Phase 3a
Phoebe Barrett and Natasha Hussain
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• We will ask you lots of questions
Psych emergencies
Psychiatry Classification
Acute dystonic reaction
Neuroleptic Malignant
Syndrome
Lithium toxicity
Behavioural
E.g. Eating disorders
Personality disorders
Psychosexual disorders
Developmental
Mental Illness
E.g. Learning disorders and
pervasive developmental
disorders (autism/ADHD)
Functional
Organic
Organic
E.g. Delirium
Dementia
Hypothyroidism
Substance
abuse
Psychoses
(loss of contact
with reality)
Neuroses
(severe “normal”
experience)
OCD
Anxiety
Schizophrenia
Phobias
Mood disorders
Bipolar, depression, mania
The Peer Teaching Society is not liable for false or misleading information…
Psych emergencies
Psychiatry Classification
Acute dystonic reaction
Neuroleptic Malignant
Syndrome
Lithium toxicity
Behavioural
E.g. Eating disorders
Personality disorders
Psychosexual disorders
Developmental
Mental Illness
E.g. Learning disorders and
pervasive developmental
disorders (autism/ADHD)
Functional
Organic
Organic
E.g. Delirium
Dementia
Hypothyroidism
Substance
abuse
Psychoses
(loss of contact
with reality)
Neuroses
(severe “normal”
experience)
OCD
Anxiety
Schizophrenia
Phobias
Mood disorders
Bipolar, depression, mania
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(1) Schizophrenia
• What is it?
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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socially withdrawn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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“PSYCHO”
• 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
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Extra-pyramidal side effects
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Acute dystonic reaction
Akathisia
Parkinsonism
Tardive dyskinesia
What are they?
The Peer Teaching Society is not liable for false or misleading information…
Psych emergencies
Psychiatry Classification
Acute dystonic reaction
Neuroleptic Malignant
Syndrome
Lithium toxicity
Behavioural
E.g. Eating disorders
Personality disorders
Psychosexual disorders
Developmental
Mental Illness
E.g. Learning disorders and
pervasive developmental
disorders (autism/ADHD)
Functional
Organic
Organic
E.g. Delirium
Dementia
Hypothyroidism
Substance
abuse
Psychoses
(loss of contact
with reality)
Neuroses
(severe “normal”
experience)
OCD
Anxiety
Schizophrenia
Phobias
Mood disorders
Bipolar, depression, mania
The Peer Teaching Society is not liable for false or misleading information…
Neuroleptic Malignant Syndrome
• What is it?
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A rare, life threatening reaction to antipsychotics (or can be to anti-depressants or anticonvulsants) within first 10/7 Tx
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Severe motor/mental/autonomic dysfunction
↑ temp
Muscle rigidity
Unstable BP, ↑ HR, ↑ sweating
High
Dysphagia
mortality
Mutism
Urinary incontinence
The Peer Teaching Society is not liable for false or misleading information…
Psych emergencies
Psychiatry Classification
Acute dystonic reaction
Neuroleptic Malignant
Syndrome
Lithium toxicity
Behavioural
E.g. Eating disorders
Personality disorders
Psychosexual disorders
Developmental
Mental Illness
E.g. Learning disorders and
pervasive developmental
disorders (autism/ADHD)
Functional
Organic
Organic
E.g. Delirium
Dementia
Hypothyroidism
Substance
abuse
Psychoses
(loss of contact
with reality)
Neuroses
(severe “normal”
experience)
OCD
Anxiety
Schizophrenia
Phobias
Mood disorders
Bipolar, depression, mania
The Peer Teaching Society is not liable for false or misleading information…
(2) Mood Disorders
• Depression
– Antidepressant therapy
– ! Serotonin syndrome
• Mania and bipolar affective disorder
– Mood stabilisers
– ! Lithium toxicity
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Depression
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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Symptoms
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Depressed mood
Energy ↓ = ‘ANERGIA’
Pleasure, interest and enjoyment ↓ = ‘ANHEDONIA’
Retardation (psychomotor) – N.B. atypically agitation
Eating changes: ↓appetite and weight – ↑in atypical
Sleep disturbance (EMW)
Suicidal/self harm thoughts
I’m a failure
Only me to blame
No concentration or attention
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Depression
Which are biological? Cognitive?
Can they exhibit psychotic features?
Delusions? Hallucinations?
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Surgical Sieve
Neurological
Idiopathic/iatrogenic
Congenital
Endocrine
Vascular
Infective
Trauma/environmental
Autoimmune
Metabolic
Inflammatory
Neoplastic (+heam)
Degenerative
+ PSYCH!!
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DD and Ix
• 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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Depression Tools
How can you diagnose depression and assess
severity?
Can you ‘screen’?
What is the criteria used re: screening?
Treatment
• 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
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Intensive psych treatments
Drugs
ECT in emergency
? Antipsychotics
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Antidepressants Quiz!
• 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
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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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Other antidepressants
• 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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Serotonin (5HT) Syndrome
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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Mood Disorders
When is depression unipolar?
When is it part of bipolar affective
disorder?
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Mania
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
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Mania
Differentials?
- Substance abuse – esp. amphetamines,
cocaine
- Schizophrenia
- Personality disorders
RFs?
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Management
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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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Mania Treatment
- Anti-manic drugs (prophylaxis);
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Lithium
Valproate
Carbamazapine
Lamotrigine
- Atypical antipsychotics – olanzapine, apiprazole,
quetiapine, risperidone
- ? Rapid tranquilisation
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Bipolar Affective Disorder
- Treat depression
- ?Rapid cycling
- Treat mania
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Lithium
• 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 SEs & Toxicity
EARLY
TOXICITY
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Mild diuresis
FINE tremor
Dry mouth
Metallic taste
LATE
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Weight gain
Hypothyroidism
Hypokalaemia
Oedema
Blurred vision
COARSE tremor
Muscle weakness
Ataxia
N and V
Hyper-reflexia
Circulatory failure
Oliguria
Seizures
Coma
The Peer Teaching Society is not liable for false or misleading information…
Lithium
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
Psych emergencies
Psychiatry Classification
Acute dystonic reaction
Neuroleptic Malignant
Syndrome
Lithium toxicity
Behavioural
E.g. Eating disorders
Personality disorders
Psychosexual disorders
Developmental
Mental Illness
E.g. Learning disorders and
pervasive developmental
disorders (autism/ADHD)
Functional
Organic
Organic
E.g. Delirium
Dementia
Hypothyroidism
Substance
abuse
Psychoses
(loss of contact
with reality)
Neuroses
(severe “normal”
experience)
OCD
Anxiety
Schizophrenia
Phobias
Mood disorders
Bipolar, depression, mania
The Peer Teaching Society is not liable for false or misleading information…
Questions?
The Peer Teaching Society is not liable for false or misleading information…