Pyschiatry - Sheffield Peer Teaching Society

Pyschiatry - Sheffield Peer Teaching Society

Psychiatry Gemma Adams & Gabrielle Zealand What we are going to cover Schizophrenia & psychotic disorders Personality disorders Psychiatric treatments

Psychiatric emergencies Lithium toxicity Acute dystonic reaction Neuroleptic malignant syndrome Serotonin syndrome The Peer Teaching Society is not liable for false or misleading information

Schizophrenia WHO defines as a severe mental disorder, characterized by profound disruptions in thinking, affecting language, perception, and the sense of self. Age of onset between 15-45. Equal gender distribution. Risk factors? Family history, intrauterine complications/infection, social isolation, migrants, abnormal family interactions. Triggers include periods of stress and high emotion and drug misuse The Peer Teaching Society is not liable for false or misleading information Delusion A false belief which is firmly sustained and based on incorrect inference about

reality. This belief is held despite evidence to the contrary and is not accounted for by the person's culture or religion. Hallucination A hallucination can be described as a sensory perception which is experienced despite there being no external stimulus. Hallucinations can occur with any sense and thus be visual, auditory, olfactory, gustatory or tactile. The Peer Teaching Society is not liable for false or misleading information Positive (or 1st rank) symptoms - Represent a change in behaviour or thoughts (one or more

indicates strong chance of having disease) Include? > Delusional perceptions > Auditory Hallucinations > Somatic Passivity > External control of emotion > Thought insertion, removal or interruption > Thought broadcasting > Lack of Insight The Peer Teaching Society is not liable for false or misleading information Negative (or chronic) symptoms - Represent a withdrawal or lack of function

- Can present as a prodromal period several years before the development of positive symptoms Include? > Underactivity (including poverty of speech) > Social withdrawal > Low motivation > Emotional flattening > Self neglect The Peer Teaching Society is not liable for false or misleading information Subtypes Paranoid- delusions of persecution, reference, grandeur, jealousy, non verbal auditory hallucinations, threatening auditory hallucinations.

Hebephrenic- Irresponsible & unpredictable behaviour, rambling incoherent speech, affective changes, poorly organised delusions and fragmented hallucinations. Poor prognosis. Catatonic- Extremes of behaviour. Stupor or excitement. Residual- Preceded by another form. Negative symptoms Simple insidious onset of functional decline. Negative symptoms The Peer Teaching Society is not liable for false or misleading information Mental State Examination Appearance- dishevelled, unkempt. Behaviour- mannerisms, withdrawal, extremes. Speech- thought blocking, loosening of associations, word salad, flight of ideas

Mood- flattened, incongruous or odd Abnormal Beliefs- delusions, somatic passivity Abnormal experiences- hallucinations Cognition attention, concentration, orientation and memory. The Peer Teaching Society is not liable for false or misleading information Investigations- rule out organic cause or differential (bipolar, schizoaffective) Management Antipsychotics Have a MDT approach. 1st line- Atypical Antipsychotics- risperidone or olanzapine with psychological interventions (CBT, family interventions)

Why do you need to do an ECG? Acute crisis team, typical or atypical antipsychotics, psychological. Rapid Tranquilisation. The Peer Teaching Society is not liable for false or misleading information Rapid Tranquilisation Calm/lightly sedate service user, reduce risk to self and others, and achieve an optimal reduction in agitation and aggression. To allow a thorough psychiatric evaluation Risks must be assessed. Oral- lorazepam, olanzapine, haloperidol (or IV) Must be properly monitored and documented

Patient should be invited to record their own recollections of events. The Peer Teaching Society is not liable for false or misleading information Other Psychotic Disorders Puerperal Sudden onset psychosis occurring days/weeks after birth. Higher risk if past psych history, 1st baby, but can be completely random. Symptoms- quickly fluctuating drastic moods, positive symptoms. Treatment- antipsychotics, mood stabilisers,

psychological. BF risk. Schizoaffective Episodic- mood and schizophrenic symptoms Manic, Depressive or Mixed. Treatment- antipsychotics, trial antidepressants, mood stabilisers. The Peer Teaching Society is not liable for false or misleading information Other Psychotic Disorders Persistent delusional disorders. Delusion persistence for at least 1 month with no identifiable organic basis.

Jealousy, erotomania, persecutory, cotards, capgras Treatment- pharmacological, psychological. Difficult to treat. Acute/Transient Psychosis Acute stressor Within 2 weeks. Doesnt meet criteria for specific disorder. No recent psychoactive drug use or withdrawal. No organic cause. The Peer Teaching Society is not liable for false or misleading information

Antipsychotics Reduce psychomotor excitement, control symptoms of psychosis and reduce hallucinations and delusions. Receptor? D2 receptors Indications? Schizophrenia, mania, 2 psychosis, Tourettes syndrome The Peer Teaching Society is not liable for false or misleading information Antipsychotics

Categories? Typical Haloperidol, chlorpromazine EPSE Less useful ive symptoms Atypical Olanzapine, quetiapine, risperidone, clozapine, aripiprazole Less EPSE

Excreted into breast milk Depot The Peer Teaching Society is not liable for false or misleading information Extra pyramidal side effects 4 extra pyramidal side effects? 1. Acute dystonia The Peer Teaching Society is not liable for false or misleading information Extra pyramidal side effects

2. Akathisia - Feeling of inner restlessness Need to constantly move Hours to weeks Use lowest dose/ switch to atypical - Propranolol, BDZ The Peer Teaching Society is not liable for false or misleading information

Extra pyramidal side effects 3. Parkinsonian syndrome - Resting tremor, rigidity, bradykinesia - Procyclidine - Change antipsychotic 4. Tardive dyskinesia - Slow onset, repetitive, involuntary, purposeless movements - Onset years later - Limit long-term use, atypicals The Peer Teaching Society is not liable for false or misleading information

Antidepressants Classes of anti-depressants? Tricyclic antidepressants (TCA) Selective serotonin reuptake inhibitors (SSRI) Monoamine oxidase inhibitors (MAOI) Noradrenergic and specific serotonergic antidepressants (NaSSA)

Serotonin noradrenaline reuptake inhibitors (SNRI) Noradrenaline reuptake inhibitors (NARI) Other The Peer Teaching Society is not liable for false or misleading information TCAs E.g. Amitriptyline, clomipramine, imipramine, dosulepin Side effects? ECG changes Anti-muscarinic

Cardio-toxic in overdose Also used in neuropathic pain The Peer Teaching Society is not liable for false or misleading information SSRIs E.g. Fluoxetine, paroxetine, citalopram, sertraline 1st line drugs GI side effects Can initially increase suicidal behaviour, caution in

teenagers Also used in eating disorders, anxiety disorders, chronic pain Interact with MAOIs The Peer Teaching Society is not liable for false or misleading information Serotonin syndrome Adverse reaction to serotonergic agents Commonly reaction with MAO-I Starting or increasing the dose, within 6 hours Autonomic hyperactivity Serotonin

syndrome Neuromuscular abnormality Mental status changes The Peer Teaching Society is not liable for false or misleading information Serotonin syndrome Clinical diagnosis Investigations:

FBC/ cultures U&Es and CK Toxicology screen CT scan, LP Management: Stop drug, supportive treatment Cyproheptadine The Peer Teaching Society is not liable for false or misleading information Antidepressants

SNRI venlafaxine, duloxetine Hypertension MAOI moclobemide, phenelzine Lots of s/e Hypertensive crisis NaSSA mirtazepine NARI buproprion Other St Johns wort, trazadone The Peer Teaching Society is not liable for false or misleading information Serotonin syndrome

Autonomic hyperactivity Serotonin syndrome Neuromuscular abnormality Mental status changes The Peer Teaching Society is not liable for false or misleading information Neuroleptic malignant syndrome Neuroleptic: a drug that depresses nerve functions Earlier definition of anti-psychotic: reduces

psychomotor excitement Dopamine Parkinsons Depot Previous NMS The Peer Teaching Society is not liable for false or misleading information Neuroleptic malignant syndrome Slower onset, in first 10 days of treatment Symptoms Autonomic dysfunction, neuromuscular abnormality (RIGIDITY), mental status changes

Parkinsonian features Investigations Exactly the same Management Pretty much the same supportive Dopaminergic drugs, dantrolene The Peer Teaching Society is not liable for false or misleading information Psychiatric emergencies Serotonin syndrome

Neuroleptic malignant syndrome Drug SSRIs/ anti-depressants Anti-psychotics Time frame Up to 6 hours

Up to 10 days Extra treatment Cyproheptadine Bromocriptine, dantrolene The Peer Teaching Society is not liable for false or misleading information Personality Disorders ICD-10 defines as A severe disturbance in the characterological condition and

behavioural tendencies of the individual, usually involving several areas of the personality and nearly always associated with considerate social and personal disruption. Risk factors? upbringing (abuse, neglect, disorder), severe aggression and disobedience in children, stressful life events, drug misuse. The Peer Teaching Society is not liable for false or misleading information What are the different types of personality disorder? The Peer Teaching Society is not liable for false or misleading information

Cluster A- MAD Paranoid Schizoid Cluster B- BAD Anti/Dissocial Borderline- unclear or disturbed self image, intense & unstable relationships, emotional crises. Histrionic Impulsive Cluster C- SAD. Can predispose to depressive disorders Anankastic (obsessive compulsive) Avoidant Dependent Can be Mixed

The Peer Teaching Society is not liable for false or misleading information Management Very difficult to treat Psychotherapy- DBT, psychodynamic, CBT, interpersonal. Pharmacology- treatment of associated conditions such as depression. The Peer Teaching Society is not liable for false or misleading information Psychological treatments

Type of therapy Number of people individual, couple, group, family (remember Matthew Peace lectures) Common themes listening, release of emotion, restoration of morale, providing information, providing a rationale , advise and guidance, suggestions Transference and counter-transference The Peer Teaching Society is not liable for false or misleading information Psychological treatments Counselling

Talking therapy Common Usually problem solving approach, often unstructured Relationship, genetic, bereavement, smoking cessation, debriefing, primary care The Peer Teaching Society is not liable for false or misleading information Psychological treatments

Cognitive behavioural therapy Cognitive errors based on long-standing beliefs influence the meaning attached to interpersonal events Depression, anxiety, OCD, PTSD Self help books, online/ telephone, in person The Peer Teaching Society is not liable for false or misleading information Psychological treatments Interpersonal psychotherapy Relationships past and present Alternate ways of coping are considered

Dialectical behavioural therapy Development of coping skills Psychodynamic Perceptions are shaped by experiences in early life Uses transference The Peer Teaching Society is not liable for false or misleading information Behavioural techniques

Relaxation Therapy Systematic Desensitisation Flooding Response Prevention Play therapy, art therapy The Peer Teaching Society is not liable for false or misleading information Mood stabilisers

Mood stabilisers Other mood stabilisers? Carbamazepine Sodium valproate The Peer Teaching Society is not liable for false or misleading information Lithium toxicity Usually occurs during chronic treatment because of reduced drug excretion Symptoms: GI symptoms, ataxia, tremor, dysarthria, change in GCS, blurred vision, muscle weakness, hyperreflexia, oliguria, renal failure,

hypokalaemia Management: Stop drug ABC Supportive management Monitor electrolytes and renal function The Peer Teaching Society is not liable for false or misleading information

Anxiolytics Benzodiazepenes Short-term measure, potentiate GABA Temazepam, diazepam, lorazepam S/E ataxia, decreased GCS, respiratory depression Physical dependence Buspirone GAD Does not carry risk of physical dependence/withdrawal The Peer Teaching Society is not liable for false or misleading information

Hypnotics Used to improve sleep Sleep hygiene Z-drugs? Zopiclone, zolpidem Every other day maximum Metallic aftertaste The Peer Teaching Society is not liable for false or misleading information Psychostimulants

Methylphenidate (ritalin) Indicated ADHD Side effects: restlessness, tremor, insomnia, poor appetite, palpitations Persistent abuse can lead to cardiac problems and a paranoid state similar to schizophrenia The Peer Teaching Society is not liable for false or misleading information

Substance misuse Dependency syndrome Alcohol Disulfiram acetaldehyde dehydrogenase Acamprosate Chlordiazepoxide DT Vitamins

Opioids Methadone Buprenorphine The Peer Teaching Society is not liable for false or misleading information Other ECT Rapid improvement of severe, life-threatening symptoms Severe depression, catatonia Bright light treatment SAD, atypical depression

The Peer Teaching Society is not liable for false or misleading information Any questions? The Peer Teaching Society is not liable for false or misleading information

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