Psychiatry 1(a) - Peer Teaching Society

Phase 3A

Bukky Olaitan and Rolla Ibrahim

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

Contents

• Psychotic disorders – schizophrenia and Treatments

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

• Quick note on non-pharmacological treatments

• - Psychiatric emergencies


Introduction


Diagnostic Hierarchy


Aetiology

• 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


Treatments

• Physical

– Pharmacotherapy (drug treatment – antipsychotic aka neuroleptics)

– ECT

– Phototherapy (light therapy)

• Psychological

• Psychosocial



Schizophrenia

• 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


Aetiology of 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


Schizophrenia Features

• Main clinical features

– Change in Thinking

– Change in perception (hallucination)

– Blunted or inappropriate affect

– Decreased level of social functioning


Schneider’s First Rank Symptoms

• 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


Other Symptoms of Schizophrenia

• Other persistent delusions

• Other persistent hallucinations

• Thought disorders – e.g thought blocking, neologisms

• Catatonic behavior – Waxy flexibility; stupor; excitement; posturing; negativism

• Negative Symptoms


Negative 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


Symptoms overview

• Positive Symptoms (Acute schizophrenia)

– Hallucinations

– Delusions

– Thought Disorders

• Negative Symptoms

(Chronic schizophrenia)

– Poverty of speech

– Affective blunting

– Lack of volition

– Socially withdrawn


Schizophrenia mental state exam

• 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 subtypes

• 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


Investigations

• 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).


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)


• Depot antipsychotic drugs

Risperidone, Haloperidol

• Side effects:

Extrapyramidal effects

Anti-dopaminergic action on basal ganglia

04/01/2010

© The University of Sheffield / Department of

Marketing and Communications

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EPSE

Extrapyramidal side effects

• Acute Dystonia

• Akathisia

• Parkinsoninan syndrome

• Tardive dyskinesia

04/01/2010



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04/01/2010

Acute Dystonia

• Occurs early stages treatment

• Severe rigidity

• Torticollis, tongue protrusion

• Treatment : - procyclidine



23

Akathisia

• Unpleasant feeling of physical restlessness

• Occurs first 2 weeks of treatment

• Treatment: beta blockers & benzodiazepines

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Parkinsoninan syndrome

• Bradykinesia

• Expressionless face

• Coarse tremors

• Festinant gait

Treatment: procyclidine, change antipsychotic

04/01/2010



25

Tardive dyskinesia

•

Chewing

• Sucking movements

• Choreoathetoid movements

Treatment:

Limit the long term use of antipsychotics

Atypical agents

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04/01/2010

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



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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

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Neuroleptic Malignant Syndrome

Rare but serious disorder

Onset first 10 days of treatment

Severe motor, mental and autonomic dysfunction

Generalised muscular hypertonicity, dysphagia, mutism, impaired consciousness

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

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04/01/2010

Blood CPK raised

Complications

Pneumonia, Thromboembolism

Cardiovascular collapse, Renal failure

Treatmen t: Stop drug

Symptomatic: maintain fluid balance

Diazepam for muscle stiffness

Dantrolene -malignant hyperthermia

Bromocriptine



30


Mood Disorders

• First Presentation

Manic Episode

Hypomania

Mania – without psychotic symptoms

Mania – with psychotic symptoms

Depressive Episode

Mild – with or without somatic symptoms

Moderate – with or without somatic symptoms

Severe – with or without psychotic symptoms


Recurrent illness

• Once it occurs more than once

Manic Depression

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

Recurrent depressive disorder – no manic episodes


Persistent mood disorder

• 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




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


Mental State Exam

• Appearance

– Downturned eyes, sagging corners of mouth

• Behaviour  Psychomotor slowing

• Speech  silent, delays

• Mood

• Thoughts - Pessimistic

• Perception

• Cognition


Classification

• 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


Differential Diagnosis

• 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


Investigations

• HISTORY!

• U&Es – conversion of psychoactive substance abuse

• FBC, TFT, LFTs

• Screen for illicit drugs

• Vit B12 and Folate levels

• Syphilitic serology


• 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

Management

• 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



• Elevated mood

• Overactivity

• Pressure or speech

• Flight of ideas

• Decreased need or sleep

• Socially disinhibited

Mania

• Increased libido

• Decreased concentration  decreased concentration

• Inflated self-esteem

• Grandiose

• Irritable / suspicious


Mental State Exam

• Appearance – selfneglect, 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


…Mania

• Peak 15-30 years, average mid-20s

• Males = Females

• Episode must be 1 week duration


Hypomania

• Similar to mania, but not as pronounced

• No delusions/hallucinations

• No disruption of ADLs

• No psychosis


DDx

• 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


Other causes

• 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


Investigation

• Same as depression

• On MRI look at frontal area


Management

• Admit  lack of insight

– Risk of dehydration

• Mood-stabilizing drugs

– Lithium or carbamazepine

• PLUS anti-psychotic


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


Lithium Toxicity

• 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


Suicide

• 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


Parasuicide

• 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


Suicide intent

• Self-harm

• Precautions to avoid discovery

• Help not sought afterwards

• Dangerous methods

– Hanging

– Electrocution

– Shooting


Question

• 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?


Neuroleptic Malignant Syndrome

• 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


…NMS

• 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


Question

• 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?


Serotonin Syndrome

• SSRI interaction with MAOI

• Presentation

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

• Myoclonus  used to differentiate between

NMS and SS





Psychiatry 1(a) - Peer Teaching Society

Contents

Introduction

Diagnostic Hierarchy

Aetiology

Treatments

Schizophrenia

Aetiology of Schizophrenia

Schizophrenia Features

Schneider’s First Rank Symptoms

Other Symptoms of Schizophrenia

Negative Symptoms of

Schizophrenia

Symptoms overview

Schizophrenia mental state exam

Schizophrenia subtypes

Investigations

Antipsychotic drugs

Mood Disorders

Recurrent illness

Persistent mood disorder

Depression

Mental State Exam

Classification

Differential Diagnosis

Investigations

Management

Mania

Mental State Exam

…Mania

Hypomania

DDx

Other causes

Investigation

Management

Lithium

Lithium Toxicity

Suicide

Parasuicide

Suicide intent

Question

Neuroleptic Malignant Syndrome

…NMS

Question

Serotonin Syndrome

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