1 Gemma Adams & Gabrielle ZealandPsychiatry Gemma Adams & Gabrielle Zealand

2 What we are going to coverSchizophrenia & psychotic disorders Personality disorders Psychiatric treatments Psychiatric emergencies Lithium toxicity Acute dystonic reaction Neuroleptic malignant syndrome Serotonin syndrome The Peer Teaching Society is not liable for false or misleading information…

3 Schizophrenia WHO defines as…‘a severe mental disorder, characterized by profound disruptions in thinking, affecting language, perception, and the sense of self.’ Age of onset between Equal gender distribution. Risk factors? Family history, intrauterine complications/infection, social isolation, migrants, abnormal family interactions. Triggers include periods of stress and high emotion and drug misuse Drugs- hallucinogens and stimulants The Peer Teaching Society is not liable for false or misleading information…

4 Delusion HallucinationA false belief which is firmly sustained and based on incorrect inference about reality. This belief is held despite evidence to the contrary and is not accounted for by the person's culture or religion. Hallucination A hallucination can be described as a sensory perception which is experienced despite there being no external stimulus. Hallucinations can occur with any sense and thus be visual, auditory, olfactory, gustatory or tactile. Example of a tactile hallucination- Formication in Delirum Tremens The Peer Teaching Society is not liable for false or misleading information…

5 Positive (or 1st rank) symptomsRepresent a change in behaviour or thoughts (one or more indicates strong chance of having disease) Include? > Delusional perceptions > Auditory Hallucinations > Somatic Passivity > External control of emotion > Thought insertion, removal or interruption > Thought broadcasting > Lack of Insight Delusional perceptions- abnormal interpretation of a normal stimulus- ‘the rainbow came out and I realised I was God’ . Auditory hallucinations- thought echo and 3rd person commentary. Can have other modalities but much more likely to be auditory Somatic passivity- passive recipient of external control – thoughts, sensations and actions The Peer Teaching Society is not liable for false or misleading information…

6 Negative (or chronic) symptomsRepresent a withdrawal or lack of function Can present as a prodromal period several years before the development of positive symptoms Include? > Underactivity (including poverty of speech) > Social withdrawal > Low motivation > Emotional flattening > Self neglect The Peer Teaching Society is not liable for false or misleading information…

7 Subtypes… Paranoid- delusions of persecution, reference, grandeur, jealousy, non verbal auditory hallucinations, threatening auditory hallucinations. Hebephrenic- Irresponsible & unpredictable behaviour, rambling incoherent speech, affective changes, poorly organised delusions and fragmented hallucinations. Poor prognosis. Catatonic- Extremes of behaviour. Stupor or excitement. Residual- Preceded by another form. Negative symptoms Simple – insidious onset of functional decline. Negative symptoms Delusions of reference- believe others are referring to them Delusions of jealousy- Hebephrenic- incongrous affect, and shallow mood Catatonic- Stupor- poverty of speech, little or no movement, uncooperative, waxy flexibility. Excitement- echolalia, echopraxia, unusual ritual like behaviour, strange movements, excessive mobility. The Peer Teaching Society is not liable for false or misleading information…

8 Mental State ExaminationAppearance- dishevelled, unkempt. Behaviour- mannerisms, withdrawal, extremes. Speech- thought ‘blocking’, loosening of associations, word salad, flight of ideas Mood- flattened, incongruous or ‘odd’ Abnormal Beliefs- delusions, somatic passivity Abnormal experiences- hallucinations Cognition – attention, concentration, orientation and memory. Incongrous- not in harmony or keeping with the surroundings or other aspects of something The Peer Teaching Society is not liable for false or misleading information…

9 Why do you need to do an ECG? Investigations- rule out organic cause or differential (bipolar, schizoaffective) Management… Antipsychotics Have a MDT approach. 1st line- Atypical Antipsychotics- risperidone or olanzapine with psychological interventions (CBT, family interventions) Why do you need to do an ECG? Acute – crisis team, typical or atypical antipsychotics, psychological. Rapid Tranquilisation. Organic cause- drug screen, CT+MRI, alcohol, EEG (temporal lobe),infection screen Atypical antipsychotics- Have less extra pyramidal side effect (akinesia, akathisia, parkinsonisms) Common SE- weight gain, sexual dysfunction, DM, increased stroke risk, drowsiness, prolonged QT Typical- chlorpramazine, haloperidol The Peer Teaching Society is not liable for false or misleading information…

10 Rapid Tranquilisation Calm/lightly sedate service user, reduce risk to self and others, and achieve an optimal reduction in agitation and aggression. To allow a thorough psychiatric evaluation Risks must be assessed. Oral- lorazepam, olanzapine, haloperidol (or IV) Must be properly monitored and documented Patient should be invited to record their own recollections of events. Rapid tranq risks- high in children, frail, pregnant, elderly, lewy body, concurrent psych. Drop of consciousness, airway obstruction, respiratory depression, drop in BP, cardiac arrest, seizure. The Peer Teaching Society is not liable for false or misleading information…

11 Other Psychotic DisordersPuerperal Sudden onset psychosis occurring days/weeks after birth. Higher risk if past psych history, 1st baby, but can be completely random. Symptoms- quickly fluctuating drastic moods, positive symptoms. Treatment- antipsychotics, mood stabilisers, psychological. BF risk. Puerperal- Mood- mania, low mood, Delusions are often to do with the baby. Mood stabilisers- lithium, carbamazepine Schizoaffective Episodic- mood and schizophrenic symptoms Manic, Depressive or Mixed. Treatment- antipsychotics, trial antidepressants, mood stabilisers. The Peer Teaching Society is not liable for false or misleading information…

12 Other Psychotic DisordersPersistent delusional disorders. Delusion persistence for at least 1 month with no identifiable organic basis. Jealousy, erotomania, persecutory, cotard’s, capgras Treatment- pharmacological, psychological. Difficult to treat. Acute/Transient Psychosis Acute stressor Within 2 weeks. Doesn’t meet criteria for specific disorder. No recent psychoactive drug use or withdrawal. No organic cause. Capgras- believe to have been replaced by a double Cotard’s- nihilistic- can be somatic Erotomania- de Clerambault- believe that someone usually of a higher status is in love with them- may have made a brief acquaintance. The Peer Teaching Society is not liable for false or misleading information…

13 Antipsychotics Reduce psychomotor excitement, control symptoms of psychosis and reduce hallucinations and delusions. Receptor? D2 receptors Indications? Schizophrenia, mania, 2° psychosis, Tourette’s syndrome The Peer Teaching Society is not liable for false or misleading information…

14 Antipsychotics Categories? Atypical Typical DepotOlanzapine, quetiapine, risperidone, clozapine, aripiprazole Less EPSE Excreted into breast milk Typical Haloperidol, chlorpromazine EPSE Less useful –ive symptoms Extra pyramidal side effects due to dopamine blockade in basal ganglia Chlorpromazine more sedating, haloperidol less sedating but higher incidence of movement disorders Clozapine useful in refractory psychosis Typical antipsychotics less useful in negative symptoms. Atypicals enter breast milk. Can be given by depot – IM injection every 1-4 weeks, increased risk of EPSE, haloperidol and risperidone can be given via depot. The Peer Teaching Society is not liable for false or misleading information…

17 Extra pyramidal side effects2. Akathisia Feeling of inner restlessness Need to constantly move Hours to weeks Use lowest dose/ switch to atypical Propranolol, BDZ The Peer Teaching Society is not liable for false or misleading information…

18 Extra pyramidal side effects3. Parkinsonian syndrome Resting tremor, rigidity, bradykinesia Procyclidine Change antipsychotic 4. Tardive dyskinesia Slow onset, repetitive, involuntary, purposeless movements Onset years later Limit long-term use, atypicals Parkinsonian syndrome: symptoms of Parkinsons. Treatment – procyclidine, change antipsychotic Tardive dyskinesia: slow onset, repetitive, involuntary, purposeless movements, e.g. tongue movements, grimacing, lip smacking. Treatment – limit long-term use of antipsychotics, use atypical agents The Peer Teaching Society is not liable for false or misleading information…

19 Antidepressants Classes of anti-depressants?Tricyclic antidepressants (TCA) Selective serotonin reuptake inhibitors (SSRI) Monoamine oxidase inhibitors (MAOI) Noradrenergic and specific serotonergic antidepressants (NaSSA) Serotonin noradrenaline reuptake inhibitors (SNRI) Noradrenaline reuptake inhibitors (NARI) Other Another class called noradrenaline reuptake inhibitors (NARI) very rarely used The Peer Teaching Society is not liable for false or misleading information…

20 TCAs E.g. Side effects? Cardio-toxic in overdoseAmitriptyline, clomipramine, imipramine, dosulepin Side effects? ECG changes Anti-muscarinic Cardio-toxic in overdose Also used in neuropathic pain ECG changes – prolongation of PR interval, prolonged QT, ST depression. Contra-indicated following MI. Anti-muscarinic - dry mouth, dry nose, blurry vision, lowered gastrointestinal motility or constipation, urinary retention, cognitive and/or memory impairment, and increased body temperature The Peer Teaching Society is not liable for false or misleading information…

21 SSRIs E.g. 1st line drugs GI side effectsFluoxetine, paroxetine, citalopram, sertraline 1st line drugs GI side effects Can initially increase suicidal behaviour, caution in teenagers Also used in eating disorders, anxiety disorders, chronic pain Interact with MAOIs Side effects – nausea, vomiting, dyspepsia, diarrhoea, abdo pain The Peer Teaching Society is not liable for false or misleading information…

22 Serotonin syndrome Serotonin syndromeAdverse reaction to serotonergic agents Commonly reaction with MAO-I Starting or increasing the dose, within 6 hours Autonomic hyperactivity Serotonin syndrome Implicated drugs: pretty much all anti-depressants, opioids, some anti-emetics, recreational drugs - Autonomic hyperactivity – hypertension, tachycardia, hyperthermia, hyperactive bowel sounds, mydriasis, excessive sweating - Neuromuscular abnormality – tremor, clonus, hypertonicity, hyperreflexia - Mental status changes – anxiety, agitation, confusion, coma Skin appearance should be normal in SS, a fact that helps to differentiate it from two similar diagnoses Neuromuscular abnormality Mental status changes The Peer Teaching Society is not liable for false or misleading information…

23 Serotonin syndrome Clinical diagnosis Investigations: Management:FBC/ cultures U&Es and CK Toxicology screen CT scan, LP Management: Stop drug, supportive treatment Cyproheptadine Can have temp up to 41, should do cultures at a temp of 38, rule out infection U&Es and CK to check for rhabdomyolysis and kidney damage CT scan LP – fever and altered mental state, ?encephalitis Severe cases need aggressive treatment and intensive care with early sedation, neuromuscular paralysis and ventilatory support Supportive – reduce fever with ice packs (to prevent DIC and organ failure) antipyretic agents have no role, as hyperthermia is due to muscular activity rather than hypothalamic mechanisms Cyprohepatidine – serotonin antagonist, also an anti-histamine Do not prescribe an SSRI together with an MAOI The Peer Teaching Society is not liable for false or misleading information…

24 Antidepressants SNRI – venlafaxine, duloxetineHypertension MAOI – moclobemide, phenelzine Lots of s/e Hypertensive crisis NaSSA – mirtazepine NARI – buproprion Other – St John’s wort, trazadone Duloxetine – good for neuropathic pain esp diabetes Noradrenaline – vasopressor and positive inotrope so avoid in hypertensive pts/ known heart disease MAOI, can’t eat foods containing tyramine e.g. cheese, pate, beer, red wine, smoked fish, liver – depression, refractory anxiety Mirtazepine are sedative, useful when patient not sleeping, Increased appetite & weight gain NARI - treatment of conditions like ADHD and narcolepsy due to their psychostimulant effects and in obesity due to their appetite suppressant effects. Buproprion – anti-depressant and smoking cessation aid, St John’s wort - plant extract, induces hepatic enzymes The Peer Teaching Society is not liable for false or misleading information…

25 Serotonin syndrome Serotonin syndrome Autonomic hyperactivityImplicated drugs: pretty much all anti-depressants, opioids, some anti-emetics, recreational drugs - Autonomic hyperactivity – hypertension, tachycardia, hyperthermia, hyperactive bowel sounds, mydriasis, excessive sweating - Neuromuscular abnormality – tremor, clonus, hypertonicity, hyperreflexia - Mental status changes – anxiety, agitation, confusion, coma Skin appearance should be normal in SS, a fact that helps to differentiate it from two similar diagnoses Neuromuscular abnormality Mental status changes The Peer Teaching Society is not liable for false or misleading information…

26 Neuroleptic malignant syndromeNeuroleptic: “a drug that depresses nerve functions” Earlier definition of anti-psychotic: “reduces psychomotor excitement” Dopamine Parkinson’s Depot Previous NMS Neuroleptic - a drug that depresses nerve functions Anti-psychotic – reduce psychomotor excitement Dopamine – another risk factor, withdrawal of anti-parkinsonian medication, depot preparations Thought to be due to dopamine blockade or dopamine depletion in hypothalamus and nigrostriatal/spinal pathways The Peer Teaching Society is not liable for false or misleading information…

27 Neuroleptic malignant syndromeSlower onset, in first 10 days of treatment Symptoms Autonomic dysfunction, neuromuscular abnormality (RIGIDITY), mental status changes Parkinsonian features Investigations Exactly the same Management Pretty much the same  supportive Dopaminergic drugs, dantrolene Rigidity rather than increased tone. Raised CK on bloods Dopaminergic drugs – bromocriptine (used to treat hyperprolactinaemia), dantrolene for temperature The Peer Teaching Society is not liable for false or misleading information…

28 Psychiatric emergenciesSerotonin syndrome Neuroleptic malignant syndrome Drug SSRIs/ anti-depressants Anti-psychotics Time frame Up to 6 hours Up to 10 days Extra treatment Cyproheptadine Bromocriptine, dantrolene Raised CK on bloods Dopaminergic drugs – bromocriptine (used to treat hyperprolactinaemia), dantrolene for temperature The Peer Teaching Society is not liable for false or misleading information…

29 Personality DisordersICD-10 defines as… A severe disturbance in the characterological condition and behavioural tendencies of the individual, usually involving several areas of the personality and nearly always associated with considerate social and personal disruption. Risk factors? upbringing (abuse, neglect, disorder), severe aggression and disobedience in children, stressful life events, drug misuse. The Peer Teaching Society is not liable for false or misleading information…

30 What are the different types of personality disorder?The Peer Teaching Society is not liable for false or misleading information…

31 Cluster A- MAD Paranoid Schizoid Cluster B- BAD Anti/Dissocial Borderline- unclear or disturbed self image, intense & unstable relationships, emotional crises. Histrionic Impulsive Cluster C- SAD. Can predispose to depressive disorders Anankastic (obsessive compulsive) Avoidant Dependent Can be Mixed Histrionic- excessive emotional, attention seeking, and over dramatic behaviour. Suggestible shallow and labile affectivity. Manipulative Impulsive- shows genuine regret and remorse Dependent- subordinate, allows others to take control over their lifes, low self esteem, fear of being alone Avoidant- hypersensitive, can’t handle criticism, restricted lifestyle, pervasive tension and apprehension Anakansic- indecisive, perfectonism, excessive conscientiousness, rigid and stubborn Dissocial- irresposible, cant maintain relationshups, low violence threshold, doesn’t experience guilt, rationalises their behaviour by blaming others Schizoid- indifferent to social relationships, emotionally cold, Paranoid- oversensitive, bears grudges, suspicious, projecion, overvalues their own abilities The Peer Teaching Society is not liable for false or misleading information…

32 Very difficult to treat Management Very difficult to treat Psychotherapy- DBT, psychodynamic, CBT, interpersonal. Pharmacology- treatment of associated conditions such as depression. The Peer Teaching Society is not liable for false or misleading information…

33 Psychological treatmentsType of therapy Number of people – individual, couple, group, family (remember Matthew Peace lectures) Common themes – listening, release of emotion, restoration of morale, providing information, providing a rationale , advise and guidance, suggestions Transference and counter-transference Transference: The set of expectations, beliefs and emotional responses that a patient brings to doctor - patient relationship Counter transference: Therapists own reactions to the patient The Peer Teaching Society is not liable for false or misleading information…

34 Psychological treatmentsCounselling Talking therapy Common Usually problem solving approach, often unstructured Relationship, genetic, bereavement, smoking cessation, debriefing, primary care In acute distress/ PTSD – more structured approach helpful e.g. CBT The Peer Teaching Society is not liable for false or misleading information…

35 Psychological treatmentsCognitive behavioural therapy Cognitive errors based on long-standing beliefs influence the meaning attached to interpersonal events Depression, anxiety, OCD, PTSD Self help books, online/ telephone, in person Other conditions where CBT maybe useful, but NICE guidance is lacking, include: Bulimia, Chronic fatigue syndrome, Drug and alcohol addiction, Chronic pain, Schizophrenia, Bipolar disorder, Learning disability, Sexual and relationship problems, Habits, Anger problems, Sleep disturbance problems. The Peer Teaching Society is not liable for false or misleading information…

36 Psychological treatmentsInterpersonal psychotherapy Relationships past and present Alternate ways of coping are considered Dialectical behavioural therapy Development of coping skills Psychodynamic Perceptions are shaped by experiences in early life Uses transference DBT – gold standard psychological treatment for borderline personality disorder, some evidence for eating disorders Psychodynamic - It states that perceptions are shaped by experiences in early life and therapy aims to identify perceptual distortions and their origin and to facilitate the development of more adaptive modes of perception and response The Peer Teaching Society is not liable for false or misleading information…

37 Behavioural techniquesRelaxation Therapy Systematic Desensitisation Flooding Response Prevention Play therapy, art therapy Systematic desensitisation – anxiety, phobias, graded exposure Flooding - less efficient and more traumatic Response prevention - OCD The Peer Teaching Society is not liable for false or misleading information…

39 Mood stabilisers Mood stabilisers Other mood stabilisers?Carbamazepine Sodium valproate The Peer Teaching Society is not liable for false or misleading information…

40 Lithium toxicity Usually occurs during chronic treatment because of reduced drug excretion Symptoms: GI symptoms, ataxia, tremor, dysarthria, change in GCS, blurred vision, muscle weakness, hyperreflexia, oliguria, renal failure, hypokalaemia Management: Stop drug ABC Supportive management Monitor electrolytes and renal function Reduced drug excretion - dehydration, worsening renal function, concurrent infections, and drug interactions The Peer Teaching Society is not liable for false or misleading information…

41 Anxiolytics Benzodiazepenes BuspironeShort-term measure, potentiate GABA Temazepam, diazepam, lorazepam S/E – ataxia, decreased GCS, respiratory depression Physical dependence Buspirone GAD Does not carry risk of physical dependence/withdrawal BDZ uses – sedative, hypnotic, anxiolytic, anticonvulsant, muscle relaxant Use acutely, not long term – 2-4 weeks maximum Reverse respiratory depression with flumazenil The Peer Teaching Society is not liable for false or misleading information…

42 Hypnotics Used to improve sleep Sleep hygiene Z-drugs?Zopiclone, zolpidem Every other day maximum Metallic aftertaste - Sleep hygiene – relaxation techniques, shower before bed, no caffeine in evenings, no electronic screens 1 hr before bed The Peer Teaching Society is not liable for false or misleading information…

43 Psychostimulants Methylphenidate (ritalin) Indicated ADHDSide effects: restlessness, tremor, insomnia, poor appetite, palpitations Persistent abuse can lead to cardiac problems and a paranoid state similar to schizophrenia Also used in narcolepsy The Peer Teaching Society is not liable for false or misleading information…

44 Substance misuse Dependency syndrome Alcohol OpioidsDisulfiram – acetaldehyde dehydrogenase Acamprosate Chlordiazepoxide – DT Vitamins Opioids Methadone Buprenorphine - Dependency syndrome – craving, difficulty controlling use, withdrawal state, tolerance, neglect of alternative pleasures/ interest, persisting use despite evidence of harm, narrowing of repertoire. Know CAGE questionaire. Disulfiram also known as antabuse – inhibits acetaldehyde dehydrogenase, prevents conversion to acetic acid, increased level of acetaldehyde leading to hangover symptoms Acamprosate reduces cravings and pleasure of drinking (naltrexone used as alternative). Chlordiazepoxide – BDZ, used to prevent delirium tremens. DT – shakes, tachycardia, hypotension sweating, hallucinations (formication), hyperthermia seizures Vitamins – b12 and thiamine, pabrinex is IV vitamin B complex Buprenorphine – synthetic partial agonist at mui opioid receptors The Peer Teaching Society is not liable for false or misleading information…

45 Other ECT Bright light treatmentRapid improvement of severe, life-threatening symptoms Severe depression, catatonia Bright light treatment SAD, atypical depression ECT – Bright light treatment – SAD – thought to be disorder of melatonin (hyperphagia, carb craving, weight gain), atypical depression. Effective if given early morning, duration 30 min -2 hrs, side effects: headache, eye strain The Peer Teaching Society is not liable for false or misleading information…

46 Any questions? The Peer Teaching Society is not liable for false or misleading information…