Psychiatry is the bestSAM TOPP CT1 IN HOUNSLOW

Tonight

u History taking/MSE/formulation/PACESu Psychotic disorders u Bipolar affective disorder u Anxiety disorders u Personality disorder

History taking u Takes a lot longer than you have in PACESu Think general history but a bit spicier u PC u HPC u PMHu Past psychiatric history - include admissions and if informal or under MHAu DH - think about medication side effects, what has/hasn’t workedu FH u Forensic history - convictions u Childhood and personal history – pregnancy/birth, upbringing, school,

relationshipsu Social history - job, benefits, housing, smoking, drugs, alcohol

History taking

u Be curious u Think about the symptoms /signs you are eliciting and what they

meanu Let the patient do the work u Don’t be scared of silence u Psychosis – patience, rapport, gently probe delusions u Mania – formal, boundaries, may need to interrupt u Depression – patience, kindness u Anxiety – focus on the effects it has on their life

Risk

u To selfu Self-harm/suicide

u Self-neglect – self-care, nutrition, physical health

u Adherence with medication

u To others u From others

u Vulnerability, retaliation

u Property u Absconding

Descriptive psychopathology

u Delusions u Fixed, unshakable beliefs, irrespective of counter-argument, that are

unexpected and not in-keeping with a patient’s cultural background

u Autochthonous delusion u Fully formed idea out of the blue

u Delusional perceptionu I saw the traffic lights turn green and I knew I had to rid London of capitalism

u Mood congruent u Seen in affective psychoses – e.g nihilistic (rotting insides) in depression or

grandiose (Jesus) in mania

u Mood incongruent u Seen in schizophrenia – often horrific beliefs discussed without obvious distress

Specific delusions

u Delusions of control (passivity phenomena)u Emotions (affect), desire to do things (impulse), actions (volition),

experience bodily sensations (somatic)

u Infestation: EKBOM – parasites (may be primary or secondary e.gcocaine)

u Jealousy: sexual partner unfaithful – OTHELLOu Love: (no longer Prince) Harry is in love with me – DE CLERAMBAULTu Misidentification: replaced by exact double – CAPGRAS - or single

person impersonating others – FREGOLIu Communicated: psychotic beliefs get transferred – FOLIE A DEUX

Hallucinations

u An internal percept without a corresponding external objectu Can be any sensory modality u Auditory

u Noises or voices u Voices – ask as much as you can. Command, thought echo, 2nd person,

3rd person, talking about or running commentary

u Visual u More common in eye pathology (e.g Charles Bonnet), epilepsy than

psychosis

u Tactile u Alcohol withdrawal, Ekbom, cocaine

Thoughts

u Thought stream u Speed, quality, quantity u Disordered: flight of ideas, poverty of thought

u Thought content u Substance u Disordered: delusions, obsessions

u Thought formu Snapping off/thought blocku Derailment/Knight’s move (break in association of thoughts)u Fusion – two or more related ideas form one idea

u Thought possession u Thought insertion, withdrawal, broadcasting

MSE

u Appearance and behaviour – age, ethnicity, body habitus, clothing, kempt, cooperative, calm/agitated, psychomotor retardation, abnormal movements (EPSEs)

u Speech – rate, volume, tone, formal thought disorder u Mood – high, low, euthymic u Affect – reactive, labile, flat, blunted u Thoughts – content (delusions, obsessions), possession (interference)u Perceptions – hallucinations, depersonlisation/derealisationu Cognition – TPPu Insight –patient’s ideas/explanation

Capacity

u Can they understand, retain, weigh up pros and cons and communicate decision

u Decision specific u Focus on treatment and setting of treatment

Setting

u GPu Community mental health team u Specialist community team – e.g EIP, CIDSu Crisis and home treatment team u Hospital

u Informal, under section of MHA

Differential diagnosis

Formulation and treatment

u Predisposing u Precipitating u Perpetuating u Bio-psycho-social approach

Schizophrenia and related psychoses

u Psychosis is an umbrella term, schizophrenia is a specific psychotic disorder

u Fundamentally a distortion in thinking and perception

Paranoid schizophrenia F20.0u At least one of the following

u Thought interference – insertion, withdrawal, broadcasting u Delusions of control (passivity); delusional perception

u Auditory hallucinations – 3rd person/running commentary

u Or at least two of the followingu Persistent hallucinations in any modality u Catatonic behaviour

u Breaks in the train of thought – incoherent speech, neologisms u Negative symptoms – paucity of speech, withdrawal, loss of interest, blunting

u Duration of at least one monthu Should not be diagnosed in presence of overt brain disease or during states of

intoxication/withdrawal

Other subtypes

u Hebephrenic schizophrenia

u Disorganised speech and behaviour, flat affect, rapid development of negative symptoms, poor prognosis

u Catatonic schizophrenia

u Prominent psychomotor disturbances between extremes of hyperkinesis and stupor and negativism/posturing

u Simple schizophrenia

u Negative symptoms gradually arise without acute episode (no delusions or hallucinations)

u Residual schizophrenia

u Previous positive symptoms less marked, negative symptoms more prominent

u Post-schizophrenic depression

u Depression in aftermath of illness. Must still have psychotic symptoms but depression dominates. Increased risk of suicide

Disorders related to schizophrenia

Schizoaffective disorder

• Schizophrenic and affective symptoms present simultaneously for at least 2 weeks

• No separate episodes of schizophrenia and affective disorders or drug use

• Treat as for schizophrenia +/-mania/depression

Schizotypal disorder

• Odd beliefs, magical thinking• Ideas of reference • Odd/eccentric behaviour, no close

friends • Suspiciousness/paranoid ideas• No delusions/hallucinations

Differential diagnosis

u Organic causes – e.g infection, inflammation, malignancy u Acute and transient psychotic disorder (time)u Mania/depression with psychotic features – congruent delusionsu Delusional disorder (no other psychotic symptoms present)

Epidemiology

u Lifetime prevalence: 15-19 per 1000 u Male:female equal u Earlier average age of onset for males (23vs 26 years)u 20% reduction in life expectancy (10-15 years)u Suicide most common cause of premature death u Significant comorbidity: metabolic syndrome, substance misuse

Cause

u Genesu Identical twin 46%, one sibling 12-15%

u Environment u Complications in pregnancy/childbirth/neonatal period

u Delayed walking and neurodevelopmental problems

u Severe maternal malnutrition

u Maternal influenza in pregnancy

u Degree of urbanisation at birth

u Use of cannabis, esp during adolescence

Pathophysiology

u Too much dopamine u Not enough glutamine u Too much serotonin u Too much noradrenaline u Not enough GABA

Treatment

u Think bio-psycho-social!u All adults following first episode of psychosis

referred to Early Intervention in Psychosis u Intense, specialist outpatient service for 3 years u Care-coordination u Medical reviews with psychiatrist and treatment

with antipsychotic medicationsu Physical health checks u Psychological intervention – CBTpu Support and education for families – carer’s

assessment, family therapy, psychoeducationu Support with employment/educations u Support with social care – housing/finance issuesu Relapse prevention

Antipsychotics!

u First generation u Chlorpromazine (first ever)u Flupentixol

u Haloperidol u Sulpiride

u Second generation u Amisulrpideu Aripiprazole

u Olanzapineu Quetiapine

u Risperidone u Lurasidoneu Caripirazine

u Clozapine

Antipsychotics

u Weird classification u FGA: more associated with EPSEs, akathisia, raised prolactin, tardive

dyskinesia, prolonged QTcu SGA: more associated with metabolic side effects u Little difference between efficacy EXCEPT clozapine u FGA role in rapid tranquilisation (e.g haloperidol) and depot

preparation (e.g flupentixol) u Right drug for the patient

What if it doesn’t work?

u If after 4-6 weeks of treatment at therapeutic dose there is no response, should change antipsychotic (if FGA, should try a SGA)

u If after a further 4-6 weeks at therapeutic dose there is still no response, CLOZAPINE (if no CI)

Common antipsychotics

u Aripiprazole – D2 partial agonist (weak 5-HT1a partial agonism and 5-HT2A antagonism)u Lovely side effect profile – lack of weight gain/sedation/prolactin/QTc,

available as depot

u BUT, can cause agitation and takes 2 weeks to work orally

Common antipsychotics

u Risperidone – D2, 5-HT2A, alpha1 and H1 antagonistu Available as depot (palliperidone)

u BUT weight gain, EPSEs, prolactin

Common antipsychotics

u Olanzapine – D1, D2, D4, 5-HT2, H1, muscarinic antagonist u Very effective (maybe marginally better than other SGAs), minimal

akathisia/prolactin

u BUT sedation, weight gain, metabolic L

Common antipsychotics

u Quetiapine – D1, D2, %-HT2, alpha1 and H1 antagonist u Limited EPSEs/prolactin

u BUT sedation, weight gain

QTc

u Prolonged QTc à torsades de pointes u Regular ECG monitoring

EPSEs

u Parkinsonismu Days to weeks

u Tremor, bradykinesia

u Reduce dose, consider switch, consider procyclidine (anticholinergic)

EPSEs

u Acute dystoniau Within hours

u Uncontrolled muscle spasm: oculogyric crisis, torticollis

u Procyclidine IM/IV

EPSEs

u Akathisia u Hours to weeks

u Restlessness (risk for suicide)

u Reduce dose, consider switch, consider propranolol, benzo, mirtazapine

EPSEs

u Tardive dyskinesia u Months to years, may be reversible

u Abnormal involuntary movements, e.g lip smacking

u Stop procyclidine if taking, switch antipsychotic (clozapine may be the best)

Neuroleptic malignant syndrome

u Life threateningu Mental state change, fever, rigidity, autonomic dysfunctionu Raised CK on bloodsu Stop antipsychotic, get help quickly - ITU

Clozapine

u Mainly blocks D1 and D4, also anti-cholinergic, histaminergic, serotonergic and adrenergic activities

u Smoking lowers plasma concentrations, caffeine increases

u CI – neutropenia, other blood dyscarasias, myocarditis/pericarditis/cardiomyopathy, severe renal, cardiac or liver disease

Monitoring

u Weekly FBC for first 18 weeks, then fortnightly until 1 year, then monthly indefinitely

u Traffic light system u Green carry on

u Amber – twice weekly monitoring

u Red – STOP clozapine, no other antipsychotics, daily bloods, haematology

Side effects

u Commonu Constipation, dry mouth, blurred vision, sedation, weight gain, nausea,

tachycardia, lower seizure threshold

u Rare but serious u Agranulocytosis, blood clot, myocarditis, pericarditis, cardiomyopathy,

NMS, diabetes, intestinal obstruction, fulminant hepatic necrosis

Case

u 55 year old lady with a past history of depression referred to the crisis team by GP due to concerns about mental state following recent appointment

u Lives alone in council owned propertyu Originally from Pakistan – studied zoology, moved to UK in 20su Worked in Tesco until about 15 years ago u Divorced (abusive partner)u No childrenu Distant cousins near London

Case

u Reluctant to let us inu Flat in squalor - hard to access rooms, flies everywhere, smells v bad, tins

of food everywhere, bags of rubbish, moldu Appeared unkempt u Told me that family was trying to kill her and poison her u She knew this because she saw two black cars pull up outside her house u Thinks she is looking after herself ok and the flat is pretty tidyu Thought consultant was trying to kill her u Did not think unwell in any way u Reports from family responding to unseen stimuli u T2DM, HTN, not taking meds

Differential diagnosis

Differential diagnosis

u Organicu Paranoid schizophrenia

u Delusional beliefs, possible auditory hallucinations, prodrome

u Schizoaffective disorderu Mania with psychotic symptoms u Depression with psychotic symptoms u Schizoid personality

What are the risks?

What are the risks?

u Physical – T2DM, living conditions, malnutrition u Others – family?u From others – retaliation?

Questions

u ‘I saw two black cars pull up outside the house and I knew my family was trying to kill me’ is an example of what?u A. Visual hallucination

u B. Delusional perception

u C. Idea of reference

u D. Grandiose delusion

u E. Thought insertion

Where should she be treated?

Where should she be treated?

u Lacks insight u Does not have capacity to consent to treatment or admission u High risks u Difficult to treat in community – will not let us in and will not take

medication u Section 135, section 2

What medication?

What medication?

u Avoid metabolic side effects u Depot might be useful u Risperidone fits nicely u Consider benzos if agitated

Question

u Following hospital admission, who would be the most appropriate team to refer to?u A. GP

u B. Community mental health team

u C. Early Intervention in Psychosis

u D. Cognitive impairment and dementia service

u E. Forensic services

What are other important management options?

Psycho-social

u CBTpu Family education/therapy u Housing – deep clean, ?supported accommodation u Job - ?fit for work, CV help, benefits support

Question

u Imagine she’s 35….u 16 weeks after starting risperidone, she develops amenorrhoea.

What is the most appropriate first line investigation?u A. Thyroid function tests

u B. Pregnancy test

u C. Ultrasound abdomen

u D. Serum prolactin

u E. MRI head

Bipolar affective disorder

u Two or more episodes where the patient’s mood and activity levels significantly disturbed

u On some occasions, hypomania/mania on others depression u BPAD 1 – mania, BPAD 2 – hypomania

Epidemiology

u Lifetime prevalence 0.3-1.5%u M:F is equal (although type II and rapid cycling more common in

females)u No significant racial differences u Mean age of onset 21 yearsu Significant morbidity – work, relationships u Completed suicide in 10% (usually depression)

Symptoms

u Maniau Persistently elevated mood (irritability)

u Increased energy – overactive, not sleeping

u Pressured speech, flight of ideas

u Needs to last at least one week or less if admitted to hospital

u Grandiose, overfamiliar

u Risky behaviours – money, drugs, alcohol, sex

u Impairs social functioning – dramatic effect on work and relationships

Mania with psychotic symptoms

u Usually mood congruent u E.g grandiose delusions

Hypomania

u Very similar to mania but less severe u Lasts for at least 4 daysu Does not impact on social functioning u Does not result in admission to hospital u Does not feature psychotic symptoms

Aetiology

u Genetic and environmental u Stressful life events may precipitate in vulnerable u Drugs

u Antidepressants

u Steroids

u Cardio- digoxin, diltiazem, propranolol

u TB meds, clarithromycin

u Parkinsons meds – levodopa, amantadine

u GI – ranitidine, metoclopramide

Treating maniau Severe behavioural disturbances – benzos u If taking antidepressant – consider stopping u If taking nothing

u Haloperidol, olanzapine, risperidone, quetiapine, u If ineffective, alternative antipsychotic u If still ineffective at max dose, add lithium u If lithium ineffective or unsuitable, sodium valproate (NOT if childbearing age)

u If already taking lithium, plasma levels to optimize treatment and consider antipsychotic

u If taking sodium valproate/others, increase or add antipsychotic u ECT

Treating severe bipolar depression

u If not taking anythingu Fluoxetine + olanzapine

u Quetiapine monotherapy

u If no response, consider lamotrigine monotherapy

Long term treatment

u Lithium is the most effective in the long termu Aim to switch from acute medications to this 4 weeks after manic

episodeu If ineffective/inappropriate, consider valproate, olanzapine or, if

previously effective, quetiapine

Lithium

u Unknown mechanismu Baseline FBC, UE, LFT, TFT, BMI, Pregnancy testu Levels 5 days after starting and 5 days after change in dose, 12

hours post dose

Side effects

u Polyuria/polydipsia (ADH antagonism)u Weight gainu GI upsetu Cognitive problemsu Hair lossu Tremoru Sedation

Long term

u Renal functionu 1% may develop irreversible ESRD

u Stopping may not slow rate of decline!

u Decision based on efficacy, patient views, MDT

u May need dose reduction as kidneys failing

u Hypothyroidismu Levothyroxine, don’t need to stop lithium

u Teratogenecityu Ebstein’s anomaly , prematurity, floppy baby

u Balance of risk

Toxicity

u Upper limit 1.2mmol/lu >1.5mmol/l most will show signsu >2.0mmol/l life threatening]u Tremor, anorexia, Nausea/vomiting, diarrhoea, lethargy u Severe signs – confusion/delirium, fasciculations, hypertonia,

hypotension, arrythmia, seizuresu Adjust dose, send to hospital, may need dialysis u Prevention – hydration, warn of early signsu Be aware of drug interactions which can increase toxicity - NSAIDs,

antacids, ACEi, ARBs, SSRIs

Sodium valproate

u May be used in acute mania or as prophylaxisu Mechanism not fully known u Side effects – GI upset, tremor, raised LFTsu Rare – irreversible hepatic failure, agranulocytosisu LFTs prior to starting and 6 monthly u Not for use in women of childbearing age unless pregnancy

prevention programme in place u High risk of spina bifida, face and skull malformation,

limb/heart/kidney/sexual organ malformation, developmental delay

Other drugs in bipolar

u Lamotrigine u Mood stabilizer and depression

u Be aware of rash – around 10% develop benign rash, minority develop Stevens Johnson syndrome

u Carbamazepine

Psycho-social intervention

u Individual and family therapiesu Psycho educationu Staying well plansu Relapse indicatorsu Preferences for treatment when unwellu Employment support u Benefits/housing support

Case

u A 35 year old man presents with the belief that he is Jesus after God has spoken to him. He is walking around the ward wearing a toga made from his bedsheet trying to ‘heal’ people. He does not accept that being in a mental health unit is acceptable as this is a ‘genuine religious experience’.

u He works as a pastor in a prison. Used to work as a lawyer and semi professional cricket player

u Sleeping lessu Speech fast, some flight of ideas

Differential

Differential

u Mania with psychotic symptoms u Elevated mood, pressured speech, lack of sleep, irritable, grandiose

delusions, auditory hallucination

u MOOD CONGRUENT delusion

u Schizoaffective disorderu EUPD

Question

u This gentleman has previously successfully been managed in the long term with quetiapine. He has recently weaned this down after a period of being well under guidance from his private psychiatrist. What medication would you start in this instance?u A. lithium

u B. quetiapine

u C. olanzapine

u D. sodium valproate

u E. fluoxetine

Anxiety disorders

Agoraphobia

u Anxiety and panic symptoms where escape difficultu E.g tube, lecture theatre, crowdsu Results in avoidanceu M:F = 1:3u Bimodal distribution – 18-35 yrs and olderu Lifetime prevalence 1.3%u Means fear of the marketplace in Greek!u Citalopram, escitalopram, paroxetineu Behavioural: exposure, relaxationu Cognitive: education re symptoms

Social phobia

u Incapacitating anxiety (not secondary to delusional or obsessive thoughts) restricted to social situations

u E.g having a conversation, meeting new people, public speakingu Blushing, sweating, shaking, dry mouth with excessive fear of

embarrassment, humiliation or people discovering the anxiety u May result in avoidance leading to work, educational and

relationship difficultiesu M:F equalu Peaks at 11-15 yrs but often people do not present until 30su CBT, SSRIs, propranolol

GAD

u >6 months of excessive worry about everyday problemsu Autonomic symptomsu Physical symptoms – chest pain, breathing problemsu Mental state symptoms – depersonalization/derealizationu Tension, tingling u F>Mu 45-59 yrs highest

Panic disorder

u Panic attacks – intense fear, horrible symptoms, develop rapidly, reach peak in 10 mins, resolve in 20-30mins

u May be spontaneous or situational u Panic disorder – recurrent panic attacks (not secondary to

something else)u Worry of another attack makes everything worse u F:M = 2:1u 15-24yrs and 45-54 yrsu Differential –substance misuse, endocrine u SSRIs, CBT

Specific phobias

u Recurring, excessive, unreasonable psychological or autonomic symptoms of anxiety with specific object

u M:F = 1:1u Mean age of onset 15 years u Trypophobiau Alektorophobia u Behavioural therapy – exposure u Cognitive – education, coping skillsu No drugs

Anxiety disorders tips

u Could well come up in PACES!u History

u Get them to talk about it freely

u How does it impact life? – work, relationships, alcohol/drugs

u Brief cognitive intervention re symptoms

u Managementu Bio – SSRIs

u Psycho – CBT, education

u Social – assess wider impact and any help needed

OCD

u Obsessionsu Idea, image or impulse that is recognized by the patient as their own

but is repetitive, intrusive and distressing

u E.g contamination, order or symmetry, safety, doubt

u Compulsionsu Behaviour or action recognised as unnecessary and purposeless, but

cannot resist performing. The drive to do the action is recognised as one’s own but there is a subjective sense of need to perform it

u E.g cleaning, checking, counting, arranging

OCD

u Mean age, 20 yearsu M:F =1:1u 0.5-3% general population u Often comorbidities – e.g depression, substance useu Differential – normal, anankastic PD, schizophrenia

OCD

u CBTu Psychoeducation u Family/carer support u SSRIs (may take 12 weeks for response)u ECT

Question

u A 21 year old lady stops attending medical school lectures after she keeps experiencing palpitations, sweating, tremor and chest pain when sitting in the middle of a row. What is the diagnosis?u A. Agoraphobia

u B. Generalised anxiety disorder

u C. Social phobia

u D. Panic disorder

u E. Emotionally Unstable Personality Disorder

Question

u A 45 year old man feels an overwhelming level of anxiety generally throughout everyday life. What would be the most appropriate medication to start?u A. Aripiprazole

u B. Clonazepam

u C. Escitalopram

u D. Mirtazapine

u E. Duloxetine

Personality disorder

u Enduring, persistent and pervasive disorders of inner experience and behaviour that cause distress and significant impairment in social functioning

Cluster A

u Paranoid – sensitive, suspicious, conspiracy theories, distrust of othersu Schizoid –emotionally cold, detachment, lack of interest in others,

fantasy world

Cluster B

u Dissocial – callous lack of concern for others, irresponsible, irritable, aggressive, unable to maintain relationships, disregard and violation of others’ rights, childhood conduct disorder

u Emotionally unstableu Impulsive type – inability to control anger, unpredictable affect and

behaviour

u Borderline type – unclear identity, intense and unstable relationships, unpredictable affect, impulsivity, threats or acts of self-harm

u Histrionic – self-dramatisation, shallow affect, egocentricity, craving attention and excitement

Cluster C

u Anxious avoidant – timid, insecure, fear of evaluation by others, self-conscious

u Anankastic – doubt, caution, pedantry, rigidity, perfectionism, preoccupation with orderliness and control

u Dependent – clingy, submissive, excess need for care, helpless when not in relationship

EUPD

u V common in psychiatry – 1/3 of all outpatients!u Often create unpleasant feelings within us (counter transference)u Top tips

u Be aware of your own feelings

u Remember the high likelihood of traumatic upbringings

u Don’t reject them further!

Management

u No licensed medicationsu Why are so many on meds?

u Co mordbid psychiatric conditions

u We like to medicate to make ourselves feel better?

u DBTu Interpersonal effectiveness, emotional regulation, distress tolerance,

core mindfulness

u Be aware of risk