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Psychiatry F4F Emer Scullion FY2What will we cover? • Depression • Anxiety • Bipolar disorder • Schizophrenia • Eating Disorders • Alcohol Dependence • OSCEs • MCQDepression Core Accessory Somatic • Low mood • Reduced self esteem • Early morning waking • Anhedonia – inabilityto • Guilt/Unworth • Diurnal variation (mood feel pleasure • Bleak/Pessimistic world worse in morning,better in • Anergia view evening) • Psychomotor agitation or • Disturbed sleep retardation • Diminished appetite • Loss of libido • Suicidal ideation • Appetite or weightloss >5%Diagnosis • Mild: 2 core + 2 accessories • Moderate: 2core + 3 accessories • Severe: 3 core + 4 accessories • With or without psychotic symptoms • With or without somatic symptoms • Usually, 2weeks BUT in severe cases can be less • Continue antidepressant for 6months after feeling better and >2years after feeling better in recurrent cases FBC – anaemia U&E – hypercalcaemia or hypocalcaemia Make sure to rule out LFT – liver disease TFT – hypothyroidism or hyperthyroidism organic causes… Bone profile B12 and folateYou are a GP and a 44year old gentleman attends your practice. He reportspersistently low mood over the past month and claims that he no longer enjoys usual work or leisure activities. He denies any change in energy levels. In addition, he has experienced early morningwakeningat 6am,2 hours earlier than normal. He is struggling to concentrate most days, and describes feelingless confident in himself. He denies other symptoms,including TNLWL or thoughts of suicide. What is the most likely diagnosis? 1) Dysthymia 1) Maladaptive disorder 3) Mild depressive Episode 4) Moderate Depressive Episode 5) Severe Depressive episode Answer = 4) Moderate depressive disorder ●2 core depressive symptoms + 3/4 additional symptoms.Treatment SSRIs- sertraline, citalopram, fluoxetine Side effects Discontinuation – mustgradually taper over 4 week period to avoid • Suicidal ideation FINISH • Sexual dysfunction (!) • Flu-like symptoms • Agitation • Insomnia w/ vivid dreams or nightmares • Weight loss • Nausea • Nausea/vomiting • Imbalance – dizziness/vertigo • Bleeding – when prescribing NSAIDs give PPI • Sensory disturbance – sparking, burning • Reduced sleep • Hyperarousal – anxiety, irritability, jerkiness • Hyponatraemia • Paroxetine has highest incidence of discontinuation sx • Fluoxetine doesn’t require gradual discontinuation Seratonin Syndrome Management- Supportive including IV fluids, benzodiazepines, cyprohep tadine Cognitive Autonomic Somatic • Headache & dilated • Shivering • Myoclonus pupils • Sweating • Hyperreflexia • Agitation • Hyperthermia • Tremor • Hallucination • HTN • Rigidity • Confusion • TachycardiaECT • Indications • Catatonia (state of immobility/stupor)- life threatening situation because of refusal of food or fluids • High suicide risk • Depressive disorder • Marked psychomotor retardation • Psychotic depression • Resistant depression • Only absolute contraindication is raised ICPA patient has returned to their GP after a trial on an SSRI for treatment of his depression. He reports that his symptoms have persisted, and wishes to try a new antidepressant. You opt to prescribe a SNRI. Which of the following is a risk associated with switching antidepressant drugs? 1) Discontinuation syndrome 2) Extra pyramidal side effects 3) Hedonistic dopamine dysregulation syndrome 4) Neuroleptic malignant syndrome 5) Serotonin syndrome●Answer: Serotonin syndrome due to excess serotonin exposure. ●Symptoms include: ●Cognitive effects: Headache, agitation, hallucinations. Autonomic effects: Shivering, sweating, hyperthermia. N&V. Somatic effects: myoclonus, hyperreflexia, tremor. ●EPSE: associated with Antipsychotic meds, especially 1 generation typical antipsychotics ●HDDS: Associated with dopaminergic medications, eg In Parkinson’s disease ●Neuroleptic malignant syndrome: a life threatening reaction to antipsychotic drugsAnxiety Disorder GAD Panic disorder • Several months (6+) • At least 1 month • Persistent “Free-floating anxiety” • Symptoms peak within first 10 minutes (may resolveover minutes orhours) • Rational sources of anxiety e.g. finances, family, health • Physical symptoms often key e.g. palpitations, nausea, sweating • Not heavily attached to onetheme or idea • Unexpected– no stimulation • May have physical symptoms though not necessarily • Anticipatory anxiety– avoidance • F>M; genetic component Management Management 1. Active monitoring +education 1. Active monitoring +education 2. Low CBT 2. CBT 3. High CBT +SSRI 3. SSRI (12 weeks) st 1 line:sertraline 4. TCA(clomipramine/imipramine) nd 2 line:SNRI (duloxetine, venlafaxine) 5. Review & refer to specialist mental health services 3 line:Preg Beta blockers for symptoms OCD • *Not classed asan anxiety disorder * • Obsessions: repetitive and persistentthoughts, images,or impulses/urges thatareintrusive, unwanted,and arecommonly associated with anxiety. Theindividual attemptsto ignoreor supressobsessionsor to neutralize themby performing compulsions • Compulsions – repetitive behaviours e.g., checking door is locked ormental acts e.g., repeating certain phrase in mind, thata person feelsdriven to perform • Risk factors: FmHx, 10-20y, preg/postnatal, hxof abuse/bullying/neglect • Severe>3 hr/day spenton obsessions/compulsions, severedistress& very little control/resistance • • Management 1. Lowintensity CBTor exposure-responseprevention (ERP) 2. SSRI (fluoxetine espfor body dysmorphic disorder, continuefor 12m, initialresponsetakes>12 weeks, usuallyhigherdose than depression) + moreintenseCBT 3. Clomipramine (TCA)PTSD • >1 month • Flashbacks, nightmare intrusive images • Avoidance • Hyperarousal • Numbing • Management o Trauma focused CBT o Eye movementdesensitization and reprocessing o SSRIs(uncommon) • Acutestressdisorder • <1month!A young woman attends the GP complaining of anxiety symptoms. She reports that her anxiety occurs in anticipation of leaving the house, and she expresses dread at being in public, crowded spaces where she cannot quickly escape. Her symptoms have frequently caused her to cancel plans, and she stays home most days. Based on this description, how would you classify her anxiety symptoms? 1) Agoraphobia 2) Generalised anxiety disorder 3) Acute stress reaction 4) Panic disorder 5) Social phobiaANSWER 1. phobias associated with situations where escape may be difficult orer of embarrassing. Patients may report fear of leaving the house, travelling alone and finding themselves in a pubic or crowded area. ● GAD: This describes a generalised and persistent ‘free floating anxiety’, months.sociated autonomic symptoms. Symptoms present for at least 6 ● Acute stress reaction: no precipitant is described ● Panic disorder: recurrent panic attacks not restricted to any particular situation. ● Social phobia: Specificanxiety relating to social situations. Commonly associated with low self esteemand fear of criticism.You meet with a patient who has been diagnosed with PTSD. They have been engaging with CBT, but still report intrusive thoughts, nightmares and hypervigilance. You decide to start them on medication. Which is the most appropriate drug? 1) Clomipramine 2) Lorazepam 3) Mirtazapine 4) Risperidone 5) VenlafaxineANSWER: 5)Venlafaxine (SNRI) is the most appropriate choice here. SSRI or SNRI are the first line pharmacological interventions in PTSD. ●Clomipramine: Tricyclic antidepressant, not indicated ●Lorazepam: Benzodiazepines are not recommended in PTSD due to concerns about tolerance and addiction ●Mirtazapine: NaSSA antidepressant, not indicated ●Risperidone: Antipsychotic medication may be indicated in treatment resistant PTSD, but is not given 1 line.Disorder Features Schizoid ‘Thevoid’. Noneed for/inability to form social relationships. MOTIVATION Things>People Personality Disorders Lack of strongfeelings Dissocial Antisocial. Lack ofempathy. • Emotionallyunstablepersonalitydisorder(EUPD) Psychopathy is secondary to this – • Unstable no disincentive to acta certain way • Self-harm ~ EUPD • Borderline of neurosis and psychosis Anxious-avoidant Trait> state. • Impulsivetype • Pervasive terror & • Uncontrolled outbursts of mood e.g., violence, anxiety, grief apprehension • Generally behave normally between outbursts • Negativeselfimage • Borderlinetype • Preoccupation with criticism • Fear of abandonment • UNSTABLE and intense relationships Dependent Feelings of inadequacy leads to • UNSTABLE identity (including, controversially, gender) one allowingotherpeopleto • Impulsive assumeresponsibility for theirlife • Recurrentsuicidalbehaviour • Treated withDBT – dialectical behaviour therapySchizophrenia • Risk of developing schizophrenia o Monozygotictwin has it- 50% o Parents has schizophrenia- 10-15% o Sibling has it- 10% o No relative with it- 1% • Other risk factors include black Caribbean ethnicity, migration, urban environment and cannabis use • Schneider’s first rank symptoms (ABCD) • Auditory hallucinations – 3 person • Broadcasting – thought broadcasting/thought withdrawal • Control – passivityphenomena • Delusions – fixed false belief independent ofpatient’s cultural backgroundFormal Thought Disorders • Pressured speech – increased production of spontaneous speech • Circumstantiality – they answer the question – falling into tangents and speaking in a roundabout manner • Tangentiality – they don’t answer the question • Loosening of associations AKA Knight’ move thinking (derailment) • Illogicality – drawingconclusions that don’t follow basic logic • Clangassociations – speaks in words connected by sound and not by content • Preservation – speaking excessively with singular focus on one topic or thought • Echolalia – repeating back words that people are saying to them • Alogia – difficulty speaking in general • Blocking – difficulty fully expressing or completing thoughts • Incoherence – word salad • Neologisms – made up words • Cotard’s thinking – think they’re dead inside/non existent. Don’t eat/drink as don’t deemit necessary.You are performing a Mental State Examination on a patient with Bipolar Disorder . You notice that he rapidly changes the subject with only a tenuous link from one topic of discussion to the next. What term describes this feature of mania? 1) Circumstantial speech 2) Flight of ideas 3) Grandiosity 4) Knight’s move 5) Tangential speechANSWER 8: Flight of ideas: The patient may jump from topic to topic, with only a tenuous link between the topics. ●Circumstantial speech: the patient may digress but ultimately returns to the original topic/ Q. ●Grandiosity: a sense of heightened self belief. May have grandiose delusions of their own importance & greatness ●Knight’s move: a type of thought disorder in which a patient jumps from topic to topic with no link between them ●Tangential speech: a digression of speech in which the patient does not get back to the point or original question.Anti- psychotics Examples • Chlorpromazine • Haloperidol • • SideEffects • EPSE 1. Acutedystonia- managed with procyclidine 2. Parkinsonism 3. Akathisia 4. TardiveDyskinesia- Tetrabenazine • Hyperprolactinaemia • Dry mouth • Constipation • Posturalhypotension • Weight gain • Sexual dysfunction • Prolonged QTinterval- musthave an ECGClozapine • Must have tried at least two other anti- psychotics for at least 6weeks ( one of which must be an atypical anti-psychotic) • If a clozapine is missed for more than 48Hrs the dose will need to restarted and retitrated • Side Effects o Neutropenia→agranulocytosis o Myocarditis- ECGand baseline bloods every 4 weeks o Hypersalivation o Sedation and weight gain o Intestinal obstruction o Seizures at high doses Clozapine Ciunselling • C/Is: uncontrolledepilepsy,seizures,myocarditis,dementia, neutropenia,orthostatic hypotension • Lipids,HbA1c, BMI, FBC, LFT,U&E, ECG,prolactin if symptomatic • Agranulocytosis(stop if patient developsthis) • Myocarditis • Hypersalvation • Reduced seizure threshold • Smoking – increases thebreakdown ofclozapine,decreasing serum levels. Stopping increaseslevels • Caffeine – inhibitsclozapine metabolism& increasesclozapineserumconcentration • Neuroleptic malignant syndrome – usuallyearlydaysof starting. Itisan adverse reaction to antipsychotic drugs • Pyrexia • Muscle rigidity ‘lead pipe’ • Decreased reflexes • Confusion • Rhabdomyolysis, increased CK • Hypertension, tachcycardia, tachypnoea • Stop, medical ward admission, IV fluids (Dantrolene), benzodiazepines • A 22 year old man has beenbrought to the psychiatric inpatient ward after his housemate grew concerned about his behaviour. His housemate tells you, the F2 doctor, thathe has become increasingly paranoidthat he was being spied onby police. He believed that undercover police were observing his house and tapping intohis phone calls. You perform a MSE on the patient and determine that he is responding to unseenstimuli andappears to be experiencing auditory hallucinations. You suspect a first time episode of Psychosis.. What is the most appropriate treatment option? 1) Amitriptyline 2) Chlordiazepoxide 3) Clozapine 4) Lithium 5) QuetiapineAnswer: 5. Quetiapine ●This would be the best treatment for a first presentation of a Psychotic episode. It is an atypical antipsychotic and its clinical effect is a result of Dopamine receptor antagonism. ●Aproduce fewer Extra-Pyramidal Side effects.ne treatment as theyA patient with Schizophrenia attends hospital after a family member grew concerned about their wellbeing. During your mental state examination, the patient describes feeling that his actions are being controlled by another person. Which phenomenon is the patient describing? 1. Auditory hallucinations 2. Neologism 3. Passivity 4. Persecutory delusions 5. Thought alienation● ANSWER: 3) Passivity phenomenon. The patient believes that an external agency is controlling their mind or body. ● Auditory Hallucinations : Perception of sounds/ voices in the absence of external stimulus This may be 2 person: talking to you. Or 3 person: running commentary. ● Neologism describes the phenomenon of making up newwords. ● Persecutory delusions: patient believes others are out to do them harm ● Thought alienation: Thought insertion, withdrawaland broadcasting Bipolar Disorder Mania Hypomania Extreme elevation in mood OR irritability Mild elevation in mood OR irritability Flight of ideas Rapid speech Week + Days ≥4 days Delusions of grandeur Increased self esteem Loss of normal functioning Function as normal May present with psychosis – auditory No need for hospitalization hallucinations, delusions of grandeur No psychotic sx *Needs urgent referral to community mental Routine referral to community mental health health/admission Management • STOP ANTIDEPRESSANT • START ANTIPSYCHOTIC first o Haloperidol, olanzapine, risperidone, quetiapine • Then start lithium (takes a long time to work) • CBT good for depressive episodes – NOT MANIC • ECT is used in severe or resistant cases • Management of BPAD presenting with depression • Lithium • Fluoxetine + olanzapine • CBT • ECT if resistantLithium Monitoring • Monitoringfor lithiumtoxicity • NSAIDs, diuretics esp thiazides, ACEi/ARBs. Dehydration. Renal failure/AKI.s have potential to cause lithium toxicity e.g., DAMN drugs, • Baseline: FBC, U&E with eGFR, TFT, ECG, weight • Levels: taken 12hours after dose aiming for 0.4-1mmol/L o Everyweek as you titrate up dosage/dose change • Ongoing: 3 months (level, TFTs & U&E) first year then 6 months • Managinglithium toxicity • Mild: volumeresuscitation with IV fluids 0.9%NaCl • Severe: haemodialysis maybe needed • Sodium bicarb is sometimes used but there is limited evidenceto this. Itworks by increasing the alkalinity of theurineto promotelithiumexcretion.Eating Disorders • SCOFF≥2 significant Physiological Abnormalities • BMI <18.5 •Hypokalaemia • •Low FSH, LH and oestrogen/ testosterone •Impaired glucose tolerance • Features •Increased GH and cortisol • Reduced BMI •Hypercholesterolaemia •Hypercarotenaemia • Bradycardia •Low T3 • Hypotension Management • Enlarged salivary glands •Adults – ED focused CBst MANTRA • Lanugo hair •Children/young ndople – 1 line: anorexia-focused •family therapy, 2 line: CBTAlcohol Dependence • GGT AST:ALT > 2:1 • B12/folate/FB(plt Hb MCV) • CAGE screeningquestions ≥2 clinically significant • Have you ever felt the need to cut down on your drinking? • Have people every annoyed you by criticizing your drinking? • Have you ever felt guilty about drinking? • Have you ever needed an eye-opener drink to get going in the morning? • AUDIT – a 10 item checklist with a total score of 40.It is more sensitive and specific than CAGE and is used by the WHO. Withdrawal • 6-12hours – sweating, tremor, tachycardia • 36hours= peak time forseizure • 40-72hours= delirium tremens (most severe form of alcohol withdrawal, manifested byaltered mentalstatus, globalconfusion, sympathetic overdrive – HTN, tachycardia, sweating, pyrexia/hypothermia) o Coarse tremor, confusion, delusions(formication – insects under skin), auditory and visualhallucinations, fever, tachycardia o Managewith benzodiazepinese.g., Librium(chlordiazepoxide)/lorazepamin liver failure • Wernicke’sencephalopathy – degenerative brain disordercaused by lack of vitamin B1/thiamine • Ataxia • Nystagmus – rapid involuntary movementsof the eyes(vertical) • Ophthalmoplegia – paralysis ofmuscleswithin or surrounding theeye • Management • Give Pabrinex (thiamine)* give pabrinex first even if BM low aswhen glucoseis given,theglucosewill morelikelybe utilized to form ATP • Untreated -> Korsakoff’ssyndrome o Anterogradeamnesia – instabilityto form new memories o ConfabulationAlcohol Detox • Use CIWA/GMAWS tool to gauge likelihood of needingadmission– assessment of severity of withdrawal • Longer term management o Naltrexone – opioid receptor antagonist, blocks the parts of the brain that feel pleasure from alcohol and narcotics o Acamprosate – reduces cravings o Disulfram – alcohol causes nausea, flushing,sweating and tachycardia A patient was admitted to hospital after an episode of haematemesis. The patient has a known history of alcohol dependence. On his second day on the ward, he appears restless, is sweating profusely and note a resting tremor. You suspect moderate alcohol withdrawal. What is the most appropriate intervention? 1) Brief Intervention 2) Give Chlordiazepoxide 3) Give Disulfiram 4) Give pabrinex 5) Methadone● ANSWER: ● withdrawal as it acts on GABA receptors to increase inhibitory effects of the neurotransmitter GABA (mimics GABA agonist effect of alcohol) ● Brief interventions do have a role in management of alcohol dependence, timethis patient is acutely unwell and this would not be the appropriate ● Disulfiramcan be given within a programme of recovery from alcohol dependence: Causes nausea and vomiting if alcohol is consumed ● Pabrinex: It is appropriate to give Pabrinex in acute alcohol withdrawal to supplement vitamin B1 deficiency. This may be given after symptomrelief is achieved with Chlordiazepoxide. ● Methadone is a substitute prescription given within a treatment programme for opioid dependence.Mental Health Order 1986 • Form 1 – nearest relative application foradmission forassessment • Form 2 – approved social worker(ASW) application for admission for assessment • Form 3 – GP application for admission for assessment (community) • Form 5 –junior doctor application forhospital inpatient to beheld for 48hours for assessment • Form 7(DAY 1 of detention) – junior doctor completes formafter initial request for assessment – 48hours • Form 8- Reg – patient admitted forassessment for a period of 7 days • Form 9 – reg – patient admitted forassessment for a further7 days • Form 10 – consultant – detain fortreatment for6 months • Must be suffering from a mental disorder • Pose a risk to themselves or others • Excludes personality disorder, sexual deviancy, drug dependence, immoral conduct • Can’t detain thosewho areintoxicated– can give temporary condition of appearing mentally disordered • A&E is called as community so form 2+3 can only be completed thereNot included Drugs of misuse Psychiatry of old ageOSCEs Psychiatry History • PC] Use patient’s words. Problem list, what is the greatest problem? • HPC] Psych systems review -Schizophrenia 1st Rank • -Depression Screen: Core, Biological, Future • -Other: anxiety, memory, insight • -RISK: to self and others • PMHx] general + psych diagnoses: first and last episodes, admissions, MH worker, self-harm • DHx] especially compliance • FHx] general + psych specific • Sx] -Circumstances: home, support, relationships and children finances (debt?), work, dependants, normal day • -Personal: birth, development, education, qualifications • -forensic history: victim or prosecutions • -Pre-morbid personality. How would they describe themselves, how would others? • -Alcohol and drug use Mental State Exam • Appearance andBehaviour: Greeting, dress, face,movement, body language. Blunted, expressive, disordered. • Speech:(HOW): Rate/ tone/volume,coherence. Pressure, retardation, spontaneous, poverty, tangential • Emotion (Mood andAffect):Sad/angry/low/guilty vs dysphoric/euthymic/expansive/labile/inappropriate/congruent • Perception: Minor (derealisation, depersonalisation) visual, auditory (3rdperson, running commentary), check other senses. • Thought Content(WHAT): Flow, passivity, interference (withdrawal,insertion, broadcast,block,echo), delusions (reference, control)preoccupationsI • Insight:Do they believe they are unwell, would they accept need for treatment? • Cognition:Orientation to TPP,concentration and attention, memory (consider MMSE)Potential OSCE topics • PsychiatryHistory and MSE • Depression • Bipolar • Anxiety • Schizophrenia • Suicide risk assessment • MHO- explain forms • Drug counselling • Lithium • Clozapine • SSRIsQuestions Emer.scullion@gmail.com