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Psych Revision

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Psychiatry Revision Paul Baillie
Mental State Exam - MSE “A Small Mammal Told Paul Creative Ideas” • Appearance and Behaviour • Speech and Language • Mood and Affect – (Affect = variability of mood) • Thoughts – Formal Thought Disorder – rate (flight of ideas), interruptions in flow, Derailment (unrelated topics), Fusion (mixing of ideas), Thought block – Delusions – Overvalued Ideas – Obsessions – Thoughts of Harm to self or others • Perceptions – Sensory Distortion – False Perception (Illusion = A misperception of a real object/stimulus) – Hallucinations – Pseudohallucinaitons = experienced “in the mind’s eye”. Not concrete. • Cognitive Function • Insight
• Mental Status Exam – Look at patients state of mind • Mini Mental State Exam – Screen sepcific for cognitive impairment
Definitions• Capgras Syndrome – When a patient believes that a person, usually their loved one has been replaced by an exact double • Compulsion – Repetitive Ritualistic behaviour such as hand washing. It is designed to reduce the anxiety associated with the accompanying obsession • Cotard’s Syndrome – Severely deressed or suicidal people believe themselves or a part of their body to be dying • De Clarambault’s Syndorme – Usually affects females. They believe that a famous person is deeply in love with them • Delerium – An acute and relatively sudden decline in attention, focus, perception and cognition. Delerium can occur in demented patients. – May be hyperactive or hypoactive – There is clouding of consciousness • Delusion – A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's culture or subculture. It is often difficult to distinguish between a delusion and an overvalued idea (in which case the individual has an unreasonable belief or idea but does not hold it as firmly as is the case with a delusion). • Autocthenis Delusion – A delusion arising without apparent cause. • Delusion of Reference – A delusion whose theme is that events, objects, or other persons in one's immediate environment have a particular and unusual significance. • Dementia – a syndrome of global cognitive impairment that is due to disease of the brain, usually of a chronic or progressive nature. – Consciousness is not clouded –only diagnosed in alert patients – Impairments of the cognitive functions are commonly accompanied and occasionally preceded, by deterioration in emotional control, social behaviour or motivation. • Extracampine Hallucination – Can hear/see etc. outside the range of normal senses. – E.g. Hear someone in scotland • Folie-a-deux – Induced Psychosis – a dilusional disorder shared by 2 or more people who are closely related emotionally. One has real psychosis the other’s is induced.
Definitions • Functional Hallucination – hallucinations that occur when a patient simultaneously receives a real stimulus in the perceptual field concerned (e.g., hallucinated voices heard simultaneously with—and specific to—the real sound of running water) • Reflex Hallucination – when a perception in one modality produces a hallucination in another modality. – e.g. seeing a doctor writing (visual) and then feeling him writing across one’s stomach (tactile). • Hallucinosis – a state characterized by the presence of hallucinations without other impairment of consciousness • Neurosis (Neurotic) – A mental disorder in which the predominant disturbance is a distressing symptom or group of symptoms that one considers unacceptable and alien to one's personality. • Obsessions – Repetitive stereotyped, thoughts / images / impulses that are resisted by the patient, but recognised as their own • Thought Echo – A form of auditory hallucination where the patient hears his own thoughts spoken aloud, either simultaneously with him thinking it or a moment or two afterwards • Thought Broadcasting – Where thoughts escape from the boundaries of one’s self and are known to others, even strangers and those some distance away • Thought Insertion – The subjective feeling that thoughts in one’s mind are not one’s own, often explained by a secondary delusion of insertion by some outside agency. • Thought Withdrawal – the subjective feeling that thoughts are missing from one's mind, often explained by a secondary delusion of extraction by some outside agency • Waxy Flexibility – Catatonic Behaviour in which if one were to move the arm of someone with waxy flexibility, they would keep their arm where you moved it until it was moved again, as if it were made from wax
The Psych Hx • Presenting Complaint • History of PC • Past Psych Hx – Have you ever been in contact with pyshiatric services before? – Hx of OD / DSH • Past Medical Hx • Drugs hx and allergies – Methyldopa (antihypertensve in pregnancy)  depression – Steroids  depression / mni • Family Hsitory • Personal Hx – Birth, developmental milestone, education, employment, pssychosexual Hx • Premorbid Personility – How would your friends describe you? – How do you cope with stress • Social History • Forensic Hx – Arrests, convictions, probations • Risk Assessment – Ever though life isn’t worth living? – Have you ever harmed yourself?
Lithium • A carbonate or citrate salt • Excreted renally like sodium • Mechanism of action – not understood! In pregnancy can cause a small increase in cardiac defects (Ebstein’s Anomaly) and it can pass though breast milk Indications • Mania – Acute or Prophylaxis • Treatment resistant depression Common Side Effects • Fine Tremor • Fatigue • Polydipsia & Polyuria • Metallic Taste • Weight gain Important Side Effects - Renal Impairment - Nephrogenic Diabetes Insipidus - Hypothyroidism (esp. in female) - Cardiac Arrythmia - Hyperparathyroidism  bones, stones, abdo moans, psych
Lithium • Prior to treatment – U&Es, TFTs, ECG • Levels Require Regular Monitoring – Serum Concentration of 0.6 -1 mmol/L – Weekly bloods until stable for 4 wks then 3 monthly – Beware • Dehydration • Drug Interactions – Haloperidol, Ibuprofen, Naproxen (NSAID), Diuretics, SSRI • Lithium toxicity – Course tremor – Ataxia – Weakness – GI Upset – Convulsions – Coma and Death (>2mmol/L) – narrow theraputic index
Other Mood Stabilising Drugs • Sodium Valproate – Licensed as depakote (semisodium valproate) for acute mania – GABA transaminase inhibitor – Not licensed for prophylaxis – No blood test needed  ↑ use – Well understood due to use in epilepsy – Not safe in pregnancy • ↑ risk of spina bifida & fetal valproate syndrome
Other Mood Stabilising Drugs • Carbamazepine – Liscenced for prophylaxis only – Patients unresponsive to lithium – Esp. rapid cycling BAD (4 episodes / year) • Olanzapine – More commonly used as an antypsychotic – Liscenced for use in acute mania and prophylaxis – Concern over long term use of atypicals – Rapid acting cf. other mood stabilisers
Antidepressants • Tricyclic Antidepressants – Act on serotonin & noradrenaline reuptake – clinical effect delayed by at least 2 weeks but pharmacological affects immediate – Side Effects: • Sedation • Antimuscarinic SE (dry mouth, dizzyness, blurred vision, urinary retention) • Arrythmias & Heart block • SSRI – Controversy over “discontinuation syndrome” - ?addictive – Safe in overdose – SEs: • HYPONATRAEMIA • SNRI – Venlafaxine and Duloxetine – Clear TCA? • NARI – Reboxitine – Little Used
Antidepressants • MAOIs – Originally used as antihypertensives – Reserved for 3rd line use • Atypical / resistant dpression e.g.”reversed fatigue features” – Phenelzine & Isocarboxazid are Irreversible MAOIs – Moclobemide is a reversible MAOI • Cheese reaction much less likely (tyramine) • Mirtazapine – Alpha-2-antagonist • Acts presynaptically to increase central NA & 5HT transmission – Sedating – useful in insomnia + depression
Typical Antipsychotics Phenothiazines Butyrophenones Thioxanthines Trifluoroperazine Chlorpromazine Droperidol Haloperidol Flupentixol Zuclopenthixol Advantages of typical antipsychotics: – Cheap – Lots of experiences with their use Disadvantages = Dopmaine SEs (see next page)
Typical Antiphsychotics DOPAMINE SIDE-EFFECTS • Mesolimbic Pathway – Block dopamine (D2&D4)  stop psychosis • Hypothalamic Pituitary Axis – Dopamine inhibits prolactin, so if you block dopamine you increase prolactin levels  Galactorrhoea and Impotence • Nigrostriatal Pathway (ADAPT SEs) – Acute Dystonia (typically oligogyric crisis) • Rx = Anticholinergc (Procyclidine) – Parkinsonism • Rx = Anticholinergc (Procyclidine) – Akathesia (feel need to move leg all the time- itchy on the inside) • Rx = Beta blocker, Benzodiazepine, anticholinergic – Tardive Dyskinesia (irreversable) • Rx = Stop or reduce antipsychotics
Typical Antiphsychotics Other Side Effects • Anticholinergic SEs: – Constipation, blurred vision, Urinary Retention, Dry mouth, confusion. • Histmine SEs: – Sedation • Alpha1 SEs: – Postural hypotension – Impotence • Weightgain, Arrythmias and decreased seizure threshold (unexplained symptoms) • Neuroleptic Malignant Syndrome – Become stiff and rigid with an unstable BP and a fluctuating temperature, whilst delirious – 30-50% Mortality – Creatinine Kinase will be in 1000s – Treatment (in a normal hospital not psych) • Sodium Dantrolene • Bromocriptine (Dopamine Agonist)
Atypical Antipsychotics • Advantages – Different SEs – patients prefer them • Affects on glucose metabolism (DKA&diabetes) • Affects on lipid metabolism – Less risk of tardive dyskinesia – At least as effective as typicals • Disavantages – Expensive (£100-200 / month) – New – less expensive – Previously there wasn’t a depot available, but now: Risperidone - Long acting depot drug - Massively expensive - Complicated Regime Alanzapine - rapid acting IM drug - no trials when coadministered with benzos
Atypicals • Examples – Olanzapine – Amisulpiride – Risperidone – long depot – Clozapine – resistant schiz • Common Side Effects: – Can still get EPSEs, especially at higher doses – Sedation – Weight gain – Decreased Seizure Threshold – Impaired Glucose Tolerance – Impaired Lipid Metabolism
Clozapine • Very expensive • Potentially Fatal Side Effects • Only drug effective in resistant schizophrenia • May have effects on negative symptoms • Reduces suicide rate in schizophrenia (may be due to the amount of monitoring required) • Side Effects of Clozapine • Sedation • Anticholinergic SEs • Weight gain • Much decreased seizure threshold • Hypersalivation (note: doesn’t fit with anticholinergic) • AGRANULOCYTOSIS – Wipe out WBCs – Infection  death
Monitoring Clozapine Treatment (due to agranulocytosis) • Before starting – Check FBC (must be normal) – Register Dr, patient, pharmacist with the manufacturer – each need to know blood test results • Subsequently – FBC weekly for 18/52 – Fortnightly for rest of the year – 4/52 for life – RED – stop clozapine and NEVER prescribe it for this patient again – AMBER – Lowered WBC count; blood tests 3x per week – GREEN – Good to go
The Dementias Pathology and Presentation • Alzheimer’s Dementia • Vascular Dementia • Lewy Body Dementia • Frontotemporal Dementia • Pick’s Disease Alzheimer’s Dementia Pathology •Neurofibrillary Tangles •Senile Plaques •Amyloid angiopathy •Granular Vascular Degeneration – ass. With Hirano bodies •Widening of Sulci and narrowing of gyri •Reduced Choline acetyltransferase  acetylcholinesterase inhibitors as treatment Presentation and Aetiology Early onset in 5% - Preselin 1 or 2 - Amyloid Precursor Protein (APP) Late onset (after 65) in 95% - APO 4 Gradual Onset & Progressive course Early Symptoms - Impaired recent memory - Impaired language performance (eg. Difficulty in naming objects, people, word finding) - Decreased attention and concentration - Mood changes e.g. flattening of emotional response - Disorientation in place and time Later stages: • Increased muscle tone  contractures • Poor mobility  bed sores • Loss of personality and responsiveness to others • Loss of coherent speech • Seizures • Incontinence • Death Vascular Dementia Pathology Leucoaraiosis = white matter ischaemia (low attentuation) Multiple infarcts (cortex or subcotex) in Multiple Infarct Dementia “100ml of the brain has to be lost before symptoms” Presentation and Aetiology Acute onset “Stepwise Deterioration” Personality preservation cf. alzheimers! Symptoms are dependent on site: • Cortical Dysarthria - is a motor speech disorder resulting from neurological injury Dysphagia - disorder of language. receptive or expressive. Amnesia Apraxia - loss of the ability to execute learned purposeful movements Hemiparesis - weakness on one side of the body • Subcortical Poor concentration Apathy Psychomotor slowing
The Dementias Pathology and Presentation Lewy Body Dementia Pathology = “ANAL” Acetylecholine transferase activity is reduced Neuromelanin is reduced  pale substantia nigra Alzheimer’s pathology (NF tangles and senile plaques) Lewy Bodies (intracellular prtoein that stains positive for Ubiquitin, seen in the substantia nigra) Presentation Early symptoms similar to other dementias… Memory impairment, Speech difficulties, Visuospatial problems More specific signs of LBD: Fluctuations in cognitive performance day to day Visual hallucinations, often complex in nature or hallucinations in other modalities Frequent Falls Symptoms of Parkinsons – stiffness, shuffling gait, tremor Sensitivity to neuroleptic medication - EPSEs Depression Systematized Delusions Frontotemporal Dementia Pathology Gliosis Cortical atrophy of frontal and temporal lobes Spongiform changes Neuronal loss Presentation and Aetiology Gradual onset of symptoms Some features similar to other dementias - inability to recognise faces (propagnosia) Other features: - incontinence - Personality change – disinhibition, sexually inappropriate behaviour, aggression or apathy and withdrawal - Excessive eating and hyperorality (insertion of inappropriate objects in the mouth ) - Problems with attention and concentration -Speech problems – Preservation, echolalia
Pick’s Disease One of the causes of the clinical syndrome now known as frontotemporal lobar degeneration. Pathology “Knife Blade Gyri” Pick Bodies (deposits of tau protein) Pick cells (swollen neurons) Hirano bodies (rod-shaped, eosinophilic depositis) Presentation Similar to other frontotemporal dementias
Alzheimer’s Disease & Anticholinesterases • Theoretic basis – the final pathway in Alzhimers is loss of cholinergic function • How to use DONEPEZIL – Only in alzheimer’s; not huntingtons or dementia – Only use in Mild to moderate Disease (MMSE >9) – Give as a trial – Monitor carefully • Effects of Donepezil – Functional improvement > cognitive • E.g. dress better – May slow decline, temporarily stop decline or even lead to improvement – not a cure!!! • Problems with Donepezil – Expensive – Questionable evidence – Rapid decline if Donepezil stopped
Multi Axial Classification (DSM IV) Axis I: Clinical Disorders Axis II: Personality Disorders Learning Disability Axis III: General Medical Conditions Axis IV: Psychosocial / Environmental problems AxisV: Global assessment of functioning
Personality Disorders • What are they? • Diagnosis • Prevalence • Aetiology • Specific Types
ICD10 Definition: “A severe disturbance in the characterological and behavioural tendencies of the individual, usually involving several areas of the personality and nearly always associated with considerable personal and social disruption” The markedly discordant behaviour and attitudes… - Arise in childhood - Persist into adulthood - Are NOT due to brain damage / disease / other psych illness - Are persistent, pervasive and clearly maladaptive - Usually involve several areas of functioning (e.g. mood, impulse control, attitudes towards others) - Result in considerable personal distress - Are usually associated with problems with at work/socially Personality Disorders Diagnosis Clear evidence of more than or equal to 3 traits/behaviours listed for the relevant personality type Prevalence Difficult to obtain accurate figures, as many individuals may never be diagnosed if they have no contact with psych services. Community 10% General practice 20% Psychiatric OP 30% Psychiatric IP 40% ↑♂ - Antisocial PD ↑♀: Borderline Histrionic Dependent
Aetiology Primarily Psychodynamic a) Early childhood experiences – parents Dependent – Parental deprivation Anakastic – Struggle with parents for control Borderline – lack of stable attachment figure b) Psychosexual development Dependent – oral stage Anakastic – anal stage c) Defence Mechanisms Borderline – splitting, protection. Anakastic – Undoing Neuro Dissocial - Abnormalities in EEG readings - Decreased Autonomic Arousal to social stressors Borderline - Decreased serotonin activity (impulsivity, irritability, low mood) - ?Dysregulation of NA system (↑arousal, irritability, anger) Personality Disorders Genetic Normal personality is ‘moderately heritable’ Social History of abuse particularly prevalent in Borderline PD patients, commonly sexual
Specific Types of PD • Paranoid Suspicious, Misconstrues actions as hostile, Persistently bears grudges, Combative, Excessive self-importance, Conspiratorial interpretations • Schizoid Emotionally cold and detached, Prefers to be alone, Insensitive to social norms/conventions Indifferent to praise / criticism • Schizotypal
• Histrionic Over-emotional, Theatrical, Shallow and labile, Egocentric, Manipulative, Inappropriate seductiveness, Longing for appreciation. • Anakastic Excessive doubt / caution, Preoccupied with lists/rules, pedantic, Rigid and stubborn, Consistent scrupulous, Perfectionist to the point of hindering tasks. • Anxious / Avoidant Persistent tension/ apprehension, believe they are socially inept/inferior to others, preoccupation with being criticised/rejected in social situations, Unwilling to become involved unless certain of being liked Specific Types of PD
• Borderline Emotional instability. Chronic feelings of emptiness. Intense unstable relationships  freq emotional crises. Excessive efforts to avoid abandonment. Suicide threats / DSH • Dissocial Callous unconcern for others’ feelings. Unable to maintain long standing relationships. Blames others. Low frustration tolerance. Tendency towards aggression/ violence. Gross disregard for social norms/rules Specific Types of PD
Management of Personalilty Disorders Most rx is focussed on Borderline PD as this tends to place the greatest demand on psych services, with patients repeatedly presenting in acute distress. Psychotherapy Dialectical Behavioural Therapy - Current treatment of choice for Borderline PD - Patient encouraged to ‘radically accept’ themselves as they are, while at the same time explore ways of changing themselves and their lives. - Modification of CBT - Combination of individual and group therapy Medication - Antipsychotics – small doses - Antidepressants – SSRIs in Borderline, Anankastic and dissocial - Carbamazepine – potential role in impulsivity
PD Prognosis • High morbidity and mortality rates • Mortality x6 in 20-39yr old age group • High risk suicide • High rates of co-morbidity with Axis I+II conditions • Prognosis for axis I conditions worse if have a PD • Tend to become less severe with increasing age.
Mental State Exam - MSE “A Small Mammal Told Paul Creative Ideas” • Appearance and Behaviour • Speech and Language • Mood and Affect – (Affect = variability of mood) • Thoughts – Formal Thought Disorder – rate (flight of ideas), interruptions in flow, Derailment (unrelated topics), Fusion (mixing of ideas), Thought block – Delusions – Overvalued Ideas – Obsessions – Thoughts of Harm to self or others • Perceptions – Sensory Distortion – False Perception (Illusion = A misperception of a real object/stimulus) – Hallucinations – Pseudohallucinaitons = experienced “in the mind’s eye”. Not concrete. • Cognitive Function • Insight
Hierarchy of Psychiatric Conditions 1. Organic - inc. substance use, prescription drugs, endocrine disorders 1. Psychoses & Mood Disorders 2. Neuroses - Eating Disorders, somatoform disorders 1. Personality Disorders
Causes of Delirium • I Infections • W Withdrawal (alcohol) • A Acute (metabolic) • T Trauma • C CNS (pathology) • H Hypoxia • D Deficiency of vitamins • E Endocrine • A Acute (vascular) • T Toxins (drugs) • H Heavy metals (lead) 20% die from delirium!!
Drugs associated with Hallucinations – “CAN PAM”? • Cardiovasculaar drugs • Beta blockers, digoxin, diltiazem, procainamide • Anti-Parkinsonian Drugs • L-DOPA, Amantadine, Anticholinergics, Bromocriptine, Pergolide • NSAIDs • Buprenorphine, Nefopam, Tramadol • Psychotropics • Amphetamines, LSD, Imipramine (TCA), Midazolam • Anti-infection Drugs • Ciprofloxacin, Intraconazole, Gentamycin • Misc • Cimetidine (H2 antagonist), Steroids, EPO, Decongestants, Khat (drug of abuse), Ketamine (anaesthetic)
Organic Differentials • Hyperthyroidism – Differential diagnosis of anxiety disorder – High arousal with anxiety, Irritability, Restlessness, Distractibility, Insomnia, affective lability inc. depression – BUT also these distinguishing features… Heat intolerance, Increased appetite with weightloss, cardiac arrythmias, tachycardia, thyroid enlargement / bruit – Differential diagnosis of delerium – Fulminant episodes of delerium can occur in 3-4% of those with hyperthyroidism. It’s characterised by fever, tachycardia, hypotension, vomiting and diarrhoea (thyroid crisis)
Organic Differentials • Hypothyroidism M:F = 1: 19 Onset = 40-60yrs Causes: OverRX of Hyperthyroidism Endstage chronic thyroiditis Drug induced hypothyroisism (lithium, carbamazepine, phenytoin) – Differential for Psychosis – There is a possibility of delusions and auditory hallucinations (myxoedema madness) – Differential for Depression – Fatigue, poor apatite, slowed activity, aches and pains, constipation, cold intolerance, weight gain, infiltration of the skin by mucopolysaccharides causing hearing, taste and smell difficulties – Note: hoarse voice, expressionless face and hair loss. Non-pitting oedema – Differential for Dementia – Cognitive impairment can be a feature including porr concentration, general intellectual decline and memory impairment
Organic Differentials • Cushing’s Syndrome – Causes: • Pituitary (C’ Disease) – increased ACTH higher incidence of depression than other two types • Adrenal – Adrenal tumour (benign or malignant) • Ectopic ACTH production – SSLC – Differential for Depression – 80% patients with cushings get depression – Severity is not linked to cortisol levels – Anxiety, apathy, fatigue, severe retardation – 3-10% commit suicide – Differential for Psychosis – Cortisol can cause psychosis, delusional hallucinations and delerium, if in high enough levels
Organic Differentials • Steroid Treatment – Differential for Psychosis – Can get hallucinations, delusions, disturbances in body image, hypomania, – Differential for Anxiety Disorder – Differential for Mania – Can get euphoria, pressured speech and hypomania These occur in the first 3 weeks of treatment
Organic Differentials • Addison’s disease – Also known as Hypocortisolism or chronic adrenal insufficiency – Adrenal hypoplasia accompanied by increased ACTH levels – Depression symptoms include… • Fatigue, apathy, anorexia, lack of initiative and poor concentration, weightloss, paranoia, delusions – Important signs an symptoms • Voice is soft and whining • Pigmentation on skin creases, nipples and the insides of the cheeks. • Anaemia • Hyperkalaemia & Hyponatraemia (lack of aldosterone) • Raised blood urea – Addisonian Crisis • Exacerbation of symptoms with fever, vomiting, epigastric pain, hypotension • Can be secondary to prescribed drugs (e.g. morphine), infections.
Organic Differentials for Anxiety • Hyperthyroidism • Phaeochromocytoma (impending doom) • Steroid Treatment Organic Differentials for Depression • Hypothyroidism • Cushing’s syndrome • Addison’s disease Organic Differentials for Psychosis • Hypothyroidism (myoedema madness) • Cushing’s syndrome • Steroid Treatment
OCD • 1. Need both Obsessions and Compulsions Obsessions are “intrusive, unpleasant thoughts or images” that are resisted by the patient but recognised as his own Compulsions are “Repetitive Unwanted Actions” • 2. Compulsions caused by Obsessions • 3. Attempts to suppress the thoughts as they are realised to be excessive or unreasonable • 4. These cause marked distress & dysfunction • It is a life-long condition • Not something which happens to everyone a little bit! • Not normal concerns * Adapted from DSM IV criteria
Common Patterns Obsessions Compulsions Contamination Worries Washing, bathing, showering Harm to self, harm to others, sexual / religious worries Checking, praying, asking for reassurance Symmetry, precision worries Arranging, ordering Saving concerns Hoarding
Diagnostic Considerations Zohar-Fineberg Obsession Compulsive Screen (Z-FOCS) 1. Do you wash or clean a lot? 2. Do you check things a lot? 3. Is there any thoughts that keep bothering you that you would like to get rid of? 4. Do your daily activities take a long time to finish? 5. Are you concerned about orderliness or symmetry? In some patients OCD symptoms begin following streptococcal infection or after use of cocaine or methylphenidate Comorbid tics are not uncommon but often overlooked despite needing a different treatment pathway. It is helpful to find out why patients think they are getting these symptoms. Then correct them.
“Obsessive Compulsive Disorders” • Speculative spectrum of disorder with biology and symptoms similar to OCD • Undefined boundaries • Includes Comorbidity – Obsessive-Compulsive Personality Disorder – Autism – Gilles de la Tourette’s 7% – Body Dysmorphic Disorder – Hypochondriasis – Eating Disorders 17% NB –Psychiatric Comorbidities occur in most patients with OCD but not all of them are considered part of the OC spectrum e.g. Depression, Schizophrenia, anxiety disorders Chicken and the Egg
Pathogenesis • OCD is a “Neuropsychiatric” condition as it has a specific neurocircitry. • CORTICO-STRIATAL-THALAMO-CORTICAL (CSTC) Dysfunction – Serotonin (5HT) & Dopamine • Increased activity in – Orbitofrontal Cortex (? Compensation for CSTC) – Ventral Striatum – Thalamus
Psychotherapy • Exposure and Response Prevention (ERP) – A hierarchy of feared stimuli is created and it is shown that anxiety decreases without the need for the compulsion. • Cognitive Interventions – Encourage patient to re-evaluate overvalued beliefs – May need this before they consent to ERP
Pharmacotherapy • Drugs are indicated in >mild OCD and if CBT doesn’t work. • First Line: – SSRI e.g. Fluoxetine LIFELONG – TCA – only Clomipramine *If bipolar comorbidity need to give mood stabaliser along side • Slow and gradual improvement • Patients generally lack insight into improvement • Resistant OCD – SSRI + antipsychotics – SSRI + Clonazepam
Mild functional impairment or patient preference for low intensity approach. Offer CBT (including ERP) and guided self help If patient cannot engage in CBT or if CBT is inadequate or patient has >mild dysfunction Offer a choice of either: Treatment with SSRIs alone (at least 12 weeks CBT alone (>10 therapist hours) Offer SSRI and CBT combined Offer either a different SSRI or clomipramine Refer to MDT with specialist expertise in OCD STEP WISE TREATMENT PLAN IN OCD
Key Points of OCD • Lifelong condition where compulsions linked to obsessions and these cause marked distress and dysfunction • CSTC dysfunction • Serotonin and Dopamine involved  Rx: SSRIs • ERP and Cognitive Therapy
Mental State Exam - MSE “A Small Mammal Told Paul Creative Ideas” • Appearance and Behaviour – Eye Contact – Movement Disorder e.g. Tardive Dyskinesia • Speech and Language – Rate,Tone and Volume – Neologisms (making up new words) • Mood and Affect – (Affect = variability of mood) – Objective and subjctive • Thoughts – Formal Thought Disorder – rate (flight of ideas), interruptions in flow, Derailment (unrelated topics), Fusion (mixing of ideas), Thought block – Delusions – Overvalued Ideas – Obsessions – Thoughts of Harm to self or others • Perceptions – Sensory Distortion – False Perception (Illusion = A misperception of a real object/stimulus) – Hallucinations – Pseudohallucinaitons = experienced “in the mind’s eye”. Not concrete. • Cognitive Function • Insight
Thoughts • Formal Thought Disorder • Rate – Flight of ideas (mania) – Retardation • Interruptions in flow – Thought block – Derailment – unrelated topics – Knights move thinking – Tangential – Fusion – mixing of ideas • Loosening of Associations • Circumstantiality • Concrete Thinking • Delusions • An unshakeable belief, usually but not always false, that is out of keeping with one’s cultural and religious upbringing and that is not amenable to logical argument • Content – Delusions of…Persecution, Grandiour, Reference (thinks something relates to you), Control, Guilt, infidelity and love • Overvalued Ideas • An acceptable, comprehensible idea pursued by the person beyond the bounds of reason and causes suffering or disturbed functioning • Obsessions • Recurrent intrusive, usually unpleasant ithoughts that the person recognises as thier won and tries to resist.
Perceptions • Sensory Distortion • Intensity and quality of perception • False Perception • Illusion – “a misinterpretation of a real obeject / stimulus” • Pareidolic Illusions • See a rabbit in the sky • Hallucinations • A percept-like experience in the absence of an external stimulus that has all the qualities of real perception in external objective space and is unwilled and cannot be controlled by the person. – Extracampine – outside normal sensory field – Reflex – stimulus in one modality  hallucination in another – Functional – normal sensory input + hallucination in same modality – Alcoholic Hallucinosis – normal auditory; starts as whistle or tapping but can develop – Affect – relate to mood (normally fear) • Pseudohallucinations • A separate form of perception from a true hallucination • Not concretely real • Experienced in internal space (“in the minds eye”)
Schizophrenia ………First coined the term and described “Schizophrenia” ……………. First tried to operationalize the clinical diagnosis through certain symptoms • Epidemiology – Lifetime risk = 1% – M = F (although a later onset in women) – In UK, African Carribean people are at greater risk – Urban> Rural – Increase in those among the lower socioeconomic class (although the disease itself could cause a drift down the social classes) – Usual Onset = 15-45 years • Male - peak onset = 24 • Female – 2 peaks (hehe) = 24 & 35 – “Paraphrenia” – onset in elderly Bleuer Schneider
Schneider’s First Rank Symptoms of Schizophrenia • Delusional Perception • Third Person Auditory Hallucinations – Arguing or commenting on one’s actions • Thought Echo • Passivity – Emotion – Impulse, acts and volition – somatic • Thought insertion • Thought withdrawal • Thought broadcasting
Schizophrenia ICD10 Diagnostic Criteria • Criteria 1 – Thought echo, insertion, withdrawal, broadcast – Delusion of passivity – Hallucinations giving running commentary or discussing patient in 3rd person – Persistent Delusions • Often bizarre e.g. they can control the weather • Criteria 2 – Persistent Hallucinations accompanied by delusions – Breaks or interpolations in the train of thought “thought disorder” • Circumstantiality • Thought Block • Word Salad • Pressured Speech – Catatonic Behaviours • Catatonic Stupor • Catatonic Excitement • Waxy Flexibility – Negative Symptoms • Loss of normal motivation or drive • Loss of awareness of socially appropriate behaviours • Flattening of mood • Difficulty in abstract thinking A Diagnosis Needs… -1 clear cut or 2 less clear cut criteria 1 symptoms (or) - 2 from criteria 2 •Needs to have been present for at least 1 month •Not due to organic cause or mood disorder
Schizophrenia Differential Diagnosis • Organic Disorders – Drug induced states (cannabis, amphtamines) – Complex – partial seizures (frontotemporal epilepsy) – Encephalitis – Syphilis (“General Paralysis of the Insane”) • Mood Disorders – Bipolar Affective Disorder • 10% have psychotic symptoms • Need to establish whether the primary disorder is affective or not – Depression with psychosis
Schizophrenia - Aetiology • Predisposing Factors – Past HX – Family Hx – Winter Birth – Pregnancy / Birth Complications – Odd clumsy child with language problems • Perpetuating Factors – Non-compliance – Continued use of illicit drugs – Ongoing Stress • Precipitating Factors – Life events – Stopping Antipsychotics – Use of illicit drugs – Living in high expressed emotion households DOPAMINE THEORY •Funcitonal Excess of Dopamine in the mesolimbic area •Amphetamine releases dopamine and causes schizophrenia-like symptoms •Antipsychotics block dopamine receptors (D2 & D4 mainly)
Schizophenia - Prognosis • 10% suicide (male, high premorbid function, depressive symptoms) • Also excess of deaths from accidents, CV disease • About ¼ only have one episode • About 1/3rd have repeated episodes, but recover in between • About 1/3rd have repeated episodes with worsening impairment Good Prognostic Factors Sudden Onset Female Short Episode Married, good social relationships No past Psych Hx Good work record Prominent mood symptoms Good compliance/concordance Older age at onset
Schizotypal Disorder • Characteristics – Eccentric Behaviour – Anomalies of thinking resembling those of schizophrenia but none definitive of it at any time – No hallucinations but often preoccupied by weird themes – Chronic course with fluctuations of intensity – Evolution and course are usually those of personality disorder – May evolve into Schizphrenia – Genetically linked to schizophrenia • More common in those related to schizos – May never come to the attention of the services
Schizotypal Disorder • Features – Inappropriate / constricted affect – Eccentric / odd behaviour – Poor rapport/ social withdrawal – Odd beliefs – Paranoid ideas – Obsessive ruminations lacking resistance – Unusual perceptive experiences – Vague, circumstantial, over-elaborate thinking with odd speech – Transient quasi-psychotic episodes • Diagnosis – 3 or 4 features for at least 2 years – Never met criteria for schizophrenia
Delusional Disorder • Characteristics – Single or set or related delusions only • The delusions are often lifelong and have variable content which may relate to life situation – Jealousy Delusions – targeted at spouse (orthello’s syndrome) – Erotomanic Delusions – someone in authority is I love with them (De Clarentbaue Syndorme) – Persecutory Delusions • Onset commonly in middle life but may be earlier • Other morbid phenomena may occur but are not constant or dominant – Not organic, schizophrenia or affective • Diagnosis – Conspicuous (easy to notice) delusions, present for at least 3 months – Clearly person not sub-cultural – No evident underlying cause
Mood (Affective) Disorders • A Mood Disorder is a disorder whereby the prevailing emotional mood is distorted or inappropriate to the circumstances. Generally either elation or depression. The mood change is accompanied by a change in the level of activity, particularly thought patterns. • Depression (Unipolar) – Major Depression – Recurrent major depression – Major Depression with psychotic symptoms (Psychotic depression) – Postpartum depression – Dysthymia • Bipolar Disorder – Bipolar I – Bipolar II – Cyclothymia
Mood (Affective) Disorders • ICD Classification – F30 Manic Episode – F31 Bipolar Affective Disorder – F32 Depressive Episode – F33 Recurrent Depressive Disorder – F34 Persistent Mood (Affective) Disorders – F38 Other Mood (Affective) Disorders – F39 Unspecified mood (affective) disorder
Depression In all varieties (mild, moderate, severe): Cardinal symptoms = Depressed mood associated with: 1. loss of interest &enjoyment (anhedonia) 2. reduced energy leading to easy fatigability (anergia) 3. diminished activity • marked tiredness after only slight effort is common • Mood changes can easily be masked by: – Irritability – Excessive consumption of alcohol – Histrionic behaviour – Exacerbation of pre-existing symptoms – Hypochondriacal preoccupation
Depression • Other common symptoms: – Reduced concentration and attention – Reduced self esteem and self confidence – Ideas of guilt and unworthiness – Bleak and pessimistic views of life – Ideas or acts of self-harm or suicide – Disturbed sleep – Diminished appetite and loss of weight • A duration of 2 weeks is required for making a diagnosis, but shorter periods may be reasonable if symptoms are un-usually severe or of rapid onset.
Depression Biological (Somatic) Symptoms – Anhedonia – loss of interest or pleasure in activities that are normally enjoyed – Lack of emotional reactivity to normal pleasurable surroundings – Early wakening (2 or more hours before usual time) – Depression worse in the mornings – Objective evidence of psychomotor retardation or agitation (remarked on or report by other people) – Poor appetite and weight loss (5% body weight in past month) – Loss of libido
Depression Classification of Depressive Disorder Mild Depressive Episode (with/without somatic syndrome) • two of three cardinal symptoms plus two others • minimum duration 2 weeks • difficult continuing with ordinary work and social activities Moderate Depressive Episode (with/without somatic syndrome) • Two of three cardinal symptoms plus three-four others • Minimum duration is about 2 weeks • Considerable difficulty in continuing with social, work or domestic activities Severe Depressive Episode without psychotic symptoms • All three cardinal symptoms plus at least four others • Should usually last at least 2 weeks • Unlikely to continue with social, work or domestic activities • Suicide is a distinct danger in a severe depressive episode
Depression Classification of Depressive Disorder Severe Depressive Episode with Psychotic Symptoms • Above criteria • With delusions, hallucinations or depressive stupor • Delusions of sin, poverty, imminent disasters Recurrent Depressive Disorder – mild, moderate, severe with/without psychotic symptoms • Repeated episodes without any history of independent episodes of mood elation or over activity that fulfil the criteria of mania • Mean age of onset in 5th decade • Individual episodes last between 3 and 12 months • Recovery usually complete between episodes • Individual episodes usually precipitated by stressful life events
Persistent Mood (Affective) Disorders • Persistant, usually fluctuating • Individual episodes are rarely severe to warrant being described as hypo manic or even mild depressive episodes • Can last for years at a time • Considerable subjective distress and disability Cyclothymia • Persistent instability of mood, numerous periods of mild depression and mild elation • Develops early in adult life • Chronic course • Mood swings unrelated to life events Dysthymia • Long standing depression of mood, very rarely severe enough to fulfil the criteria for RDD • Begins in adult life, lasts for several years • Most of the time feel tired and depressed; everything is an effort; nothing is enjoyed
Persistent Mood (Affective) Disorders Epidemiology • Lifetime rates show much variability (4-30%) true figure lies between 10-20%. • The mean age of onset is 27 years • Women : Men = 2 : 1 • Rates are higher in the divorces and unemployed • A high co-morbidity with other disorders Aetiology • Genetics – Family clustering: the risk of mood disorders is increased in first degree relatives of probands – The risk appears to be specific to the depressive illness phenotype – Twin studies MZ 46%, DZ 20% – Adoptive studies 31% of psychiatric disorders in biological parents cf 12% in adoptive parents • Monoamine Hypothesis – Serotonin, noradrenaline and dopamine play a major role in the adaptive responses • Endocrine Hypothesis – Hypothalamic-pituitary axis, cortisol and dexamethasone suppression test • Dexamethasone suppression test can be positive in depression as well as Cushing’s. • Psychosocial Theories – Parental deprivation and early environment – Recent life events – Learned helplessness – Cognitive theories – core beliefs, dysfunctional assumptions and negative automatic thoughts – Psychoanalytical theory – Anger turned in
Treatment Issues • Newer Antidepressants – tend to be well tolerated in OD – SSRIs – Fluoxetine, Citalopram, Sertraline, Escitalopram, Paroxetine – SNRIs – Venlafaxine & Duloxetine – Alpha 2 Antagonts – Mirtazepine – NARI – Reboxtine, Nortriptyline (Clean TCAs?) • Classical Antidepressants: – TCAs: • Imipramine Desipramine • Amitriptyline Doxepine • Clomipramine Nortriptiline • Monoamine Oxidase Inhibitors – Very old drugs – Phenalazine – Tranylcypromine – Moclobomide – Main use for atypical cases Side Effects: Cheese reaction due to Tyramine Cheese or red wine  Arrythmia
Treatment NICE Guidelines for treating Depression • Screen high risk groups • Mild depression who do not want/need treatment – reassess in 2 weeks. • Mild depression – short term CBT • SSRIs should be first choice medications • Severe Depression – Meds + CBT • Continue meds for 2 years if more than 2 episodes with functional impairment NICE guidelines • CBT should be used in recurrent and drug resistant depression • Guidelines apply to those over 18. • Antidepressants are rarely useful in children and adolescents
SSRIs • Fluoxetine was first on the market • Now a wide choice (6 in the BNF) • Subject of controversy – DISCONTINUATION SYNDROME • Paroxetine has bad effects when stopped – this is NOT addiction! • Advan – Efficacious – we’ll toleraced – Safe in OD • Diadvan – Discontinuation syndrome
Tricyclics • First useful antidpressant • IMIPRAMINE was the first discovered and this was by accident • Act on Serotonin and Noradrenaline reuptake • Pharmacological effect immediate but clinical effects take 2 weeks • Advan – Cheap – Efficacious and large body of research • Disadvan – Side Effects: • Anticholinergic – Dry mouth, urinary retension, blurred vision • Sedation • Arrythmias and Heart block (OVERDOSE suicide) 
MAOIs (Monamineoxidase inhibitors) • Originally prescribed as antihypertensives – Delay breakdown of NA and 5HT • Reserved for 3rd line! – Atypical or treatment resistant depression – E.g. reserved for vegetative state • Well documented problems – Tyramine (cheese) Reaction producing hypertensive crisis (ironic as originally prescribed for hypertension) • Little used inpractice • Phelezine, Isocarbxazid – Irreversible inhibitors of MAO-A • Moclobemide – Reversible inhibitor of MAO-A – Cheese reaction much less likely but can still occur! (just need more red wine, cheese, swordfish etc)
SNRIs (Serotonin and NA reuptake Inhibitors) • Like SSRIs but involve NA as well • E.g. Venlafaxine – Bicyclic Antidepresant – ? A clean tricyclic? – Recent concerns over arrythmias NARIs (NA reuptake inhibitors) • Pure NA reuptake inhibition • E.g. Reboxitine • Little used in practice Alpha 2 Antagonists /Noradrenergic and specific serotonergic antidepressant (NaSSA) • Act presynaptically • Increase central NA and 5HT transmission • Mirtazepine – sedating. Useful in insomnia + depression
Antidepressant Strategy • SSRI 1st line – Allow 1-3 weeks before improvement – Increase dose to maximum – Allow 4 weeks without response before considering a change • Different SSRI / different class 2nd line – Cross-taper between drugs – ie. Have both going at the same time • Venlafaxine 3rd line – At one point CMS had concerns about cardiotoxicity – Now not felt to pose an undue risk • Augmentation – With mood stabilisers e.g. lithium • Combination Therapy – Different antidepressants together – Beware interactions – Serotonin Syndrome • Occurs in OD and combination therapy • Altered mental state, agitation tremor, shivering, diarrhoea, hyper-reflexia (usually lower rather than upper limbs), myoclonus, mydriasis, ataxia and hyperthermia • Need to exclude Neuroleptic Malignant Syndrome • ECT Maintenance - Maintain treatment for 6 months - same drugs at same dose - slowly withdraw - Longer if indicated - up to 2 years if recurrent depression (NICE) - Indefinite treatment may be required
Mania Types: • Hypomania • Mania without psychotic symptoms • Mania with psychotic symptoms Symptoms in Mania • Elated mood, irritability. • Sustained for at least one week, which is severe enough to disrupt the usual activities – Increased energy – Pressure for speech – Decreased need for sleep – Grandiosity, expansive optimism or self inflated esteem, disinhibition – Reckless behaviour e.g Spending sprees – Increased sexual libido – Flight of ideas, pressure of speech
Mania Classification • Hypomania – Lesser degree of mania – Symptoms not to the extend that they lead to severe disruption of work/result in social rejection – Present for at least several days on end • Mania without psychotic symptoms – Elated mood out of keeping with individuals circumstances – Mood may be irritable and suspicious rather than elated – First attack 15-30 years – Last for at least 1 week • Mania with psychotic symptoms – More severe form with delusions and hallucinations
Bipolar Disorder • Characterised by two or more episodes of depression, hypomania or mania (1 of which has to be mania) • Characteristically recovery is usual between episodes • Median duration for an episode – Mania = 4 months – Depression = 6 months • First episode – any age
Bipolar Disorder Epidemiology • Lifetime risk lies between 0.3-1.5% • F : M = 1:1 • Mean age of onset is 21 years Aetiology • Genetics – Familial clustering: relatives of bipolar probands have increased risks of unipolar depression and bipolar disorder – Twin studies: Concordance rate is 70% in MZ, but 20% in DZ – Genetic influence is greater in bipolar disorder than unipolar depression!
Bipolar Disorder • Question: What are the Differences Between Bipolar I and Bipolar II Disorders? • Answer: The most important distinctions between Bipolar I and II are: – A person with BP II experiences hypomanic episodes but not manic episodes. The difference between mania and hypomania is a matter of severity - hypomania generally does not impair a person's daily functioning or cause the need for hospitalization. – Experience of psychotic symptoms such as hallucinations or paranoia indicates Bipolar I Disorder; the presence of such symptoms rules out Bipolar II.
Bipolar Disorder Treatment of Mania • Acute episode – is admission required? (danger) – Antipsychotics • Olanzapine – Benzodiazepines – Mood stabilisers • Lithium – Anticonvulsants • Sodium Valproate • Prophylaxis – Mood Stabilisers • Lithium carbonate – Antipsychotics • Olanzapine – Anticonvulsants: – Carbamazepine Course and Outcome • The mean number of episodes in a lifetime is 7 to 11 and the episodes increase in frequency with increasing age. • Suicide is more frequent in bipolar disorder than in recurrent depressive disorder.
Lithium Rx • Used in acute mania in bipolar disorder – Initially, lithium is often used in conjunction with antipsychotic drugs as it can take up to a month for lithium to have an effect. • Also used in Mania Prophylaxis • To start lithium you need an ECG & baseline bloods (U&Es, TFT) • Need to monitor lithium levels closely as therapeutic dose (0.6 to 1.2 mmol/L) is very close to toxic dose (1.5mmol/l can be fatal) • Also need to monitor U&Es and TFTs as lithium interferes with the regulation of sodium and water – concurrent use of diuretics should be avoided • An important potential consequence of long-term lithium usage is the development of renal diabetes insipidus (inability to concentrate urine). Patients should therefore be maintained on lithium treatment after 3-5 years only if, on assessment, benefit persists. • Lithium is teratogenic and can get into breast milk – increasing the likelihood of Ebstein’s anomaly Common Side Effects - Fine tremor - Fatigue - Polydispia & polyuria - Metallic Taste - Weight Gain Lithium Toxicity - Course tremor - Weakness - Ataxia - GI upset - Convulsions - Coma and death Important Side Effects - Renal Impairment - Nephrogenic Diabetes Insipidus - Hypothyroidism - Cardiac Arrythmias
Anticonvulsants (As mood stabilising drugs) • Sodium Valproate – Liscenced as Semisodium Valproate (Depakote) for acute mania – GABA transaminase inhibitor – Prophylaxis (not liscenced) – Increasingly used – no blood tests – Well understood as many on it for epilepsy • Carbamazepine – Licensed for Prophylaxis only – Patients unresponsive to lithium – Especially good in rapid cycling Bipolar • 4 distinct episodes / year • Lithium said to be less useful • Olanzapine – Atypical antipsychotic – Lisenced for acute mania and prophylaxis – Concern over long term affects of atypicals
Electroconvulsive Therapy • Most (in)famous treatment in psychiatry • Poor public image • Effective in depression – Emergencies – Treatment resistance • Can be used in mania and schizophrenia • NICE guidelines relegate it to “last resort” • Can be given in extreme circumstances – E.g. pregnancy – Threatening OD – No eating or drinking • Given twice weekly • Maximum 12 treatments • EEG monitored during treatment • Side Effects – Headache (temporal muscle contraction) – Semantic Memory Loss • Short lived and recovers in 3 months
rTMS Repetitive Trans-cranial Magnetic Stimulation • Still in early stages • Promises benefits without SEs • No anaesthetics needed! Psychosurgery • Extremely poor public image • Still of value in severe intractable illness e.g. OCD • Very few centres nationally • Several procedures – Cingulotomy (OCD) – Subcausate tractomy (major depression) • Subject to section 57 MHA – If consent of pt and three people (one doctor and two others who cannot be doctors) have to certify that the person concerned is capable of understanding the nature, purpose and likely effects of the treatment and has consented to it. These three people are appointed by the Mental Health Act Commission.
Anxiety Related Disorders • A small amount of stress can be beneficial  increases productivity (Kaplin Myer Curve) • Anxiety become pathological when it is extreme, situational (e.g. phobias) or reduces functioning.
Anxiety Related Disorders Physiology of Acute Anxiety: • ADRENALINE – Tachycardia, tachypnoea, chest tightness, dizzyness, parasthesia, sweating, epigastric discomfort, diarrhoea Physiology of Chronic Anxiety • ­CORTISOL – Physiological­excessive worry, irritability, difficulty concentrating, muscle tension (tension headaches), sleep and appetite disturbance, deterioration in physical health – CVS, gastro, immune etc. • Noise sensitivity.
Anxiety Related Disorders • Classification of Anxiety Disorders • Need to rule out: • Thyroid disorders SAH • Seizure disorder Hypoglycaemia • CNS / extracranial neoplasia Drug intoxication / withdrawal • SAH Phaeochromocytoma
Anxiety Related Disorders Acute Stress Reaction • immediate and brief response to sudden intense stressor e.g. bereavement, car accident, abuse • response starts within an hour • Begins to diminish after 48 hrs • Epidemiolgy – 13% survivors of violent crimes • Certain vunerability factors e.g. traumatic childhood • Symptoms: – Increased arousal – Dissociative numbness – Depersonalisation – – Derealisation – don’t feel part of surroundings – Dissociative amnesia – Uncontrollable grief – Inappropriate and purposeless activity • Treatment ­ As it is transient, psychiatrists rarely treat it. ­ Usually GP, surgical wards, A&E staff ­ Help to reduce emotional response ­ Help with more appropriate coping mechanisms ­ Debriefing – little evidence!
Post Traumatic Stress Disorder • Response to severely stressful (life threatening) events e.g. serious RTA, war events, major fires, natural disasters • Intense • Prolonged • Sometimes delayed • Term first used during Vietnam War (90% of Vietnam ware veterans met diagnostic criteria). Before this it was called “shell shock”.
Post Traumatic Stress Disorder Clinical Picture • 3 main groups – Hyperarousal ­ anxiety, irritability, insomnia – Intrusions ­ intense, intrusive imagery, recurrent distressing dreams (reexperiencing the event) – Avoidance ­ avoidance of reminders, people, feeling of detachment (triggers can bring on the intrusions) • Other features: – Maladaptive coping – alcohol, drugs, self harm – Depression – Guilt – esp. survivors
Treatment of PTSD • Counselling to provide emotional support • CBT – education on anxiety, cognitive restructuring, anger management • Eye movement and desensitisation reprocessing (EMDR) – Used in America and Army – Cross eyes then recount the event – Need relaxation • “Rewind” Therapy – Dissociated recount e.g. watch event on tv – can fast­forward or rewind • Medication – Anxiolytics – SSRIs Prognosis • 50% recover during first year • Rest may continue for prolonged periods • Recovery less likely if initial symptoms severe
Adjustment Disorder • Extreme emotional reaction in response to new life circumstances e.g. divorce, bereavement, loss of job (Non-life threatening event) • Symptoms include severe anxiety, depressed mood etc. • Symptoms should be present within 3 months of event for diagnosis • Counselling may play a role • Drug treatment can be counter productive
Generalised Anxiety Disorder • Symptoms of anxiety persistent – not related to specific circumstances • Worries generally widespread • Co­morbidity with depression is common • Exclude physical illness – thyrotoxicosis, haemochromocytoma, hypoglycaemia etc. • Treatment – Relaxation Therapy – CBT – Medication
Generalised Anxiety Disorder Treatment – Relaxation training • Breathing Exercises – slow down  less tachypnoea  less headaches • Muscle Relaxation • Distraction Techniques – CBT • Our thoughts affect our emotions which affect our behaviours • Example – You have arranged to meet someone in the pub and she doesn’t show – Possible reactions: 1. She stood me up. She’s a cheat  anger 2. He may have had an accident I need to phone A&E  Anxiety & fear 3. I knew he didn’t like me  depression • Attempt to identify negative unhelpful thinking and replace with helpful logical thoughts • Recommend 15­20 sessions • Homework important – diaries etc. • Motivation important – Medication • Avoid Benzodiazepines due to dependence • Beta Blockers may be helpful • Antidepressant have anxiolytic effects and therefore can use SSRIs, SNRIs, TCAs etc.
Panic Attacks • Sudden, unprovoked episodes of acute anxiety that usually peak within a few minutes and last less than one hour • May begin gradually increasing feelings of tension and apprehension • Physical symptoms include palpatations, sweating, shaking, hyperventilation, shortness of breath and feeling dizzy. • Cognitive symptoms include feelings of losing control, going mad or fear of dying and an overwhelming need to escape. • Patients say there is no prodrome but often there is – recognition and control
Panic Attacks Treatment of Panic Disorder – Explanation of adrenaline – Relaxation techniques • Distraction techniques • Reducing rate of breathing • Muscle relaxation – CBT – identify catastrophic thinking & replace with more helpful thinking. • Cognitive restructuring (changing the tape they play)
Phobic Anxiety Disorders • Anxiety is only precipitated by certain well defined situations – Out of proportion to the demands of the stimulus – Cannot be reasoned away – Beyond voluntary control – Leads to avoidance • Treatment – Relaxation Training – Desensitisation – “Systematic Desensitisation” • Graded • Anxiety provoking but within perceived limits • Carried out daily • Anxiety scored and timed – Adjunctive Anxiolytics – CBT • Explanation of symptoms
Phobic Anxiety Disorders Simple Phobia • Specific stimulus e.g. animals, insects blood, injections, flying, choking • 13% female vs 4% male • Most develop in childhood Social Phobia • Exaggerated anxiety in situations when person feels observed or criticised by others • Fear of blushing, losing control of bowels • M = F (the only phobia) • 4% prevelance Agoraphobia – Anxiety provoked by leaving home, particularly crowded places making escape more difficult – 3x more common in women – 3% of all women – Worst social phobia
Neurotic Disorders Treatment • Panic Disorder – High dose SSRI • OCD – High dose SSRI • Bulaemia Nervosa – High dose SSRI • PTSD – May respond to SSRI – Benzos at time of trauma • Generalised Anxiety Disorder – Beta blockers – Venlafaxine and Pregabalin now liscenced – Benzos short term but tolerance and dependence • Insomnia – Only treat for short periods (2­3 wks due to tolerance and dependence) – Benzos (short acting) – Z drugs – zolpidem, zimovane
Alcohol and Substance Abuse Genetic Factors – Family History – Antisocial Personaility Disorder – Anxiety – Depression • Iowa Study – genetic effects in males and females – environmental factors in males • Goodwin et al 1973 – Copenhagen study – 4x increase in male adoptees from alcoholic parent adopted soon after birth • Strong association between alcoholism and dopamine D2 receptor gene – craving linked to dopamine dysfunction
Alcohol and Substance Abuse Childhood Experiences • Birth trauma • ADHD • Abandonment by parents • Death of parent / sibling before age of 15 • Over­gratification or deprivation • Sexual or emotional abuse Adolescent Experiences • Learning or Conduct disorder • Family structure breakdown • Poor parent / child relationship • Lack of values / religion • Substance misusing peers • Inadequate coping skills / knowledge Environmental Factors • Economic availability • Social availability • Physical availability • Employment • Stress • Loss events • Peers
Alcohol and Substance Abuse • Spectrum Disorder – Social Use – Problematic Use – Dependence Dependence Dependence Syndrome • Salience - importance • Tolerance – need increasing doses for same effects • Impaired control • Compulsion – despite knowing it’s bad for you • Withdrawal syndrome • Relief use • Reinstallment (like being in love)
Alcohol and Substance Abuse Biology of Addictive Behaviour • Positive reinforcing effects of substances • Negative reinforcers • Tolerance • Withdrawal • Craving • Neuro­adatation Pathological Intoxication • Mania a potu – May be a basis of a defending plea • Murder after a small amount of ethanol • Amnesia • Observed to be in a trance / automatism • EEG abnormalities strengthen diagnosis
Alcohol and Substance Abuse Alcohol related amnesias • Transient amnesia due to intoxication • Amnesia can be total with abrupt onset and recovery with no subsequent recall • Patchy amnesia – indistinct boundaries with islands of memory • Once experienced may become a regular occurrence Transient Hallucinatory Experiences • Debate as to how best to classify alcohol related experiences • May herald onset of DTs or alcoholic hallucinosis? – part of continuum • May be transient without progression • Essentially fleeting and sudden experience of variety of perpetual disturbances
Delerium Tremens • Varied clinical picture – best viewed as a unitary condition with a continuum of severity and variety of symptom clusters • Can occur on only partial withdrawal • Trauma / Infection may be related factors • Triad • Delerium • Hallucinatory Experiences • Tremor NB other elements may be present as well • Disturbance fluctuates – worse at night or in shadowy conditions • Transient hallucinatory experiences may precede for weeks
DTs • Delirium – fluctuating, clouding of the consciousness, potentially disorientated in time, place and person – ‘the clinical syndrome of confusion, variable degrees of clouding of consciousness, visual illusions and/or visual hallucinations, lability of affect, and disorientation. The clinical features can vary markedly in severity hour by hour. Delirium is a stereotyped response by the brain to a variety of insults and is similar in presentation whatever the primary cause’ *OHoP • Hallucinations – vivid, chaotic, bizarre and affect any modality • Visual hallucinations – Classically horrible and freigthening – rats / snakes – “Microscopic” (leprachauns) • Paranoid Delusions – enemies blowing in gas into room • Paranoid Mood – “Every stimulus misinterpreted but clouding doesn’t allow systemisation of delusional idea” • Occupational Delusions / Hallucinations – barman serving drinks – bricklayer laying bricks
Alcoholic Hallucinosis • Auditory Hallucinations – Unformed noises, snatches of music or voices • Phonemes – Running (“He”) commentary or 2nd (you) person hallucinations • Several phonemes – Favourable or derogatory • Imperative Quality – acting out of behaviour • Intermitent • No clouding of Consciousness (no delerium) • Blurred relationship with alcohol • Patient may not disclose experience unless specifically asked • Can persist for weeks / months – If >6months think schziophrenia! • No complicated paranoid ideation
Alcohol Withdrawal Fits • Heavily dependent patient – Withdrawal or partial withdrawal may cause fit • 30% of patients with fit is prelude to DTs – Usually occur in first 12­24hours • Grand Mal – Rarely status • Future withdrawal associated with greater risk of fits or DTs – kindling phenomenon
Wernicke­Korsakoff’s Syndrome • 10% of chronic alcoholics develop W­K • Acute Presentation – Wernicke’s Encephalopathy • Clouding of consciousness • Ataxia • Nystagmus – lateral and vertical • Anisocoria (difference in pupil size) • Peripheral Neuropathy • Opthalmoplegia ­ CNIII • It is caused by thiamine deficiency (Vit B1), which creates lesions in: – Floor of third ventricle – Mamillary bodies – Brain stem – Thalamic nuclei • Need urgent rx with Thiamine to prevent Korsakoff’s psychosis! • Untreated Mortality rate = 20%
Korsakoff’s Psychosis • 80% of survivor of Wernicke’s develop Korsakoff’s • Presentation – Korsakoff’s Psychosis • Anterograde and Retrograde Amnesia • Confabulation • Hallucinations • Due to lesions in the – Aquaductal grey matter – Mamillary Bodies – Thalamus • 20% require long term institutionalisation
Alcoholic Dementia • Brain shrinkage in alcoholics is due to loss of white matter • Increase in ventricular size • Reduction in size of corpus callosum • 50% alcoholics aged 50+ attending tertiary care will show cognitive impairment
Defence Mechanisms• Denial – most common mechanism used by Substance Abusers (SAs) – existence of problem – consequences of the addiction – shame – normal reaction – “primitive denial” – Requires intervention “secondary denial” – Gentle confrontation • Projection – attributing one’s own unacknowledged feelings, impulses or thoughts to others – blame others for use of substances – flip­side to self blame to protect from depression • Rationalisation – avoids conflict by utilising reassuring / self­serving explanations for the behaviour – e.g “I drink to sleep” – “to cope with my relationship” • Altruism – healthy in recovery • Displacement – feelings onto less threatening objects – e.g. kick the cat • Humour – Dealing with stressors by emphasising the funny / ironic • Intellectualisation
Stages in Treatment of Alcohol Dependence 1. Acute Interventions ­ detoxification / withdrawal 2. Evaluation and Assessment followed by Appropriate Intervention (Psych­social intervention) 3. Abstinence Maintenance ­ after care/ relapse prevention Indications for Admissions 1 severe symptoms 2 medical / psychiatric complications 3 history of withdrawal fits 4 history of DTs 5 No social support
Management of Alcohol • Majority of patients do NOT require medication • Majority of patients do NOT require in­patient detoxification (60% successful detox at home) • Explanation of symptoms, reassurance and relaxation training • Insomnia – simple hypnotic Indications for Medication • Severe Symptoms • History of withdrawal fits • Malnutrition • Mild symptoms appearing at high blood alcohol levels (>150mg) • Physical illness • Withdrawal symptoms can occur when intake reduced
Detoxification • Sedatives – E.g. diazepam, chlordiazepoxide – Prevent simple withdrawal, DTs,fits – Start on high dose and reduce it over 7­10 days – Oxazepam is best in those with liver failure • B vitamins ­ Thiamine – Oral – not well absorbed – Parenteral – can cause anaphylaxis – Prevents Wernicke­Korsakoff Syndrome NB the DTs have 30% mortality, so prevention is importnat
Rx of Withdrawal Benzodiazepines • Sedative and anti­convulsant • Long acting (diazepam or chlordiazepoxide) – half life 30­60 hours. • Chlordiazepoxide – 20­30mg QDS • In patients may require up to 400mg / day • Decrease over 7­10 day period • Nausea and vomiting  Sub­lingual lorazepam • Severe liver damage  Oxazepam / lorazepam (not hydroxylated by the liver)
Rx of Withdrawal Carbamazepine • Used in Europe more than UK/ USA • Superior to placebo and equal to oxazepam for mild / moderate withdrawal • Limited data on efficacy for preventing seizures and delirium • Does NOT cause respiratory depression, inhibit learning • No potential abuse and reduces “kindling phenomenon”. – (the progressive intensification of the withdrawal syndrome following repeated episodes of ethanol intoxication and withdrawal. Kindling is a phenomenon in which a weak electrical or chemical stimulus, which initially causes no overt behaviorual responses, results in the appearance of behavioural effects, such as seizures, when it is administered repeatedly) Chlormethiazole • Used in Europe mainly • trials show its better than placebo but size of studies were not adequate to draw conclusions about seizure prevention and delirium Symptom Trigger Therapy • Patient monitored by structured assessment scale and given medication at a certain threshold • Administer less medication than fixed dose protocols • Shorter periods of treatment • Seizures were not observed in a study of patients treated this way
Rx of Withdrawal • Withdrawal Seizures – Benzodiazepines drug of choice – Diazepam more effective than phenytoin – more rapid peak level – In severe withdrawal with risk of seizures then give loading dose of chlordiazepoxide (80­100mg) – Convulsions  iv diazepam 10mg • Delerium Tremens – Give benzodiazepines in adequate dose to control the agitation and produce sedation – IM administration unpredictable – Vitamin supplements – Physical problems – Rehydration / electrolyte imbalance
Rx of Withdrawal Vitamins • Thiamine implicated in Wernicke’s encephalopathy, Korsakoff’s psychosis and peripheral neuropathy • Nicotinic acid , Folate and Vitamin E deficiencies can occur • Pabrinex I.V. – risk of anaphylaxis with parenteral administration • Oral vitamins – thiamine 200mg daily Parenteral Vs Oral • Reduced oral thiamine absorption in abstemious alcoholics by 30% • Oral thiamine may not prevent W­K • Aim in prevention is to restore B complex vitamins as quickly as possible • Number of studies show benefit of high dose parenteral therapy
Deterrent Medication • NOT intended as aversion therapy • Disulfiram causes inhibition of ALDH (Aldehyde Dehydrogenase) lasting several days. • Calcium Carbimide – Effects wear off after 24 hours – Quicker onset and shorter reaction
Deterrent Medication Disulfiram • Blood alcohol levels have to be zero! • Explanation of effects • Emphasize need to discontinue for 7 days before drinking again • Titrate dose – some require 400mg daily • Carry warning card Antabuse Reaction (Disulfiram) • Flushing • Nausea and Vomiting • Dyspnoea • Palpitations and marked hypotension • Dizziness • Headaches • May be life threatening!
Deterrent Medication Naltrexone • Alcohol associated with enhanced opioid activity • Animal models show decreased alcohol preference following administration of opioid antagonists • Naltrexone is a pure opioid antagonist and blocks opioid induce euphoria Acamprosate • Suppression of alcohol consumption in alcohol preferring or alcohol dependent rats. • Reduced calcium flux into neurones • Inhibits excitatory amino acids • Mode of action unknown but may be by affecting craving by inhibiting positive reinforcement effects • Initiate ASAP after detox • Combine with counselling • Maintain on it for 1 year • Does not interact with alcohol • Does not interact with benzos – assisted withdrawal can be initiated if necessary
Rx of dependence Psychosocial Treatment of Alcohol Dependence • Alcoholics anonymous – 70% of patients attending AA regularly were abstinent after a year (cf. <50% who did not attend regularly) • Minnesota Method • Family and Marital therapy • Social skills training • Brief interventions FRAMES Feedback ­ personal risks Responsibility ­ for change Advice ­ cut down Menu ­ give alternative options Empathetic interviewing Self­efficacy
Alcoholic Investigations • FBC – MCV • Not B12 or folate deficiency • Direct toxicity on bone marrow • LFTs • Carbohydrate Deficient Transferrin – picks up 6 units / day in previous week • Vitamin B12 and folate – deficiency  macrocytosis • Thyroid function • Chest X-ray – may have TB!
Assessing Cognition • What is Cognition? • Cognition is the ability to use and integrate basic capacities such as perception, language, behaviour, actions, memory and thoughts in order to interact appropriately with the world. • NB. Left Hemisphere is dominant in 90% of right handed and 60% of left handed people. Memory .
Cognition • 3 stages to form a memory: ­ Storage ­ Coding ­ Retrieval • Explicit memory is available to conscious access while implicit memory is not. • Explicit memory is based in the limbic system (Parahippocampal gyrus, Amygdala, Mamillary Body, Fornix, Thalamus, and Dentate Gyrus) and temporal neocortex. • Implicit memory is based in the Basal Ganglia and different parts of the cerebral cortex.
*Orientation to Time and Place and Person* • Normal people who are in hospital for long periods of time lose track of time. • Depends on memory • Impaired in delirium and late stages of dementia. • Testing orientation to Time, Place and Person • ­ Orientation to time – day, date, month, year, season • ­ Orientation to place – name of the building, floor, town, country • ­ Orientation to person – name, relationship, job *Attention and Concentration* • Attention is the ability to focus on the question in hand; the ability to maintain this focus for a long enough period of time. • More impaired in delirium than dementia • Could be impaired in depression (pseudodementia) • To test attention – Serial seven test – spelling a familiar word backwards e.g. WORLD – Days of the week backwards – Months of the year backwards – Counting down *Language* • Language is more than just speech (body language, social cues etc.) • Language Comprehension and expression • Wernicke’s area occupies the posterior superior part of the temporal lobe – it is responsible for language comprehension. • Broca’s area occupies the inferior pre­frontal region in the dominant hemisphere – it is responsible for the motor aspect of speech • To test speech – Listen to the patient’s spontaneous speech (fluent or non­fluent, content) – Assess comprehension by asking the patient to carry out a simple task – Assess nominal aphasia by asking patient to name objects e.g. Pen – Assess repetition by asking the patient to repeat a sentence “No ifs, ands, or buts”
*Frontal Lobe Functions* • Cognitive Functions attributed to the frontal lobes: Abstract thinking – Problem Solving – Behaviour – Planning – Personality – Motivation – Sequencing of Behaviour – Set shifting / mental flexibility – Estimation / general knowledge • Disorders affecting frontal lobes functioning – Dementia of the frontal lobe type (Pick’s disease) – Bilateral anterior cerebral artery infarction – Subarachnoid haemorrhage (ant. Communicating artery) – Head Injury – Huntington’s disease – Advanced Parkinson’s Disease – Progressive Supranuclear Palsy – Wilson’s Disease • Testing Frontal Lobes functions – Cognitive estimate test – Verbal fluency (25 words in a minute in one category or F,A,S) – Proverb interpretation – Motor sequencing test – Alternating sequencing – Look for any personality changes
Clinical Syndromes to Remember • Dementia – multiple areas of cognitive impairment. A syndrome caused by disease of the brain (e.g. Alzheimer’s disease), usually progressive and irreversible. Consciousness is usually unimpaired. • Delerium – a syndrome of acute onset of Cortical impairments, together with perceptual disturbance of the sleep/wake cycle. The cause is usually an acute medical illness and is frequently reversible, although more common in pre­existing dementia. • Amnesia – a specific impairment of memory. In the amnesic syndrome (Korsakoff’s syndrome) there is dense impairment of the registration of new memories. Other cognitive skills are comparatively well preserved. • Pseudodementia – Not dementia but look like dementia, mainly due to depression. Hence called “Depressive Pseudodementia”. Typically answer questions by “Do Not Know”. It is mainly caused by lack of concentration and loss of interest. Associated features of depression. It improves when mood improves.
Depressive Pseudodementia is the term applied to apparent cognitive impairment associated with psychiatric disorders, most often depression (50­100%). Four criteria proposed by Caine (1981) for diagnosis: • 1) intellectual impairment in a patient with a primary psychiatric disorder • 2) features of impairment are similar to those seen in CNS disorders • 3) the cognitive deficits are reversible • 4) there is no known neurological condition to account for the presentation PREVALENCE: Of patients referred for dementia evaluation, reports in the literature have ranged from 2% to 32% found to have a pseudodementia, with most reporting about 10%.
Abbreviated Mental Test Score • A rough screening tool for confusion. • AMT 8­10 = normal cognition • AMT <8 = Significant impairment in cognition • The ten questions… – Time of day (to nearest hour) – Year – Place – Identify two people – Age – Birthday – Give them an Address to remember; pt must repeat this to test registration and again after 5 minutes to test delayed recall – Name of monarch – Dates of second world war – Count Backwards from 20­1 In those with suspected Dementia, it is usual to proceed to more detailed cognitive testing with the Mini Mental State Examination
Mini Mental State Exam (MMSE) • Developed by Folstein • A good screening test but not a diagnostic tool! • Easy to administer, could be used as a routine test • High inter­rater reliability • Does not test frontal lobe functions or new learning • Not sensitive to slight changes • 24/30 is the cut off score??? Some say 26/30 is impaired • People with early mild dementia may could score above this cut­off • Could be affected by age, education and socio­economic status. • It is susceptible to “floor effect” – the effect of an intervention is underestimated because the dependent measure artificially restricts how low scores can be.
Mini Mental State Exam (MMSE) • Orientation to place – Country, county, town, 2 main streets nearby where you live, Floor of Building (5) • Orientation to time – Year, season, Month, Day, Date (5) • Memory Registration – I would like you to remember these three words, apple, table, penny. Can you repeat them? • Concentration – Spell “world” backwards (5) – Or – Take seven from 100, stop after five repeats. Very high error rate in normal popn • Memory delayed recall – What were those three words I asked you to remember before the spelling? • Naming objects – Name a watch and a pencil (2) • Repeating a sentence – Repeat this; “No ifs, ands or buts” • 3 Stage Task – “Please take this piece of paper in your right hand, fold it in half with both of your hands and place it on the floor” • Reading – Please do what this says “close your eyes” • Writing – please write a sentence • Copying – Please copy this picture (interlinked pentagons)
CAMGOC CAMGOC • Developed in Cambridge • Computerised version • Detailed, could be exhausting to some patients • Diagnostic criteria • Takes about an hour to complete
Mental Health Act 2007 • The MHA 2007 amends the MHA 1983 and the Mental Capacity Act 2005 A note on the Mental Capacity Act: Five Statutory Principle: 1) A person must be assumed to have capacity unless it is established that they lack capacity 2) A person is not to be treated as unable to make a decision unless all practicable steps have been taken to help him to do so 3) A person is not to be treated as unable to make a decision because he makes an unwise decision. 4) Any action taken under this act must be done so in the patients best interest A court of Protection will help with difficult decisions. The act includes LASTING POWERS OF ATTOURNEY
Mental Health Act 2007 • Section 2 - admission for assessment up to 28 days • Section 3 - admission for treatment, up to 6 months initially • Section 4 - emergency admission for up to 72 hours initially • Section 5 - People who are voluntary inpatients can be detained by a doctor or nurse pending a further assessment • Section 5(2)  Dr’s holding power • Section 5(4)  Nurses holding power • Section 117- Gives the statutory authorities a duty to make arrangements for continuing support and aftercare
Forensic Sections • Community psych nurse screens criminals • Section 35 – Remand to hospital for report on mental state – Up to 12 weeks • Section 36 – Remanded back to hospital for rx – up to 12 weeks • Section 48/49 – Removed to hospital from prison in those undergoing court proceedings – Restriction order • No leave outside hospital • No discharge by RMO – No appeal against section 48/49 • Section 37/41 – “Hospital Order” • Court decides pt “unwell” • Supervised by Ministry of Justice Mental Health Team • Section 47 – Remand from prison in those already sentenced • E.g. Relapse / new condition
Supervised Community Treatment Options • Detained pts can be discharged under supervision • Agreement that patient will take meds in community • Cannot restrain them or forcefully medicate • Agreement that if they don’t take their meds they’ll be detained under the original detention • Renewed every 6 months • Monitored by family, blood tests etc.
Mental Health Act • Under what section and for how long can a person be detained for assessment? – Section 2 – 28 days • How long can this section be renewed or extended for? – It can’t be • What are the conditions of the section? – Interest of own health or safety or the safety of others
Mental Health Act • Under what section and for how long can a person be detained for treatment? – Section 3 – 6 months • How long can this section be renewed or extended for? – It can be renewed for a further 6 months, then for a year at a time. • What are the conditions of the section? – Interest of own health or safety or the safety of others and the treatment cannot be provided unless he is detained – In the case of psychopathic disorder or mental impairment, treatment is likely to alleviate or prevent deterioration of his condition – Cannot normally be imposed if the nearest relative objects – Based on two medical recommendations + Approved Social Worker (ASW) • One of which has to be section 12 approved and one has to had previous acquaintance with the patient • They need to have a common diagnosis Note: Most Rx can be given without consent for three months. Then you need to do a section 58 to give rx. You need a section 58 at any time to give ECT.
Mental Health Act • Under what section and for how long can a person be detained for emergency admission for assessment? – Section 4 – 72 hours • How long can this section be renewed or extended for? – If during the 72 hours a second medical recommendation is made, the section 4 is converted to a section 2. • What are the conditions of the section? – Interest of own health or safety or the safety of others – Only needs one medical recommendation – It is of urgent necessity for the patient to be admitted under section 2 – Compliance with section 2 requirements would involve “undersirable delay” – The doctors should either know the pt or be section 12 approved
Mental Health Act • Under what section and for how long can a voluntary patient be detained by a NURSE for assessment? – Section 5(4) – 6 hours • Under what section and for how long can a voluntary patient be detained by a DOCTOR for assessment? – Section 5 (2) – 72 hours – The Dr must be the Dr in charge of the patient’s care or be nominated by this dr • How long can these sections be renewed or extended for? – 5 (2) can’t be – 5 (4)  A doctor can then change it to a section 5(2) when they arrive, but this officially begins when the nurse originally reported the section5(4)
Mental Health Act • Under what section can the “Responsible Medical Officer” (dr in charge of treatment for the patient) grant “leave” to people detained under the MHA – Section 17 • What section deals with transfers? – Section 19
Alcohol Addiction • It is estimated that 5% of the population is dependent upon alcohol. Of these… – 70% dysphoria – 20% depressive illness – 25% attempt suicide • Alcoholic Hallucinosis – Third person auditary hallucinations while drinking large amounts of alcohol or having recently stopped. – Distinct from DTs as it occurs in clear consciousness – There can be visual hallucinations; however, if other features of psychosis are present it is important to considerschizophrenia. • Delirium Tremens – Occurs on days 3 to 4 of withdrawal – An acute confusional state precipitated by alcohol withdrawal – Clouding of consciousness – Delusions and hallucinations – Tremor – Thiamine needs to be given to reduce the chance of korsakoffs
Alcohol Addiction • Dementia – Heavy drinking over a prolonged period can cause visuo-spacial impairment, damaged frontal lobe functioning and memory impairment. – CT evidence of this in 2/3rd of dependents • Cerebral atrophy / ventricular enlargement – May be reversible but often permanent • Wernicke’s Encephalopathy – Due to thiamine deficiency – Not only in alcoholism – Due to damage to mamillary bodies, brain stem, thalamus and cerebellum – Clinical features include… • Visual gaze disturbance – Nystagmus – Conjugate gaze and sixth nerve palsies • Ataxia • Peripheral Neuropathy • Clouding of consciousness and disorientation • Anxiety and confusion • Nausea and vomiting – Potentially reversible with thiamine
Alcohol Addiction • Korsakoff’s syndorme (amnesic syndrome) – Due to thiamine deficiency and occurs after Wernicke’s encephalopathy – Impairment of recent memory and new learning out of keeping with other cognitive losses plus • Confabulation • Stereotyped thinking • Visuospacial impairment • Reduced insight • Reduced initiative • No evidence of altered consciousness • Foetal Alcohol Syndrome – Excess alcohol in pregnancy is >1 unit / day – Features include • Growth retardation • Developmental delay • Specific facial abnormalities • Increased risk of stillbirth • Mood disorders and hyperactivity
Alcohol Dependence Treatment • Disulfiram – Alcohol dehydrogenase inhibitor  when alcohol is consumed acetaldehyde builds up • Acamprosate – GABA receptor antagonist • Naltrexone – Opioid receptor antagonist
Effects of fun drugs • Hallucinogens (LSD, magic mushrooms, mescaline) – Visual disturbances or hallucinations – Altered state of awareness – Synesthesia  see sounds, hear pictures etc. – At higher dose, increased sympathetic activity • Hyperthermia, anxiety, (the bad trip) • Volatile Substances (glue, solvents) – Rapid onset of euphoria, perpetual change and hallucinations – Ataxia, nystagmus, confusion, coma and death! – Chronic use is associated with a cerebellar syndrome as well as liver damage • Opiate (heroine, morphine, pethidine, methadone) – Analgesia – Euphoria & intense feeling of well-being – Drowsiness and sleep – Pupil constriction, sweating, dry mouth – Bradycardia, hypotension (decreased symp activity) – Resp suppression, antitussive  aspiration – Nausea and vomiting – WITHDRAWAL is not life-threatening!
Effects of fun drugs • STIMULANTS – Ecstasy (MDMA) • This is an amphetamine with hallucinogenic properties – Increased symp activity (hypertension, hyperthermia, sceating) – Increased sensuality and energy levels – Reduced appetite – Insomnia – Amphetamine (speed, whizz) – Increases symp activity – Euphoria and increased energy – Anxiety, panic, paranoia, hallucinations – Dilated pupils, dry mouth, ataxia, irregular respiration – Psychosis – OD  cerebral haemorrhage / cardiac arrythmias – Cocaine – See above (same as amphetamines) – Withdrawal is not life threatening
Medication assisted withdrawal • OPIOIDS – Lofexidine – Alpha 2 agonist – Methadone • Tablet. Can be crushed and injected. • Associated with Long QT syndrome which can cause arrythmias – Buprenorphine – Partial opiate agonist  less effects than heroin and if heroin taken there is no effects from it
SUICIDE • 5000 suicides occur each year in the UK • 25% in recent contact with the Mental Health Services • 160-200 psychiatric inpatients die each year by suicide • Highest risk – 14 days post-discharge • 1/5th non-compliant, 1/3rd Disengaged • Male : Female = 3:1 (25-34 yrs 80% are male) • 74% of suicides result from three methods – Hanging – Poisoning – Jumping • Females  poisoning • Men  Hanging, Poisoning, Jumping • Overall reduction in suicides since 1997
SUICIDE DEMOGRAPHICS • Median Age = 43 • Commoner in men (60%) • Divorced > single/widowed > married • Increased in unemployed (40%) • Chronic illness is a risk factor as is living alone • Common Disorders – Affective Disorders (Depression and Bipolar) = 46% of total • Suicide is more frequent in bipolar disorder than in recurrent depressive disorder. – Schizophrenia = 19% of total – Personality Disorder = 8% of total – Alcohol and Drugs Misuse hx = 74%
Management of Suicidal Acts• Physical Rx – A&E • Assessment by member of the MDT • Check capacity • Risk of further attempts – Hx of previous attempts – Drug / alcohol misuse – Psychiatric history, personality disorder • Assessment of seriousness of attempt – Planning – Attempts to conceal / avoid detection – Help seeking – how did they get to hospital? – Final Acts – Lethality – Feeling following survival – Number of pills • Assess protective factors • Admission / home treatment for serious attempt – Level of observation • Treat underlying mental illness • Psychological Help and follow-up
Violence • Homicide= the killing of one human by another – ~50 homicides take place each year by people who have recently been in contact with the MHS • Schizophrenia most common diagnosis – Less likely to kill strangers – 90% committed by men – Median Age 28 years • Stranger homicide – No increase with care in the community – Kicking and hitting more than weapons • Risk factors – Paranoid delusions – Command Hallucinations – Sexually inappropriate behaviour – Denial of previous dangerous acts
Violence • Risk is not static! – Need continual risk assessment (gathering of information and analysis of potential outcomes of identified behaviours and identifying specific risk factors of relevance and the context in which they may occur. Link historical info, clinical factors and statistics; whilst anticipating future change)
Eating Disorders Anorexia Nervosa • History & Epidemiology – First described by Marc’e in 1959 and named by the William Gull, and English physican. – Usually begins in adolescence most often between 16-17 years – Approximately 0.2-0.5% of young women – 95% are female – More common in occupational groups such as dancers, models and athletes where thinness is highly valued • Aetiology – Genetics – MZ twins > DZ twins. Relatives increase risk – Individual experience & personality • Excess of obsessive, inhibited and impulsive traits. Common in anxious-avoidant personality types – Family Dynamics • Dominant intrusive mothers and passive ineffectual fathers • Enmeshed rigid family structure with conflict avoidance
Eating Disorders • Can affect almost any physiological system – Vomiting & laxative use can cause hypokalemia and can be life threatening. – Pancreatitis – Parotid enlargement, hypoglycaemia, hypercholesterolaemia, oesophageal rupture – Acute gastric dilation on refeeding – Lanugo = fine airs over the body
Anoxia Nervosa diagnosis requires all of… • 15% less body weight than normal (BMI<17.5) • Body Image Distortion – dread of fatness as an overvalued idea • Attempt to lose weight by eating less fattening foods and one or more of… – Exercise – Purging – Vomiting – Misuse of diuretics / stimulants • Abnormality of hypothalmic-pituitary-gonadal axis – Amenorrhoea – Increased GH and coritsol – Decrease T3 • If onset is prepubertal, the sequence of pubertal events is delayed
Anorexia Nervosa • Anorexia is the most common chronic illness in teenage females • Half of these patients binge eat and then get remorse and try to lose weight. • Amenorrhoea occurs in about1/5th of cases • Anorexia N’ increases the risk of “feeling POGD” – Depression – GAD – Phobic disorder – Obsessive-compulsive disorder • 15% develop Bulaemia N • Mortality – 0.5-1% per year of illness – 20% morality rate
Anorexia Nervosa • Mainly psychological • Inpatient indications – Very low weight or rapid weight-loss – Serious physical complications e.g hypokalemia – Severe psychiatric co-morbidity e.g. depression – Failure of out-patient rx • In-patient Treatment – Weight restoration – Prescribed diet aiming at weight gain of approx 1kg / week – Setting the “target weight” – May include operant reinforcement – Treatment of complications – Restructured cognition – Education about diet and support • Outpatient Rx – Pychdynamic / CBT • Education about anorexia and its effects • Family therapy in younger
Bulimia Nervosa • Russell first described Bulimia in 1979 • Russell’s sign – callouses on back of hands (self induced vomiting) • The symptoms of BN sometime occur in Anorexia but it also occurs without preceding anorexia nervosa. • Patients are usually of normal weight • It has two components: – 1  Bulimia – 2  A behaviour intended to prevent weight-gain • Epidemiology – Affects 4% of female adolescents (More common than anorexia nervosa) – Peak incidence is late adolescence or early 20s (later than anorexia nervosa) – 30% have prior hx of anorexia… – SO there 15% of anorexics develop BN… 30% of those with BN had AN… but there are more Bulaemics… Gash! • Aetiology – Genetics • Less important than in anorexia nervosa – Appox 30% suffered sexual abuse as children cf. 10% general population – Neurotransmitters • Abnormalities of serotonin system may predispose to it
Bulimia Nervosa Diagnosis • Diagnostic criteria ICD 10:10 – Recurrent episodes of Binge eating • At least twice / week for 3months • Significantly larger than most people would eat • Sense of lack of control over eating – Recurrent inappropriate compensatory behaviour • Self induced vomiting (SIV) • Alternating periods of starvation • Diuretic / stimulant abuse • Purgative abuse – Unduely influenced by body shape and weight – Disturbance does not occur exclusively during episodes of anorexia nervosa
Bulimia Nervosa Treatment • In contrast to anorexia most pts can be treated as outpatients • CBT 10-20 sessions • SSRIs lead to a modest decrease in binge frequency at 60mg/day (more than normal depression dose) Outcome • 50% of patients are likely to recover completely • Around 20% will remain persistently symptomatic and 30% will have mild symptoms or a remitting and relapsing course • Good prognosis – Younger age at onset – short history – Higher social class – Family hs of alcohol abuse – Absence of any personality disorder
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Psych Revision

  • 2. Mental State Exam - MSE “A Small Mammal Told Paul Creative Ideas” • Appearance and Behaviour • Speech and Language • Mood and Affect – (Affect = variability of mood) • Thoughts – Formal Thought Disorder – rate (flight of ideas), interruptions in flow, Derailment (unrelated topics), Fusion (mixing of ideas), Thought block – Delusions – Overvalued Ideas – Obsessions – Thoughts of Harm to self or others • Perceptions – Sensory Distortion – False Perception (Illusion = A misperception of a real object/stimulus) – Hallucinations – Pseudohallucinaitons = experienced “in the mind’s eye”. Not concrete. • Cognitive Function • Insight
  • 3. • Mental Status Exam – Look at patients state of mind • Mini Mental State Exam – Screen sepcific for cognitive impairment
  • 4. Definitions• Capgras Syndrome – When a patient believes that a person, usually their loved one has been replaced by an exact double • Compulsion – Repetitive Ritualistic behaviour such as hand washing. It is designed to reduce the anxiety associated with the accompanying obsession • Cotard’s Syndrome – Severely deressed or suicidal people believe themselves or a part of their body to be dying • De Clarambault’s Syndorme – Usually affects females. They believe that a famous person is deeply in love with them • Delerium – An acute and relatively sudden decline in attention, focus, perception and cognition. Delerium can occur in demented patients. – May be hyperactive or hypoactive – There is clouding of consciousness • Delusion – A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person's culture or subculture. It is often difficult to distinguish between a delusion and an overvalued idea (in which case the individual has an unreasonable belief or idea but does not hold it as firmly as is the case with a delusion). • Autocthenis Delusion – A delusion arising without apparent cause. • Delusion of Reference – A delusion whose theme is that events, objects, or other persons in one's immediate environment have a particular and unusual significance. • Dementia – a syndrome of global cognitive impairment that is due to disease of the brain, usually of a chronic or progressive nature. – Consciousness is not clouded –only diagnosed in alert patients – Impairments of the cognitive functions are commonly accompanied and occasionally preceded, by deterioration in emotional control, social behaviour or motivation. • Extracampine Hallucination – Can hear/see etc. outside the range of normal senses. – E.g. Hear someone in scotland • Folie-a-deux – Induced Psychosis – a dilusional disorder shared by 2 or more people who are closely related emotionally. One has real psychosis the other’s is induced.
  • 5. Definitions • Functional Hallucination – hallucinations that occur when a patient simultaneously receives a real stimulus in the perceptual field concerned (e.g., hallucinated voices heard simultaneously with—and specific to—the real sound of running water) • Reflex Hallucination – when a perception in one modality produces a hallucination in another modality. – e.g. seeing a doctor writing (visual) and then feeling him writing across one’s stomach (tactile). • Hallucinosis – a state characterized by the presence of hallucinations without other impairment of consciousness • Neurosis (Neurotic) – A mental disorder in which the predominant disturbance is a distressing symptom or group of symptoms that one considers unacceptable and alien to one's personality. • Obsessions – Repetitive stereotyped, thoughts / images / impulses that are resisted by the patient, but recognised as their own • Thought Echo – A form of auditory hallucination where the patient hears his own thoughts spoken aloud, either simultaneously with him thinking it or a moment or two afterwards • Thought Broadcasting – Where thoughts escape from the boundaries of one’s self and are known to others, even strangers and those some distance away • Thought Insertion – The subjective feeling that thoughts in one’s mind are not one’s own, often explained by a secondary delusion of insertion by some outside agency. • Thought Withdrawal – the subjective feeling that thoughts are missing from one's mind, often explained by a secondary delusion of extraction by some outside agency • Waxy Flexibility – Catatonic Behaviour in which if one were to move the arm of someone with waxy flexibility, they would keep their arm where you moved it until it was moved again, as if it were made from wax
  • 6. The Psych Hx • Presenting Complaint • History of PC • Past Psych Hx – Have you ever been in contact with pyshiatric services before? – Hx of OD / DSH • Past Medical Hx • Drugs hx and allergies – Methyldopa (antihypertensve in pregnancy)  depression – Steroids  depression / mni • Family Hsitory • Personal Hx – Birth, developmental milestone, education, employment, pssychosexual Hx • Premorbid Personility – How would your friends describe you? – How do you cope with stress • Social History • Forensic Hx – Arrests, convictions, probations • Risk Assessment – Ever though life isn’t worth living? – Have you ever harmed yourself?
  • 7. Lithium • A carbonate or citrate salt • Excreted renally like sodium • Mechanism of action – not understood! In pregnancy can cause a small increase in cardiac defects (Ebstein’s Anomaly) and it can pass though breast milk Indications • Mania – Acute or Prophylaxis • Treatment resistant depression Common Side Effects • Fine Tremor • Fatigue • Polydipsia & Polyuria • Metallic Taste • Weight gain Important Side Effects - Renal Impairment - Nephrogenic Diabetes Insipidus - Hypothyroidism (esp. in female) - Cardiac Arrythmia - Hyperparathyroidism  bones, stones, abdo moans, psych
  • 8. Lithium • Prior to treatment – U&Es, TFTs, ECG • Levels Require Regular Monitoring – Serum Concentration of 0.6 -1 mmol/L – Weekly bloods until stable for 4 wks then 3 monthly – Beware • Dehydration • Drug Interactions – Haloperidol, Ibuprofen, Naproxen (NSAID), Diuretics, SSRI • Lithium toxicity – Course tremor – Ataxia – Weakness – GI Upset – Convulsions – Coma and Death (>2mmol/L) – narrow theraputic index
  • 9. Other Mood Stabilising Drugs • Sodium Valproate – Licensed as depakote (semisodium valproate) for acute mania – GABA transaminase inhibitor – Not licensed for prophylaxis – No blood test needed  ↑ use – Well understood due to use in epilepsy – Not safe in pregnancy • ↑ risk of spina bifida & fetal valproate syndrome
  • 10. Other Mood Stabilising Drugs • Carbamazepine – Liscenced for prophylaxis only – Patients unresponsive to lithium – Esp. rapid cycling BAD (4 episodes / year) • Olanzapine – More commonly used as an antypsychotic – Liscenced for use in acute mania and prophylaxis – Concern over long term use of atypicals – Rapid acting cf. other mood stabilisers
  • 11. Antidepressants • Tricyclic Antidepressants – Act on serotonin & noradrenaline reuptake – clinical effect delayed by at least 2 weeks but pharmacological affects immediate – Side Effects: • Sedation • Antimuscarinic SE (dry mouth, dizzyness, blurred vision, urinary retention) • Arrythmias & Heart block • SSRI – Controversy over “discontinuation syndrome” - ?addictive – Safe in overdose – SEs: • HYPONATRAEMIA • SNRI – Venlafaxine and Duloxetine – Clear TCA? • NARI – Reboxitine – Little Used
  • 12. Antidepressants • MAOIs – Originally used as antihypertensives – Reserved for 3rd line use • Atypical / resistant dpression e.g.”reversed fatigue features” – Phenelzine & Isocarboxazid are Irreversible MAOIs – Moclobemide is a reversible MAOI • Cheese reaction much less likely (tyramine) • Mirtazapine – Alpha-2-antagonist • Acts presynaptically to increase central NA & 5HT transmission – Sedating – useful in insomnia + depression
  • 13. Typical Antipsychotics Phenothiazines Butyrophenones Thioxanthines Trifluoroperazine Chlorpromazine Droperidol Haloperidol Flupentixol Zuclopenthixol Advantages of typical antipsychotics: – Cheap – Lots of experiences with their use Disadvantages = Dopmaine SEs (see next page)
  • 14. Typical Antiphsychotics DOPAMINE SIDE-EFFECTS • Mesolimbic Pathway – Block dopamine (D2&D4)  stop psychosis • Hypothalamic Pituitary Axis – Dopamine inhibits prolactin, so if you block dopamine you increase prolactin levels  Galactorrhoea and Impotence • Nigrostriatal Pathway (ADAPT SEs) – Acute Dystonia (typically oligogyric crisis) • Rx = Anticholinergc (Procyclidine) – Parkinsonism • Rx = Anticholinergc (Procyclidine) – Akathesia (feel need to move leg all the time- itchy on the inside) • Rx = Beta blocker, Benzodiazepine, anticholinergic – Tardive Dyskinesia (irreversable) • Rx = Stop or reduce antipsychotics
  • 15. Typical Antiphsychotics Other Side Effects • Anticholinergic SEs: – Constipation, blurred vision, Urinary Retention, Dry mouth, confusion. • Histmine SEs: – Sedation • Alpha1 SEs: – Postural hypotension – Impotence • Weightgain, Arrythmias and decreased seizure threshold (unexplained symptoms) • Neuroleptic Malignant Syndrome – Become stiff and rigid with an unstable BP and a fluctuating temperature, whilst delirious – 30-50% Mortality – Creatinine Kinase will be in 1000s – Treatment (in a normal hospital not psych) • Sodium Dantrolene • Bromocriptine (Dopamine Agonist)
  • 16. Atypical Antipsychotics • Advantages – Different SEs – patients prefer them • Affects on glucose metabolism (DKA&diabetes) • Affects on lipid metabolism – Less risk of tardive dyskinesia – At least as effective as typicals • Disavantages – Expensive (£100-200 / month) – New – less expensive – Previously there wasn’t a depot available, but now: Risperidone - Long acting depot drug - Massively expensive - Complicated Regime Alanzapine - rapid acting IM drug - no trials when coadministered with benzos
  • 17. Atypicals • Examples – Olanzapine – Amisulpiride – Risperidone – long depot – Clozapine – resistant schiz • Common Side Effects: – Can still get EPSEs, especially at higher doses – Sedation – Weight gain – Decreased Seizure Threshold – Impaired Glucose Tolerance – Impaired Lipid Metabolism
  • 18. Clozapine • Very expensive • Potentially Fatal Side Effects • Only drug effective in resistant schizophrenia • May have effects on negative symptoms • Reduces suicide rate in schizophrenia (may be due to the amount of monitoring required) • Side Effects of Clozapine • Sedation • Anticholinergic SEs • Weight gain • Much decreased seizure threshold • Hypersalivation (note: doesn’t fit with anticholinergic) • AGRANULOCYTOSIS – Wipe out WBCs – Infection  death
  • 19. Monitoring Clozapine Treatment (due to agranulocytosis) • Before starting – Check FBC (must be normal) – Register Dr, patient, pharmacist with the manufacturer – each need to know blood test results • Subsequently – FBC weekly for 18/52 – Fortnightly for rest of the year – 4/52 for life – RED – stop clozapine and NEVER prescribe it for this patient again – AMBER – Lowered WBC count; blood tests 3x per week – GREEN – Good to go
  • 20. The Dementias Pathology and Presentation • Alzheimer’s Dementia • Vascular Dementia • Lewy Body Dementia • Frontotemporal Dementia • Pick’s Disease Alzheimer’s Dementia Pathology •Neurofibrillary Tangles •Senile Plaques •Amyloid angiopathy •Granular Vascular Degeneration – ass. With Hirano bodies •Widening of Sulci and narrowing of gyri •Reduced Choline acetyltransferase  acetylcholinesterase inhibitors as treatment Presentation and Aetiology Early onset in 5% - Preselin 1 or 2 - Amyloid Precursor Protein (APP) Late onset (after 65) in 95% - APO 4 Gradual Onset & Progressive course Early Symptoms - Impaired recent memory - Impaired language performance (eg. Difficulty in naming objects, people, word finding) - Decreased attention and concentration - Mood changes e.g. flattening of emotional response - Disorientation in place and time Later stages: • Increased muscle tone  contractures • Poor mobility  bed sores • Loss of personality and responsiveness to others • Loss of coherent speech • Seizures • Incontinence • Death Vascular Dementia Pathology Leucoaraiosis = white matter ischaemia (low attentuation) Multiple infarcts (cortex or subcotex) in Multiple Infarct Dementia “100ml of the brain has to be lost before symptoms” Presentation and Aetiology Acute onset “Stepwise Deterioration” Personality preservation cf. alzheimers! Symptoms are dependent on site: • Cortical Dysarthria - is a motor speech disorder resulting from neurological injury Dysphagia - disorder of language. receptive or expressive. Amnesia Apraxia - loss of the ability to execute learned purposeful movements Hemiparesis - weakness on one side of the body • Subcortical Poor concentration Apathy Psychomotor slowing
  • 21. The Dementias Pathology and Presentation Lewy Body Dementia Pathology = “ANAL” Acetylecholine transferase activity is reduced Neuromelanin is reduced  pale substantia nigra Alzheimer’s pathology (NF tangles and senile plaques) Lewy Bodies (intracellular prtoein that stains positive for Ubiquitin, seen in the substantia nigra) Presentation Early symptoms similar to other dementias… Memory impairment, Speech difficulties, Visuospatial problems More specific signs of LBD: Fluctuations in cognitive performance day to day Visual hallucinations, often complex in nature or hallucinations in other modalities Frequent Falls Symptoms of Parkinsons – stiffness, shuffling gait, tremor Sensitivity to neuroleptic medication - EPSEs Depression Systematized Delusions Frontotemporal Dementia Pathology Gliosis Cortical atrophy of frontal and temporal lobes Spongiform changes Neuronal loss Presentation and Aetiology Gradual onset of symptoms Some features similar to other dementias - inability to recognise faces (propagnosia) Other features: - incontinence - Personality change – disinhibition, sexually inappropriate behaviour, aggression or apathy and withdrawal - Excessive eating and hyperorality (insertion of inappropriate objects in the mouth ) - Problems with attention and concentration -Speech problems – Preservation, echolalia
  • 22. Pick’s Disease One of the causes of the clinical syndrome now known as frontotemporal lobar degeneration. Pathology “Knife Blade Gyri” Pick Bodies (deposits of tau protein) Pick cells (swollen neurons) Hirano bodies (rod-shaped, eosinophilic depositis) Presentation Similar to other frontotemporal dementias
  • 23. Alzheimer’s Disease & Anticholinesterases • Theoretic basis – the final pathway in Alzhimers is loss of cholinergic function • How to use DONEPEZIL – Only in alzheimer’s; not huntingtons or dementia – Only use in Mild to moderate Disease (MMSE >9) – Give as a trial – Monitor carefully • Effects of Donepezil – Functional improvement > cognitive • E.g. dress better – May slow decline, temporarily stop decline or even lead to improvement – not a cure!!! • Problems with Donepezil – Expensive – Questionable evidence – Rapid decline if Donepezil stopped
  • 24.
  • 25. Multi Axial Classification (DSM IV) Axis I: Clinical Disorders Axis II: Personality Disorders Learning Disability Axis III: General Medical Conditions Axis IV: Psychosocial / Environmental problems AxisV: Global assessment of functioning
  • 26. Personality Disorders • What are they? • Diagnosis • Prevalence • Aetiology • Specific Types
  • 27. ICD10 Definition: “A severe disturbance in the characterological and behavioural tendencies of the individual, usually involving several areas of the personality and nearly always associated with considerable personal and social disruption” The markedly discordant behaviour and attitudes… - Arise in childhood - Persist into adulthood - Are NOT due to brain damage / disease / other psych illness - Are persistent, pervasive and clearly maladaptive - Usually involve several areas of functioning (e.g. mood, impulse control, attitudes towards others) - Result in considerable personal distress - Are usually associated with problems with at work/socially Personality Disorders Diagnosis Clear evidence of more than or equal to 3 traits/behaviours listed for the relevant personality type Prevalence Difficult to obtain accurate figures, as many individuals may never be diagnosed if they have no contact with psych services. Community 10% General practice 20% Psychiatric OP 30% Psychiatric IP 40% ↑♂ - Antisocial PD ↑♀: Borderline Histrionic Dependent
  • 28. Aetiology Primarily Psychodynamic a) Early childhood experiences – parents Dependent – Parental deprivation Anakastic – Struggle with parents for control Borderline – lack of stable attachment figure b) Psychosexual development Dependent – oral stage Anakastic – anal stage c) Defence Mechanisms Borderline – splitting, protection. Anakastic – Undoing Neuro Dissocial - Abnormalities in EEG readings - Decreased Autonomic Arousal to social stressors Borderline - Decreased serotonin activity (impulsivity, irritability, low mood) - ?Dysregulation of NA system (↑arousal, irritability, anger) Personality Disorders Genetic Normal personality is ‘moderately heritable’ Social History of abuse particularly prevalent in Borderline PD patients, commonly sexual
  • 29. Specific Types of PD • Paranoid Suspicious, Misconstrues actions as hostile, Persistently bears grudges, Combative, Excessive self-importance, Conspiratorial interpretations • Schizoid Emotionally cold and detached, Prefers to be alone, Insensitive to social norms/conventions Indifferent to praise / criticism • Schizotypal
  • 30. • Histrionic Over-emotional, Theatrical, Shallow and labile, Egocentric, Manipulative, Inappropriate seductiveness, Longing for appreciation. • Anakastic Excessive doubt / caution, Preoccupied with lists/rules, pedantic, Rigid and stubborn, Consistent scrupulous, Perfectionist to the point of hindering tasks. • Anxious / Avoidant Persistent tension/ apprehension, believe they are socially inept/inferior to others, preoccupation with being criticised/rejected in social situations, Unwilling to become involved unless certain of being liked Specific Types of PD
  • 31. • Borderline Emotional instability. Chronic feelings of emptiness. Intense unstable relationships  freq emotional crises. Excessive efforts to avoid abandonment. Suicide threats / DSH • Dissocial Callous unconcern for others’ feelings. Unable to maintain long standing relationships. Blames others. Low frustration tolerance. Tendency towards aggression/ violence. Gross disregard for social norms/rules Specific Types of PD
  • 32. Management of Personalilty Disorders Most rx is focussed on Borderline PD as this tends to place the greatest demand on psych services, with patients repeatedly presenting in acute distress. Psychotherapy Dialectical Behavioural Therapy - Current treatment of choice for Borderline PD - Patient encouraged to ‘radically accept’ themselves as they are, while at the same time explore ways of changing themselves and their lives. - Modification of CBT - Combination of individual and group therapy Medication - Antipsychotics – small doses - Antidepressants – SSRIs in Borderline, Anankastic and dissocial - Carbamazepine – potential role in impulsivity
  • 33. PD Prognosis • High morbidity and mortality rates • Mortality x6 in 20-39yr old age group • High risk suicide • High rates of co-morbidity with Axis I+II conditions • Prognosis for axis I conditions worse if have a PD • Tend to become less severe with increasing age.
  • 34.
  • 35. Mental State Exam - MSE “A Small Mammal Told Paul Creative Ideas” • Appearance and Behaviour • Speech and Language • Mood and Affect – (Affect = variability of mood) • Thoughts – Formal Thought Disorder – rate (flight of ideas), interruptions in flow, Derailment (unrelated topics), Fusion (mixing of ideas), Thought block – Delusions – Overvalued Ideas – Obsessions – Thoughts of Harm to self or others • Perceptions – Sensory Distortion – False Perception (Illusion = A misperception of a real object/stimulus) – Hallucinations – Pseudohallucinaitons = experienced “in the mind’s eye”. Not concrete. • Cognitive Function • Insight
  • 36.
  • 37. Hierarchy of Psychiatric Conditions 1. Organic - inc. substance use, prescription drugs, endocrine disorders 1. Psychoses & Mood Disorders 2. Neuroses - Eating Disorders, somatoform disorders 1. Personality Disorders
  • 38. Causes of Delirium • I Infections • W Withdrawal (alcohol) • A Acute (metabolic) • T Trauma • C CNS (pathology) • H Hypoxia • D Deficiency of vitamins • E Endocrine • A Acute (vascular) • T Toxins (drugs) • H Heavy metals (lead) 20% die from delirium!!
  • 39. Drugs associated with Hallucinations – “CAN PAM”? • Cardiovasculaar drugs • Beta blockers, digoxin, diltiazem, procainamide • Anti-Parkinsonian Drugs • L-DOPA, Amantadine, Anticholinergics, Bromocriptine, Pergolide • NSAIDs • Buprenorphine, Nefopam, Tramadol • Psychotropics • Amphetamines, LSD, Imipramine (TCA), Midazolam • Anti-infection Drugs • Ciprofloxacin, Intraconazole, Gentamycin • Misc • Cimetidine (H2 antagonist), Steroids, EPO, Decongestants, Khat (drug of abuse), Ketamine (anaesthetic)
  • 40. Organic Differentials • Hyperthyroidism – Differential diagnosis of anxiety disorder – High arousal with anxiety, Irritability, Restlessness, Distractibility, Insomnia, affective lability inc. depression – BUT also these distinguishing features… Heat intolerance, Increased appetite with weightloss, cardiac arrythmias, tachycardia, thyroid enlargement / bruit – Differential diagnosis of delerium – Fulminant episodes of delerium can occur in 3-4% of those with hyperthyroidism. It’s characterised by fever, tachycardia, hypotension, vomiting and diarrhoea (thyroid crisis)
  • 41. Organic Differentials • Hypothyroidism M:F = 1: 19 Onset = 40-60yrs Causes: OverRX of Hyperthyroidism Endstage chronic thyroiditis Drug induced hypothyroisism (lithium, carbamazepine, phenytoin) – Differential for Psychosis – There is a possibility of delusions and auditory hallucinations (myxoedema madness) – Differential for Depression – Fatigue, poor apatite, slowed activity, aches and pains, constipation, cold intolerance, weight gain, infiltration of the skin by mucopolysaccharides causing hearing, taste and smell difficulties – Note: hoarse voice, expressionless face and hair loss. Non-pitting oedema – Differential for Dementia – Cognitive impairment can be a feature including porr concentration, general intellectual decline and memory impairment
  • 42. Organic Differentials • Cushing’s Syndrome – Causes: • Pituitary (C’ Disease) – increased ACTH higher incidence of depression than other two types • Adrenal – Adrenal tumour (benign or malignant) • Ectopic ACTH production – SSLC – Differential for Depression – 80% patients with cushings get depression – Severity is not linked to cortisol levels – Anxiety, apathy, fatigue, severe retardation – 3-10% commit suicide – Differential for Psychosis – Cortisol can cause psychosis, delusional hallucinations and delerium, if in high enough levels
  • 43. Organic Differentials • Steroid Treatment – Differential for Psychosis – Can get hallucinations, delusions, disturbances in body image, hypomania, – Differential for Anxiety Disorder – Differential for Mania – Can get euphoria, pressured speech and hypomania These occur in the first 3 weeks of treatment
  • 44. Organic Differentials • Addison’s disease – Also known as Hypocortisolism or chronic adrenal insufficiency – Adrenal hypoplasia accompanied by increased ACTH levels – Depression symptoms include… • Fatigue, apathy, anorexia, lack of initiative and poor concentration, weightloss, paranoia, delusions – Important signs an symptoms • Voice is soft and whining • Pigmentation on skin creases, nipples and the insides of the cheeks. • Anaemia • Hyperkalaemia & Hyponatraemia (lack of aldosterone) • Raised blood urea – Addisonian Crisis • Exacerbation of symptoms with fever, vomiting, epigastric pain, hypotension • Can be secondary to prescribed drugs (e.g. morphine), infections.
  • 45. Organic Differentials for Anxiety • Hyperthyroidism • Phaeochromocytoma (impending doom) • Steroid Treatment Organic Differentials for Depression • Hypothyroidism • Cushing’s syndrome • Addison’s disease Organic Differentials for Psychosis • Hypothyroidism (myoedema madness) • Cushing’s syndrome • Steroid Treatment
  • 46.
  • 47. OCD • 1. Need both Obsessions and Compulsions Obsessions are “intrusive, unpleasant thoughts or images” that are resisted by the patient but recognised as his own Compulsions are “Repetitive Unwanted Actions” • 2. Compulsions caused by Obsessions • 3. Attempts to suppress the thoughts as they are realised to be excessive or unreasonable • 4. These cause marked distress & dysfunction • It is a life-long condition • Not something which happens to everyone a little bit! • Not normal concerns * Adapted from DSM IV criteria
  • 48. Common Patterns Obsessions Compulsions Contamination Worries Washing, bathing, showering Harm to self, harm to others, sexual / religious worries Checking, praying, asking for reassurance Symmetry, precision worries Arranging, ordering Saving concerns Hoarding
  • 49. Diagnostic Considerations Zohar-Fineberg Obsession Compulsive Screen (Z-FOCS) 1. Do you wash or clean a lot? 2. Do you check things a lot? 3. Is there any thoughts that keep bothering you that you would like to get rid of? 4. Do your daily activities take a long time to finish? 5. Are you concerned about orderliness or symmetry? In some patients OCD symptoms begin following streptococcal infection or after use of cocaine or methylphenidate Comorbid tics are not uncommon but often overlooked despite needing a different treatment pathway. It is helpful to find out why patients think they are getting these symptoms. Then correct them.
  • 50. “Obsessive Compulsive Disorders” • Speculative spectrum of disorder with biology and symptoms similar to OCD • Undefined boundaries • Includes Comorbidity – Obsessive-Compulsive Personality Disorder – Autism – Gilles de la Tourette’s 7% – Body Dysmorphic Disorder – Hypochondriasis – Eating Disorders 17% NB –Psychiatric Comorbidities occur in most patients with OCD but not all of them are considered part of the OC spectrum e.g. Depression, Schizophrenia, anxiety disorders Chicken and the Egg
  • 51. Pathogenesis • OCD is a “Neuropsychiatric” condition as it has a specific neurocircitry. • CORTICO-STRIATAL-THALAMO-CORTICAL (CSTC) Dysfunction – Serotonin (5HT) & Dopamine • Increased activity in – Orbitofrontal Cortex (? Compensation for CSTC) – Ventral Striatum – Thalamus
  • 52. Psychotherapy • Exposure and Response Prevention (ERP) – A hierarchy of feared stimuli is created and it is shown that anxiety decreases without the need for the compulsion. • Cognitive Interventions – Encourage patient to re-evaluate overvalued beliefs – May need this before they consent to ERP
  • 53. Pharmacotherapy • Drugs are indicated in >mild OCD and if CBT doesn’t work. • First Line: – SSRI e.g. Fluoxetine LIFELONG – TCA – only Clomipramine *If bipolar comorbidity need to give mood stabaliser along side • Slow and gradual improvement • Patients generally lack insight into improvement • Resistant OCD – SSRI + antipsychotics – SSRI + Clonazepam
  • 54. Mild functional impairment or patient preference for low intensity approach. Offer CBT (including ERP) and guided self help If patient cannot engage in CBT or if CBT is inadequate or patient has >mild dysfunction Offer a choice of either: Treatment with SSRIs alone (at least 12 weeks CBT alone (>10 therapist hours) Offer SSRI and CBT combined Offer either a different SSRI or clomipramine Refer to MDT with specialist expertise in OCD STEP WISE TREATMENT PLAN IN OCD
  • 55. Key Points of OCD • Lifelong condition where compulsions linked to obsessions and these cause marked distress and dysfunction • CSTC dysfunction • Serotonin and Dopamine involved  Rx: SSRIs • ERP and Cognitive Therapy
  • 56.
  • 57. Mental State Exam - MSE “A Small Mammal Told Paul Creative Ideas” • Appearance and Behaviour – Eye Contact – Movement Disorder e.g. Tardive Dyskinesia • Speech and Language – Rate,Tone and Volume – Neologisms (making up new words) • Mood and Affect – (Affect = variability of mood) – Objective and subjctive • Thoughts – Formal Thought Disorder – rate (flight of ideas), interruptions in flow, Derailment (unrelated topics), Fusion (mixing of ideas), Thought block – Delusions – Overvalued Ideas – Obsessions – Thoughts of Harm to self or others • Perceptions – Sensory Distortion – False Perception (Illusion = A misperception of a real object/stimulus) – Hallucinations – Pseudohallucinaitons = experienced “in the mind’s eye”. Not concrete. • Cognitive Function • Insight
  • 58. Thoughts • Formal Thought Disorder • Rate – Flight of ideas (mania) – Retardation • Interruptions in flow – Thought block – Derailment – unrelated topics – Knights move thinking – Tangential – Fusion – mixing of ideas • Loosening of Associations • Circumstantiality • Concrete Thinking • Delusions • An unshakeable belief, usually but not always false, that is out of keeping with one’s cultural and religious upbringing and that is not amenable to logical argument • Content – Delusions of…Persecution, Grandiour, Reference (thinks something relates to you), Control, Guilt, infidelity and love • Overvalued Ideas • An acceptable, comprehensible idea pursued by the person beyond the bounds of reason and causes suffering or disturbed functioning • Obsessions • Recurrent intrusive, usually unpleasant ithoughts that the person recognises as thier won and tries to resist.
  • 59. Perceptions • Sensory Distortion • Intensity and quality of perception • False Perception • Illusion – “a misinterpretation of a real obeject / stimulus” • Pareidolic Illusions • See a rabbit in the sky • Hallucinations • A percept-like experience in the absence of an external stimulus that has all the qualities of real perception in external objective space and is unwilled and cannot be controlled by the person. – Extracampine – outside normal sensory field – Reflex – stimulus in one modality  hallucination in another – Functional – normal sensory input + hallucination in same modality – Alcoholic Hallucinosis – normal auditory; starts as whistle or tapping but can develop – Affect – relate to mood (normally fear) • Pseudohallucinations • A separate form of perception from a true hallucination • Not concretely real • Experienced in internal space (“in the minds eye”)
  • 60.
  • 61. Schizophrenia ………First coined the term and described “Schizophrenia” ……………. First tried to operationalize the clinical diagnosis through certain symptoms • Epidemiology – Lifetime risk = 1% – M = F (although a later onset in women) – In UK, African Carribean people are at greater risk – Urban> Rural – Increase in those among the lower socioeconomic class (although the disease itself could cause a drift down the social classes) – Usual Onset = 15-45 years • Male - peak onset = 24 • Female – 2 peaks (hehe) = 24 & 35 – “Paraphrenia” – onset in elderly Bleuer Schneider
  • 62. Schneider’s First Rank Symptoms of Schizophrenia • Delusional Perception • Third Person Auditory Hallucinations – Arguing or commenting on one’s actions • Thought Echo • Passivity – Emotion – Impulse, acts and volition – somatic • Thought insertion • Thought withdrawal • Thought broadcasting
  • 63. Schizophrenia ICD10 Diagnostic Criteria • Criteria 1 – Thought echo, insertion, withdrawal, broadcast – Delusion of passivity – Hallucinations giving running commentary or discussing patient in 3rd person – Persistent Delusions • Often bizarre e.g. they can control the weather • Criteria 2 – Persistent Hallucinations accompanied by delusions – Breaks or interpolations in the train of thought “thought disorder” • Circumstantiality • Thought Block • Word Salad • Pressured Speech – Catatonic Behaviours • Catatonic Stupor • Catatonic Excitement • Waxy Flexibility – Negative Symptoms • Loss of normal motivation or drive • Loss of awareness of socially appropriate behaviours • Flattening of mood • Difficulty in abstract thinking A Diagnosis Needs… -1 clear cut or 2 less clear cut criteria 1 symptoms (or) - 2 from criteria 2 •Needs to have been present for at least 1 month •Not due to organic cause or mood disorder
  • 64. Schizophrenia Differential Diagnosis • Organic Disorders – Drug induced states (cannabis, amphtamines) – Complex – partial seizures (frontotemporal epilepsy) – Encephalitis – Syphilis (“General Paralysis of the Insane”) • Mood Disorders – Bipolar Affective Disorder • 10% have psychotic symptoms • Need to establish whether the primary disorder is affective or not – Depression with psychosis
  • 65. Schizophrenia - Aetiology • Predisposing Factors – Past HX – Family Hx – Winter Birth – Pregnancy / Birth Complications – Odd clumsy child with language problems • Perpetuating Factors – Non-compliance – Continued use of illicit drugs – Ongoing Stress • Precipitating Factors – Life events – Stopping Antipsychotics – Use of illicit drugs – Living in high expressed emotion households DOPAMINE THEORY •Funcitonal Excess of Dopamine in the mesolimbic area •Amphetamine releases dopamine and causes schizophrenia-like symptoms •Antipsychotics block dopamine receptors (D2 & D4 mainly)
  • 66. Schizophenia - Prognosis • 10% suicide (male, high premorbid function, depressive symptoms) • Also excess of deaths from accidents, CV disease • About ¼ only have one episode • About 1/3rd have repeated episodes, but recover in between • About 1/3rd have repeated episodes with worsening impairment Good Prognostic Factors Sudden Onset Female Short Episode Married, good social relationships No past Psych Hx Good work record Prominent mood symptoms Good compliance/concordance Older age at onset
  • 67. Schizotypal Disorder • Characteristics – Eccentric Behaviour – Anomalies of thinking resembling those of schizophrenia but none definitive of it at any time – No hallucinations but often preoccupied by weird themes – Chronic course with fluctuations of intensity – Evolution and course are usually those of personality disorder – May evolve into Schizphrenia – Genetically linked to schizophrenia • More common in those related to schizos – May never come to the attention of the services
  • 68. Schizotypal Disorder • Features – Inappropriate / constricted affect – Eccentric / odd behaviour – Poor rapport/ social withdrawal – Odd beliefs – Paranoid ideas – Obsessive ruminations lacking resistance – Unusual perceptive experiences – Vague, circumstantial, over-elaborate thinking with odd speech – Transient quasi-psychotic episodes • Diagnosis – 3 or 4 features for at least 2 years – Never met criteria for schizophrenia
  • 69. Delusional Disorder • Characteristics – Single or set or related delusions only • The delusions are often lifelong and have variable content which may relate to life situation – Jealousy Delusions – targeted at spouse (orthello’s syndrome) – Erotomanic Delusions – someone in authority is I love with them (De Clarentbaue Syndorme) – Persecutory Delusions • Onset commonly in middle life but may be earlier • Other morbid phenomena may occur but are not constant or dominant – Not organic, schizophrenia or affective • Diagnosis – Conspicuous (easy to notice) delusions, present for at least 3 months – Clearly person not sub-cultural – No evident underlying cause
  • 70. Mood (Affective) Disorders • A Mood Disorder is a disorder whereby the prevailing emotional mood is distorted or inappropriate to the circumstances. Generally either elation or depression. The mood change is accompanied by a change in the level of activity, particularly thought patterns. • Depression (Unipolar) – Major Depression – Recurrent major depression – Major Depression with psychotic symptoms (Psychotic depression) – Postpartum depression – Dysthymia • Bipolar Disorder – Bipolar I – Bipolar II – Cyclothymia
  • 71. Mood (Affective) Disorders • ICD Classification – F30 Manic Episode – F31 Bipolar Affective Disorder – F32 Depressive Episode – F33 Recurrent Depressive Disorder – F34 Persistent Mood (Affective) Disorders – F38 Other Mood (Affective) Disorders – F39 Unspecified mood (affective) disorder
  • 72. Depression In all varieties (mild, moderate, severe): Cardinal symptoms = Depressed mood associated with: 1. loss of interest &enjoyment (anhedonia) 2. reduced energy leading to easy fatigability (anergia) 3. diminished activity • marked tiredness after only slight effort is common • Mood changes can easily be masked by: – Irritability – Excessive consumption of alcohol – Histrionic behaviour – Exacerbation of pre-existing symptoms – Hypochondriacal preoccupation
  • 73. Depression • Other common symptoms: – Reduced concentration and attention – Reduced self esteem and self confidence – Ideas of guilt and unworthiness – Bleak and pessimistic views of life – Ideas or acts of self-harm or suicide – Disturbed sleep – Diminished appetite and loss of weight • A duration of 2 weeks is required for making a diagnosis, but shorter periods may be reasonable if symptoms are un-usually severe or of rapid onset.
  • 74. Depression Biological (Somatic) Symptoms – Anhedonia – loss of interest or pleasure in activities that are normally enjoyed – Lack of emotional reactivity to normal pleasurable surroundings – Early wakening (2 or more hours before usual time) – Depression worse in the mornings – Objective evidence of psychomotor retardation or agitation (remarked on or report by other people) – Poor appetite and weight loss (5% body weight in past month) – Loss of libido
  • 75. Depression Classification of Depressive Disorder Mild Depressive Episode (with/without somatic syndrome) • two of three cardinal symptoms plus two others • minimum duration 2 weeks • difficult continuing with ordinary work and social activities Moderate Depressive Episode (with/without somatic syndrome) • Two of three cardinal symptoms plus three-four others • Minimum duration is about 2 weeks • Considerable difficulty in continuing with social, work or domestic activities Severe Depressive Episode without psychotic symptoms • All three cardinal symptoms plus at least four others • Should usually last at least 2 weeks • Unlikely to continue with social, work or domestic activities • Suicide is a distinct danger in a severe depressive episode
  • 76. Depression Classification of Depressive Disorder Severe Depressive Episode with Psychotic Symptoms • Above criteria • With delusions, hallucinations or depressive stupor • Delusions of sin, poverty, imminent disasters Recurrent Depressive Disorder – mild, moderate, severe with/without psychotic symptoms • Repeated episodes without any history of independent episodes of mood elation or over activity that fulfil the criteria of mania • Mean age of onset in 5th decade • Individual episodes last between 3 and 12 months • Recovery usually complete between episodes • Individual episodes usually precipitated by stressful life events
  • 77. Persistent Mood (Affective) Disorders • Persistant, usually fluctuating • Individual episodes are rarely severe to warrant being described as hypo manic or even mild depressive episodes • Can last for years at a time • Considerable subjective distress and disability Cyclothymia • Persistent instability of mood, numerous periods of mild depression and mild elation • Develops early in adult life • Chronic course • Mood swings unrelated to life events Dysthymia • Long standing depression of mood, very rarely severe enough to fulfil the criteria for RDD • Begins in adult life, lasts for several years • Most of the time feel tired and depressed; everything is an effort; nothing is enjoyed
  • 78. Persistent Mood (Affective) Disorders Epidemiology • Lifetime rates show much variability (4-30%) true figure lies between 10-20%. • The mean age of onset is 27 years • Women : Men = 2 : 1 • Rates are higher in the divorces and unemployed • A high co-morbidity with other disorders Aetiology • Genetics – Family clustering: the risk of mood disorders is increased in first degree relatives of probands – The risk appears to be specific to the depressive illness phenotype – Twin studies MZ 46%, DZ 20% – Adoptive studies 31% of psychiatric disorders in biological parents cf 12% in adoptive parents • Monoamine Hypothesis – Serotonin, noradrenaline and dopamine play a major role in the adaptive responses • Endocrine Hypothesis – Hypothalamic-pituitary axis, cortisol and dexamethasone suppression test • Dexamethasone suppression test can be positive in depression as well as Cushing’s. • Psychosocial Theories – Parental deprivation and early environment – Recent life events – Learned helplessness – Cognitive theories – core beliefs, dysfunctional assumptions and negative automatic thoughts – Psychoanalytical theory – Anger turned in
  • 79. Treatment Issues • Newer Antidepressants – tend to be well tolerated in OD – SSRIs – Fluoxetine, Citalopram, Sertraline, Escitalopram, Paroxetine – SNRIs – Venlafaxine & Duloxetine – Alpha 2 Antagonts – Mirtazepine – NARI – Reboxtine, Nortriptyline (Clean TCAs?) • Classical Antidepressants: – TCAs: • Imipramine Desipramine • Amitriptyline Doxepine • Clomipramine Nortriptiline • Monoamine Oxidase Inhibitors – Very old drugs – Phenalazine – Tranylcypromine – Moclobomide – Main use for atypical cases Side Effects: Cheese reaction due to Tyramine Cheese or red wine  Arrythmia
  • 80. Treatment NICE Guidelines for treating Depression • Screen high risk groups • Mild depression who do not want/need treatment – reassess in 2 weeks. • Mild depression – short term CBT • SSRIs should be first choice medications • Severe Depression – Meds + CBT • Continue meds for 2 years if more than 2 episodes with functional impairment NICE guidelines • CBT should be used in recurrent and drug resistant depression • Guidelines apply to those over 18. • Antidepressants are rarely useful in children and adolescents
  • 81. SSRIs • Fluoxetine was first on the market • Now a wide choice (6 in the BNF) • Subject of controversy – DISCONTINUATION SYNDROME • Paroxetine has bad effects when stopped – this is NOT addiction! • Advan – Efficacious – we’ll toleraced – Safe in OD • Diadvan – Discontinuation syndrome
  • 82. Tricyclics • First useful antidpressant • IMIPRAMINE was the first discovered and this was by accident • Act on Serotonin and Noradrenaline reuptake • Pharmacological effect immediate but clinical effects take 2 weeks • Advan – Cheap – Efficacious and large body of research • Disadvan – Side Effects: • Anticholinergic – Dry mouth, urinary retension, blurred vision • Sedation • Arrythmias and Heart block (OVERDOSE suicide) 
  • 83. MAOIs (Monamineoxidase inhibitors) • Originally prescribed as antihypertensives – Delay breakdown of NA and 5HT • Reserved for 3rd line! – Atypical or treatment resistant depression – E.g. reserved for vegetative state • Well documented problems – Tyramine (cheese) Reaction producing hypertensive crisis (ironic as originally prescribed for hypertension) • Little used inpractice • Phelezine, Isocarbxazid – Irreversible inhibitors of MAO-A • Moclobemide – Reversible inhibitor of MAO-A – Cheese reaction much less likely but can still occur! (just need more red wine, cheese, swordfish etc)
  • 84. SNRIs (Serotonin and NA reuptake Inhibitors) • Like SSRIs but involve NA as well • E.g. Venlafaxine – Bicyclic Antidepresant – ? A clean tricyclic? – Recent concerns over arrythmias NARIs (NA reuptake inhibitors) • Pure NA reuptake inhibition • E.g. Reboxitine • Little used in practice Alpha 2 Antagonists /Noradrenergic and specific serotonergic antidepressant (NaSSA) • Act presynaptically • Increase central NA and 5HT transmission • Mirtazepine – sedating. Useful in insomnia + depression
  • 85. Antidepressant Strategy • SSRI 1st line – Allow 1-3 weeks before improvement – Increase dose to maximum – Allow 4 weeks without response before considering a change • Different SSRI / different class 2nd line – Cross-taper between drugs – ie. Have both going at the same time • Venlafaxine 3rd line – At one point CMS had concerns about cardiotoxicity – Now not felt to pose an undue risk • Augmentation – With mood stabilisers e.g. lithium • Combination Therapy – Different antidepressants together – Beware interactions – Serotonin Syndrome • Occurs in OD and combination therapy • Altered mental state, agitation tremor, shivering, diarrhoea, hyper-reflexia (usually lower rather than upper limbs), myoclonus, mydriasis, ataxia and hyperthermia • Need to exclude Neuroleptic Malignant Syndrome • ECT Maintenance - Maintain treatment for 6 months - same drugs at same dose - slowly withdraw - Longer if indicated - up to 2 years if recurrent depression (NICE) - Indefinite treatment may be required
  • 86. Mania Types: • Hypomania • Mania without psychotic symptoms • Mania with psychotic symptoms Symptoms in Mania • Elated mood, irritability. • Sustained for at least one week, which is severe enough to disrupt the usual activities – Increased energy – Pressure for speech – Decreased need for sleep – Grandiosity, expansive optimism or self inflated esteem, disinhibition – Reckless behaviour e.g Spending sprees – Increased sexual libido – Flight of ideas, pressure of speech
  • 87. Mania Classification • Hypomania – Lesser degree of mania – Symptoms not to the extend that they lead to severe disruption of work/result in social rejection – Present for at least several days on end • Mania without psychotic symptoms – Elated mood out of keeping with individuals circumstances – Mood may be irritable and suspicious rather than elated – First attack 15-30 years – Last for at least 1 week • Mania with psychotic symptoms – More severe form with delusions and hallucinations
  • 88. Bipolar Disorder • Characterised by two or more episodes of depression, hypomania or mania (1 of which has to be mania) • Characteristically recovery is usual between episodes • Median duration for an episode – Mania = 4 months – Depression = 6 months • First episode – any age
  • 89. Bipolar Disorder Epidemiology • Lifetime risk lies between 0.3-1.5% • F : M = 1:1 • Mean age of onset is 21 years Aetiology • Genetics – Familial clustering: relatives of bipolar probands have increased risks of unipolar depression and bipolar disorder – Twin studies: Concordance rate is 70% in MZ, but 20% in DZ – Genetic influence is greater in bipolar disorder than unipolar depression!
  • 90. Bipolar Disorder • Question: What are the Differences Between Bipolar I and Bipolar II Disorders? • Answer: The most important distinctions between Bipolar I and II are: – A person with BP II experiences hypomanic episodes but not manic episodes. The difference between mania and hypomania is a matter of severity - hypomania generally does not impair a person's daily functioning or cause the need for hospitalization. – Experience of psychotic symptoms such as hallucinations or paranoia indicates Bipolar I Disorder; the presence of such symptoms rules out Bipolar II.
  • 91. Bipolar Disorder Treatment of Mania • Acute episode – is admission required? (danger) – Antipsychotics • Olanzapine – Benzodiazepines – Mood stabilisers • Lithium – Anticonvulsants • Sodium Valproate • Prophylaxis – Mood Stabilisers • Lithium carbonate – Antipsychotics • Olanzapine – Anticonvulsants: – Carbamazepine Course and Outcome • The mean number of episodes in a lifetime is 7 to 11 and the episodes increase in frequency with increasing age. • Suicide is more frequent in bipolar disorder than in recurrent depressive disorder.
  • 92. Lithium Rx • Used in acute mania in bipolar disorder – Initially, lithium is often used in conjunction with antipsychotic drugs as it can take up to a month for lithium to have an effect. • Also used in Mania Prophylaxis • To start lithium you need an ECG & baseline bloods (U&Es, TFT) • Need to monitor lithium levels closely as therapeutic dose (0.6 to 1.2 mmol/L) is very close to toxic dose (1.5mmol/l can be fatal) • Also need to monitor U&Es and TFTs as lithium interferes with the regulation of sodium and water – concurrent use of diuretics should be avoided • An important potential consequence of long-term lithium usage is the development of renal diabetes insipidus (inability to concentrate urine). Patients should therefore be maintained on lithium treatment after 3-5 years only if, on assessment, benefit persists. • Lithium is teratogenic and can get into breast milk – increasing the likelihood of Ebstein’s anomaly Common Side Effects - Fine tremor - Fatigue - Polydispia & polyuria - Metallic Taste - Weight Gain Lithium Toxicity - Course tremor - Weakness - Ataxia - GI upset - Convulsions - Coma and death Important Side Effects - Renal Impairment - Nephrogenic Diabetes Insipidus - Hypothyroidism - Cardiac Arrythmias
  • 93. Anticonvulsants (As mood stabilising drugs) • Sodium Valproate – Liscenced as Semisodium Valproate (Depakote) for acute mania – GABA transaminase inhibitor – Prophylaxis (not liscenced) – Increasingly used – no blood tests – Well understood as many on it for epilepsy • Carbamazepine – Licensed for Prophylaxis only – Patients unresponsive to lithium – Especially good in rapid cycling Bipolar • 4 distinct episodes / year • Lithium said to be less useful • Olanzapine – Atypical antipsychotic – Lisenced for acute mania and prophylaxis – Concern over long term affects of atypicals
  • 94. Electroconvulsive Therapy • Most (in)famous treatment in psychiatry • Poor public image • Effective in depression – Emergencies – Treatment resistance • Can be used in mania and schizophrenia • NICE guidelines relegate it to “last resort” • Can be given in extreme circumstances – E.g. pregnancy – Threatening OD – No eating or drinking • Given twice weekly • Maximum 12 treatments • EEG monitored during treatment • Side Effects – Headache (temporal muscle contraction) – Semantic Memory Loss • Short lived and recovers in 3 months
  • 95. rTMS Repetitive Trans-cranial Magnetic Stimulation • Still in early stages • Promises benefits without SEs • No anaesthetics needed! Psychosurgery • Extremely poor public image • Still of value in severe intractable illness e.g. OCD • Very few centres nationally • Several procedures – Cingulotomy (OCD) – Subcausate tractomy (major depression) • Subject to section 57 MHA – If consent of pt and three people (one doctor and two others who cannot be doctors) have to certify that the person concerned is capable of understanding the nature, purpose and likely effects of the treatment and has consented to it. These three people are appointed by the Mental Health Act Commission.
  • 96. Anxiety Related Disorders • A small amount of stress can be beneficial  increases productivity (Kaplin Myer Curve) • Anxiety become pathological when it is extreme, situational (e.g. phobias) or reduces functioning.
  • 97. Anxiety Related Disorders Physiology of Acute Anxiety: • ADRENALINE – Tachycardia, tachypnoea, chest tightness, dizzyness, parasthesia, sweating, epigastric discomfort, diarrhoea Physiology of Chronic Anxiety • ­CORTISOL – Physiological­excessive worry, irritability, difficulty concentrating, muscle tension (tension headaches), sleep and appetite disturbance, deterioration in physical health – CVS, gastro, immune etc. • Noise sensitivity.
  • 98. Anxiety Related Disorders • Classification of Anxiety Disorders • Need to rule out: • Thyroid disorders SAH • Seizure disorder Hypoglycaemia • CNS / extracranial neoplasia Drug intoxication / withdrawal • SAH Phaeochromocytoma
  • 99. Anxiety Related Disorders Acute Stress Reaction • immediate and brief response to sudden intense stressor e.g. bereavement, car accident, abuse • response starts within an hour • Begins to diminish after 48 hrs • Epidemiolgy – 13% survivors of violent crimes • Certain vunerability factors e.g. traumatic childhood • Symptoms: – Increased arousal – Dissociative numbness – Depersonalisation – – Derealisation – don’t feel part of surroundings – Dissociative amnesia – Uncontrollable grief – Inappropriate and purposeless activity • Treatment ­ As it is transient, psychiatrists rarely treat it. ­ Usually GP, surgical wards, A&E staff ­ Help to reduce emotional response ­ Help with more appropriate coping mechanisms ­ Debriefing – little evidence!
  • 100. Post Traumatic Stress Disorder • Response to severely stressful (life threatening) events e.g. serious RTA, war events, major fires, natural disasters • Intense • Prolonged • Sometimes delayed • Term first used during Vietnam War (90% of Vietnam ware veterans met diagnostic criteria). Before this it was called “shell shock”.
  • 101. Post Traumatic Stress Disorder Clinical Picture • 3 main groups – Hyperarousal ­ anxiety, irritability, insomnia – Intrusions ­ intense, intrusive imagery, recurrent distressing dreams (reexperiencing the event) – Avoidance ­ avoidance of reminders, people, feeling of detachment (triggers can bring on the intrusions) • Other features: – Maladaptive coping – alcohol, drugs, self harm – Depression – Guilt – esp. survivors
  • 102. Treatment of PTSD • Counselling to provide emotional support • CBT – education on anxiety, cognitive restructuring, anger management • Eye movement and desensitisation reprocessing (EMDR) – Used in America and Army – Cross eyes then recount the event – Need relaxation • “Rewind” Therapy – Dissociated recount e.g. watch event on tv – can fast­forward or rewind • Medication – Anxiolytics – SSRIs Prognosis • 50% recover during first year • Rest may continue for prolonged periods • Recovery less likely if initial symptoms severe
  • 103. Adjustment Disorder • Extreme emotional reaction in response to new life circumstances e.g. divorce, bereavement, loss of job (Non-life threatening event) • Symptoms include severe anxiety, depressed mood etc. • Symptoms should be present within 3 months of event for diagnosis • Counselling may play a role • Drug treatment can be counter productive
  • 104. Generalised Anxiety Disorder • Symptoms of anxiety persistent – not related to specific circumstances • Worries generally widespread • Co­morbidity with depression is common • Exclude physical illness – thyrotoxicosis, haemochromocytoma, hypoglycaemia etc. • Treatment – Relaxation Therapy – CBT – Medication
  • 105. Generalised Anxiety Disorder Treatment – Relaxation training • Breathing Exercises – slow down  less tachypnoea  less headaches • Muscle Relaxation • Distraction Techniques – CBT • Our thoughts affect our emotions which affect our behaviours • Example – You have arranged to meet someone in the pub and she doesn’t show – Possible reactions: 1. She stood me up. She’s a cheat  anger 2. He may have had an accident I need to phone A&E  Anxiety & fear 3. I knew he didn’t like me  depression • Attempt to identify negative unhelpful thinking and replace with helpful logical thoughts • Recommend 15­20 sessions • Homework important – diaries etc. • Motivation important – Medication • Avoid Benzodiazepines due to dependence • Beta Blockers may be helpful • Antidepressant have anxiolytic effects and therefore can use SSRIs, SNRIs, TCAs etc.
  • 106. Panic Attacks • Sudden, unprovoked episodes of acute anxiety that usually peak within a few minutes and last less than one hour • May begin gradually increasing feelings of tension and apprehension • Physical symptoms include palpatations, sweating, shaking, hyperventilation, shortness of breath and feeling dizzy. • Cognitive symptoms include feelings of losing control, going mad or fear of dying and an overwhelming need to escape. • Patients say there is no prodrome but often there is – recognition and control
  • 107. Panic Attacks Treatment of Panic Disorder – Explanation of adrenaline – Relaxation techniques • Distraction techniques • Reducing rate of breathing • Muscle relaxation – CBT – identify catastrophic thinking & replace with more helpful thinking. • Cognitive restructuring (changing the tape they play)
  • 108. Phobic Anxiety Disorders • Anxiety is only precipitated by certain well defined situations – Out of proportion to the demands of the stimulus – Cannot be reasoned away – Beyond voluntary control – Leads to avoidance • Treatment – Relaxation Training – Desensitisation – “Systematic Desensitisation” • Graded • Anxiety provoking but within perceived limits • Carried out daily • Anxiety scored and timed – Adjunctive Anxiolytics – CBT • Explanation of symptoms
  • 109. Phobic Anxiety Disorders Simple Phobia • Specific stimulus e.g. animals, insects blood, injections, flying, choking • 13% female vs 4% male • Most develop in childhood Social Phobia • Exaggerated anxiety in situations when person feels observed or criticised by others • Fear of blushing, losing control of bowels • M = F (the only phobia) • 4% prevelance Agoraphobia – Anxiety provoked by leaving home, particularly crowded places making escape more difficult – 3x more common in women – 3% of all women – Worst social phobia
  • 110. Neurotic Disorders Treatment • Panic Disorder – High dose SSRI • OCD – High dose SSRI • Bulaemia Nervosa – High dose SSRI • PTSD – May respond to SSRI – Benzos at time of trauma • Generalised Anxiety Disorder – Beta blockers – Venlafaxine and Pregabalin now liscenced – Benzos short term but tolerance and dependence • Insomnia – Only treat for short periods (2­3 wks due to tolerance and dependence) – Benzos (short acting) – Z drugs – zolpidem, zimovane
  • 111. Alcohol and Substance Abuse Genetic Factors – Family History – Antisocial Personaility Disorder – Anxiety – Depression • Iowa Study – genetic effects in males and females – environmental factors in males • Goodwin et al 1973 – Copenhagen study – 4x increase in male adoptees from alcoholic parent adopted soon after birth • Strong association between alcoholism and dopamine D2 receptor gene – craving linked to dopamine dysfunction
  • 112. Alcohol and Substance Abuse Childhood Experiences • Birth trauma • ADHD • Abandonment by parents • Death of parent / sibling before age of 15 • Over­gratification or deprivation • Sexual or emotional abuse Adolescent Experiences • Learning or Conduct disorder • Family structure breakdown • Poor parent / child relationship • Lack of values / religion • Substance misusing peers • Inadequate coping skills / knowledge Environmental Factors • Economic availability • Social availability • Physical availability • Employment • Stress • Loss events • Peers
  • 113. Alcohol and Substance Abuse • Spectrum Disorder – Social Use – Problematic Use – Dependence Dependence Dependence Syndrome • Salience - importance • Tolerance – need increasing doses for same effects • Impaired control • Compulsion – despite knowing it’s bad for you • Withdrawal syndrome • Relief use • Reinstallment (like being in love)
  • 114. Alcohol and Substance Abuse Biology of Addictive Behaviour • Positive reinforcing effects of substances • Negative reinforcers • Tolerance • Withdrawal • Craving • Neuro­adatation Pathological Intoxication • Mania a potu – May be a basis of a defending plea • Murder after a small amount of ethanol • Amnesia • Observed to be in a trance / automatism • EEG abnormalities strengthen diagnosis
  • 115. Alcohol and Substance Abuse Alcohol related amnesias • Transient amnesia due to intoxication • Amnesia can be total with abrupt onset and recovery with no subsequent recall • Patchy amnesia – indistinct boundaries with islands of memory • Once experienced may become a regular occurrence Transient Hallucinatory Experiences • Debate as to how best to classify alcohol related experiences • May herald onset of DTs or alcoholic hallucinosis? – part of continuum • May be transient without progression • Essentially fleeting and sudden experience of variety of perpetual disturbances
  • 116. Delerium Tremens • Varied clinical picture – best viewed as a unitary condition with a continuum of severity and variety of symptom clusters • Can occur on only partial withdrawal • Trauma / Infection may be related factors • Triad • Delerium • Hallucinatory Experiences • Tremor NB other elements may be present as well • Disturbance fluctuates – worse at night or in shadowy conditions • Transient hallucinatory experiences may precede for weeks
  • 117. DTs • Delirium – fluctuating, clouding of the consciousness, potentially disorientated in time, place and person – ‘the clinical syndrome of confusion, variable degrees of clouding of consciousness, visual illusions and/or visual hallucinations, lability of affect, and disorientation. The clinical features can vary markedly in severity hour by hour. Delirium is a stereotyped response by the brain to a variety of insults and is similar in presentation whatever the primary cause’ *OHoP • Hallucinations – vivid, chaotic, bizarre and affect any modality • Visual hallucinations – Classically horrible and freigthening – rats / snakes – “Microscopic” (leprachauns) • Paranoid Delusions – enemies blowing in gas into room • Paranoid Mood – “Every stimulus misinterpreted but clouding doesn’t allow systemisation of delusional idea” • Occupational Delusions / Hallucinations – barman serving drinks – bricklayer laying bricks
  • 118. Alcoholic Hallucinosis • Auditory Hallucinations – Unformed noises, snatches of music or voices • Phonemes – Running (“He”) commentary or 2nd (you) person hallucinations • Several phonemes – Favourable or derogatory • Imperative Quality – acting out of behaviour • Intermitent • No clouding of Consciousness (no delerium) • Blurred relationship with alcohol • Patient may not disclose experience unless specifically asked • Can persist for weeks / months – If >6months think schziophrenia! • No complicated paranoid ideation
  • 119. Alcohol Withdrawal Fits • Heavily dependent patient – Withdrawal or partial withdrawal may cause fit • 30% of patients with fit is prelude to DTs – Usually occur in first 12­24hours • Grand Mal – Rarely status • Future withdrawal associated with greater risk of fits or DTs – kindling phenomenon
  • 120. Wernicke­Korsakoff’s Syndrome • 10% of chronic alcoholics develop W­K • Acute Presentation – Wernicke’s Encephalopathy • Clouding of consciousness • Ataxia • Nystagmus – lateral and vertical • Anisocoria (difference in pupil size) • Peripheral Neuropathy • Opthalmoplegia ­ CNIII • It is caused by thiamine deficiency (Vit B1), which creates lesions in: – Floor of third ventricle – Mamillary bodies – Brain stem – Thalamic nuclei • Need urgent rx with Thiamine to prevent Korsakoff’s psychosis! • Untreated Mortality rate = 20%
  • 121. Korsakoff’s Psychosis • 80% of survivor of Wernicke’s develop Korsakoff’s • Presentation – Korsakoff’s Psychosis • Anterograde and Retrograde Amnesia • Confabulation • Hallucinations • Due to lesions in the – Aquaductal grey matter – Mamillary Bodies – Thalamus • 20% require long term institutionalisation
  • 122. Alcoholic Dementia • Brain shrinkage in alcoholics is due to loss of white matter • Increase in ventricular size • Reduction in size of corpus callosum • 50% alcoholics aged 50+ attending tertiary care will show cognitive impairment
  • 123. Defence Mechanisms• Denial – most common mechanism used by Substance Abusers (SAs) – existence of problem – consequences of the addiction – shame – normal reaction – “primitive denial” – Requires intervention “secondary denial” – Gentle confrontation • Projection – attributing one’s own unacknowledged feelings, impulses or thoughts to others – blame others for use of substances – flip­side to self blame to protect from depression • Rationalisation – avoids conflict by utilising reassuring / self­serving explanations for the behaviour – e.g “I drink to sleep” – “to cope with my relationship” • Altruism – healthy in recovery • Displacement – feelings onto less threatening objects – e.g. kick the cat • Humour – Dealing with stressors by emphasising the funny / ironic • Intellectualisation
  • 124. Stages in Treatment of Alcohol Dependence 1. Acute Interventions ­ detoxification / withdrawal 2. Evaluation and Assessment followed by Appropriate Intervention (Psych­social intervention) 3. Abstinence Maintenance ­ after care/ relapse prevention Indications for Admissions 1 severe symptoms 2 medical / psychiatric complications 3 history of withdrawal fits 4 history of DTs 5 No social support
  • 125. Management of Alcohol • Majority of patients do NOT require medication • Majority of patients do NOT require in­patient detoxification (60% successful detox at home) • Explanation of symptoms, reassurance and relaxation training • Insomnia – simple hypnotic Indications for Medication • Severe Symptoms • History of withdrawal fits • Malnutrition • Mild symptoms appearing at high blood alcohol levels (>150mg) • Physical illness • Withdrawal symptoms can occur when intake reduced
  • 126. Detoxification • Sedatives – E.g. diazepam, chlordiazepoxide – Prevent simple withdrawal, DTs,fits – Start on high dose and reduce it over 7­10 days – Oxazepam is best in those with liver failure • B vitamins ­ Thiamine – Oral – not well absorbed – Parenteral – can cause anaphylaxis – Prevents Wernicke­Korsakoff Syndrome NB the DTs have 30% mortality, so prevention is importnat
  • 127. Rx of Withdrawal Benzodiazepines • Sedative and anti­convulsant • Long acting (diazepam or chlordiazepoxide) – half life 30­60 hours. • Chlordiazepoxide – 20­30mg QDS • In patients may require up to 400mg / day • Decrease over 7­10 day period • Nausea and vomiting  Sub­lingual lorazepam • Severe liver damage  Oxazepam / lorazepam (not hydroxylated by the liver)
  • 128. Rx of Withdrawal Carbamazepine • Used in Europe more than UK/ USA • Superior to placebo and equal to oxazepam for mild / moderate withdrawal • Limited data on efficacy for preventing seizures and delirium • Does NOT cause respiratory depression, inhibit learning • No potential abuse and reduces “kindling phenomenon”. – (the progressive intensification of the withdrawal syndrome following repeated episodes of ethanol intoxication and withdrawal. Kindling is a phenomenon in which a weak electrical or chemical stimulus, which initially causes no overt behaviorual responses, results in the appearance of behavioural effects, such as seizures, when it is administered repeatedly) Chlormethiazole • Used in Europe mainly • trials show its better than placebo but size of studies were not adequate to draw conclusions about seizure prevention and delirium Symptom Trigger Therapy • Patient monitored by structured assessment scale and given medication at a certain threshold • Administer less medication than fixed dose protocols • Shorter periods of treatment • Seizures were not observed in a study of patients treated this way
  • 129. Rx of Withdrawal • Withdrawal Seizures – Benzodiazepines drug of choice – Diazepam more effective than phenytoin – more rapid peak level – In severe withdrawal with risk of seizures then give loading dose of chlordiazepoxide (80­100mg) – Convulsions  iv diazepam 10mg • Delerium Tremens – Give benzodiazepines in adequate dose to control the agitation and produce sedation – IM administration unpredictable – Vitamin supplements – Physical problems – Rehydration / electrolyte imbalance
  • 130. Rx of Withdrawal Vitamins • Thiamine implicated in Wernicke’s encephalopathy, Korsakoff’s psychosis and peripheral neuropathy • Nicotinic acid , Folate and Vitamin E deficiencies can occur • Pabrinex I.V. – risk of anaphylaxis with parenteral administration • Oral vitamins – thiamine 200mg daily Parenteral Vs Oral • Reduced oral thiamine absorption in abstemious alcoholics by 30% • Oral thiamine may not prevent W­K • Aim in prevention is to restore B complex vitamins as quickly as possible • Number of studies show benefit of high dose parenteral therapy
  • 131. Deterrent Medication • NOT intended as aversion therapy • Disulfiram causes inhibition of ALDH (Aldehyde Dehydrogenase) lasting several days. • Calcium Carbimide – Effects wear off after 24 hours – Quicker onset and shorter reaction
  • 132. Deterrent Medication Disulfiram • Blood alcohol levels have to be zero! • Explanation of effects • Emphasize need to discontinue for 7 days before drinking again • Titrate dose – some require 400mg daily • Carry warning card Antabuse Reaction (Disulfiram) • Flushing • Nausea and Vomiting • Dyspnoea • Palpitations and marked hypotension • Dizziness • Headaches • May be life threatening!
  • 133. Deterrent Medication Naltrexone • Alcohol associated with enhanced opioid activity • Animal models show decreased alcohol preference following administration of opioid antagonists • Naltrexone is a pure opioid antagonist and blocks opioid induce euphoria Acamprosate • Suppression of alcohol consumption in alcohol preferring or alcohol dependent rats. • Reduced calcium flux into neurones • Inhibits excitatory amino acids • Mode of action unknown but may be by affecting craving by inhibiting positive reinforcement effects • Initiate ASAP after detox • Combine with counselling • Maintain on it for 1 year • Does not interact with alcohol • Does not interact with benzos – assisted withdrawal can be initiated if necessary
  • 134. Rx of dependence Psychosocial Treatment of Alcohol Dependence • Alcoholics anonymous – 70% of patients attending AA regularly were abstinent after a year (cf. <50% who did not attend regularly) • Minnesota Method • Family and Marital therapy • Social skills training • Brief interventions FRAMES Feedback ­ personal risks Responsibility ­ for change Advice ­ cut down Menu ­ give alternative options Empathetic interviewing Self­efficacy
  • 135. Alcoholic Investigations • FBC – MCV • Not B12 or folate deficiency • Direct toxicity on bone marrow • LFTs • Carbohydrate Deficient Transferrin – picks up 6 units / day in previous week • Vitamin B12 and folate – deficiency  macrocytosis • Thyroid function • Chest X-ray – may have TB!
  • 136.
  • 137. Assessing Cognition • What is Cognition? • Cognition is the ability to use and integrate basic capacities such as perception, language, behaviour, actions, memory and thoughts in order to interact appropriately with the world. • NB. Left Hemisphere is dominant in 90% of right handed and 60% of left handed people. Memory .
  • 138. Cognition • 3 stages to form a memory: ­ Storage ­ Coding ­ Retrieval • Explicit memory is available to conscious access while implicit memory is not. • Explicit memory is based in the limbic system (Parahippocampal gyrus, Amygdala, Mamillary Body, Fornix, Thalamus, and Dentate Gyrus) and temporal neocortex. • Implicit memory is based in the Basal Ganglia and different parts of the cerebral cortex.
  • 139. *Orientation to Time and Place and Person* • Normal people who are in hospital for long periods of time lose track of time. • Depends on memory • Impaired in delirium and late stages of dementia. • Testing orientation to Time, Place and Person • ­ Orientation to time – day, date, month, year, season • ­ Orientation to place – name of the building, floor, town, country • ­ Orientation to person – name, relationship, job *Attention and Concentration* • Attention is the ability to focus on the question in hand; the ability to maintain this focus for a long enough period of time. • More impaired in delirium than dementia • Could be impaired in depression (pseudodementia) • To test attention – Serial seven test – spelling a familiar word backwards e.g. WORLD – Days of the week backwards – Months of the year backwards – Counting down *Language* • Language is more than just speech (body language, social cues etc.) • Language Comprehension and expression • Wernicke’s area occupies the posterior superior part of the temporal lobe – it is responsible for language comprehension. • Broca’s area occupies the inferior pre­frontal region in the dominant hemisphere – it is responsible for the motor aspect of speech • To test speech – Listen to the patient’s spontaneous speech (fluent or non­fluent, content) – Assess comprehension by asking the patient to carry out a simple task – Assess nominal aphasia by asking patient to name objects e.g. Pen – Assess repetition by asking the patient to repeat a sentence “No ifs, ands, or buts”
  • 140. *Frontal Lobe Functions* • Cognitive Functions attributed to the frontal lobes: Abstract thinking – Problem Solving – Behaviour – Planning – Personality – Motivation – Sequencing of Behaviour – Set shifting / mental flexibility – Estimation / general knowledge • Disorders affecting frontal lobes functioning – Dementia of the frontal lobe type (Pick’s disease) – Bilateral anterior cerebral artery infarction – Subarachnoid haemorrhage (ant. Communicating artery) – Head Injury – Huntington’s disease – Advanced Parkinson’s Disease – Progressive Supranuclear Palsy – Wilson’s Disease • Testing Frontal Lobes functions – Cognitive estimate test – Verbal fluency (25 words in a minute in one category or F,A,S) – Proverb interpretation – Motor sequencing test – Alternating sequencing – Look for any personality changes
  • 141. Clinical Syndromes to Remember • Dementia – multiple areas of cognitive impairment. A syndrome caused by disease of the brain (e.g. Alzheimer’s disease), usually progressive and irreversible. Consciousness is usually unimpaired. • Delerium – a syndrome of acute onset of Cortical impairments, together with perceptual disturbance of the sleep/wake cycle. The cause is usually an acute medical illness and is frequently reversible, although more common in pre­existing dementia. • Amnesia – a specific impairment of memory. In the amnesic syndrome (Korsakoff’s syndrome) there is dense impairment of the registration of new memories. Other cognitive skills are comparatively well preserved. • Pseudodementia – Not dementia but look like dementia, mainly due to depression. Hence called “Depressive Pseudodementia”. Typically answer questions by “Do Not Know”. It is mainly caused by lack of concentration and loss of interest. Associated features of depression. It improves when mood improves.
  • 142. Depressive Pseudodementia is the term applied to apparent cognitive impairment associated with psychiatric disorders, most often depression (50­100%). Four criteria proposed by Caine (1981) for diagnosis: • 1) intellectual impairment in a patient with a primary psychiatric disorder • 2) features of impairment are similar to those seen in CNS disorders • 3) the cognitive deficits are reversible • 4) there is no known neurological condition to account for the presentation PREVALENCE: Of patients referred for dementia evaluation, reports in the literature have ranged from 2% to 32% found to have a pseudodementia, with most reporting about 10%.
  • 143. Abbreviated Mental Test Score • A rough screening tool for confusion. • AMT 8­10 = normal cognition • AMT <8 = Significant impairment in cognition • The ten questions… – Time of day (to nearest hour) – Year – Place – Identify two people – Age – Birthday – Give them an Address to remember; pt must repeat this to test registration and again after 5 minutes to test delayed recall – Name of monarch – Dates of second world war – Count Backwards from 20­1 In those with suspected Dementia, it is usual to proceed to more detailed cognitive testing with the Mini Mental State Examination
  • 144. Mini Mental State Exam (MMSE) • Developed by Folstein • A good screening test but not a diagnostic tool! • Easy to administer, could be used as a routine test • High inter­rater reliability • Does not test frontal lobe functions or new learning • Not sensitive to slight changes • 24/30 is the cut off score??? Some say 26/30 is impaired • People with early mild dementia may could score above this cut­off • Could be affected by age, education and socio­economic status. • It is susceptible to “floor effect” – the effect of an intervention is underestimated because the dependent measure artificially restricts how low scores can be.
  • 145. Mini Mental State Exam (MMSE) • Orientation to place – Country, county, town, 2 main streets nearby where you live, Floor of Building (5) • Orientation to time – Year, season, Month, Day, Date (5) • Memory Registration – I would like you to remember these three words, apple, table, penny. Can you repeat them? • Concentration – Spell “world” backwards (5) – Or – Take seven from 100, stop after five repeats. Very high error rate in normal popn • Memory delayed recall – What were those three words I asked you to remember before the spelling? • Naming objects – Name a watch and a pencil (2) • Repeating a sentence – Repeat this; “No ifs, ands or buts” • 3 Stage Task – “Please take this piece of paper in your right hand, fold it in half with both of your hands and place it on the floor” • Reading – Please do what this says “close your eyes” • Writing – please write a sentence • Copying – Please copy this picture (interlinked pentagons)
  • 146. CAMGOC CAMGOC • Developed in Cambridge • Computerised version • Detailed, could be exhausting to some patients • Diagnostic criteria • Takes about an hour to complete
  • 147.
  • 148. Mental Health Act 2007 • The MHA 2007 amends the MHA 1983 and the Mental Capacity Act 2005 A note on the Mental Capacity Act: Five Statutory Principle: 1) A person must be assumed to have capacity unless it is established that they lack capacity 2) A person is not to be treated as unable to make a decision unless all practicable steps have been taken to help him to do so 3) A person is not to be treated as unable to make a decision because he makes an unwise decision. 4) Any action taken under this act must be done so in the patients best interest A court of Protection will help with difficult decisions. The act includes LASTING POWERS OF ATTOURNEY
  • 149. Mental Health Act 2007 • Section 2 - admission for assessment up to 28 days • Section 3 - admission for treatment, up to 6 months initially • Section 4 - emergency admission for up to 72 hours initially • Section 5 - People who are voluntary inpatients can be detained by a doctor or nurse pending a further assessment • Section 5(2)  Dr’s holding power • Section 5(4)  Nurses holding power • Section 117- Gives the statutory authorities a duty to make arrangements for continuing support and aftercare
  • 150. Forensic Sections • Community psych nurse screens criminals • Section 35 – Remand to hospital for report on mental state – Up to 12 weeks • Section 36 – Remanded back to hospital for rx – up to 12 weeks • Section 48/49 – Removed to hospital from prison in those undergoing court proceedings – Restriction order • No leave outside hospital • No discharge by RMO – No appeal against section 48/49 • Section 37/41 – “Hospital Order” • Court decides pt “unwell” • Supervised by Ministry of Justice Mental Health Team • Section 47 – Remand from prison in those already sentenced • E.g. Relapse / new condition
  • 151. Supervised Community Treatment Options • Detained pts can be discharged under supervision • Agreement that patient will take meds in community • Cannot restrain them or forcefully medicate • Agreement that if they don’t take their meds they’ll be detained under the original detention • Renewed every 6 months • Monitored by family, blood tests etc.
  • 152. Mental Health Act • Under what section and for how long can a person be detained for assessment? – Section 2 – 28 days • How long can this section be renewed or extended for? – It can’t be • What are the conditions of the section? – Interest of own health or safety or the safety of others
  • 153. Mental Health Act • Under what section and for how long can a person be detained for treatment? – Section 3 – 6 months • How long can this section be renewed or extended for? – It can be renewed for a further 6 months, then for a year at a time. • What are the conditions of the section? – Interest of own health or safety or the safety of others and the treatment cannot be provided unless he is detained – In the case of psychopathic disorder or mental impairment, treatment is likely to alleviate or prevent deterioration of his condition – Cannot normally be imposed if the nearest relative objects – Based on two medical recommendations + Approved Social Worker (ASW) • One of which has to be section 12 approved and one has to had previous acquaintance with the patient • They need to have a common diagnosis Note: Most Rx can be given without consent for three months. Then you need to do a section 58 to give rx. You need a section 58 at any time to give ECT.
  • 154. Mental Health Act • Under what section and for how long can a person be detained for emergency admission for assessment? – Section 4 – 72 hours • How long can this section be renewed or extended for? – If during the 72 hours a second medical recommendation is made, the section 4 is converted to a section 2. • What are the conditions of the section? – Interest of own health or safety or the safety of others – Only needs one medical recommendation – It is of urgent necessity for the patient to be admitted under section 2 – Compliance with section 2 requirements would involve “undersirable delay” – The doctors should either know the pt or be section 12 approved
  • 155. Mental Health Act • Under what section and for how long can a voluntary patient be detained by a NURSE for assessment? – Section 5(4) – 6 hours • Under what section and for how long can a voluntary patient be detained by a DOCTOR for assessment? – Section 5 (2) – 72 hours – The Dr must be the Dr in charge of the patient’s care or be nominated by this dr • How long can these sections be renewed or extended for? – 5 (2) can’t be – 5 (4)  A doctor can then change it to a section 5(2) when they arrive, but this officially begins when the nurse originally reported the section5(4)
  • 156. Mental Health Act • Under what section can the “Responsible Medical Officer” (dr in charge of treatment for the patient) grant “leave” to people detained under the MHA – Section 17 • What section deals with transfers? – Section 19
  • 157.
  • 158. Alcohol Addiction • It is estimated that 5% of the population is dependent upon alcohol. Of these… – 70% dysphoria – 20% depressive illness – 25% attempt suicide • Alcoholic Hallucinosis – Third person auditary hallucinations while drinking large amounts of alcohol or having recently stopped. – Distinct from DTs as it occurs in clear consciousness – There can be visual hallucinations; however, if other features of psychosis are present it is important to considerschizophrenia. • Delirium Tremens – Occurs on days 3 to 4 of withdrawal – An acute confusional state precipitated by alcohol withdrawal – Clouding of consciousness – Delusions and hallucinations – Tremor – Thiamine needs to be given to reduce the chance of korsakoffs
  • 159. Alcohol Addiction • Dementia – Heavy drinking over a prolonged period can cause visuo-spacial impairment, damaged frontal lobe functioning and memory impairment. – CT evidence of this in 2/3rd of dependents • Cerebral atrophy / ventricular enlargement – May be reversible but often permanent • Wernicke’s Encephalopathy – Due to thiamine deficiency – Not only in alcoholism – Due to damage to mamillary bodies, brain stem, thalamus and cerebellum – Clinical features include… • Visual gaze disturbance – Nystagmus – Conjugate gaze and sixth nerve palsies • Ataxia • Peripheral Neuropathy • Clouding of consciousness and disorientation • Anxiety and confusion • Nausea and vomiting – Potentially reversible with thiamine
  • 160. Alcohol Addiction • Korsakoff’s syndorme (amnesic syndrome) – Due to thiamine deficiency and occurs after Wernicke’s encephalopathy – Impairment of recent memory and new learning out of keeping with other cognitive losses plus • Confabulation • Stereotyped thinking • Visuospacial impairment • Reduced insight • Reduced initiative • No evidence of altered consciousness • Foetal Alcohol Syndrome – Excess alcohol in pregnancy is >1 unit / day – Features include • Growth retardation • Developmental delay • Specific facial abnormalities • Increased risk of stillbirth • Mood disorders and hyperactivity
  • 161. Alcohol Dependence Treatment • Disulfiram – Alcohol dehydrogenase inhibitor  when alcohol is consumed acetaldehyde builds up • Acamprosate – GABA receptor antagonist • Naltrexone – Opioid receptor antagonist
  • 162. Effects of fun drugs • Hallucinogens (LSD, magic mushrooms, mescaline) – Visual disturbances or hallucinations – Altered state of awareness – Synesthesia  see sounds, hear pictures etc. – At higher dose, increased sympathetic activity • Hyperthermia, anxiety, (the bad trip) • Volatile Substances (glue, solvents) – Rapid onset of euphoria, perpetual change and hallucinations – Ataxia, nystagmus, confusion, coma and death! – Chronic use is associated with a cerebellar syndrome as well as liver damage • Opiate (heroine, morphine, pethidine, methadone) – Analgesia – Euphoria & intense feeling of well-being – Drowsiness and sleep – Pupil constriction, sweating, dry mouth – Bradycardia, hypotension (decreased symp activity) – Resp suppression, antitussive  aspiration – Nausea and vomiting – WITHDRAWAL is not life-threatening!
  • 163. Effects of fun drugs • STIMULANTS – Ecstasy (MDMA) • This is an amphetamine with hallucinogenic properties – Increased symp activity (hypertension, hyperthermia, sceating) – Increased sensuality and energy levels – Reduced appetite – Insomnia – Amphetamine (speed, whizz) – Increases symp activity – Euphoria and increased energy – Anxiety, panic, paranoia, hallucinations – Dilated pupils, dry mouth, ataxia, irregular respiration – Psychosis – OD  cerebral haemorrhage / cardiac arrythmias – Cocaine – See above (same as amphetamines) – Withdrawal is not life threatening
  • 164. Medication assisted withdrawal • OPIOIDS – Lofexidine – Alpha 2 agonist – Methadone • Tablet. Can be crushed and injected. • Associated with Long QT syndrome which can cause arrythmias – Buprenorphine – Partial opiate agonist  less effects than heroin and if heroin taken there is no effects from it
  • 165.
  • 166. SUICIDE • 5000 suicides occur each year in the UK • 25% in recent contact with the Mental Health Services • 160-200 psychiatric inpatients die each year by suicide • Highest risk – 14 days post-discharge • 1/5th non-compliant, 1/3rd Disengaged • Male : Female = 3:1 (25-34 yrs 80% are male) • 74% of suicides result from three methods – Hanging – Poisoning – Jumping • Females  poisoning • Men  Hanging, Poisoning, Jumping • Overall reduction in suicides since 1997
  • 167. SUICIDE DEMOGRAPHICS • Median Age = 43 • Commoner in men (60%) • Divorced > single/widowed > married • Increased in unemployed (40%) • Chronic illness is a risk factor as is living alone • Common Disorders – Affective Disorders (Depression and Bipolar) = 46% of total • Suicide is more frequent in bipolar disorder than in recurrent depressive disorder. – Schizophrenia = 19% of total – Personality Disorder = 8% of total – Alcohol and Drugs Misuse hx = 74%
  • 168. Management of Suicidal Acts• Physical Rx – A&E • Assessment by member of the MDT • Check capacity • Risk of further attempts – Hx of previous attempts – Drug / alcohol misuse – Psychiatric history, personality disorder • Assessment of seriousness of attempt – Planning – Attempts to conceal / avoid detection – Help seeking – how did they get to hospital? – Final Acts – Lethality – Feeling following survival – Number of pills • Assess protective factors • Admission / home treatment for serious attempt – Level of observation • Treat underlying mental illness • Psychological Help and follow-up
  • 169. Violence • Homicide= the killing of one human by another – ~50 homicides take place each year by people who have recently been in contact with the MHS • Schizophrenia most common diagnosis – Less likely to kill strangers – 90% committed by men – Median Age 28 years • Stranger homicide – No increase with care in the community – Kicking and hitting more than weapons • Risk factors – Paranoid delusions – Command Hallucinations – Sexually inappropriate behaviour – Denial of previous dangerous acts
  • 170. Violence • Risk is not static! – Need continual risk assessment (gathering of information and analysis of potential outcomes of identified behaviours and identifying specific risk factors of relevance and the context in which they may occur. Link historical info, clinical factors and statistics; whilst anticipating future change)
  • 171.
  • 172. Eating Disorders Anorexia Nervosa • History & Epidemiology – First described by Marc’e in 1959 and named by the William Gull, and English physican. – Usually begins in adolescence most often between 16-17 years – Approximately 0.2-0.5% of young women – 95% are female – More common in occupational groups such as dancers, models and athletes where thinness is highly valued • Aetiology – Genetics – MZ twins > DZ twins. Relatives increase risk – Individual experience & personality • Excess of obsessive, inhibited and impulsive traits. Common in anxious-avoidant personality types – Family Dynamics • Dominant intrusive mothers and passive ineffectual fathers • Enmeshed rigid family structure with conflict avoidance
  • 173. Eating Disorders • Can affect almost any physiological system – Vomiting & laxative use can cause hypokalemia and can be life threatening. – Pancreatitis – Parotid enlargement, hypoglycaemia, hypercholesterolaemia, oesophageal rupture – Acute gastric dilation on refeeding – Lanugo = fine airs over the body
  • 174. Anoxia Nervosa diagnosis requires all of… • 15% less body weight than normal (BMI<17.5) • Body Image Distortion – dread of fatness as an overvalued idea • Attempt to lose weight by eating less fattening foods and one or more of… – Exercise – Purging – Vomiting – Misuse of diuretics / stimulants • Abnormality of hypothalmic-pituitary-gonadal axis – Amenorrhoea – Increased GH and coritsol – Decrease T3 • If onset is prepubertal, the sequence of pubertal events is delayed
  • 175. Anorexia Nervosa • Anorexia is the most common chronic illness in teenage females • Half of these patients binge eat and then get remorse and try to lose weight. • Amenorrhoea occurs in about1/5th of cases • Anorexia N’ increases the risk of “feeling POGD” – Depression – GAD – Phobic disorder – Obsessive-compulsive disorder • 15% develop Bulaemia N • Mortality – 0.5-1% per year of illness – 20% morality rate
  • 176. Anorexia Nervosa • Mainly psychological • Inpatient indications – Very low weight or rapid weight-loss – Serious physical complications e.g hypokalemia – Severe psychiatric co-morbidity e.g. depression – Failure of out-patient rx • In-patient Treatment – Weight restoration – Prescribed diet aiming at weight gain of approx 1kg / week – Setting the “target weight” – May include operant reinforcement – Treatment of complications – Restructured cognition – Education about diet and support • Outpatient Rx – Pychdynamic / CBT • Education about anorexia and its effects • Family therapy in younger
  • 177. Bulimia Nervosa • Russell first described Bulimia in 1979 • Russell’s sign – callouses on back of hands (self induced vomiting) • The symptoms of BN sometime occur in Anorexia but it also occurs without preceding anorexia nervosa. • Patients are usually of normal weight • It has two components: – 1  Bulimia – 2  A behaviour intended to prevent weight-gain • Epidemiology – Affects 4% of female adolescents (More common than anorexia nervosa) – Peak incidence is late adolescence or early 20s (later than anorexia nervosa) – 30% have prior hx of anorexia… – SO there 15% of anorexics develop BN… 30% of those with BN had AN… but there are more Bulaemics… Gash! • Aetiology – Genetics • Less important than in anorexia nervosa – Appox 30% suffered sexual abuse as children cf. 10% general population – Neurotransmitters • Abnormalities of serotonin system may predispose to it
  • 178. Bulimia Nervosa Diagnosis • Diagnostic criteria ICD 10:10 – Recurrent episodes of Binge eating • At least twice / week for 3months • Significantly larger than most people would eat • Sense of lack of control over eating – Recurrent inappropriate compensatory behaviour • Self induced vomiting (SIV) • Alternating periods of starvation • Diuretic / stimulant abuse • Purgative abuse – Unduely influenced by body shape and weight – Disturbance does not occur exclusively during episodes of anorexia nervosa
  • 179. Bulimia Nervosa Treatment • In contrast to anorexia most pts can be treated as outpatients • CBT 10-20 sessions • SSRIs lead to a modest decrease in binge frequency at 60mg/day (more than normal depression dose) Outcome • 50% of patients are likely to recover completely • Around 20% will remain persistently symptomatic and 30% will have mild symptoms or a remitting and relapsing course • Good prognosis – Younger age at onset – short history – Higher social class – Family hs of alcohol abuse – Absence of any personality disorder

Editor's Notes

  1. Read 1 – 4 OCD is thought to be a life-long condition. However, there have been reports of some acute OCD episodes and most case show improvements over time. Now OCD is NOT what happens to everyone a little bit. When you get home you may have a certain order of doing things; first your keys go on the cupboard then your bag in the corner of the room facing inwards and then your wallet on the desk. Never another way. This is not OCD. Not unless these compulsions are due to thoughts that something terrible will happen if you change the order. It is also not just normal everyday rational worries. Bomb deplosive experts do not have OCD because they always cut the wires in a certain order.
  2. There are certain patterns of behaviour which are particularily common in OCD. Interestingly these seem to be pretty constant across time and place - similar symptoms occurs despite the culture.
  3. It has been suggested that disorders with overlapping symptoms and biological similarity with OCD fall within a putative spectrum of obsessive compulsive disorders.
  4. OCD is termed a Neuropsychiatric disorder as it has a specific area of the brain which is involved. The processes involved in OCD are too complex for this presentation and are still only theoretical. Suffice to say there is a particularly important pathway in the brain called the Cortico-Striato-Thalamo-Cortical Pathway, containing many serotonergic neurons which doesn’t work as normal in OCD. More detail is really just required for research and an academic knowledge behind the treatments.
  5. In cognitive interventions several belief domains are important.1. Inflated responsibilty 2. overimportance of thoughts 3. excessive concern about controlling one’s thoughts 4. overestimation of threat Now there are several different theories behind the psychobiological deficit in OCD but im not going to go into these as I’ve probab;y taken too much time already. Although it’s worth noting that Freud’s theory of unconscious aggressive instincts that are admitted to awareness because of incomplete repression necitating defence mechanisms in the form of compulsive rituals to reduce guilt and anxiety.
  6. The first line of therapy in OCD is an SSRI. At the moment there doesn’t seem to be a difference in effects between the different SSRIs but that’s probably due to studies being too small. If this doesn’t work or the patient dosnt tolerate SSRIs, Clomipramine has similar efficacy but is obviously worse in terms of overdose risk. If this doesn’t work after 12 weeks, then there are several treatments which have not much grounding in evidence what so ever but are used… antipsychotics (typical or atypical) and clonazepam (a benzo derivative). Due to the lack of insight experienced by most patients with improving symptoms it can be useful to get relatives to