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Phase 3a Phoebe Barrett and Natasha Hussain

Psychiatry. Phase 3a Phoebe Barrett and Natasha Hussain. The Peer Teaching Society is not liable for false or misleading information…. We will ask you lots of questions. Psych emergencies Acute dystonic reaction Neuroleptic Malignant Syndrome Lithium toxicity.

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Phase 3a Phoebe Barrett and Natasha Hussain

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  1. Psychiatry Phase 3a Phoebe Barrett and Natasha Hussain The Peer Teaching Society is not liable for false or misleading information…

  2. We will ask you lots of questions

  3. Psych emergencies Acute dystonic reaction Neuroleptic Malignant Syndrome Lithium toxicity Psychiatry Classification Behavioural Mental Illness E.g. Eating disorders Personality disorders Psychosexual disorders Developmental E.g. Learning disorders and pervasive developmental disorders (autism/ADHD) Functional Organic Neuroses (severe “normal” experience) Psychoses (loss of contact with reality) Organic Substance abuse E.g. Delirium Dementia Hypothyroidism OCD Anxiety Phobias Schizophrenia Mood disorders Bipolar, depression, mania The Peer Teaching Society is not liable for false or misleading information…

  4. Psych emergencies Acute dystonic reaction Neuroleptic Malignant Syndrome Lithium toxicity Psychiatry Classification Behavioural Mental Illness E.g. Eating disorders Personality disorders Psychosexual disorders Developmental E.g. Learning disorders and pervasive developmental disorders (autism/ADHD) Functional Organic Neuroses (severe “normal” experience) Psychoses (loss of contact with reality) Organic Substance abuse E.g. Delirium Dementia Hypothyroidism OCD Anxiety Phobias Schizophrenia Mood disorders Bipolar, depression, mania The Peer Teaching Society is not liable for false or misleading information…

  5. (1) Schizophrenia • What is it? The Peer Teaching Society is not liable for false or misleading information…

  6. A psychotic mental illness characterised by ≥ 1 month of a number of certain symptoms • What are the symptoms of schizophrenia? (at least 8) The Peer Teaching Society is not liable for false or misleading information…

  7. What are the purple ones? The Peer Teaching Society is not liable for false or misleading information…

  8. Who gets schizophrenia and what the are main risk factors for getting it? The Peer Teaching Society is not liable for false or misleading information…

  9. Adolescents/young adults, both sexes get it (men it occurs earlier) • RF – heavy cannabis/skunk use, FH, complications in pregnancy, severe maternal malnutrition The Peer Teaching Society is not liable for false or misleading information…

  10. What investigations might you do to rule out organic pathology (name investigation or a differential you are trying to rule out) The Peer Teaching Society is not liable for false or misleading information…

  11. Bloods – FBC, U&E, LFTs, TFTs, glucose, Calcium, cortisol • Drug and alcohol screen • ECG • Urine dipstick/MSU • CT/MRI head The Peer Teaching Society is not liable for false or misleading information…

  12. Treatment of schizophrenia? The Peer Teaching Society is not liable for false or misleading information…

  13. Anti psychotics (typicals v atypicals?) • Benzodiazepines • Procyclidine (why?) • Plus talking therapies, family therapy, education, CBT, social/housing/community support The Peer Teaching Society is not liable for false or misleading information…

  14. So what are these side effects? (at least 6) The Peer Teaching Society is not liable for false or misleading information…

  15. “PSYCHO” • P - ↑ prolactin and extra-Pyramidal side effects (EPSEs) • S – sexual dysfunction • Y – You get fat • C – CV effects - ↑ HR, BP changes, arrhymias, QT prolongation • H – Hyperglycaemia and Diabetes • O – other – Anti-muscarinic side effects e.g. Dry eyes, mouth, constipation -Bad withdrawal if stopped The Peer Teaching Society is not liable for false or misleading information…

  16. Extra-pyramidal side effects • Acute dystonic reaction • Akathisia • Parkinsonism • Tardivedyskinesia What are they? The Peer Teaching Society is not liable for false or misleading information…

  17. Psych emergencies Acute dystonic reaction Neuroleptic Malignant Syndrome Lithium toxicity Psychiatry Classification Behavioural Mental Illness E.g. Eating disorders Personality disorders Psychosexual disorders Developmental E.g. Learning disorders and pervasive developmental disorders (autism/ADHD) Functional Organic Neuroses (severe “normal” experience) Psychoses (loss of contact with reality) Organic Substance abuse E.g. Delirium Dementia Hypothyroidism OCD Anxiety Phobias Schizophrenia Mood disorders Bipolar, depression, mania The Peer Teaching Society is not liable for false or misleading information…

  18. Neuroleptic Malignant Syndrome • What is it? The Peer Teaching Society is not liable for false or misleading information…

  19. A rare, life threatening reaction to anti-psychotics (or can be to anti-depressants or anti-convulsants) within first 10/7 Tx • Severe motor/mental/autonomic dysfunction • ↑ temp • Muscle rigidity • Unstable BP, ↑ HR, ↑ sweating • Dysphagia • Mutism • Urinary incontinence High mortality The Peer Teaching Society is not liable for false or misleading information…

  20. Psych emergencies Acute dystonic reaction Neuroleptic Malignant Syndrome Lithium toxicity Psychiatry Classification Behavioural Mental Illness E.g. Eating disorders Personality disorders Psychosexual disorders Developmental E.g. Learning disorders and pervasive developmental disorders (autism/ADHD) Functional Organic Neuroses (severe “normal” experience) Psychoses (loss of contact with reality) Organic Substance abuse E.g. Delirium Dementia Hypothyroidism OCD Anxiety Phobias Schizophrenia Mood disorders Bipolar, depression, mania The Peer Teaching Society is not liable for false or misleading information…

  21. (2) Mood Disorders • Depression • Antidepressant therapy • ! Serotonin syndrome • Mania and bipolar affective disorder • Mood stabilisers • ! Lithium toxicity The Peer Teaching Society is not liable for false or misleading information…

  22. Depression What classification system can we use? What are the symptoms of depression? = 3 core ones At least 2 of these, every day, for 2 weeks The Peer Teaching Society is not liable for false or misleading information…

  23. Symptoms • D Depressed mood • E Energy ↓ = ‘ANERGIA’ • P Pleasure, interest and enjoyment ↓ = ‘ANHEDONIA’ • R Retardation (psychomotor) – N.B. atypically agitation • E Eating changes: ↓appetite and weight – ↑in atypical • S Sleep disturbance (EMW) • S Suicidal/self harm thoughts • I I’m a failure • O Only me to blame • N No concentration or attention The Peer Teaching Society is not liable for false or misleading information…

  24. Depression Which are biological? Cognitive? Can they exhibit psychotic features? Delusions? Hallucinations? The Peer Teaching Society is not liable for false or misleading information…

  25. Surgical Sieve Neurological Degenerative Idiopathic/iatrogenic Congenital Endocrine Vascular Infective Trauma/environmental Autoimmune Metabolic Inflammatory Neoplastic (+heam) + PSYCH!! Peer Teaching Society is not liable for false or misleading information…

  26. DD and Ix • Psych – schizophrenia, anxiety, PND, hypoactive delirium etc! • Neuro– encephalitic disorder, PD, dementia, MS (CSF, brain imaging, MMSE) • Iatrogenic (drugs); • Anticonvulsants, antipsychotics, anabolic steroids • Beta blockers, • Contraceptives (progesterone), CCBs, corticosteroids • Drugs for PD, e.g. levadopa The Peer Teaching Society is not liable for false or misleading information…

  27. DD and Ix • Endocrine; • Hypoglycaemia - glucose • Hypothyroid (hyper in anxiety) -TFTs • Cushing’s - cortisol • HyperPTH (high calcium) - PTH/ Ca and phosphate levels • Vascular - CVD - Cholesterol • Infective - post viral, Lyme disease, neurosyphilis, AIDs and other chronic – bloods, virology The Peer Teaching Society is not liable for false or misleading information…

  28. DD and Ix • Trauma– bleeds? - imaging • Environmental; • Alcoholism, MCV, LFTs (gamma GT) • Drugs such as cannabis, benzodiazepines, amphetamines - urine • Autoimmune – SLE - ANA, ESR, anti dsDNA • Neoplastic – SOL - imaging • Haem– anaemia- FBC, vitB12/folate The Peer Teaching Society is not liable for false or misleading information…

  29. Depression Tools How can you diagnose depression and assess severity? Can you ‘screen’? What is the criteria used re: screening?

  30. Treatment • Mild • Low intensity psychological interventions: self help/ telephone sessions/group CBT, exercise classes • Moderate • More intense psychological interventions – individual CBT, counselling, interpersonal therapy • + Antidepressant drugs • Severe • Intensive psych treatments • Drugs • ECT in emergency • ? Antipsychotics The Peer Teaching Society is not liable for false or misleading information…

  31. Antidepressants Quiz! • SE: hypertensive crisis if eat cheese! • E.g: phenelzine • Action: block monoamine oxidase enzyme = x breakdown of monoamine neurotransmitters dopamine, serotonin and norepinephrine • Answer: MAOIs • Use in treatment of drug resistant/atypical depression The Peer Teaching Society is not liable for false or misleading information…

  32. Antidepressants Quiz! • SE: • Anticholinergic: dry mouth, blurred vision, constipation, urinary retention, postural hypotension, drowsiness, sweating • E.g: clomipramine • Answer: TCAs • Can help with poor sleep • Problems: cardiotoxic in overdose • ECG changes??

  33. Antidepressants Quiz! • SE: GI bleeds, dyspepsia • E.g: paroxetine • Action: inhibit reuptake of serotonin by presynaptic cells • Pros: less cardiotoxicand safer in overdose than TCAs  first line drugs • Answer: SSRIs • ?Why not in children & adolescents? The Peer Teaching Society is not liable for false or misleading information…

  34. Other antidepressants • SNRIs; • E.g. duloxetine, S/E: anticholinergic • Also used in OCD, ADHD, anxiety • Trazadone – sedating, good for anxiety • Mirtazapine – increases appetite and is anxiolytic The Peer Teaching Society is not liable for false or misleading information…

  35. Serotonin (5HT) Syndrome Which drugs can cause this? Symptoms include; • Agitation/restlessness • Hyperpyrexia • Tachycardia • Hypertension • Loss of co-ordination • Myoclonus • Rigidity • Coma Treatment– withdrawal of causative drug(s), benzodiazapine, cyproheptadine The Peer Teaching Society is not liable for false or misleading information…

  36. Mood Disorders When is depression unipolar? When is it part of bipolar affective disorder? The Peer Teaching Society is not liable for false or misleading information…

  37. Mania How would you describe somebody with mania? Cardinal feature? The Peer Teaching Society is not liable for false or misleading information…

  38. Mania • Appearance/behaviour • Psychomotor overactivity – little sleep, distracted • ? Brightly coloured, mismatched clothing • Increased appetite and libido • Mood and affect • Usually elated • Congruous • Speech • Uninterruptable/pressured, rapid • Perception • May have delusions of persecution or grandiose – mood congruent • Thoughts • Flight of ideas, hallucinations (usually auditory) • Cognition • Insight • Often absent The Peer Teaching Society is not liable for false or misleading information…

  39. Mania Differentials? • Substance abuse – esp. amphetamines, cocaine • Schizophrenia • Personality disorders RFs? The Peer Teaching Society is not liable for false or misleading information…

  40. Management • Co-ordinated care • Rapid access to support in crisis • ?Hospitalisation – MHA • Psychological care – education, promoting social funtioningetc • Medication • Annual reviews The Peer Teaching Society is not liable for false or misleading information…

  41. Mania Treatment • Anti-manic drugs (prophylaxis); • Lithium • Valproate • Carbamazapine • Lamotrigine • Atypical antipsychotics – olanzapine, apiprazole, quetiapine, risperidone • ? Rapid tranquilisation The Peer Teaching Society is not liable for false or misleading information…

  42. Bipolar Affective Disorder • Treat depression • ?Rapid cycling • Treat mania The Peer Teaching Society is not liable for false or misleading information…

  43. Lithium • Monitor • Lithium levels; • 12 hours after administration • Weekly until levels stable after initiation/dose change • Then every 3/12 • U&E – baseline and every 6/12 • TFTs – every 6/12 N.B. Pregnancy test prior – Ebstein’s anomaly Avoid diuretics!

  44. Lithium SEs & Toxicity • TOXICITY • Blurred vision • COARSE tremor • Muscle weakness • Ataxia • N and V • Hyper-reflexia • Circulatory failure • Oliguria • Seizures • Coma • EARLY • Mild diuresis • FINE tremor • Dry mouth • Metallic taste • LATE • Weight gain • Hypothyroidism • Hypokalaemia • Oedema The Peer Teaching Society is not liable for false or misleading information…

  45. Lithium Treatment; • Supportive • Stop lithium dose and recheck levels • IV fluids/encourage diuresis (monitor fluid balance) • Monitor U&Es • Consider dialysis • Treat seizures If mild, generous amounts of sodium salts and fluid will reverse toxicity

  46. Psych emergencies Acute dystonic reaction Neuroleptic Malignant Syndrome Lithium toxicity Psychiatry Classification Behavioural Mental Illness E.g. Eating disorders Personality disorders Psychosexual disorders Developmental E.g. Learning disorders and pervasive developmental disorders (autism/ADHD) Functional Organic Neuroses (severe “normal” experience) Psychoses (loss of contact with reality) Organic Substance abuse E.g. Delirium Dementia Hypothyroidism OCD Anxiety Phobias Schizophrenia Mood disorders Bipolar, depression, mania The Peer Teaching Society is not liable for false or misleading information…

  47. Questions? The Peer Teaching Society is not liable for false or misleading information…

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