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Abdulla Laraib Psychiatry Depression Personality Disorder Antipsychotic Medication Anxiety Bipolar Disorder Mental Health Act Eating Disorders Schizophrenia Alcohol withdrawalMaria, a 55 year old female presents to her GP with a one-month history of poor sleep and irritable mood. She explains that every day she feels past month as her appetite has been low. During the consultation, shehe becomes tearful as she explains that she has recently gone through a divorce from her husband of 20 years. Which scale would be most useful in diagnosing Maria’s condition? A. Epworth B. PHQ-9 C. HAD D. Beck Depression Inventory E. GAD-7Maria, a 55 year old female presents to her GP with a one-month she feels sad and no longer gets any enjoyment from life. She has lost 3kg in the past month as her appetite has been low. During the consultation, she becomes tearful as she explains that she has recently gone through a divorce from her husband of 20 years. Which scale would be most useful in diagnosing Maria’s condition? A. Epworth B. PHQ-9 C. HAD D. Beck Depression Inventory E. GAD-7 Major Depressive Disorder Screening Tools - BDI (Beck depression inventory) – self rated - Patient Health Questionaire-9 (PHQ) – self rated- community based - Hospital Anxiety Depression Scale (HAD) - Edinburgh Postnatal Depression Scale (Self rated) – pregnancy - HAMD (Hamilton depression rating scale) – clinician rated Screening Questions (NICE CKS) • During the last month have you often been bothered by feeling down, depressed, or hopeless? • Do you have little interest or pleasure in doing things? Depression The ICD-11 recognises the following main diagnoses regarding depression: 1. Single depressive episode 2. Recurrent depressive disorder 3. Dysthymic disorder 4. Mixed depressive and anxiety disorder Depressive Episode following characteristic symptoms occurring most Cognitive behavioural cluster of the day, nearly every day during a period lasting - Reduced concentration and sustained at least 2 weeks and are not manifestation of attention /marked indecisiveness organic cause. - Low self esteem, guilt, At least one symptom from the Affective cluster - Hopeless about the future must be present. - Recurrent thoughts of death / evidence of suicide attempt - Low mood - Anhedonia Neurovegetative cluster Affective cluster - Sleep (delayed onset / waking during night or early morning wakefulness) 1. observed (tearful, defeated), kids (irritable) - Appetite changes (up or down) - Psychomotor agitation (restlessness 2. incl. reduced libido)leasure in activities (also or being slow down) - Reduced energy and fatigue Investigations The severity of depression depends on the intensity and frequency of symptoms, their Clinical Diagnosis duration, and impact on personal and social functioning. The National Institute for Health • PHQ-9 / HAD / Edinburgh Scale and Care Excellence (NICE) guideline classifies new episodes of depression according to severity on the PHQ-9 Investigations to rule out organic scale [NICE, 2022b]: cause: • 'Less severe depression' — this • FBC, U+Es encompasses subthreshold and mild depression, defined as depression • TFTs scoring less than 16 on the PHQ-9 Consider: scale. • 24 hour cortisol • 'More severe depression' — this • Vitamin B12 encompasses moderate and severe depression, defined as depression • Folic acid scoring 16 or more on the PHQ-9 scale. Management Bio-psycho-social Model discontinuation syndrome include: • Biological • 1 line: SSRI e.g. citalopram, sertraline, fluoxetine (Consider if mild) Flu-like symptoms • Sertraline is recommended post MI • Anxiety and suicidality • Fluoxetine = longest half life • Mood and concentration • Paroxetine = shortest half life (discontinuation syndrome risk highest) changes • Citalorpram increased Long QT (needs ECG before starting) • Stomach upset (nausea, • Important to follow patient up (increased risk of suicide <30 yrs old diarrhoea) • 2 line: SNRI (Duloxetine and venlafaxine) • Dizziness and imbalance • Psychological • Insomnia • Psycho-education: self help books, online resources • Vivid dreams • Cognitive behavioural therapy • Irritability • Social • Crying spells • Social services input/ signposting to relevant authorities e.g. for • Sensory symptoms (e.g. housing parasthesias or brain zaps, sensations shocks)ing electricSevere Depression • Psychiatric referral (Community Mental Health Team) • Hospitalisation • Consider RISK to self and others • Other management options • ECT (Catatonic depression – only initiated by psychiatrist) • Benzodiazepines • AntipsychoticsAntidepressant options if a person is taking medication for a comorbid condition.Ali, a 22 year old male, presents to the GP with a 7 day history of elevated mood. He states that he has been feeling very energetic over the past week and his savings to buy a Tesla and is planning to drive around the world. The GPst used notices he is rapidly moving from one topic of discussion to the next, and that his speech is pressured. Which one of the following features indicate this is an episode of mania rather than hypomania? A. Decreased appetite B. Insomnia C. Duration of symptoms D. Pressured speech E. Flight of ideasAli, a 22 year old male, presents to the GP with a 7 day history of elevated mood. He states that he has been feeling very energetic over the past week and his savings to buy a Tesla and is planning to drive around the world. The GPst used notices he is rapidly moving from one topic of discussion to the next, and that his speech is pressured. Which one of the following features indicate this is an episode of mania rather than hypomania? A. Decreased appetite B. Insomnia C. Duration of symptoms D. Pressured speech E. Flight of ideas Bipolar Disorder Mania Hypomania >7 days <7 days, typically 3-4 days Severe functional impairment No significant functional impairment, lesser form Elevated energy/ activity: grandiosity, of mania extravagance, rapid speech, increased libido, No psychotic features reduced sleep Less likely to require hospitalisation Thought disorder: flight of ideas, poor concentration, confusion Cyclothymic disorder - numerous periods of Psychotic symptoms subthreshold hypomanic and depressive symptoms - Delusions of grandeur over a two year period - Auditory hallucinations Young mania rating scale = good scale to assess severity Bipolar Disorder • Periods of mania/ hypomania alongside episodes of depression • Onset usually in late teens and 20s • Risk Factors: family history, stressful life events • Bipolar Type 1: ≥1 episode of mania +/- depressive episode • Bipolar Type 2: episode of hypomania + depressive episode Management of Bipolar Disorder • Patient referred to community crisis team if in manic episode • If the patient is on an antidepressant, it should be tapered and discontinued • Admission: if the patient is a risk to themselves or others admission may be required Acute management: trial an oral antipsychotic • First line: NICE suggests one of haloperidol, olanzapine, quetiapine, or risperidone • Second line: trial an alternative antipsychotic medication • Third line: Lithium or valproate may be considered Long term management: commenced four weeks after resolution with the following options available • Continue current therapy for mania or • Lithium • Add valproate if lithium is ineffective Typical Antipsychotics Atypical Antipsychotics - Haloperidol, chlorpromazine - Olanzapine, risperidone, clozapine, quietapine, amisulpride, aripiprazole Mechanism of action Dopmaine D2 Receptor Antagonists Act on a variety of receptors (D2, D3, Block transmission in mesolimbic pathways D4, 5HT) Adverse effects Extrapyramidal side-effects Weight gain • Acute dystonia – tx procyclidine Dyslipidaemia (esp. Olanzapine) • Akathisia Hyperprolactinaemia (Risperidone) • Parkinsonism (bradykinesia, rigidity, Aripiprazole – good side effect profile tremor) • Tardive dyskinesia Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation, sedation, weight gain Raised prolactin Impaired glucose tolerance Neuroleptic Malignant Syndrome Prolonged QT – HaloperidolAli is admitted with an acute episode of mania. He is initially treated with haloperidol which seems to improve his mental state. Later that day he develops a high fever, tachycardia, tachypnoea and muscle rigidity. Which drug may be beneficial in the treatment of this patient? A. Quetiapine B. Metoclopramide C. Granulocyte colony stimulating factor (G-CSF) D. Raclopride E. BromocriptineAli is admitted with an acute episode of mania. He is initially treated with haloperidol which seems to improve his mental state. Later that day he develops a high fever, tachycardia, tachypnoea and muscle rigidity. Which drug may be beneficial in the treatment of this patient? A. Quetiapine B. Metoclopramide C. Granulocyte colony stimulating factor (G-CSF) D. Raclopride E. Bromocriptine Neuroleptic Malignant Syndrome • Rare but dangerous condition – 10% mortality • May occur in hours to days after starting an antipsychotic • Also with stopping dopaminergic drugs e.g. levodopa Clinical Features • Pyrexia • Muscle rigidity • Autonomic lability (Hypertension, tachycardia, tachypnoea) • Altered mentals status (delirium/ confusion) Management • Stop antipsychotic, liaison psychiatry input • IV fluids, benzodiazepines • Dantrolene/ bromocriptine in severe cases Serotonin Syndrome • Caused by SSRIs, Monoamine oxidase inhibitors, ecstasy • Onset within hours Clinical Features ▪ Neuromuscular excitation: hyperreflexia, clonus, muscle rigidity ▪ Autonomic excitation: hyperthermia, sweating ▪ Altered mental state: confusion Management • IV fluids, benzodiazepines • Liaison psychiatry input • Severe cases: serotonin antagonists ➢Cyproheptadine, chlorpromazineGeorgia is a 27 year old female being seen in the GP following discharge for a psychotic illness which was diagnosed as schizophrenia. Her symptoms included hallucinations and persecutory delusions. She tells the GP that whilst in hospital, she believed the government was implanting thoughts into her mind and that others could hear what she was thinking. She recalls being unable to speak at one point during her hospital admission, although she feels much better now. Which of the following is not a first rank symptom of schizophrenia? A. Thought insertion B. Thought broadcasting C. Visual hallucinations D. Auditory hallucinations E. Delusional perceptionsGeorgia is a 27 year old female being seen in the GP following discharge for a psychotic illness which was diagnosed as schizophrenia. Her symptoms included hallucinations and persecutory delusions. She tells the GP that whilst in hospital, she believed the government was implanting thoughts into her mind and that others could hear what she was thinking. She recalls being unable to speak at one point during her hospital admission, although she feels much better now. Which of the following is not a first rank symptom of schizophrenia? A. Thought insertion B. Thought broadcasting C. Visual hallucinations D. Auditory hallucinations E. Delusional perceptions Schizophrenia • One month of disturbance in one of the following modalities: • thinking (e.g., delusions, disorganisation in the form of thought (disorder)) • perception (e.g., hallucinations) • self-experience (e.g., the experience that one's feelings, impulses, thoughts, or behaviour are under the control of an external force) / passivity • cognition (e.g., impaired attention, verbal memory, and social cognition) • volition (e.g., loss of motivation) • affect (e.g., blunted emotional expression), • behaviour (e.g., behaviour that appears bizarre or purposeless • unpredictable or inappropriate emotional responses that interfere with the organisation of behaviour). Risk of Developing Schizophrenia •Monozygotic twin has schizophrenia = 50% •Parent has schizophrenia = 10-15% •Sibling has schizophrenia = 10% •No relatives with schizophrenia = 1%At least two of the following symptoms must be present (by the individual’s report or through observation by the clinician or other informants) most of the time for a period of 1 month or more. At least one of the qualifying symptoms should be from item a) through d) below: • a) Persistent delusions (e.g., grandiose delusions, delusions of reference, persecutory delusions). • b) Persistent hallucinations (most commonly auditory, although they may be in any sensory modality). • c) Disorganized thinking (formal thought disorder) (e.g., tangentiality and loose associations, irrelevant speech, neologisms). When severe, the person’s speech may be so incoherent as to be incomprehensible (‘word salad’). • d) Experiences of influence, passivity or control (i.e., the experience that one’s feelings, impulses, actions or thoughts are not generated by oneself, are being placed in one’s mind or withdrawn from one’s mind by others, or that one’s thoughts are being broadcast to others). Others: • e) Negative symptoms such as affective flattening, alogia or paucity of speech, avolition, asociality and anhedonia. • f) Grossly disorganised behaviour that impedes goal-directed activity (e.g., behaviour that appears bizarre or purposeless, unpredictable or inappropriate emotional responses that interferes with the ability to organize behaviour.) • g) Psychomotor disturbances such as catatonic restlessness or agitation, posturing, waxy flexibility, negativism, mutism, or stupor. Note: If the full syndrome of Catatonia is present in the context of Schizophrenia, the diagnosis of Catatonia Associated with Another Mental Disorder should also be assigned.•Anti-psychotic work by blocking which pathway in the brain? • The mesolimbic pathway • The mesocortical pathway • The mesobasal pathway • The nigrostriatal pathway • The tuberoinfundibular pathway •The mesocortical pathway•Anti-psychotic work by blocking which pathway in the brain? • The mesolimbic pathway • The mesocortical pathway • The mesobasal pathway • The nigrostriatal pathway • The tuberoinfundibular pathway •The mesocortical pathwayDopaminergic pathways • A(dopamine) receptors in the mesolimbic pathway of the brain. This action reduces dopamine activity, which is thought to be hyperactive in patients with schizophrenia, hallucinations and delusions.ymptoms such as • Negative symptoms include social withdrawal, lack of symptoms are thought to be more related to hypoactivity in the prefrontal cortex • Hyperprolactinemia can be a side effect of antipsychotic treatment due to D-2 receptor blockade but it occurs in the tuberoinfundibular pathway.The blockade of D-2 receptors inhibits dopamine's inhibitory effect on prolactin release, leading to increased levels of prolactin. • Extrapyramidal side effects, such as parkinsonism, dystonia these occur in the nigrostriatal pathway blockade but Schizophrenia Over a period of ≥ 1 month, patients must have one first rank symptom OR at least two other symptoms Schneider’s First Rank Symptoms 1. Auditory Hallucinations (e.g. third person persecutory) 2. Delusional Perception 3. Thought Disorder ▪ Insertion, broadcast, withdrawal 4. Passivity phenomena ▪ Belief that body is under the control of an external influence catatonia, avolition (poor motivation)ted affect, anhedonia, alogia, neologisms, Schizophrenia Investigations: rule out an organic Management cause • First Onset Psychosis / Crisis • Urine drug screen: ?substance Resolution/ Home Treatment induced psychosis Team • Oral antipsychotic e.g. • Infectious cause: syphilis or HIV olanzapine, quetiapine testing • Psychological interventions: CBT, • CT or MRI brain: rule out art therapy, family interventions intracranial pathology, such as space-occupying lesion • Endocrine screen: e.g. high • antipsychotictrial an alternative cortisolA 29-year-old man with a history of treatment resistant schizophrenia comes into the emergency department complaining of a general malaise over the last few days with accompanying chest pain. He looks uncomfortable and sweaty on the bed. Which of the following medications is most likely to have caused these symptoms? A. Clozapine B. Olanzapine C. Citalopram D. Mirtazapine E. AmitriptylineA 29-year-old man with a history of treatment resistant schizophrenia comes into the emergency department complaining of a general malaise over the last few days with accompanying chest pain. He looks uncomfortable and sweaty on the bed. Which of the following medications is most likely to have caused these symptoms? A. Clozapine B. Olanzapine C. Citalopram D. Mirtazapine E. Amitriptyline Schizophrenia Management • First Onset Psychosis / Crisis Resolution/ Home Treatment Team • Oral antipsychotic e.g. olanzapine, quietapine • Psychological interventions: CBT, art therapy, family interventions • Second line: trial an alternative antipsychotic • Treatment resistant schizophrenia → Clozapine Clozapine • Very effective – used in treatment resistant schizophrenia • Extensive side effect profile • Constipation – most common • Myocarditis, ↓seizure threshold, intestinal obstruction, hypersalivation • Life threatening – Agranulocytosis • Dose adjustment if smoking is stopped/ started during treatment • FBC monitoringA 41-year-old man with a history of severe depression is admitted informally to the mental health ward following an attempt to jump off a bridge. He had to be restrained by members of the public. deemed to be a high risk to himself.d. On assessment, he is still actively suicidal and A decision is made to section the patient under the Mental Health Act. Which section of the mental health act should be used in the first instance? A. Section 2 B. Section 3 C. Section 4 D. Section 5(2) E. Common LawA 41-year-old man with a history of severe depression is admitted informally to the mental health ward following an attempt to jump off a bridge. He had to be restrained by members of the public. deemed to be a high risk to himself.d. On assessment, he is still actively suicidal and A decision is made to section the patient under the Mental Health Act. Which section of the mental health act should be used in the first instance? A. Section 2 B. Section 3 C. Section 4 D. Section 5(2) E. Common Law Mental Health Act • Allows you to detain a patient a mental disorder who is at risk of harm to themselves or others (nothing to do with capacity) • Only allows you to treat mental illness without consent • Exception: physical harm caused by mental illness e.g. self harm lacerations or overdose Types of Section Section 2: 28 days for assessment (by 2 doctors – one MHA approved) Section 3: 6 months for treatment (by 2 doctors – one MHA approved) – can be renewed Section 4: 72 hours for emergency assessment (by 1 doctor and an approved mental health practitioner or closest relative) – used if Section 2 would cause unacceptable delay Section 5(2): 72 hours for assessment of inpatient(doctor in charge of patient’s care) Section 5(4): 6 hours for assessment of patient already in hospital (by nurse) Common law: used in the emergency department to keep patients from leaving and treating them A 26-year-old woman presents with a six-month history of difficulty sleeping. She often lies awake at night tightness and palpitations. She thinks that she may be suffering from anxiety and has tried mindfulness, sleep hygiene and reducing caffeine with little benefit and would like to try medication. Which of the following would be the most appropriate medication to prescribe? • 1) Diazepam 2) Duloxetine 3) Mirtazapine 4) Sertraline 5) Zopiclone A 26-year-old woman presents with a six-month history of difficulty sleeping. She often lies awake at night tightness and palpitations. She thinks that she may be suffering from anxiety and has tried mindfulness, sleep hygiene and reducing caffeine with little benefit and would like to try medication. Which of the following would be the most appropriate medication to prescribe? • 1) Diazepam 2) Duloxetine 3) Mirtazapine 4) Sertraline 5) Zopiclone Generalised Anxiety Disorder DSM-V • >6 months of excessive worry about everyday issues that is disproportionate to any inherent risk → distress, or impairment • The worry is not confined to features of another mental disorder, or as a result of substance abuse, or a general medical condition Clinical Features (at least 3 of the following most of the time) • Restlessness, nervousness • Being easily fatigued • Poor Concentration • Irritability • Muscle Tension • Sleep disturbance Generalised Anxiety Disorder • May only present with physical symptoms • Palpitations, chest pain • Dizziness • Epigastric discomfort, nausea/ vomiting • Examination and investigation is needed to rule out an organic cause • Key Differentials • Hyperthyroidism: weight loss, warm, moist skin, heat intolerance • Cardiac disease: e.g. atrial fibrillation; palpitations, dizziness, chest pain • Pulmonary disease: e.g. COPD • Medication-induced anxiety: e.g. salbutamol, theophylline, beta-blockers, St John’s wort • Recreational drugs and alcohol Generalised Anxiety Disorder Risk Factors • Family history of anxiety • Physical or emotional stress • History of physical, sexual or emotional trauma • Other anxiety disorder oPanic disorder (25% of people with GAD) oSocial phobia oOther specific phobia Generalised Anxiety Disorder Management • Cognitive Behavioural Therapy • Alternative: psychodynamic psychotherapy • Mindfulness training/ sleep hygiene education/ exercise/ self help • SSRI as first line • Sertaline, citalopram • SNRI ( ie Duloxetine if first line is ineffective • Benzodiazepines are not routinely used • Reserved for acute anxiety Alcohol Withdrawal Clinical Features • 6-12 hours: tremor, sweating, tachycardia, anxiety • 36 hours: peak incidence of seizures • 48-72 hours – Delirium tremens • Coarse tremor, confusion, delusions, hallucinations Management • CIWA-Ar Scoring – IV Chlordiazepoxide (long acting benzodiazepine) • Nutritional support: IV Pabrinex (thiamine) • Prevents/ treats Wernicke’s encephalopathy • General measures: IV fluids, electrolyte replacement, monitoring blood glucose, Personality Disorder • Disordered personality traits that interfere with normal functioning. • Affects around 1 in 20. Cluster A: Odd or Eccentric ▪ Paranoid; Schizoid; Schizotypal Cluster B: Dramatic, Emotional or Erratic ▪ Antisocial; Borderline (Emotionally unstable); Histrionic Cluster C: Anxious and Fearful ▪ Obsessive-Compulsive; Avoidant; Dependent Cluster A Paranoid Schizoid Schizotypal •Hypersensitivity and an unforgiving •Indifference to praise and criticism •Hypersensitivity and an unforgiving attitude when insulted •Preference for solitary activities attitude when insulted •Unwarranted tendency to questions •Lack of interest in sexual •Unwarranted tendency to questions the loyalty of friends interactions the loyalty of friends •Reluctance to confide in others •Lack of desire for companionship •Reluctance to confide in others •Preoccupation with conspirational •Emotional coldness •Preoccupation with conspirational beliefs and hidden meaning •Few interests beliefs and hidden meaning •Unwarranted tendency to perceive •Few friends or confidants other than •Unwarranted tendency to perceive attacks on their character family attacks on their character Cluster B Antisocial Borderline (Emotionally Histrionic Narcisstic Unstable) •Failure to conform to •Efforts to avoid real or •Histrionic Grandiose sense of self social norms with respect imagined abandonment Inappropriate sexual importance to lawful behaviours as •Unstable interpersonal seductiveness •Preoccupation with indicated relationships which •Need to be the centre of fantasies of unlimited •More common in men alternate between attention success, power, or beauty •Deception, repeatedly idealization and devaluation •Rapidly shifting and •Sense of entitlement lying, use of aliases, or •Unstable self image shallow expression of •Taking advantage of others conning others for personal •Impulsivity (e.g. Spending, emotions to achieve own needs profit or pleasure sex, substance abuse) •Suggestibility •Lack of empathy •Impulsiveness or failure to •Recurrent suicidal •Physical appearance used •Excessive need for plan ahead behaviour for attention seeking admiration •Irritability and •Chronic feelings of purposes •Chronic envy aggressiveness emptiness •Self dramatization •Arrogant and haughty •Reckless disregard for the •Difficulty controlling •Relationships considered attitude safety of self or others; temper to be more intimate than •Consistent irresponsibility •Quasi psychotic thoughts they are •Lack of remorse Cluster C Obsessive Compulsive Avoidant Dependent •Is occupied with details, rules, lists, •Avoidance of occupational activities •Difficulty making everyday decisions order, organization, or agenda to the which involve significant without excessive reassurance from point that the key part of the activity interpersonal contact due to fears of others is gone criticism, or rejection. •Need for others to assume •Perfectionist •Unwillingness to be involved unless responsibility for major areas of their •Is extremely dedicated to work and certain of being liked life efficiency to the elimination of spare •Preoccupied with ideas that they are •Difficulty in expressing disagreement time activities being criticised or rejected in social with others due to fears of losing •Is meticulous, scrupulous, and rigid situations support about etiquettes of morality, ethics, •Restraint in intimate relationships •Lack of initiative or values due to the fear of being ridiculed •Unrealistic fears of being left to care •Is not capable of disposing worn out •Reluctance to take personal risks due for themselves or insignificant things even when they to fears of embarrassment •Urgent search for another have no sentimental meaning •Views self as inept and inferior to relationship as a source of care and others support when a close relationship •Social isolation accompanied by a ends craving for social contact Unexplained Symptoms Somatisation Disorder • Multiple physical symptoms for at least 2 years • Refusal to accept reassurance or negative test results Illness Anxiety (Hypochrondrial Disorder) • Persistent belief in the presence of an underlying serious DISEASE, e.g. cancer • Refusal to accept reassurance or negative test results Conversion Disorder • Typically involves loss of motor or sensory function • Patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering)