity, dysphagia, mutism, impaired consciousness

Hyperpyrexia, unstable BP, tachycardia, excessive sweating, urinary incontinence


Communications30

Blood CPK raised

ComplicationsPneumonia, Thromboembolism Cardiovascular collapse, Renal failure

Treatment: Stop drug

Symptomatic: maintain fluid balance

Diazepam for muscle stiffnessDantrolene -malignant hyperthermiaBromocriptine


• First Presentation

Mood Disorders


Manic Episode Depressive Episode

HypomaniaMania – without psychotic symptomsMania – with psychotic symptoms

Mild – with or without somatic symptomsModerate – with or without somatic symptomsSevere – with or without psychotic symptoms

• Once it occurs more than once

Recurrent illness


Manic Depression

Bipolar affective disorder – two or more episodes with at least one manic

Recurrent depressive disorder – no manic episodes

• Mood isn’t elevated enough for hypomania or low enough for depression

• Dysthymia – Constant low mood• Cyclothymia – instability of mood with

numerous periods of elevated and low mood– Doesn’t disturbed ADLs

Persistent mood disorder




Depression

• Low mood for 2 weeks• Anergia• Anhedonia• Cognitive

– Poor concentration– Decreased confidence– Hopelessness– Worthlessness– Guilt– Thoughts of suicide

• Biological/Somatic– Sleep disturbance– Early morning wakening– Decreased weight. 5% in

1 month– Decreased appetite– Diurral mood

disturbance– Decreased libido


• Females > males– Lifetime risk males 5-12%– Females 9-26%– Women are more likely to admit

• Late 30s


• Appearance – Downturned eyes, sagging corners of mouth

• Behaviour Psychomotor slowing• Speech silent, delays• Mood• Thoughts - Pessimistic• Perception• Cognition

Mental State Exam


• Mild – continue with ADLs• Moderate – continue with some difficulty• Severe

– Continue with difficulty. Somatic symptoms• With/out delusions, hallucinations, manic episodes• Masked depression

– Somatic complaints. – Seasonal affective disorder

Classification


• Primary or secondary diagnosis of depression• Organic causes

– Hypothyroidism, Parkinson’s, MS– 25% of Cushing’s patients are depressed

• Alcohol and drugs• Schizophrenia – negative symptoms

– Biological symptoms don’t fit

• Bipolar affective disorder• Dementia

Differential Diagnosis


• HISTORY!• U&Es – conversion of psychoactive substance

abuse• FBC, TFT, LFTs• Screen for illicit drugs• Vit B12 and Folate levels• Syphilitic serology

Investigations


Management

• SSRI!– First line. Less OD– Citalopram - preferred– Fluroxetine – common,

but hard to withdraw. More in chidren

– Sertraline – first line in older patients. Useful post-MI

– Paroxetine

• Side-effects– G.I.– Insomnia– Hyponatraemia

• Citalopram and QT interval– Dose dependant

prolongation• Interaction

– NSAIDs– Warfarin/Heparin – NO!– Avoid TRIPTANS


• Tricyclic Antidepressants– Clomipramine – Lofepramine – less

cardiotoxic– Not used as much

because of S.E.s• Cardiotoxic• Neuro symptoms• Tiredness

• MAOI– Interactions with food

• ECT– Life threatening

depression.– Attempted suicide

• CBT



Mania

• Elevated mood• Overactivity• Pressure or speech• Flight of ideas• Decreased need or sleep• Socially disinhibited

• Increased libido• Decreased

concentration decreased concentration

• Inflated self-esteem• Grandiose• Irritable / suspicious


Mental State Exam

• Appearance – self-neglect, flamboyantly dressed

• Behaviour – Difficult to sit still

• Speech – Pressure of speech

• Mood – euphoric, irritable

• Thought– Inflated views of

importance– Psychotic symptoms –

irritability, suspicious• Perception

– Preoccupation of fine details

• Cognition– Poor attention

• Insight - nope


• Peak 15-30 years, average mid-20s• Males = Females• Episode must be 1 week duration

…Mania


• Similar to mania, but not as pronounced• No delusions/hallucinations• No disruption of ADLs• No psychosis

Hypomania


• Organic causes– Hyperthyroidism, neurosyphilus– Don’t account of pressure of speech

• Alcohol and drugs– Blood, urine, history, collateral

• Schizophrenia– Similar to first rank symptoms. No pressure of speech

• Schizoaffective disorder• Personality disorder

DDx


• Precipitating factor– Psychosocial stressess – ‘Vulnerability factors’

• Perpetuating and mediating factors– Psychologica factors – learned helplessness– Electrolyte – reduced sodium!– Decreased REM

• Genetics• Cognitive theory

– All about one’s views and interpretation of experiences

Other causes


• Same as depression• On MRI look at frontal area

Investigation


• Admit lack of insight– Risk of dehydration

• Mood-stabilizing drugs– Lithium or carbamazepine

• PLUS anti-psychotic

Management


Lithium• Anti-suicidal! • Use

– Prophylaxis of mania– Tx of mania, 2 wks to work.

Use anti-psychotic• Low Therapeutic ratio

– Plasma 0.4-1.0mmol/l– 12 hrs after dose

• Mechanism– Reduces dopamine and

glutamine excitory– Increases GABA inhibitory

• Contraindications– Renal insufficiency– CVS insufficiency– Hypothyroidism,

Addisons

• S.E.s– Dehydration

• U&Es and TFTs check reguarly


• 0-0.5mmol/L– GI effects, fine tremor, dry mouth, polyuria, vertigo,

oedema• 1.0-1.5mmol/L

– Coarse tremor, ataxia, dysarthria, nystagmus, renal impairment, anorexia, muscle weakness

• 2.0-2.5mmol/L– Hyperreflexia, hyperextension of limbs, convulsions,

toxic psychosis, syncope– Oliguria, circulatory failure, coma, death

Lithium Toxicity


• Epidemiology– Men > women. Over 45 yrs– Higher in: single, divorced, widowed, extreme

clases– 90% suffer from psychiatric disorder– Previous attempt, 100x greater risk

• What to do?!– Inpatient if at risk– Psychomotor retardation – greater risk after

improvement

Suicide


• 90% cases deliberate self-poisoning• Females > males. 15-25 years. Lower class,

unemployed, single• SSRIs are less toxic than MAOI or tricyclics• Associated with psychiatric disorders

Parasuicide


• Self-harm• Precautions to avoid discovery• Help not sought afterwards• Dangerous methods

– Hanging– Electrocution– Shooting

Suicide intent


• Patient started on an clozapine 8 days ago presents with tachycardia, urinary incontinence, and diarrhea. On examination you note dysphagia and an unstable BP.

• What blood test would you do?• What is the diagnosis?• What is the management?

Question


• Rare but severe motor, mental and autonomic dysfunction

• First 10 days of treatment• Rigidity, diarrhea, dysphagia, mutism,

impaired consciousness• 20% die without treatment• Autonomic changes: tachycardia, excessive

sweating, unstable BP, urinary incontinence

Neuroleptic Malignant Syndrome


• Investigation– Blood CK– Raised because of muscle rigidity

• Treatment– STOP DRUG! – Supportive: fluid balance– Muscle stiffness Diazepam– Malignant hyperthermia Dantrolene

• Complications– Pneuonia, Thromboembolism, CVS collapse, renal failure

…NMS


• Patient already on treatment for depression, was started on Phenelzine (MAOI) 5 days ago presents with rigidity, diarrhoea, and myoclonus.

• What is the diagnosis?• What medication does this interact with?

Question


• SSRI interaction with MAOI• Presentation

– Agitation, hyperpyrexial (common), rigidity, myoclonus, diarrhea

• Myoclonus used to differentiate between NMS and SS

Serotonin Syndrome





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Phase 3A Bukky Olaitan and Rolla Ibrahim The Peer Teaching Society is not liable for false or misleading information…