Psychiatry

Depression

• Disorder causing persistent low mood, energy + reduced interest in activities/anhedonia (1/2 core symptoms for 2w)

• Assoc w/ serotonin (5-HT) neurotransmitter activity disturbance

• Influenced by genetic, psychological + environmental factors

What tool is used to assess severity of depression

PHQ-9 Questionnaire

• 5-9 = mild

• 10-14 = moderate

• 15-19 = moderately severe

• 20-17 = severe

Depression presentations

• emotional: anxiety, irritability, low self-esteem, guilt

• Cognitive: poor concentration + memory

• Physical: low energy, poor appetite/overeating, abnormal sleep

What is included in a risk assessment

• self neglect

• Self-harm

• Harm to others

• Suicidal thoughts + previous attempts

Admission required if immediate safeguarding issue

Non-pharmaceutical management of depression

• active monitoring + self help

• Lifestyle modification (exercise, diet, stress, alcohol)

• CBT/counselling/psychotherapy

Psychotic depression

psychosis accompanies depression (indicates severe depression)

• delusions

• Hallucinations

• Thought disorder

Tx: antipsychotics + antidepressants, consider ECT

SSRI MOA + examples

Bind to SERTs + inhibit reuptake at presynaptic membrane → more 5HT in synapses

• Fluoxetine → first-line in children + adolescents (long half-life)

• Sertraline (anti-anxiety effect)

• Citalopram (QT prolongation)

• Paroxetine (assoc w/ weight gain)

SSRI side effects

• GI symptoms

• Headaches

• Sexual dysfunction

• Increased suicidal risk

• Risk of bleeding (esp. w/ anticoagulants + NSAIDs)

TCA examples

• Amitriptyline

• Nortriptyline

Typically used to treat neuropathic pain at low dose (high dose for depression)

Contraindicated in heart disease + high risk suicide

TCA side effects

• arrhythmias (tachycardia, QT prolongation, BBB)

• Dry mouth

• Constipation + urine retention

• Cognitive impairment

• Sedation

Mirtazapine key side effects

• sedation (low dose eg 15mg)

• Increased appetite + weight gain

• Less likely to cause sexual dysfunction

Antidepressant guidelines

• Starting: review w/in 2w (1w in patients 18-25)

• Swapping: SSRI + SRNI can be swapped directly (except fluoxetine), others require cross-tapering over several weeks

• Stopping: continue for min 6m before stopping. Dose reduced slowly over 4w

Discontinuation symptoms

Start w/in 2-3 days of suddenly stopping antidepressants - resolves 1-2w

• flu-like symptoms

• Electric shock sensation

• Irritability

• Insomnia + vivid dreams

Serotonin Syndrome

Caused by excessive serotonin activity → associated w/ high doses + multiple antidepressants used together

• altered mental state

• ANS hyperactivity: tachycardia, hypertension, hyperthermia

• Neuromuscular hyperactivity: hyperreflexia, tremor, rigidity

Generalised Anxiety Disorder + presentations

Excessive + disproportional anxiety impacting daily activity (assessed using GAD-7). Persistent symptoms for min 6m

• restlessness

• Excessive + uncontrollable worrying

• Palpitations, SOB

• Tremor, muscle tension

• Sleep disturbances, tiredness

Secondary causes of anxiety

• substance use/withdrawal

• Hyperthyroidism

• Phaeochromocytoma

• Cushing’s disease

Anxiety management

• lifestyle modification + CBT

• SSRIs- sertraline, paroxetine (first-line for GAD + panic disorder)

• SNRIs, pregabalin (GAD)

• Propranolol

• Benzodiazapine (short term)

Panic disorder

• Recurrent, unexpected panic attacks over 1m period (no trigger)

• May occur w/ GAD

• Little anxiety between attacks

Bipolar disorder + diagnosis

Recurrent episodes of depression + mania/hypomania (Typical onset <25). DSM-V:

• Bipolar I: at least 1 episode of mania

• Bipolar II: at least 1 episode of major depression + hypomania

Features of mania

• abnormally elevated mood

• Increased energy, decreased sleep

• Grandiosity, ambition, risk-taking behaviour

• Flight of ideas (rapid generating + jumping between)

• Pressure speech

• Psychosis (hallucinations + delusions)

Acute manic episode treatment options

Requires urgent referral to mental health specialist

• Antipsychotics (first-line), lithium or sodium valproate

• Existing antidepressants tapered + stopped

Acute depressive episode treatment options

• olanzapine + fluoxetine

• Antipsychotics

• Lamotrigine

Long-term Bipolar disorder management

• lithium (serum levels taken 12hrs after most recent dose)

• Alternatives: sodium valproate, olanzapine

Lithium adverse effects

• Fine tremor

• Weight gain

• CKD

• Hypothyroidism + goitre

• Nephrogenic diabetes insipidus

• Hyperparathyroidism + hypercalcaemia

Phobias

Persistent intense anxiety + fear relating to specific trigger

• agoraphobia → places/situations that maybe difficult to escape

• Social situations

Psychosis + positive symptoms

Impaired connection w/ reality → distorted perception + interpretation

• hallucinations: perceiving things that are not true

• Delusions: fixed, unshakable false beliefs

• Thought disorder: cognitive disorganisation = abnormal speech/behaviour

Psychosis differentials

• mania

• Schizophrenia

• Substances + medications

• Brain tumours

• Infection (CJD, HIV, neurosyphilis)

• Dementia

Schizophrenia

• Type of long-term psychosis (onset 15-30)

• pt unable to distinguish own thoughts/ideas from reality → disorder of thinking, perceiving + motivation

• Prodrome → active → chronic/residual phase (relapsing + remitting condition)

Schizophrenia positive symptoms (active phase)

• auditory hallucinations

• Somatic passivity (External entity is controlling)

• Thought insertion/withdrawal, broadcasting

• Delusions → Persecutory, grandiose, passivity, thought interference, ideas of reference

Schizophrenia negative symptoms (chronic phase) 4A’s

• affective flattening (minimal emotional reaction)

• Alogia (reduced speech)

• Anhedonia + Asociality

• Avoliation (loss of motivation)

Schizoaffective + schizopheriform disorder

• schizoaffective: symptoms of schizophrenia + bipolar disorder → psychosis, depression + mania

• Schizopherniform: schizophrenia features last <6m

Schizophrenia diagnosis + management

DSM-V criteria: prodrome symptoms ~6m + active phase symptoms at least 1m

Antipsychotics + CBT

Typical/1st gen antipsychotics MoA + examples

Block post synaptic D2 receptors in mesolimbic pathway

• Haloperidol

• Chlorpromazine

Atypical/2nd gen antipsychotics MoA + examples

Block D2 receptors in mesolimbic + 5HT in mesocortical pathway

• Quetiapine

• Olanzapine

• Aripiprazole

Depot antipsychotics

IM injections every 2w-3m, useful for poor adherence.

• aripiprazole

• Flupentixol

• Risperidone

Clozapine

Oral atypical antipsychotics→ used when other treatments fail

Requires close monitoring due to adverse effects:

• Agranulocytosis

• Myocarditis or cardiomyopathy

• Constipation

• Seizures

Monitoring requirements prior to antipsychotics

• BP + pulse

• Weight + waist circumference

• Bloods: Hba1c, lipid profile, prolactin

• ECG

Antipsychotics side effects

• weight gain

• Diabetes

• Prolonged QT interval

• Raised prolactin

Extra-pyramidal side-effects of antipsychotics

• akathisia: psychomotor restlessness + inability to stay still

• Dystonia: abnormal muscle tone + posture

• Pseudo-parkinsonism: tremor + rigidity

• Tardive dyskinesia: abnormal facial movements

Neuroleptic malignant syndrome

Life threatening complication of antipsychotics

• muscle rigidity

• Hyperthermia

• Altered consciousness

• Autonomic dysfunction (fluctuating BP + tachycardia)

• Raised creatine kinase + leukocytosis

Neuroleptic malignant syndrome management

• stopping medication

• IV fluids + benzodiazepines

Severe: bromocriptine (dopamine agonist) or dantrolene (muscle relaxant)

Mental State Examination

Assesses pts presenting with mental health symptoms/disorders

1. Appearance and behaviour

2. Speech

3. Mood and affect

4. Thought

5. Perception

6. Cognition

7. Insight + Judgement

Appearance + behaviour assoc w/ depressed pts

• poor self-care/hygiene

• Self-harm scars

• Psychomotor retardation

• Reduced eye contact

• Tearful

Appearance + behaviour assoc w/ manic pts

• bright/extravagant or inappropriate outfits

• Disheveled

• Hyperactive + talkative

• Sexually inappropriate behaviour

• Psychomotor agitation

Appearance + behaviour assoc w/ schizophrenia pts

• unkempt/self-neglect

• Dressed inappropriately

• Agitated/suspicious/aggressive

• Withdrawn/quiet

• Catatonia (unusual posture/actions/sounds or blank + unresponsive)

Types of speech

• alogia (poverty of speech) → depression

• Pressured (fast, difficult to interrupt) → mania

• Poverty of content (speech w/o meaning) → schizophrenia

• Neologisms

Types of mood

• euthymia (normal)

• Blunted affect (reduced emotional range) → depression

• Labile (mood changes quickly from elevated to angry/depressed) → mania

• affective flattening (reduced emotional reactions) → schizophrenia

Examples of thought disorders

• Somatic passivity (believing that an external entity is controlling their sensations and actions)

• Thought insertion/withdrawal (believing that an external entity is inserting or removing their thoughts)

• Thought broadcasting (believing that others are overhearing their thoughts)

• Persecutory delusions (a false belief that a person or group is going to harm them)

• Ideas of reference (a false belief that unconnected events or details in the world directly relate to them)

• Preoccupations (being focused and absorbed with one thought without being able to move to the next)

• Loosening of associations (no logical association linking one thought to the next)

• Knight’s move thinking (jumping from one thought to another without a logical association or flow)

• Tangentiality (goes off on a tangent from the original topic without returning to that topic)

Mental Health Act Assessment

• detailed evaluation to determine whether to detain someone

• can result in compulsory admission under Section 2 or 3

• Application + admission organised by Approved Mental Health Professional or nearest relative

• Requires 2 medical practitioners → section 12 doctor + another doctor

MHA Section 2

• compulsory admission following a Mental Health Act assessment → maximum period of 28 days

• Cannot be renewed

• Either discharged or further detention under section 3

MHA section 3

• compulsory admission for treatment → Max 6 months

• Responsible clinician can renew for further treatment

MHA section 4

• detain pts for max 72hrs in urgent scenarios when other

• Requires AMHP + 1 doctor

MHA section 5 (2) + (4)

2 → used in emergency to detain patients voluntarily hospitalised pt, lasts max 72hrs (requires 1 doctor)

4 → sed in emergency to detain patients voluntarily hospitalised pt, lasts max 6hrs 9requires 1 nurse

MHA section 136

• used by the police to remove someone that appears to have a mental health disorder from a public place

• Lasts max 24hrs

Define dementia

Progressive + irreversible loss of higher cortical function w/o decreased consciousness (Eg memory, concentration, judgement)

Present for at least 6m

Dementia risk factors

• diabetes

• high alcohol intake

• Smoking

• Social isolation

• FHx

• Cognitive inactivity

• increasing age

Dementia DDX

• psychiatric: depression, psychosis, delirium

• endocrine: hypercalcaemia, hypothyroidism, Cushing’s, Addison’s

• neurological: Huntington’s, Parkinson’s, tumours

• nutritional: B12 + thiamine deficiency

• anticholinergic medications

Alzheimer's disease types

Sporadic: (90%)

• late onset (>60)

• genetics + environmental → ApoE e4 gene

Familial:

• early onset + faster progression (~40)

• PSEN1 chromosome 14 or PSEN2 chromosome 1

• Trisomy 21

Alzheimer's pathophysiology

• Beta amyloid plaques outside neurones

• Tau proteins become hyperphosphorylated + aggregate → neurofibrillary tangles inside neurone

• impaired neurone signalling + apoptosis

• Atrophy = narrow gyri, wider sulci + enlarged ventricles

Alzheimer's clinical presentations

slow + progressive

• short term memory impairment

• impaired reasoning

• poor concentration

• language impairment

• dyspraxia/apraxia

Frontotemporal dementia clinical presentations

• personality/behavioural changes (frontal lobe)

• aphasia/language impairment (temporal lobe)

• worsening memory (late)

• inability to learn new things

• apathy

vascular dementia pathology

• multiple infarctions/chronic ischaemia = less blood flow + O2 delivery

• permanent damage to brain tissue = necosis → loss of mental functions

• stepwise progression

Vascular dementia causes

• cerebral/carotid artery atherosclerosis

• carotid artery embolisation

• hypertension

• vasculitis

vascular dementia management

• antihypertensives

• statins

• anticoagulants

• lifestyle modification

vascular dementia clinical presentations

affected cortical area dependent

• frontal → personality change, executive dysfunction

• temporal → anterograde amnesia

• left parietal → aphasia, apraxia

• right parietal → confusion

Lewy body dementia pathophysiology

• progressive dementia → faster decline than AD

• misfolded alpha-synuclein protein aggregate in substantia nigra neurones

• Lewy bodies: eosinophilic inclusions in cytoplasm

Lewy body dementia clinical presentations

early → cognitive (AD)

• fluctuating cognitive impairment

• visual hallucinations

• depression

late → parkinsonism

• resting tremor

• reduced facial expressions

• bradykinesia

Cognitive assessment examples

• MMSE (<27)

• GPCOG/mini-COG

• ACE-III (<88)

• 6CIT

dementia investigations

• FBC, LFT, U&Es, TFT

• CRP + ESR

• Calcium

• HbA1c

• B12 + folate

• mid-stream urine (MSU)

• CT head

First line drug management for mild-mod dementia

AchE-I:

• Rivastigmine

• Donepezile hydrochloride

• Galantamine (if not tolerated)

MoA: Indirect acetylcholinesterase agonist = more Ach in synaptic cleft

Side effects assoc w/ AChE-I

• anxiety/depression

• Drowsiness

• Decreased appetite

• Arrhythmias

• Diarrhoea

Drug management for mod-severe dementia

memantine hydrochloride (not in frontotemporal)

NMDA receptor antagonist

Side effects: hypertension, dyspnoea, headaches, drowsiness