PsychiatryPsychiatry

Step IIIStep III

HypochondriasisHypochondriasis

The following clues need to be considered in making this daignosis: The following clues need to be considered in making this daignosis:

Appropriate medical evaluation failed to find evidence of serious Appropriate medical evaluation failed to find evidence of serious diseasedisease

Patient's preoccupation persisted despite adequate reassurancePatient's preoccupation persisted despite adequate reassurance Preoccupation lasted for 6 months or morePreoccupation lasted for 6 months or more Preoccupation caused marked distress or impairment in functioning Preoccupation caused marked distress or impairment in functioning Voiced concerns that are unrealistic but not beyond reason; for Voiced concerns that are unrealistic but not beyond reason; for

example, the patient may believe headaches indicate a brain tumor example, the patient may believe headaches indicate a brain tumor ( If its beyond reason then you will have to call it a “Delusion”)( If its beyond reason then you will have to call it a “Delusion”)

Failure of the patient to be reassured after appropriate work-ups Failure of the patient to be reassured after appropriate work-ups causing him or her to seek further tests and consultations causing him or her to seek further tests and consultations

HypochondriasisHypochondriasis

Hypochondriasis Associations:Hypochondriasis Associations: Seen in 50% of all patients with panic disorder Seen in 50% of all patients with panic disorder major depressive disordermajor depressive disorder In these In these patients, coexisting hypochondriasis will patients, coexisting hypochondriasis will

respond to treatment for the primary disorderrespond to treatment for the primary disorder. .

D/DD/D1. Physical Disease1. Physical Disease Conditions with diffuse symptomatology involving many Conditions with diffuse symptomatology involving many

organ systems may, when undiagnosed, mimic organ systems may, when undiagnosed, mimic hypochondriasis hypochondriasis

Occasionally occult malignancies or early stages of Occasionally occult malignancies or early stages of multisystem disease (e.g., lupus) explain what at first multisystem disease (e.g., lupus) explain what at first appears to be hypochondriasis. It is most important to first appears to be hypochondriasis. It is most important to first rule out physical disease rule out physical disease

2. Major depressive episode 2. Major depressive episode Depressed mood, sleep and appetite changes, loss of Depressed mood, sleep and appetite changes, loss of

interest, low self-esteem interest, low self-esteem Depressed patients in primary care usually have Depressed patients in primary care usually have

unexplained somatic complaints and are worried about unexplained somatic complaints and are worried about what is wrong with them but have typical symptoms and what is wrong with them but have typical symptoms and signs of depression signs of depression

3. 3.

D/DD/D

3. Panic disorder 3. Panic disorder Recurrent panic attacks with persistent dread of future attacks Recurrent panic attacks with persistent dread of future attacks Panic patients in primary care usually have numerous somatic Panic patients in primary care usually have numerous somatic

symptoms and anxiety about their health. However, they also symptoms and anxiety about their health. However, they also have recurrent panic attacks and worry about future attacks have recurrent panic attacks and worry about future attacks

4. Obsessive-compulsive disorder 4. Obsessive-compulsive disorder Repetitious unwanted thoughts (obsessions) and repetitious Repetitious unwanted thoughts (obsessions) and repetitious

unwanted actions (compulsions) unwanted actions (compulsions) Patients with hypochondriasis do not have other obsessions or Patients with hypochondriasis do not have other obsessions or

compulsions. Obsessions often involve contamination or harming compulsions. Obsessions often involve contamination or harming someone; compulsions often involve cleaning or checking someone; compulsions often involve cleaning or checking

D/DD/D5. Specific phobia of illness 5. Specific phobia of illness Fear and avoidance of a specific illness (e.g., Fear and avoidance of a specific illness (e.g.,

AIDS) AIDS) Patients with hypochondriasis have a conviction Patients with hypochondriasis have a conviction

that serious disease is already present, whereas that serious disease is already present, whereas patients with illness phobia fear contracting patients with illness phobia fear contracting illnesses they do not have illnesses they do not have

6. Somatization disorder 6. Somatization disorder Multiple somatic symptoms involving many organ Multiple somatic symptoms involving many organ

systems with onset <30 years systems with onset <30 years Somatization disorder occurs predominantly in Somatization disorder occurs predominantly in

women and involves multiple unexplained women and involves multiple unexplained symptoms. By contrast, hypochondriasis is symptoms. By contrast, hypochondriasis is characterized chiefly by abnormal attitudes (i.e., characterized chiefly by abnormal attitudes (i.e., fear, worry) fear, worry)

D/DD/D

7. Psychotic disorders (schizophrenia, 7. Psychotic disorders (schizophrenia, delusional disorder, major depressive delusional disorder, major depressive disorder with psychotic features) disorder with psychotic features)

Patients with hypochondriasis have Patients with hypochondriasis have overvalued ideas but not delusional overvalued ideas but not delusional beliefs. Overvalued ideas are strongly beliefs. Overvalued ideas are strongly held, but delusional ideas are held, but delusional ideas are accompanied by unshakeable conviction accompanied by unshakeable conviction and are often bizarreand are often bizarre

Hypochondriasis - TherapyHypochondriasis - Therapy1.1. Adopt a systematic approach to patients with Adopt a systematic approach to patients with

hypochondriasis. hypochondriasis. Here, you should aim to continue to care not a cureHere, you should aim to continue to care not a cure Arrange regularly scheduled follow-ups. Arrange regularly scheduled follow-ups. Provide an explainationProvide an explaination Develop and maintain a positive relationship using Develop and maintain a positive relationship using

interviewing skills. interviewing skills. 2. Cognitive behavioral therapy as a primary mode of 2. Cognitive behavioral therapy as a primary mode of

therapytherapy3. In patients with hypochondriasis who have coexisting 3. In patients with hypochondriasis who have coexisting

depressive or anxiety disorders, rx with an depressive or anxiety disorders, rx with an antidepressant. antidepressant. Start treatment with a serotonin Start treatment with a serotonin reuptake inhibitor at low dose; for example, start reuptake inhibitor at low dose; for example, start sertraline, 12.5 mg/d, and increase by 12.5 mg every 5 sertraline, 12.5 mg/d, and increase by 12.5 mg every 5 days as tolerated until a daily dose of 50 mg is achieved days as tolerated until a daily dose of 50 mg is achieved

Somatization DisorderSomatization Disorder Diagnostic criteria for a Somatoform DisorderDiagnostic criteria for a Somatoform Disorder

Physical symptoms that cannot be explained by an organic causePhysical symptoms that cannot be explained by an organic cause ““Secondary Gain “ aiming conditions are ruled out (Malingering or Secondary Gain “ aiming conditions are ruled out (Malingering or

Factitious Disorder) Factitious Disorder) Causes significant dysfunction Causes significant dysfunction

Specific criteria for Somatization Disorder Specific criteria for Somatization Disorder Symptoms longer than 2 years Symptoms longer than 2 years Unexplained physical symptom with onset prior to age 30.Unexplained physical symptom with onset prior to age 30. Symptoms are vague and involve multiple organ symptomsSymptoms are vague and involve multiple organ symptoms

At least 2 Gastrointestinal (nausea, vomiting, bloating) At least 2 Gastrointestinal (nausea, vomiting, bloating) At least 4 Pain ( Headache, abdominal pain, chestpain, dyspareunia) At least 4 Pain ( Headache, abdominal pain, chestpain, dyspareunia) At least 1 Neurologic ( deafness, blindness, diplopia, fainting, dysphagia) At least 1 Neurologic ( deafness, blindness, diplopia, fainting, dysphagia) At least 1 Sexual / genitourinary ( erectile dysfunction, dyspareunia, At least 1 Sexual / genitourinary ( erectile dysfunction, dyspareunia,

menorrhagia, irregular menses) menorrhagia, irregular menses) Important clues in history that can help in diagnosisImportant clues in history that can help in diagnosis

Extensive work up in the past that has been non diagnostic Extensive work up in the past that has been non diagnostic Patient tends to switch physicians often because of dissatisfaction with Patient tends to switch physicians often because of dissatisfaction with

previous physiciansprevious physicians

Somatization - managementSomatization - management

Never tell the patient that its “all in her head”Never tell the patient that its “all in her head” Avoid excess investigations.Avoid excess investigations. A single physician should try to establish a A single physician should try to establish a

long term empathetic relationship with the long term empathetic relationship with the patient. patient.

Cognitive therapyCognitive therapy Group therapyGroup therapy

DeliriumDelirium

DeliriunDeliriun

PREDISPOSING FACTORSPREDISPOSING FACTORS Age Age Cognitive impairmentCognitive impairment Increased comorbidity Increased comorbidity Male gender Male gender Depression Depression Alcohol abuse Alcohol abuse Sensory impairment Sensory impairment

PRECIPITATING FACTORSPRECIPITATING FACTORS >6 total medications >6 total medications >3 new inpatient medications>3 new inpatient medications Psychotropic medicationPsychotropic medication Infection Infection ICU admission ICU admission Hip fracture Hip fracture Dehydration Dehydration Environmental changeEnvironmental change Restraint use Restraint use Malnutrition Malnutrition Catheter use Catheter use Iatrogenic event Iatrogenic event

Screening - DeliriumScreening - Delirium Perform a short mental status assessment for Perform a short mental status assessment for

delirium at least daily in all hospitalized patients delirium at least daily in all hospitalized patients aged 70 or older aged 70 or older

Daily, Screen inpatients who are predisposed to Daily, Screen inpatients who are predisposed to delirium, including those with cognitive delirium, including those with cognitive impairment or multiple comorbidities and those impairment or multiple comorbidities and those admitted to the ICU admitted to the ICU

Use for assessment for delirium: Use for assessment for delirium: Confusion Assessment Method Confusion Assessment Method Mini-Mental Status Examination Mini-Mental Status Examination Remember Delirium can have various Remember Delirium can have various

Psychomotor variants – hypoactive, hyperactive, Psychomotor variants – hypoactive, hyperactive, mixed and normal psychomotor activitymixed and normal psychomotor activity

Confusion Assessment Confusion Assessment MethodMethod Confusion Assessment Method Instrument (CAM)Confusion Assessment Method Instrument (CAM)

Acute OnsetAcute Onset 1. Is there evidence of an acute change in mental status from the patient's baseline?_____YES 1. Is there evidence of an acute change in mental status from the patient's baseline?_____YES

_____NO _____UNCERTAIN _____NOT APPLICABLE _____NO _____UNCERTAIN _____NOT APPLICABLE

InattentionInattention (The questions listed under this topic are repeated for each topic where applicable.)(The questions listed under this topic are repeated for each topic where applicable.) 2A. Did the patient have difficulty focusing attention (for example, being easily distractible or having 2A. Did the patient have difficulty focusing attention (for example, being easily distractible or having

difficulty keeping track of what was being said)? _____Not present at any time during interview difficulty keeping track of what was being said)? _____Not present at any time during interview _____Present at some time during interview, but in mild form _____Present at some time during _____Present at some time during interview, but in mild form _____Present at some time during interview, in marked form _____Uncertaininterview, in marked form _____Uncertain

2B. 2B. (If present or abnormal)(If present or abnormal) Did this behavior fluctuate during the interview (that is tend to come Did this behavior fluctuate during the interview (that is tend to come and go or increase and decrease in severity)? _____YES _____NO _____UNCERTAIN_____NOT and go or increase and decrease in severity)? _____YES _____NO _____UNCERTAIN_____NOT APPLICABLE 2C. (APPLICABLE 2C. (If present or abnormal)If present or abnormal) Please describe this behaviour: Please describe this behaviour:

Disorganized ThinkingDisorganized Thinking 3. Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant 3. Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant

conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? _____YES _____NO _____UNCERTAIN _____NOT APPLICABLE _____YES _____NO _____UNCERTAIN _____NOT APPLICABLE

Altered Level of ConsciousnessAltered Level of Consciousness 4. Overall, how would you rate this patient's level of 4. Overall, how would you rate this patient's level of consciousness? _____Alert consciousness? _____Alert (normal)(normal) _____Vigilant _____Vigilant (hyperalert, overly sensitive to environmental (hyperalert, overly sensitive to environmental stimuli, startled very easily)stimuli, startled very easily) _____Lethargic _____Lethargic (drowsy, easily aroused)(drowsy, easily aroused) _____Stupor _____Stupor (difficult to (difficult to arouse)arouse) _____Coma _____Coma (unarousable)(unarousable) _____Uncertain _____Uncertain

CAM - ScoringCAM - Scoring

To have a positive CAM result, the patient must display:To have a positive CAM result, the patient must display:

1. Presence of 1. Presence of acute onsetacute onset and and fluctuating discourcefluctuating discource

ANDAND

2. 2. InattentionInattention

AND AND EITHER EITHER

3. Disorganized thinking3. Disorganized thinking

OR OR

4. Altered level of consciousness 4. Altered level of consciousness

Differential DiagnosisDifferential DiagnosisDifferential diagnoses include: Differential diagnoses include: Dementia Dementia Depression Depression Partial syndrome of delirium Partial syndrome of delirium Bipolar disease Bipolar disease Note that any Note that any acute changeacute change in mental status in mental status

should be considered delirium until proven should be considered delirium until proven otherwise because of reversibility and the otherwise because of reversibility and the consequences of missing the diagnosis. consequences of missing the diagnosis.

In hospitalized patients with altered cognition, In hospitalized patients with altered cognition, assess delirium first, followed by partial syndrome assess delirium first, followed by partial syndrome of delirium, depression, and then dementia. of delirium, depression, and then dementia.

Evaluating differential diagnosisEvaluating differential diagnosis1. Dementia1. DementiaInsidious onset, slow progression, level of consciousness is usually normal, Insidious onset, slow progression, level of consciousness is usually normal,

attention is preserved until late in the courseattention is preserved until late in the course Any acute mental status change in a demented patient is likely to be Any acute mental status change in a demented patient is likely to be

superimposed delirium. Dementia (or cognitive impairment) is a strong risk superimposed delirium. Dementia (or cognitive impairment) is a strong risk factor for delirium; the two disorders commonly co-exist factor for delirium; the two disorders commonly co-exist

2. Depression2. Depression Depressed mood is present. Psychomotor retardation or agitation also may be Depressed mood is present. Psychomotor retardation or agitation also may be

present. present. Level of consciousness and attention is usually normal Level of consciousness and attention is usually normal A study showed that one third of consults for “depression” in the hospital were A study showed that one third of consults for “depression” in the hospital were

hypoactive delirium hypoactive delirium 3. Bipolar disease, especially acute mania3. Bipolar disease, especially acute mania Acute mania may be confused with hyperactive delirium, but is less common Acute mania may be confused with hyperactive delirium, but is less common

in the elderly. Usually the changes and fluctuations in the elderly. Usually the changes and fluctuations are less acuteare less acute than than delirium. Inattention, disorganized thinking, and psychomotor agitation may be delirium. Inattention, disorganized thinking, and psychomotor agitation may be presentpresent

Bipolar disease Bipolar disease rarely presents in old agerarely presents in old age. Patients with this disease usually . Patients with this disease usually have a history of psychiatric illness or are taking medications that suggest the have a history of psychiatric illness or are taking medications that suggest the diagnosis. diagnosis. If in doubt, perform the full delirium work-upIf in doubt, perform the full delirium work-up

4. Partial syndrome of delirium4. Partial syndrome of delirium Patients show some of the characteristics of delirium, but not enough to fulfill Patients show some of the characteristics of delirium, but not enough to fulfill

all criteria. Sometimes progresses to full-blown deliriumall criteria. Sometimes progresses to full-blown delirium Associated with poor outcome and should be evaluated and treated similar to Associated with poor outcome and should be evaluated and treated similar to

“full-blown” delirium “full-blown” delirium

Ways to Prevent Hospital Ways to Prevent Hospital Delirium – high yieldDelirium – high yieldPrevent delirium in hospitalized patients by ensuring: Prevent delirium in hospitalized patients by ensuring: Assessment of multiple risk factors Assessment of multiple risk factors Cognitive Cognitive

impairment , Sleep deprivation , Immobility, Visual impairment , Sleep deprivation , Immobility, Visual impairment, Hearing impairment & Dehydration impairment, Hearing impairment & Dehydration

Targeted treatment to correct or reduce the impact of risk Targeted treatment to correct or reduce the impact of risk factors factors

Avoidance of medications deemed inappropriate for older Avoidance of medications deemed inappropriate for older patients patients

Geriatrics consultation Geriatrics consultation Nursing-based interventions Nursing-based interventions Consider proactive, preoperative geriatric consultation to Consider proactive, preoperative geriatric consultation to

reduce postoperative delirium in hip fracture patients reduce postoperative delirium in hip fracture patients

Managing DeliriumManaging Delirium1. 1. Remove contributing factors, such asRemove contributing factors, such as: : Offending medications , Fluid and electrolyte Offending medications , Fluid and electrolyte

abnormalities , Severe pain , Hypoxemia , Severe abnormalities , Severe pain , Hypoxemia , Severe anemia , Infections , Sensory deprivation anemia , Infections , Sensory deprivation

2. 2. Maintain behavior control through behavioral or Maintain behavior control through behavioral or social measures rather than pharmacologic or social measures rather than pharmacologic or physical restraints. physical restraints.

Note that a family member or caregiver will often Note that a family member or caregiver will often ameliorate mild to moderate agitation; hiring a “sitter” or ameliorate mild to moderate agitation; hiring a “sitter” or keeping the patient near the nursing station may be keeping the patient near the nursing station may be adequate. adequate.

Be aware that treatment with sedating medications may Be aware that treatment with sedating medications may be necessary for severe or life-threatening agitation. be necessary for severe or life-threatening agitation. There is no rationale for treating hypoactive delirium with There is no rationale for treating hypoactive delirium with sedating medications. sedating medications.

Avoid use of physical restraints unless no safer alternative Avoid use of physical restraints unless no safer alternative is feasible and the patient is physically endangering self or is feasible and the patient is physically endangering self or others. others.

Managing DeliriumManaging DeliriumRecognize that patients with delirium are vulnerable and require Recognize that patients with delirium are vulnerable and require

attentive supportive care to meet their needs and avoid iatrogenic attentive supportive care to meet their needs and avoid iatrogenic complications. complications.

Minimize indwelling catheters and other “tethers” such as intravenous Minimize indwelling catheters and other “tethers” such as intravenous lines, EKG leads, and restraints; let the patient out of bed as soon as lines, EKG leads, and restraints; let the patient out of bed as soon as possible. possible.

Monitor urinary and bowel output, and avoid urinary retention and fecal Monitor urinary and bowel output, and avoid urinary retention and fecal impaction which can contribute to delirium. impaction which can contribute to delirium.

Pay careful attention to nutrition, including assistance with meals and Pay careful attention to nutrition, including assistance with meals and possible hand feeding—delirious patients may have difficulty attending to possible hand feeding—delirious patients may have difficulty attending to food and are at risk for acute malnutrition. food and are at risk for acute malnutrition.

Provide adequate sensory input, including use of glasses and hearing Provide adequate sensory input, including use of glasses and hearing aids, provision of clocks, calendar, and adequate lighting, and appropriate aids, provision of clocks, calendar, and adequate lighting, and appropriate interpersonal contact. interpersonal contact.

Be aware that frequent orientation and structured interpersonal contact Be aware that frequent orientation and structured interpersonal contact may facilitate cognitive “reconditioning.” may facilitate cognitive “reconditioning.”

Recognize that environmental modifications such as minimizing staff Recognize that environmental modifications such as minimizing staff noise, use of vibrating (silent) pagers, eliminating waking for vital signs noise, use of vibrating (silent) pagers, eliminating waking for vital signs except if essential, and reduced lighting at the nursing station may except if essential, and reduced lighting at the nursing station may improve sleep at night. improve sleep at night.

Managing DeliriumManaging DeliriumConsider using drugs to manage agitation in Consider using drugs to manage agitation in

delirium, but not at the risk of worsening or delirium, but not at the risk of worsening or prolonging the delirium itself. prolonging the delirium itself.

Note that haloperidol and risperidone should be Note that haloperidol and risperidone should be considered as the “least of the evils” and should considered as the “least of the evils” and should only be used in life-threatening circumstances only be used in life-threatening circumstances (such as in the ICU) or when behavioral (such as in the ICU) or when behavioral measures have been ineffective. measures have been ineffective.

Use the lowest dose of the least toxic agent that Use the lowest dose of the least toxic agent that successfully controls the agitation. successfully controls the agitation.

Note that haloperidol in low doses is equally Note that haloperidol in low doses is equally efficacious as atypical antipsychotics and may be efficacious as atypical antipsychotics and may be less likely to cause oversedation, hemodynamic less likely to cause oversedation, hemodynamic compromise, or respiratory depression compared compromise, or respiratory depression compared to benzodiazepines. to benzodiazepines.

Drug Rx for agitation Drug Rx for agitation associated with Deliriumassociated with Delirium

1. Haloperidol : Usually agent of choice1. Haloperidol : Usually agent of choice Advantages: Relatively non-sedating. Few hemodynamic effects. May prevent Advantages: Relatively non-sedating. Few hemodynamic effects. May prevent

delirium following hip surgerydelirium following hip surgery Side effects : Extrapyramidal symptoms, especially if >2 mg/d, Neuroleptic Side effects : Extrapyramidal symptoms, especially if >2 mg/d, Neuroleptic

malignant syndromemalignant syndrome Evidence: In a randomized trial comparing haloperidol, chlorpromazine, and Evidence: In a randomized trial comparing haloperidol, chlorpromazine, and

lorazepam in the treatment of agitated delirium in young patients with AIDS, lorazepam in the treatment of agitated delirium in young patients with AIDS, haloperidol had fewer side effects or adverse sequelae . Haloperidol may haloperidol had fewer side effects or adverse sequelae . Haloperidol may prevent delirium following hip surgery prevent delirium following hip surgery

2. Olanzapine : 2. Olanzapine : Advantages : Increased sedationAdvantages : Increased sedation Side effects : Hyperglycemia, May have fewer extrapyramidal side effects Side effects : Hyperglycemia, May have fewer extrapyramidal side effects 3. Risperidone: 3. Risperidone: Benefits : Similar to haloperidol, Relatively nonsedating, Few hemodynamic effectsBenefits : Similar to haloperidol, Relatively nonsedating, Few hemodynamic effectsMay have fewer extrapyramidal symptomsMay have fewer extrapyramidal symptoms4. Lorazepam :4. Lorazepam : Benefits : Second line agent. However, first line in cases of Use in delirium due Benefits : Second line agent. However, first line in cases of Use in delirium due

to alcohol withdrawal, patients with Parkinson's disease, patients with history to alcohol withdrawal, patients with Parkinson's disease, patients with history of neuroleptic malignant syndrome of neuroleptic malignant syndrome

Disadvantages : More paradoxical excitation, respiratory depression than haldol Disadvantages : More paradoxical excitation, respiratory depression than haldol

Serotonin Serotonin SyndromeSyndrome- Occurs in a setting of a serotinergic drug ( refer the list) - Occurs in a setting of a serotinergic drug ( refer the list) can occur at can occur at therapeutic doses, over dosage or as an inadvertant interaction between therapeutic doses, over dosage or as an inadvertant interaction between the drugs.the drugs.-Be aware of differentiating NMS from Serotonin Syndrome as patients Be aware of differentiating NMS from Serotonin Syndrome as patients may be on both types of drugs at same time ( eg: pts with bipolar may be on both types of drugs at same time ( eg: pts with bipolar disorder may be may be on an antimanic drug/antipsychotic + SSRI)disorder may be may be on an antimanic drug/antipsychotic + SSRI)- Be aware that classic features such as muscular hypertonicity and Be aware that classic features such as muscular hypertonicity and hyperthermia occur only in life threatening cases. Recognize that it has a hyperthermia occur only in life threatening cases. Recognize that it has a spectrum of clinical features.spectrum of clinical features.- Recognize that Clonus and Hyperreflexia are highly suggestive of Recognize that Clonus and Hyperreflexia are highly suggestive of serotonin syndrome in mild to moderate cases.serotonin syndrome in mild to moderate cases.- Remember that if there is severe muscle rigidity ( hypertonicity ), it can Remember that if there is severe muscle rigidity ( hypertonicity ), it can mask the diagnostic features of serotonin syndrome such as clonus and mask the diagnostic features of serotonin syndrome such as clonus and hyperreflexiahyperreflexia

A Case That Shook Medicine

How One Man's Rage Over His Daughter's Death Sped Reform of Doctor TrainingBy Barron H. Lerner

Special to The Washington PostTuesday, November 28, 2006; Page HE01

Many people have vowed to avenge the untimely death of a relative. Lawyer and journalist Sidney Zion actually did so -- to the benefit of patients and

doctors-in-training nationwide.

“ “ Libby Zion (18) dies in 1984 of Libby Zion (18) dies in 1984 of an interaction between an interaction between Meperidine and PhenelzineMeperidine and Phenelzine””

Physical ExamPhysical Exam

Physical examination should include a Physical examination should include a focused assessment of deep-tendon focused assessment of deep-tendon reflexes, clonus, and muscle rigidity, in reflexes, clonus, and muscle rigidity, in addition to an evaluation of the size and addition to an evaluation of the size and reactivity of the pupils, the dryness of the reactivity of the pupils, the dryness of the oral mucosa, the intensity of bowel sounds, oral mucosa, the intensity of bowel sounds, skin color, and the presence or absence of skin color, and the presence or absence of diaphoresis. diaphoresis.

Spectrum of Clinical FeaturesSpectrum of Clinical Features

Drugs and Drug Interactions Associated with the Serotonin Syndrome

Caution!Caution! Remember Remember Administration of serotonergic agents Administration of serotonergic agents

within within five weeksfive weeks after the discontinuation of fluoxetine after the discontinuation of fluoxetine therapy has produced a drug interaction culminating in therapy has produced a drug interaction culminating in the serotonin syndrome, presumably the result of the the serotonin syndrome, presumably the result of the demethylation of fluoxetine to norfluoxetine, a demethylation of fluoxetine to norfluoxetine, a serotonergic metabolite with a longer serum half-life serotonergic metabolite with a longer serum half-life than its parent compound than its parent compound

Remember Serotonin is metabolized by MAO-A to 5-Remember Serotonin is metabolized by MAO-A to 5-HIAA HIAA Specific drugs, such as MAOIs that are Specific drugs, such as MAOIs that are irreversible or nonselective or that inhibit monoamine irreversible or nonselective or that inhibit monoamine oxidase subtype A, are strongly associated with severe oxidase subtype A, are strongly associated with severe cases of the syndrome, especially when these agents cases of the syndrome, especially when these agents are used in combination with meperidine, are used in combination with meperidine, dextromethorphan, SSRIs, or dextromethorphan, SSRIs, or methylenedioxymethamphetamine (MDMA, or methylenedioxymethamphetamine (MDMA, or "ecstasy) eg: Interaction b/w Phenelzine ( MAO – A "ecstasy) eg: Interaction b/w Phenelzine ( MAO – A inhibitor) and Meperidine has lead to death of a patient inhibitor) and Meperidine has lead to death of a patient

Findings in Patient with Moderately Severe Findings in Patient with Moderately Severe

SerotoniSyndromeSerotoniSyndrome

Hyperkinetic neuromuscular findings of tremor or clonus and hyperreflexia should Hyperkinetic neuromuscular findings of tremor or clonus and hyperreflexia should lead the clinician to consider the diagnosis of the serotonin syndrome.lead the clinician to consider the diagnosis of the serotonin syndrome.

Remember “MYDRIASIS” is the KEY. Where as in Neuroleptic Malignant Sydrome Remember “MYDRIASIS” is the KEY. Where as in Neuroleptic Malignant Sydrome you will usually see Normal sized pupils you will usually see Normal sized pupils

Algorithm for DiagnosisAlgorithm for Diagnosis

The neuromuscular features of clonus and hyperreflexia are highly diagnostic The neuromuscular features of clonus and hyperreflexia are highly diagnostic for the serotonin syndrome, and their occurrence in the setting of for the serotonin syndrome, and their occurrence in the setting of serotonergic drug use establishes the diagnosis. Clinicians should be aware serotonergic drug use establishes the diagnosis. Clinicians should be aware that muscle rigidity can overwhelm other neuromuscular findings and mask that muscle rigidity can overwhelm other neuromuscular findings and mask the diagnosis the diagnosis

Lab AnomaliesLab Anomalies

Laboratory abnormalities that occur in Laboratory abnormalities that occur in severe cases include metabolic acidosis, severe cases include metabolic acidosis, rhabdomyolysis, elevated levels of serum rhabdomyolysis, elevated levels of serum aminotransferases and creatinine, seizures, aminotransferases and creatinine, seizures, renal failure, and disseminated renal failure, and disseminated intravascular coagulopathy.intravascular coagulopathy.

Many of these abnormalities arise, Many of these abnormalities arise, however, as a consequence of poorly however, as a consequence of poorly treated hyperthermia. treated hyperthermia.

ManagementManagement Discontinue the precipitant drug.Discontinue the precipitant drug.

Mild cases ( hyperreflexia and tremor but no fever) Mild cases ( hyperreflexia and tremor but no fever) supportive care ( IV supportive care ( IV Fluids, vitals), Benzodiazepenes ( to control agitation and provide Fluids, vitals), Benzodiazepenes ( to control agitation and provide sedation)sedation)

Moderate cases Moderate cases address cardiorespiratory and thermal abnormalities, address cardiorespiratory and thermal abnormalities, give 5HT2a Antagonists ( Cyproheptadine is first choice or give 5HT2a Antagonists ( Cyproheptadine is first choice or Chlorpromozine as alternative)Chlorpromozine as alternative)

Hyperthermic pts with temp > 41C Hyperthermic pts with temp > 41C give above therapies + sedation + give above therapies + sedation + neuromuscular paralysis ( vecuronium) + orotracheal Intubation. Control neuromuscular paralysis ( vecuronium) + orotracheal Intubation. Control of hyperthermia needs eliminating excessive muscle activity of hyperthermia needs eliminating excessive muscle activity hence hence induce neuromuscular paralysis with Vecuronium followed by orotracheal induce neuromuscular paralysis with Vecuronium followed by orotracheal intubation and ventilationintubation and ventilation

There is no role for antipyretic agents in the management of the serotonin There is no role for antipyretic agents in the management of the serotonin syndrome; the increase in body temperature is due to muscular activity, syndrome; the increase in body temperature is due to muscular activity, not an alteration in the hypothalamic temperature set point. not an alteration in the hypothalamic temperature set point.

Dantrolene, a centrally acting muscle relaxant is not useful hereDantrolene, a centrally acting muscle relaxant is not useful here Bromocriptine which is used in NMS, has no role here Bromocriptine which is used in NMS, has no role here in fact, it may in fact, it may

worsen serotinergic signs.worsen serotinergic signs.

Differential DiagnosisDifferential Diagnosis Anticholinergic PoisoningAnticholinergic Poisoning

Patients with the anticholinergic syndrome have Patients with the anticholinergic syndrome have normal reflexes and show the "toxidrome" of normal reflexes and show the "toxidrome" of mydriasismydriasis; ; agitated deliriumagitated delirium; ; dry oral mucosadry oral mucosa; ; hot, hot, dry, erythematous skindry, erythematous skin; ; urinary retentionurinary retention; and ; and an an absence of bowel soundsabsence of bowel sounds. .

Hyperactive bowel sounds - along with Hyperactive bowel sounds - along with neuromuscular abnormalities neuromuscular abnormalities (clonus/hyperreflexia/rigidity), diaphoresis, and (clonus/hyperreflexia/rigidity), diaphoresis, and normal skin color — distinguish the serotonin normal skin color — distinguish the serotonin syndrome from the anticholinergic toxidrome syndrome from the anticholinergic toxidrome

Differential DiagnosisDifferential Diagnosis Neuroleptic Malignant Syndrome Neuroleptic Malignant Syndrome Neuroleptic malignant syndrome is Neuroleptic malignant syndrome is

an an idiopathic ( idiosyncratic) idiopathic ( idiosyncratic) reaction to dopamine antagonists, a reaction to dopamine antagonists, a condition that is defined by a condition that is defined by a slow onsetslow onset, , bradykinesia or akinesiabradykinesia or akinesia, , "lead "lead pipe" muscular rigiditypipe" muscular rigidity, , hyperthermiahyperthermia, fluctuating consciousness, and , fluctuating consciousness, and autonomic instability (HYPER/HYPOTENSION)autonomic instability (HYPER/HYPOTENSION). .

Remember that Hyperthermia in response to neuroleptic administration Remember that Hyperthermia in response to neuroleptic administration is an idiopathic response; the normal outcome is hypothermia. is an idiopathic response; the normal outcome is hypothermia.

Signs and symptoms of the neuroleptic malignant syndrome typically Signs and symptoms of the neuroleptic malignant syndrome typically evolve evolve during several days, in contrast to the rapid onset and hyperkinesia of the serotonin syndrome. ( In NMS, you have rigidity . ( In NMS, you have rigidity but no Hyperkinesia. However, as discussed earlier in severe cases of but no Hyperkinesia. However, as discussed earlier in severe cases of serotonin syndrome, severe rigidity can mask these hyperkinetic serotonin syndrome, severe rigidity can mask these hyperkinetic neuromuscular findings ( clonus/ hypereflexia etc) neuromuscular findings ( clonus/ hypereflexia etc) so, look at so, look at pupillary size as next step in differentiation. In Serotonin Syndrome, you pupillary size as next step in differentiation. In Serotonin Syndrome, you have Mydriasis.have Mydriasis.

Knowledge of the precipitating drug also helps in distinguishing between Knowledge of the precipitating drug also helps in distinguishing between syndromes: dopamine antagonists produce bradykinesia, whereas syndromes: dopamine antagonists produce bradykinesia, whereas serotonin agonists produce hyperkinesia ( Clonus and Hyperreflexia)serotonin agonists produce hyperkinesia ( Clonus and Hyperreflexia)

Differential DiagnosisDifferential Diagnosis Malignant HyperthermiaMalignant Hyperthermia Malignant hyperthermia is a pharmacogenetic disorder Malignant hyperthermia is a pharmacogenetic disorder

characterized by increasing concentrations of end-tidal characterized by increasing concentrations of end-tidal carbon dioxide, hypertonicity (rigidity) , hyperthermia, and carbon dioxide, hypertonicity (rigidity) , hyperthermia, and metabolic acidosis. metabolic acidosis.

The disorder occurs within minutes after exposure to The disorder occurs within minutes after exposure to inhalational anesthetic agents. Also, seen with inhalational anesthetic agents. Also, seen with Succinylcholine. Succinylcholine.

On physical examination, the On physical examination, the skin is often mottled, with skin is often mottled, with cyanotic areas contrasting with patches of bright red cyanotic areas contrasting with patches of bright red flushingflushing. . The rigor mortis–like rigidity of skeletal muscles The rigor mortis–like rigidity of skeletal muscles and “hyporeflexia” that are seen in malignant hyperthermia and “hyporeflexia” that are seen in malignant hyperthermia further distinguish this condition from the serotonin further distinguish this condition from the serotonin syndrome syndrome

Rx – Dantrolene, Supportive careRx – Dantrolene, Supportive care

DementiaDementia

Check Neurology SlidesCheck Neurology Slides

DepressionDepression

Depression - PreventionDepression - Prevention Offer counseling to patients who have Offer counseling to patients who have

experienced stressful events, trauma, or losses. experienced stressful events, trauma, or losses. Inquire about previous episodes of depression in Inquire about previous episodes of depression in

patients currently without symptoms of patients currently without symptoms of depression, and stress the importance of early depression, and stress the importance of early intervention. intervention.

Screen for symptoms of depression in women Screen for symptoms of depression in women during the 4 to 6 weeks after giving birth, during the 4 to 6 weeks after giving birth, particularly in women with psychosocial stress particularly in women with psychosocial stress during pregnancy and history of psychiatric during pregnancy and history of psychiatric disorder. disorder.

Consider antepartum counseling for women with Consider antepartum counseling for women with risk factors for postpartum depression risk factors for postpartum depression

DSM IV Criteria for DepressionDSM IV Criteria for Depression A) Five or more of the following symptoms have been present during the same 2-week A) Five or more of the following symptoms have been present during the same 2-week

period and represent a change from previous functioning; at least one of the period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure.symptoms is either 1) depressed mood or 2) loss of interest or pleasure.

1) Depressed mood most of the day, nearly every day as self-reported or observed by 1) Depressed mood most of the day, nearly every day as self-reported or observed by others.others.

2) Diminished interest or pleasure in all or almost all activities most of the day, nearly 2) Diminished interest or pleasure in all or almost all activities most of the day, nearly every day.every day.

3) Significant weight loss when not dieting, or weight gain; or decrease or increase in 3) Significant weight loss when not dieting, or weight gain; or decrease or increase in appetite nearly every day.appetite nearly every day.

4) Insomnia or hypersomnia nearly every day.4) Insomnia or hypersomnia nearly every day. 5) Psychomotor agitation or retardation nearly every day5) Psychomotor agitation or retardation nearly every day 6) Fatigue or loss of energy nearly every day.6) Fatigue or loss of energy nearly every day. 7) Feelings of worthlessness or excessive or inappropriate guilt nearly every day.7) Feelings of worthlessness or excessive or inappropriate guilt nearly every day. 8) Diminished ability to think or concentrate nearly every day.8) Diminished ability to think or concentrate nearly every day. 9) Recurrent thoughts of death, recurrent suicidal ideation without a specific plan.9) Recurrent thoughts of death, recurrent suicidal ideation without a specific plan. B) The symptoms do not meet criteria for a mixed episodeB) The symptoms do not meet criteria for a mixed episode C) The symptoms cause clinically significant distress or impairment in social, C) The symptoms cause clinically significant distress or impairment in social,

occupational, or other areas of functioning.occupational, or other areas of functioning. D) The symptoms are not due to the direct physiological effects of a substance (drug D) The symptoms are not due to the direct physiological effects of a substance (drug

or medication) or a general medical condition (hypothyroidism).or medication) or a general medical condition (hypothyroidism). E) The symptoms are not better accounted for by bereavement, i.e., after the loss of a E) The symptoms are not better accounted for by bereavement, i.e., after the loss of a

loved one, loved one, the symptoms persist for longer than 2 months or are characterized the symptoms persist for longer than 2 months or are characterized by marked functional impairmentby marked functional impairment, morbid preoccupation with worthlessness, , morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.suicidal ideation, psychotic symptoms, or psychomotor retardation.

D/DD/D Medical Disorders Medical Disorders Recognize that there is an increased prevalence of depression in the Recognize that there is an increased prevalence of depression in the

following conditions: following conditions: Medical conditions: Medical conditions:

Hypothyroidism Hypothyroidism Cushing's disease Cushing's disease Dementia Dementia Parkinson's disease Parkinson's disease Stroke Stroke Multiple sclerosis Multiple sclerosis Cancer Cancer Diabetes Diabetes Coronary heart disease Coronary heart disease Fibromyalgia and other chronic pain states Fibromyalgia and other chronic pain states Chronic fatigue syndrome Chronic fatigue syndrome Vitamin B12 deficiency Vitamin B12 deficiency Infectious disease such as TB, viral hepatitis Infectious disease such as TB, viral hepatitis

Prescription drug effects: Prescription drug effects: Glucocorticoids Glucocorticoids Interferon Interferon Reserpine and other centrally acting antihypertensives Reserpine and other centrally acting antihypertensives

Substance abuse: Substance abuse: Anabolic steroids Anabolic steroids Ethyl alcohol Ethyl alcohol Cocaine or amphetamine withdrawal Cocaine or amphetamine withdrawal

D/DD/DMOOD DISORDERS : Differentiate major MOOD DISORDERS : Differentiate major

depression from other mood syndromes depression from other mood syndromes using DSM-IV criteria including: using DSM-IV criteria including:

Dysthymic disorder Dysthymic disorder Bipolar disorder Bipolar disorder Minor depression Minor depression Situational adjustment reaction with Situational adjustment reaction with

depressed mood depressed mood Grief Grief Seasonal affective disorder Seasonal affective disorder

D/D D/D Dysthymia : Dysthymia is a chronic mood disorder Dysthymia : Dysthymia is a chronic mood disorder

characterized by depressed mood or anhedonia at least characterized by depressed mood or anhedonia at least half the time for at least 2 years accompanied by two or half the time for at least 2 years accompanied by two or more vegetative or psychological symptoms and functional more vegetative or psychological symptoms and functional impairment. Rx : Antidepressantsimpairment. Rx : Antidepressants

Situational adjustment reaction with depressed mood : Situational adjustment reaction with depressed mood : Subsyndromal depression with Subsyndromal depression with clear precipitant.clear precipitant. Usually Usually resolves with resolution of acute stressor without resolves with resolution of acute stressor without medication . Supportive counselling and identification of medication . Supportive counselling and identification of stressor is required.stressor is required.

Seasonal Affective disorder : A subtype of major Seasonal Affective disorder : A subtype of major depression, occurring with seasonal change, typically fall depression, occurring with seasonal change, typically fall or winter onset and seasonal remission, rarely onset is in or winter onset and seasonal remission, rarely onset is in the spring with remission in the fall or winter. It should the spring with remission in the fall or winter. It should have occurred in the two previous years, without have occurred in the two previous years, without nonseasonal depression. More common in northern nonseasonal depression. More common in northern latitudes latitudes Responds to bright-light therapy and adjuvant Responds to bright-light therapy and adjuvant therapy with SSRIs therapy with SSRIs

D/DD/D Premenstrual Dysphoric disorder: Characterized by depressed mood, anxiety, Premenstrual Dysphoric disorder: Characterized by depressed mood, anxiety,

and irritability during the week before menses, resolving with menses and irritability during the week before menses, resolving with menses May May respond to SSRI treatment; intermittent treatment during part of the menstrual respond to SSRI treatment; intermittent treatment during part of the menstrual cycle may be effective cycle may be effective

Grief Reaction : The syndrome of major depression may be transiently present Grief Reaction : The syndrome of major depression may be transiently present in normal grief, however sadness without the complete syndrome is more in normal grief, however sadness without the complete syndrome is more common. Duration, intensity of symptoms, and associated change in function is common. Duration, intensity of symptoms, and associated change in function is variable and commonly affected by cultural and societal factors variable and commonly affected by cultural and societal factors Pervasive Pervasive and generalized guilt and persistent vegetative signs and symptoms that are and generalized guilt and persistent vegetative signs and symptoms that are not consistent with the patient's or family's expectations for normal grief should not consistent with the patient's or family's expectations for normal grief should arouse concern arouse concern Bereavement is often a precipitant of true mood disorder, Bereavement is often a precipitant of true mood disorder, and patients in this state should be carefully assessed and followed. and patients in this state should be carefully assessed and followed. do do supportive counseling . Remember supportive counseling . Remember Loss of self-esteem and Anhedonia is a Loss of self-esteem and Anhedonia is a symptom of depression rather than griefsymptom of depression rather than grief

Dementia : Characterized by impaired memory, judgement and other higher Dementia : Characterized by impaired memory, judgement and other higher cortical functions cortical functions see DEMENTIA Slides see DEMENTIA Slides

Anxiety disorderAnxiety disorder Psychotic disorders ( thought disorders) : Major depression may be Psychotic disorders ( thought disorders) : Major depression may be

accompanied by mood congruent hallucinations/ delusions ( where as mood accompanied by mood congruent hallucinations/ delusions ( where as mood incongruent delusions/ hallucinations may suggest a primary psychotic incongruent delusions/ hallucinations may suggest a primary psychotic disorder. )disorder. )

Depression – Indications for hospitalizationDepression – Indications for hospitalization

Hospitalize patients: Hospitalize patients: With significant suicidal ideation or intent who do not have With significant suicidal ideation or intent who do not have

adequate safeguards in their family environment adequate safeguards in their family environment With intent to hurt others With intent to hurt others To assess their ability to care for themselves and adhere To assess their ability to care for themselves and adhere

to their treatment in light of the supports available in their to their treatment in light of the supports available in their home environment home environment

Who are in need of detoxification or substance abuse Who are in need of detoxification or substance abuse treatment treatment

Who are candidates for ECT Who are candidates for ECT With comorbid dysfunctional family systems that With comorbid dysfunctional family systems that

exacerbate their depressive disorder or interfere with exacerbate their depressive disorder or interfere with treatment treatment

Depression – Drug therapyDepression – Drug therapyA. Treat first episodes of depression to achieve complete A. Treat first episodes of depression to achieve complete

remission, and continue treatment for 4 to 9 months remission, and continue treatment for 4 to 9 months thereafter. thereafter.

Aim for complete remission of symptoms and return to Aim for complete remission of symptoms and return to normal functioning. normal functioning.

If remission is not achieved with the initial antidepressant, If remission is not achieved with the initial antidepressant, switch to another agent or consider adding or switching to switch to another agent or consider adding or switching to cognitive therapy. cognitive therapy.

In first episodes, continue treatment with antidepressant In first episodes, continue treatment with antidepressant medication at the same dosage required to achieve medication at the same dosage required to achieve remission for an additional 4 to 9 months. remission for an additional 4 to 9 months.

Consider long-term maintenance therapy in patients over Consider long-term maintenance therapy in patients over age 70 and in those with diabetes mellitus. age 70 and in those with diabetes mellitus.

B. Treat recurrences of major depression with long-term B. Treat recurrences of major depression with long-term maintenance therapy maintenance therapy

Depression – Drug Depression – Drug therapytherapy

Treat patients who are suffering a first recurrence of major depression for Treat patients who are suffering a first recurrence of major depression for longer than the initial episode. longer than the initial episode.

For first recurrence, consider maintenance treatment for one to two times For first recurrence, consider maintenance treatment for one to two times the interepisode interval, e.g., if the second episode occurs 18 months the interepisode interval, e.g., if the second episode occurs 18 months after the first episode, the treatment should be 18 to 36 months. after the first episode, the treatment should be 18 to 36 months.

For older patients (>70 years) with major depression who respond to an For older patients (>70 years) with major depression who respond to an SSRI, consider treating for 2 years to prevent recurrence. SSRI, consider treating for 2 years to prevent recurrence.

Consider lifetime maintenance therapy for patients with three or more Consider lifetime maintenance therapy for patients with three or more recurrences or patients with a first recurrence and risk factors for further recurrences or patients with a first recurrence and risk factors for further recurrences including: recurrences including:

1.Family history of bipolar disorder 1.Family history of bipolar disorder 2. Recurrence within 1 year of successful treatment of previous 2. Recurrence within 1 year of successful treatment of previous

episode episode 3.Young age of onset (adolescent) 3.Young age of onset (adolescent) 4.Severe (debilitating or suicidal attempt) and sudden onset of 4.Severe (debilitating or suicidal attempt) and sudden onset of

symptoms symptoms

Depression – Drug TherapyDepression – Drug Therapy Counsel patients to improve Counsel patients to improve medication medication

adherenceadherence, emphasizing: , emphasizing: The importance of taking the medication daily The importance of taking the medication daily That symptomatic improvement may be noticed That symptomatic improvement may be noticed

within 1 week but often takes 2 to 4 weeks within 1 week but often takes 2 to 4 weeks That they must continue to take medicine even if That they must continue to take medicine even if

feeling better feeling better That they must not stop taking the antidepressant That they must not stop taking the antidepressant

without checking with their physician without checking with their physician Potential side effects Potential side effects Offer St. John's wort as a potential treatment for Offer St. John's wort as a potential treatment for

patients with mild to moderate depression or patients with mild to moderate depression or subsyndromal depression subsyndromal depression

Anti-Depressant DrugsAnti-Depressant DrugsA. SSRI : Fluoxetine, Duloxetine, Paroxetine, Citalopram, Fluvoxamine A. SSRI : Fluoxetine, Duloxetine, Paroxetine, Citalopram, Fluvoxamine Side Side

effects : Nausea and diarrhea, anxiety, nervousness, somnolence, impaired effects : Nausea and diarrhea, anxiety, nervousness, somnolence, impaired sexual function sexual function

All SSRIs are contraindicated with MAOIs in view of possible SEROTONIN All SSRIs are contraindicated with MAOIs in view of possible SEROTONIN SYNDROMESYNDROME

B. SNRI : Venlafaxine (Effexor), Mirtazepine Side effects : Gastrointestinal B. SNRI : Venlafaxine (Effexor), Mirtazepine Side effects : Gastrointestinal complaints (nausea, dry mouth, anorexia, constipation, and flatulence), complaints (nausea, dry mouth, anorexia, constipation, and flatulence), CNS complaints (dizziness, somnolence, insomnia, nervousness, abnormal CNS complaints (dizziness, somnolence, insomnia, nervousness, abnormal dreams, and tremor), sweating, abnormalities of sexual function (abnormal dreams, and tremor), sweating, abnormalities of sexual function (abnormal ejaculation and impotence in men, anorgasmia in women, and decreased ejaculation and impotence in men, anorgasmia in women, and decreased libido), problems of special senses (abnormal vision), cardiovascular effects libido), problems of special senses (abnormal vision), cardiovascular effects (hypertension and vasodilatation), and yawning (hypertension and vasodilatation), and yawning

C. Bupropion : Dopamine reuptake inhibitor, Advantage : very less weight gain. C. Bupropion : Dopamine reuptake inhibitor, Advantage : very less weight gain. Adverse effects : lowers seizure threshold, Anorexia, dry mouth, rash, Adverse effects : lowers seizure threshold, Anorexia, dry mouth, rash, sweating, tinnitus, tremor, abdominal pain, agitation, anxiety, dizziness, sweating, tinnitus, tremor, abdominal pain, agitation, anxiety, dizziness, insomnia, myalgia, nausea, palpitation, pharyngitis, and urinary frequency insomnia, myalgia, nausea, palpitation, pharyngitis, and urinary frequency

D. TCAs : Amitryptiline, Nortryptiline, Amoxapine, Imipramine, Clomipramine, D. TCAs : Amitryptiline, Nortryptiline, Amoxapine, Imipramine, Clomipramine, Side EffectsSide Effects : mainly anticholinergic : mainly anticholinergic Dry mouth, dizziness, constipation, Dry mouth, dizziness, constipation, nausea. Sedation, Anticholinergic hypotension, Orthostatic hypotension , nausea. Sedation, Anticholinergic hypotension, Orthostatic hypotension , Prolongs QT interval and can lead to Torsades depointes Prolongs QT interval and can lead to Torsades depointes

For pts with Torsades due to Tricyclic overdose , Admit to ICU and treat with For pts with Torsades due to Tricyclic overdose , Admit to ICU and treat with bicarbonate. If Torsades give magnesium and lidocaine. D/C all QT bicarbonate. If Torsades give magnesium and lidocaine. D/C all QT prolonging drugs.prolonging drugs.

E.E. Weight gain is a significant side effect, except with BupropionWeight gain is a significant side effect, except with BupropionF.F. Mirtazipine can cause Agranulocytosis – monitor blood counts, report to ER Mirtazipine can cause Agranulocytosis – monitor blood counts, report to ER

if sorethroat, fever, chills etc appearsif sorethroat, fever, chills etc appears

ST.Johns WortST.Johns Wort Definitive method of action unclear. Animal studies suggest Definitive method of action unclear. Animal studies suggest

St. John's wort may work by inhibition of serotonin uptake. St. John's wort may work by inhibition of serotonin uptake. HypericumHypericum extract also has been shown to decrease cell extract also has been shown to decrease cell surface 5-HT receptors surface 5-HT receptors

Attractive to patients with moderate depression who are Attractive to patients with moderate depression who are unwilling or unable to take conventional treatment. Adverse unwilling or unable to take conventional treatment. Adverse effects are generally mild effects are generally mild GI symptoms, dizziness or GI symptoms, dizziness or confusion, sedation, dry mouth, photosensitivity confusion, sedation, dry mouth, photosensitivity

St. John's wort activates cytochrome P450 and may reduce St. John's wort activates cytochrome P450 and may reduce the concentration of medications such as digoxin, the concentration of medications such as digoxin, theophylline, simvastatin, and warfarin.theophylline, simvastatin, and warfarin.

St. John's wort interferes with antiretroviral therapy by St. John's wort interferes with antiretroviral therapy by activating 3A4 isoform of cytochrome P450. This effect may activating 3A4 isoform of cytochrome P450. This effect may result in decreased concentrations of protease inhibitors and result in decreased concentrations of protease inhibitors and nonnucleoside reverse transcriptase inhibitors.nonnucleoside reverse transcriptase inhibitors.St. John's wort should not be used in conjunction with St. John's wort should not be used in conjunction with SSRIs, especially in the elderly, as it may cause symptoms SSRIs, especially in the elderly, as it may cause symptoms of serotonin excess (hyperthermia, tachycardia, diaphoresis, of serotonin excess (hyperthermia, tachycardia, diaphoresis, rigidity) rigidity)

Depression – Non drug therapyDepression – Non drug therapy Consider psychotherapeutic options including: Consider psychotherapeutic options including:

Cognitive therapy Cognitive therapy Interpersonal therapy Interpersonal therapy Problem-solving therapy Problem-solving therapy

Offer patients with mild to moderate depression Offer patients with mild to moderate depression psychotherapeutic options or drug therapy. Offer patients psychotherapeutic options or drug therapy. Offer patients with severe depression combination therapy with with severe depression combination therapy with psychotherapy and antidepressants psychotherapy and antidepressants

Consider Consider combined drug therapy and psychotherapycombined drug therapy and psychotherapy in in patients with mild to moderate depression, but recognize patients with mild to moderate depression, but recognize that there is limited available evidence showing added that there is limited available evidence showing added benefit. benefit.

Treat patients with dysthymia with antidepressant Treat patients with dysthymia with antidepressant medication, but note that psychotherapy may play a role medication, but note that psychotherapy may play a role in treating residual symptoms. in treating residual symptoms.

Treat patients with a history of major depression with Treat patients with a history of major depression with current subsyndromal depression using drug therapy to current subsyndromal depression using drug therapy to achieve complete remission and offer psychotherapy to achieve complete remission and offer psychotherapy to treat residual symptoms. treat residual symptoms.

Pregnancy & Mood disordersPregnancy & Mood disorders Understand peri-partum mood disordersUnderstand peri-partum mood disorders Differentiate post partum blues from post Differentiate post partum blues from post

partum depressionpartum depression Managing post partum blues and post Managing post partum blues and post

partum psychosispartum psychosis Which drugs are safe in treating mania in Which drugs are safe in treating mania in

pregnancy?pregnancy?

Mania - PregnancyMania - Pregnancy

Lithium is teratogenic (Ebstein anomaly )Lithium is teratogenic (Ebstein anomaly ) Valproic acid causes neural tube defects. Valproic acid causes neural tube defects. First trimester: Haloperidol for psychosis, clonazepam for First trimester: Haloperidol for psychosis, clonazepam for

agitation; if mood stabilizer is necessary, lithium may be first agitation; if mood stabilizer is necessary, lithium may be first choice ( category D drug, but risk may be acceptable given the choice ( category D drug, but risk may be acceptable given the problem of mania. ECT is an alternative ( but it as a problem of mania. ECT is an alternative ( but it as a monotherpay may not be sufficient for mood stabilization – monotherpay may not be sufficient for mood stabilization – ECT is safe in pregnancy, only issue might be fetal ECT is safe in pregnancy, only issue might be fetal arrhythmias).arrhythmias).

Second/Third trimester/Postpartum: Lithium or Second/Third trimester/Postpartum: Lithium or anticonvulsants, haloperidol and/or clonazepam if truly needed. anticonvulsants, haloperidol and/or clonazepam if truly needed. Continue treatment postpartum if no obstetric complications. Continue treatment postpartum if no obstetric complications. Follow breast-fed infants closelyFollow breast-fed infants closely

Eating DisordersEating Disorders

Screen these pts Screen these pts Ask direct questions to screen for abnormal eating Ask direct questions to screen for abnormal eating

practices (calorie restriction, binging, purging etc) practices (calorie restriction, binging, purging etc) in these groups:in these groups:

Adolescents participating in gymnastics, dance, Adolescents participating in gymnastics, dance, wrestling, swimming, and other athletic programs wrestling, swimming, and other athletic programs

Adolescents with chronic diseases Adolescents with chronic diseases Adolescents with a history of obsessive-Adolescents with a history of obsessive-

compulsive personality traits or childhood anxiety compulsive personality traits or childhood anxiety disorders disorders

Persons with a family history of eating disorders Persons with a family history of eating disorders

DiagnosisDiagnosisSymptoms: Symptoms: 1. Ask about diagnostic criteria: 1. Ask about diagnostic criteria: Eating and exercise patterns Eating and exercise patterns Weight and patterns of weight loss Weight and patterns of weight loss Attitudes about weight, body image, fear of weight gain Attitudes about weight, body image, fear of weight gain Amenorrhea or delayed menarche in females Amenorrhea or delayed menarche in females Use of diuretics, laxatives, or purging behaviors Use of diuretics, laxatives, or purging behaviors 2. Ask about medical complications: 2. Ask about medical complications: Abdominal pain Abdominal pain Bloating Bloating Constipation Constipation Cold intolerance Cold intolerance Dizziness, fatigue, and vague complaints Dizziness, fatigue, and vague complaints Loss of libido in both sexes Loss of libido in both sexes Changes in menstrual regularity, intensity, or duration in Changes in menstrual regularity, intensity, or duration in

females females

Diagnosis – Look on physicalDiagnosis – Look on physical Eroded tooth enamel from repeated forced Eroded tooth enamel from repeated forced

vomiting vomiting Hair and skin changes such as yellow skin and Hair and skin changes such as yellow skin and

lanugo lanugo Pitting edema or poor skin turgor Pitting edema or poor skin turgor Brittle nails Brittle nails Dry scaly skin Dry scaly skin Parotid gland swelling Parotid gland swelling Russell's sign or abrasions on the dorsum of the Russell's sign or abrasions on the dorsum of the

hand hand Muscle weakness and muscle wasting Muscle weakness and muscle wasting Discomfort or avoidance of being weighed Discomfort or avoidance of being weighed Weight loss recent > 10%Weight loss recent > 10%

Anorexia NervosaAnorexia Nervosa

Diagnose anorexia nervosa when all the Diagnose anorexia nervosa when all the following are present: following are present:

Intense fear of gaining weight Intense fear of gaining weight Undue emphasis on body shape Undue emphasis on body shape Body weight <85% of predicted Body weight <85% of predicted Amenorrhea for 3 consecutive months Amenorrhea for 3 consecutive months

Bulimia NervosaBulimia NervosaDiagnose bulimia nervosa when all the following are present: Diagnose bulimia nervosa when all the following are present:

Recurrent episodes of binge eating characterized by Recurrent episodes of binge eating characterized by eating a larger amount of food than most people would eating a larger amount of food than most people would eat in a discrete period and a sense of having no control eat in a discrete period and a sense of having no control over eating during the episode over eating during the episode

Recurrent, inappropriate, compulsive behavior to prevent Recurrent, inappropriate, compulsive behavior to prevent weight gain, such as self-induced vomiting; abuse of weight gain, such as self-induced vomiting; abuse of laxatives, diuretics, or other drugs; or excessive exerciselaxatives, diuretics, or other drugs; or excessive exercise

Binging and purging at least twice per week for 3 months Binging and purging at least twice per week for 3 months

Self-evaluation unduly influenced by body shape and Self-evaluation unduly influenced by body shape and weight weight

Complications – Eating DisordersComplications – Eating Disorders Cardiac arrhythmiasCardiac arrhythmias Congestive Heart FailureCongestive Heart Failure Electrolyte disturbancesElectrolyte disturbances AmenorrheaAmenorrhea OsteoporosisOsteoporosis Stress fracturesStress fractures EndocrinopathiesEndocrinopathies

LabsLabs1. Obtain the following lab values in all patients: 1. Obtain the following lab values in all patients: CBC, CBC, ElectrolytesElectrolytes, BUN , Creatinine, Glucose, , BUN , Creatinine, Glucose,

TSH TSH

2. Obtain the following lab values in 2. Obtain the following lab values in malnourished and symptomatic patients: malnourished and symptomatic patients:

Calcium, Calcium, MagnesiumMagnesium, , PhosphorusPhosphorus, Albumin , Albumin

Liver function, Liver function, ECG ECG

3. Obtain 3. Obtain FSH, LH, prolactin levels, and bone FSH, LH, prolactin levels, and bone densitometry if amenorrhea is present. densitometry if amenorrhea is present.

Differential DiagnosisDifferential Diagnosis Consider other medical causes of weight loss, Consider other medical causes of weight loss,

progressive weight loss, and amenorrhea, such progressive weight loss, and amenorrhea, such as: as:

Chronic infections Chronic infections Intestinal disorders with malabsorption Intestinal disorders with malabsorption Endocrinopathies Endocrinopathies Malignancy Malignancy Other psychiatric illnesses Other psychiatric illnesses Consider differential diagnosis early in Consider differential diagnosis early in

treatment, because patients may be in denial or treatment, because patients may be in denial or may withhold information concerning their fear of may withhold information concerning their fear of fat. fat.

DiagnosisDiagnosis Some step3 questions might give you a pt with Some step3 questions might give you a pt with

eating disorder and may ask you to figure out eating disorder and may ask you to figure out the next step by giving you clues through acid-the next step by giving you clues through acid-base, electrolyte imbalancesbase, electrolyte imbalances

Hypokalemia, hypochloremic Alkalosis seen Hypokalemia, hypochloremic Alkalosis seen with Vomitingwith Vomiting

Hypokalemia, Non anion gap Acidosis seen Hypokalemia, Non anion gap Acidosis seen with Laxative abuse with Laxative abuse Stool Laxative screen Stool Laxative screen

Hypokalemia, Metabolic Alkalosis seen with Hypokalemia, Metabolic Alkalosis seen with Diuretic abuse Diuretic abuse Urine Diuretic screen Urine Diuretic screen

Treatment – Eating DisordersTreatment – Eating DisordersHospitalize patient for: Hospitalize patient for: Severe malnutrition and associated complications: Severe malnutrition and associated complications:

Weight <75% of individually estimated healthy body Weight <75% of individually estimated healthy body Metabolic abnormalities: Metabolic abnormalities:

Potassium <3 mEq/L Potassium <3 mEq/L Marked orthostatic hypotension, with one of the following: Marked orthostatic hypotension, with one of the following:

An increase in pulse of >20 bpm An increase in pulse of >20 bpm Blood pressure <90/60 mm Hg Blood pressure <90/60 mm Hg A decrease in blood pressure of >20 mm Hg after standing A decrease in blood pressure of >20 mm Hg after standing

Bradycardia (heart rate <40 bpm) and other cardiac arrhythmias Bradycardia (heart rate <40 bpm) and other cardiac arrhythmias Inability to sustain core body temperature (<97°F [36.1°C]) Inability to sustain core body temperature (<97°F [36.1°C]) Signs of inadequate cerebral perfusion Signs of inadequate cerebral perfusion Signs of dehydration or hepatic, renal, or cardiovascular organ Signs of dehydration or hepatic, renal, or cardiovascular organ

compromise requiring acute treatment compromise requiring acute treatment Comorbid psychiatric problems that heighten suicidal risk Comorbid psychiatric problems that heighten suicidal risk

such as exacerbation of a mood disorder or severe alcohol such as exacerbation of a mood disorder or severe alcohol abuse abuse

Anorexia - RefeedingAnorexia - RefeedingUndertake refeeding of hospitalized patients with anorexia nervosa with care: Undertake refeeding of hospitalized patients with anorexia nervosa with care: Set a realistic weight gain target of 2 to 3 lbs per week Set a realistic weight gain target of 2 to 3 lbs per week Start intake levels at 30 to 40 kcal/kg per day (approximately 1000 to 1600 Start intake levels at 30 to 40 kcal/kg per day (approximately 1000 to 1600

kcal per day) and progressively increase to as high as 70 to 100 kcal/kg per kcal per day) and progressively increase to as high as 70 to 100 kcal/kg per day day

Monitor serum potassium levels regularly in patients who are persistent Monitor serum potassium levels regularly in patients who are persistent vomiters, and treat hypokalemia with oral or intravenous potassium vomiters, and treat hypokalemia with oral or intravenous potassium

When life-preserving nutrition must be provided to a patient who refuses to When life-preserving nutrition must be provided to a patient who refuses to eat, choose nasogastric over intravenous feedings eat, choose nasogastric over intravenous feedings

Monitor patients for refeeding syndrome, especially those being aggressively Monitor patients for refeeding syndrome, especially those being aggressively refed orally, enterally, or parenterally refed orally, enterally, or parenterally

At the initiation of treatment, monitor vital signs, food and fluid intake, and At the initiation of treatment, monitor vital signs, food and fluid intake, and output, and look for edema, rapid weight gain, signs of congestive heart output, and look for edema, rapid weight gain, signs of congestive heart failure, and gastrointestinal symptoms failure, and gastrointestinal symptoms

Monitor serum phosphorus, magnesium, potassium, and calcium daily for 5 Monitor serum phosphorus, magnesium, potassium, and calcium daily for 5 days after initiating refeeding and every other day for several weeks days after initiating refeeding and every other day for several weeks thereafter thereafter

Obtain ECGs as indicatedObtain ECGs as indicated Provide phosphorus, magnesium, and/or potassium supplementation when Provide phosphorus, magnesium, and/or potassium supplementation when

indicated indicated

Non-Drug therapyNon-Drug therapy

Recommend psychotherapy for all patients with Recommend psychotherapy for all patients with anorexia nervosa.anorexia nervosa.

Consider cognitive behavioral therapy for Consider cognitive behavioral therapy for patients with bulimia nervosa. Consider patients with bulimia nervosa. Consider medication (either fluoxetine or imipramine) in medication (either fluoxetine or imipramine) in conjunction with Cognitive Behavior therapy.conjunction with Cognitive Behavior therapy.

Recommend nutritional rehabilitation to all Recommend nutritional rehabilitation to all patients with anorexia nervosa and bulimia patients with anorexia nervosa and bulimia nervosa.nervosa.

Drug TherapyDrug TherapyConsider the following therapy options: Consider the following therapy options: Fluoxetine, 60 mg/d (one of the FDA-approved indications for Fluoxetine, 60 mg/d (one of the FDA-approved indications for

fluoxetine), or sertraline, 100 mg/d (not FDA approved), to fluoxetine), or sertraline, 100 mg/d (not FDA approved), to reduce the frequency of binge eating and purging (bulemia). reduce the frequency of binge eating and purging (bulemia). However, Psychotropic drugs have a minimal role in AnorexiaHowever, Psychotropic drugs have a minimal role in Anorexia

Ondansetron, a 5-HT3 antagonist, to decrease binge eating Ondansetron, a 5-HT3 antagonist, to decrease binge eating and purging and purging

Topiramate, a broad-spectrum anti-epileptic drug, to decrease Topiramate, a broad-spectrum anti-epileptic drug, to decrease binge eating and purging binge eating and purging

Light therapy in patients with bulimia nervosa with seasonal Light therapy in patients with bulimia nervosa with seasonal exacerbation of symptoms exacerbation of symptoms

Note that bupropion is contraindicated in the treatment of Note that bupropion is contraindicated in the treatment of eating disorders due to an elevated incidence of grand mal eating disorders due to an elevated incidence of grand mal seizures. seizures.

Start estrogen and progesterone replacement with combined Start estrogen and progesterone replacement with combined oral contraceptives in patients with anorexia who have been oral contraceptives in patients with anorexia who have been amenorrheic for more than 3 months to preserve bone mass amenorrheic for more than 3 months to preserve bone mass

Exercise Induced AmenorrheaExercise Induced Amenorrhea

Female Athlete Triad : Disordered eating , Female Athlete Triad : Disordered eating , osteoporosis and osteoporosis and amenorrheaamenorrhea that occurs in that occurs in women engaged in regular strenuous women engaged in regular strenuous exerciseexercise or sports activities or sports activities

Weight loss in athletes Weight loss in athletes low body fat low body fat low low Leptin levels Leptin levels disruption of GnRh pulsatility disruption of GnRh pulsatility Reduced LH, FSH Reduced LH, FSH Anovulation and Reduced Anovulation and Reduced estrogen estrogen Amenorrhea. Low body fat means Amenorrhea. Low body fat means reduced peripheral (adipocyte) aromatization of reduced peripheral (adipocyte) aromatization of androgen precursors to estrogen, further androgen precursors to estrogen, further lowering total estrogen levels. lowering total estrogen levels.

High Risk of High Risk of Osteoporosis and Stress fractures ( Osteoporosis and Stress fractures ( get an x-ray if you suspect stress fracture)get an x-ray if you suspect stress fracture)

Exercise Induced Exercise Induced AmenorrheaAmenorrheaManagementManagement Get Dexa scanGet Dexa scan Rule out other differentials Rule out other differentials prolactinomas, prolactinomas,

hypothyroidism, PCOShypothyroidism, PCOS Decreasing intensity of training and improving Decreasing intensity of training and improving

nutritional status are crucial steps in reversing nutritional status are crucial steps in reversing the pattern of menstrual irregularity. the pattern of menstrual irregularity.

Since oligomenorrhea is correlated with low Since oligomenorrhea is correlated with low bone density, bone density, calcium supplementation and calcium supplementation and adequate vitamin Dadequate vitamin D intake are essential for bone intake are essential for bone health. health.

Start Estrogen replacement in the form of Low Start Estrogen replacement in the form of Low dose oral contraceptives.( for cycle regulation dose oral contraceptives.( for cycle regulation and to improve bone density)and to improve bone density)

SchizophreniaSchizophrenia

Diagnosis - SchizophreniaDiagnosis - Schizophrenia1. The presence of at least two of the following for most of 1. The presence of at least two of the following for most of

time for at least 1 month: time for at least 1 month: Delusions Delusions Hallucinations Hallucinations Disorganized speech such as frequent derailment or Disorganized speech such as frequent derailment or

incoherence incoherence Grossly disorganized or catatonic behavior Grossly disorganized or catatonic behavior Negative symptoms such as affective flattening, alogia, or Negative symptoms such as affective flattening, alogia, or

avolition avolition 2. Look for family history2. Look for family history3. There should be continuous signs of disturbance for at 3. There should be continuous signs of disturbance for at

least 6 months.least 6 months.4. R/o Organic brain disease, metabolic disorders, drug 4. R/o Organic brain disease, metabolic disorders, drug

abuse, infectious diseases ( HIV, Sepsis, syphilis, brain abuse, infectious diseases ( HIV, Sepsis, syphilis, brain abscess, septic emboli) and malignanciesabscess, septic emboli) and malignancies

Schizo-affective disorderSchizo-affective disorder At least two of the DSM IV criteria in the At least two of the DSM IV criteria in the

previous slide for at least 1 month + previous slide for at least 1 month + features of one of the following mood features of one of the following mood disordersdisorders

A.A. DepressionDepression

B.B. ManiaMania

Depression and Mania - Depression and Mania - CriteriaCriteria1. Depression (at least five of the following for a 2-week period, including 1. Depression (at least five of the following for a 2-week period, including

at least one of the first two items): at least one of the first two items): Depressed mood most of the day Depressed mood most of the day Markedly diminished interest or pleasure in almost all activities Markedly diminished interest or pleasure in almost all activities Significant weight change Significant weight change Insomnia or hypersomnia Insomnia or hypersomnia Psychomotor agitation or retardation Psychomotor agitation or retardation Fatigue or loss of energy Fatigue or loss of energy Feelings of worthlessness or excessive inappropriate guilt Feelings of worthlessness or excessive inappropriate guilt Diminished ability to think or concentrate Diminished ability to think or concentrate Recurrent thoughts of death or suicide Recurrent thoughts of death or suicide

2. Mania (four or more of the following at the same time, lasting at least 1 2. Mania (four or more of the following at the same time, lasting at least 1 week or if hospitalization is needed; first item is required): week or if hospitalization is needed; first item is required): Elevated, expansive, or irritable mood lasting at least 1 week Elevated, expansive, or irritable mood lasting at least 1 week Inflated self-esteem or grandiosity Inflated self-esteem or grandiosity Decreased need for sleep Decreased need for sleep More talkative than usual or pressure to keep talking More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Flight of ideas or subjective experience that thoughts are racing Distractibility Distractibility Increase in goal-directed activity, excessive involvement in pleasurable Increase in goal-directed activity, excessive involvement in pleasurable

activities that have a high potential for painful consequences activities that have a high potential for painful consequences

Schizophrenia - Schizophrenia - ManagementManagement Hospitalize patients whose behavior may Hospitalize patients whose behavior may

cause harm to themselves or others cause harm to themselves or others Obtain psych consultObtain psych consult Form an alliance with the patient's families Form an alliance with the patient's families

in caring for the pt as it is an essential part in caring for the pt as it is an essential part of management. of management.

Cognitive therapyCognitive therapy Psychoeducational family interventionsPsychoeducational family interventions

Schizophrenia - DrugsSchizophrenia - DrugsA. Second-generation agents (First- Line therapy)A. Second-generation agents (First- Line therapy)

OlanzapineOlanzapine RisperidoneRisperidone ClozapineClozapine ZiprasidoneZiprasidone Quetiapine 6. AripiprazoleQuetiapine 6. Aripiprazole

B. First-generation AgentsB. First-generation Agents TrifluperazineTrifluperazine ThiothixineThiothixine HaloperidolHaloperidol FluphenazineFluphenazine ChlorpromozineChlorpromozine

C. Mood-stabilizers : Carbamazepine, Lamotrigine, lithium, C. Mood-stabilizers : Carbamazepine, Lamotrigine, lithium, Divalproex sodium – use as adjuncts in schizoaffective Divalproex sodium – use as adjuncts in schizoaffective disorderdisorder

D. Anti-Depressants : use as adjunct in schizoaffective disorderD. Anti-Depressants : use as adjunct in schizoaffective disorderE. ANXIOLYTICS: BZDs ( Alprozolam, lorazepam, clonazepam, E. ANXIOLYTICS: BZDs ( Alprozolam, lorazepam, clonazepam,

diazepam, oxazepam), Buspirone. diazepam, oxazepam), Buspirone. All BZDs cause All BZDs cause tolerance and may need up-titration of dose. Buspirone does tolerance and may need up-titration of dose. Buspirone does not cause tolerance or sedationnot cause tolerance or sedation

Drugs - Benefits- Side effect Drugs - Benefits- Side effect ComparisionComparision All second generation agents haveAll second generation agents have less less extrapyramidal side effects extrapyramidal side effects

( Akathisia, Acute dystonia, tardive dyskinesia, parkinsonism).( Akathisia, Acute dystonia, tardive dyskinesia, parkinsonism). First generation agents are pure D2 antagonists where as second First generation agents are pure D2 antagonists where as second

generatio are both D2 and serotinergic antagonists.generatio are both D2 and serotinergic antagonists. Anticholinergic side effects ( drymouth, sedation, constipation) can occur Anticholinergic side effects ( drymouth, sedation, constipation) can occur

with most schizophrenia drugs.with most schizophrenia drugs. Recognize presentation of anti-cholinergic delirium in geriatric pts using Recognize presentation of anti-cholinergic delirium in geriatric pts using

these drugs.these drugs. Most agents – CPZ, Second generation agents – can cause orthostatic Most agents – CPZ, Second generation agents – can cause orthostatic

hypotension. More of a problem with CPZ due to its Alpha1 antagonizing hypotension. More of a problem with CPZ due to its Alpha1 antagonizing properties.properties.

Recognize Hyperprolactinemia can occur with most of these drugs Recognize Hyperprolactinemia can occur with most of these drugs because they are dopamine (D2) antagonists. Less risk of because they are dopamine (D2) antagonists. Less risk of hyperprolactinemia and sexual dysfunction with Queitapine and hyperprolactinemia and sexual dysfunction with Queitapine and Aripiprazole.Aripiprazole.

Weight-gain is a problem. Weight-gain is a problem. Only drugs that do not cause much weight gain Only drugs that do not cause much weight gain are Ziprasidone and Aripiprazole. Olanzapine, Queitapine and Risperidone are Ziprasidone and Aripiprazole. Olanzapine, Queitapine and Risperidone cause significant weight gaincause significant weight gain

Neuroleptic Malignant syndrome is more likely with first generation Neuroleptic Malignant syndrome is more likely with first generation agents, however, can be possible with second generation agents. agents, however, can be possible with second generation agents.

Photosensitivity is a unique side effect of CPZ.Photosensitivity is a unique side effect of CPZ.

Drugs - Benefits- Side effect Drugs - Benefits- Side effect ComparisionComparision

Weight gain that’s a common side effect of these drugs – Weight gain that’s a common side effect of these drugs – lead to insulin resistance and dyslipidemia. Get lipid panel lead to insulin resistance and dyslipidemia. Get lipid panel and FBS and FBS

Clozapine has a dreadful side effect – Agranulocytosis – Clozapine has a dreadful side effect – Agranulocytosis – hence monitor blood count. D/C the drug if signs of infection hence monitor blood count. D/C the drug if signs of infection appears and then get a blood count stat. appears and then get a blood count stat.

Clozapine also has high risk of seizures. Haloperidol reduces Clozapine also has high risk of seizures. Haloperidol reduces seizure threshold.seizure threshold.

Haloperidol, Ziprasidone can prolong QT interval. Caution : Haloperidol, Ziprasidone can prolong QT interval. Caution : concomitant use with quinolones, anti-arrythmics, Tricyclics concomitant use with quinolones, anti-arrythmics, Tricyclics etc that also prolong QT – can lead to Torsades/ Vfibetc that also prolong QT – can lead to Torsades/ Vfib

Risperidone is usually first choice to treat Schizophrenia Risperidone is usually first choice to treat Schizophrenia because it is because it is least sedatingleast sedating. Use olanzapine if insomnia is an . Use olanzapine if insomnia is an issue ( Anticholinergic – sedative effect). If positive symptoms issue ( Anticholinergic – sedative effect). If positive symptoms are very predominant, use Haloperidol. are very predominant, use Haloperidol.

Schizophrenia - Schizophrenia - ManagementManagement In Symptomatic schizophrenia, start antipsychotic In Symptomatic schizophrenia, start antipsychotic

treatment ASAP.treatment ASAP. For Typical symptoms of schizophrenia or For Typical symptoms of schizophrenia or

schizoaffective disorder, consider the newer, second-schizoaffective disorder, consider the newer, second-generation antipsychotics as generation antipsychotics as first-line agents.first-line agents.

Start lowest possible doses to minimize side effects.Start lowest possible doses to minimize side effects. Improvements can be slow and may take 4 to 6 weeks to Improvements can be slow and may take 4 to 6 weeks to

achieve a medication-steady blood state achieve a medication-steady blood state SO, avoid SO, avoid increasing the dosage before an adequate periodincreasing the dosage before an adequate period

Continue antipsychotic medication for at least 1 year Continue antipsychotic medication for at least 1 year after a full remission of psychotic symptoms. After this a after a full remission of psychotic symptoms. After this a trial trial off off medication may be considered except in suicidal medication may be considered except in suicidal or violent patients or violent patients

In chronic, relapsing illness, use antipsychotic In chronic, relapsing illness, use antipsychotic medications for a minimum of 5 symptom-free years.medications for a minimum of 5 symptom-free years.

Schizophrenia - managementSchizophrenia - management

In stable pts, reduce dose reduction to the lowest possible dose In stable pts, reduce dose reduction to the lowest possible dose that controls symptoms that controls symptoms When tapering medications, reduce the When tapering medications, reduce the dose very slowly (10% to 20% per month) and observe the patient dose very slowly (10% to 20% per month) and observe the patient every 2 weeks. Return to the previously effective dose if there is every 2 weeks. Return to the previously effective dose if there is an exacerbation of symptoms.an exacerbation of symptoms.

Use clozapine in Use clozapine in treatment-refractory patientstreatment-refractory patients ( and for those ( and for those with predominant negative symptoms) in whom adequate trials of with predominant negative symptoms) in whom adequate trials of at least two agentsat least two agents from dissimilar chemical groups have failed from dissimilar chemical groups have failed and when adherence is not an issue. ( Caution: Agranulocytosis)and when adherence is not an issue. ( Caution: Agranulocytosis)

Use lowest possible doses in the elderly.Use lowest possible doses in the elderly. Use long-acting injectable (risperidone) or depot (haloperidol or Use long-acting injectable (risperidone) or depot (haloperidol or

fluphenazine) medication in patients nonadherent to oral therapy fluphenazine) medication in patients nonadherent to oral therapy or those who are forgetful about using Rx.or those who are forgetful about using Rx.

Schizophrenia - Schizophrenia - managementmanagement Be sure to monitor weight monthly and test for blood Be sure to monitor weight monthly and test for blood

glucose and lipid abnormalities at least every 12 weeks in glucose and lipid abnormalities at least every 12 weeks in patients on second-generation agents. patients on second-generation agents.

Recognize that side effects of some second-generation Recognize that side effects of some second-generation antipsychotics may lead to health problems such as antipsychotics may lead to health problems such as obesity and diabetes obesity and diabetes

Consider prophylactic use of anti-Parkinson agents such Consider prophylactic use of anti-Parkinson agents such as benztropine to reduce extrapyramidal side effects on a as benztropine to reduce extrapyramidal side effects on a case-by-case basis when using antipsychotic agents. case-by-case basis when using antipsychotic agents.

Consider clozapine in people who are judged to be at risk Consider clozapine in people who are judged to be at risk for suicidal behavior for suicidal behavior

In patients with concurrent mood symptoms use adjuncts In patients with concurrent mood symptoms use adjuncts to Antipsychotic therapy – to Antipsychotic therapy –

1. For Depression use SSRIs1. For Depression use SSRIs 2. For Mania – use mood stabilizers2. For Mania – use mood stabilizers 3. For anxiety, use anxiolyitics3. For anxiety, use anxiolyitics

Addressing Extrapyramidal Side effectsAddressing Extrapyramidal Side effects

AkathisiaAkathisia : An acute side effect. Can also be Tardive. : An acute side effect. Can also be Tardive. Acute means onset Acute means onset within 6 weekswithin 6 weeks of initiation of the drug. of initiation of the drug. Tardive akathisia is the one that appears after a minimum Tardive akathisia is the one that appears after a minimum of 3 months’ exposure to an antipsychotic agent. Akathisia of 3 months’ exposure to an antipsychotic agent. Akathisia can also appear as a withdrawal from antipsychotics.can also appear as a withdrawal from antipsychotics.

Common with first-generation antipsychotics Common with first-generation antipsychotics (neuroleptics)(neuroleptics)

Defined as subjective (feeling of inner restlessness and Defined as subjective (feeling of inner restlessness and the urge to move) as well as objective components the urge to move) as well as objective components (rocking while standing or sitting, lifting feet as if marching (rocking while standing or sitting, lifting feet as if marching on the spot and crossing and uncrossing the legs while on the spot and crossing and uncrossing the legs while sitting) sitting) Treatment is Beta blockers. If b-blocker fails, Treatment is Beta blockers. If b-blocker fails, consider BZDs. If everything failed, use clonidine/ consider BZDs. If everything failed, use clonidine/ amantidine.amantidine.

Addressing Extrapyramidal Side effectsAddressing Extrapyramidal Side effects Distinguishing Akathisia and Restless Legs SyndromeDistinguishing Akathisia and Restless Legs Syndrome

                            Akathisia                    Restless Legs Syndrome                            Akathisia                    Restless Legs SyndromePositionPosition                            Sub-diaphragmatic       Usually from ankle to knee                            Sub-diaphragmatic       Usually from ankle to kneeMyoclonic jerksMyoclonic jerks                            Rare                               Very common: especially at night                            Rare                               Very common: especially at nightSubjective distressSubjective distress                            Almost invariable         Common and is due to disturbed sleep                            Almost invariable         Common and is due to disturbed sleepRelieved by movementRelieved by movement                            Rarely                           Almost always                            Rarely                           Almost alwaysMotor componentMotor component                            Almost always               Rarely                            Almost always               RarelySensory componentSensory component                            Usually present             Always present; dysesthesia                            Usually present             Always present; dysesthesiaWorsening on lyingWorsening on lying                            Rare                              Very common                            Rare                              Very commonSleep disturbanceSleep disturbance                            Rare                              Almost always present                            Rare                              Almost always presentMovements if able to sleepMovements if able to sleep                            Stop                                Continue almost unabated                            Stop                                Continue almost unabatedHelp from behavioral tricks e.g. walking, stretching, massage, cold compressesHelp from behavioral tricks e.g. walking, stretching, massage, cold compresses                            Rare                              Almost always                            Rare                              Almost always

Addressing Extrapyramidal Side effectsAddressing Extrapyramidal Side effects Acute DystoniaAcute Dystonia : : DystoniaDystonia is a brief or sustained muscle spasm, often with is a brief or sustained muscle spasm, often with

slow abnormal movements. Although any muscle group may be involved, it slow abnormal movements. Although any muscle group may be involved, it most commonly affects facial muscles (eyes, jaw, tongue).most commonly affects facial muscles (eyes, jaw, tongue).

In differentiating from Tardive dyskinesia In differentiating from Tardive dyskinesia consider the onset. Onset here is consider the onset. Onset here is acute ( acute ( within 24 hrswithin 24 hrs after administering the agent) after administering the agent)

Acute dystonia – causes Acute dystonia – causes 1. Toxic causes : Metoclopromide, Antipsychotics (Haloperidol, phenothiazines), 1. Toxic causes : Metoclopromide, Antipsychotics (Haloperidol, phenothiazines),

Lithium, chloroquine, levodopa, cocaineLithium, chloroquine, levodopa, cocaine 2. Non toxic : Spinocerebellar degeneration, Thyrotoxicosis, Wilsons disease, 2. Non toxic : Spinocerebellar degeneration, Thyrotoxicosis, Wilsons disease,

Tumor, A-V malformation, CVATumor, A-V malformation, CVA Differential : Catatonic states, Dyskinesias, SeizuresDifferential : Catatonic states, Dyskinesias, Seizures Treatment : Dystonias may increase in severity after initial presentation and Treatment : Dystonias may increase in severity after initial presentation and

therefore all patients should be treated. Initial treatment is usually provided therefore all patients should be treated. Initial treatment is usually provided with a parenteral formulation, followed by oral medication for 2 to 3 days to with a parenteral formulation, followed by oral medication for 2 to 3 days to prevent recurrence. Milder forms can be treated with oral medication alone. prevent recurrence. Milder forms can be treated with oral medication alone. Choices: ( physiology involves cholinergic excess. So use, anticholinergic Rx)Choices: ( physiology involves cholinergic excess. So use, anticholinergic Rx)

1. Benztropine : 1mg IM/IV followed by 1mg orally daily1. Benztropine : 1mg IM/IV followed by 1mg orally daily 2. Diphenhydram 1MG/KG IM/IV followed by oral2. Diphenhydram 1MG/KG IM/IV followed by oral 3. Diazepam3. Diazepam 4. Trihehiphenydyl. 4. Trihehiphenydyl.

Types of Acute DystoniaTypes of Acute DystoniaVarious types of Various types of dystoniadystonia, involving particular , involving particular

muscle groups have been described: muscle groups have been described: Laryngeal Laryngeal dystoniadystonia - spasm of pharyngeal and - spasm of pharyngeal and

laryngeal muscles resulting in stridor. laryngeal muscles resulting in stridor. Oculogyric crisis - spasm of extra-ocular Oculogyric crisis - spasm of extra-ocular

muscles, forcing the eyes into upward or lateral muscles, forcing the eyes into upward or lateral gaze. gaze.

Opisthotonus - spasm of all paravertebral Opisthotonus - spasm of all paravertebral muscles, forcing the trunk and neck into muscles, forcing the trunk and neck into hyperextension. hyperextension.

Retrocollis - spasm of paravertebral neck Retrocollis - spasm of paravertebral neck muscles, forcing the neck into hyperextension.muscles, forcing the neck into hyperextension.

Torticollis - spasm of lateral neck muscles, Torticollis - spasm of lateral neck muscles, twisting the neck to one side. twisting the neck to one side.

Addressing Extrapyramidal Side effectsAddressing Extrapyramidal Side effectsTARDIVE DYSKINESIATARDIVE DYSKINESIA

Occurs with long term use of antipsychotics/ Dopamine antagonistsOccurs with long term use of antipsychotics/ Dopamine antagonists Risk factors for developing TDRisk factors for developing TD: treatment with first generation antipsychotics, : treatment with first generation antipsychotics,

More than 6 monthsMore than 6 months of antipsychotic treatment, Increased length of medication of antipsychotic treatment, Increased length of medication therapy, Antipsychotic dose change—either increase or decrease, Diagnosis of therapy, Antipsychotic dose change—either increase or decrease, Diagnosis of organic mental disorder or mood disorder, Increasing age, Diabetes and organic mental disorder or mood disorder, Increasing age, Diabetes and Genetics Genetics

Eventhough more common with First generation (typical) antipsychotics it also Eventhough more common with First generation (typical) antipsychotics it also copmmonly occurs with second generation drugs.copmmonly occurs with second generation drugs.

Symptoms : Symptoms : Involuntary movements, which develop with after long term Involuntary movements, which develop with after long term antipsychotic exposure, are present for at least 4 weeks and may be:antipsychotic exposure, are present for at least 4 weeks and may be:

Choreiform movements (rapid, jerky, nonrepetitive, purposeless) Choreiform movements (rapid, jerky, nonrepetitive, purposeless) Athetoid movements (slow, sinuous, continual) Athetoid movements (slow, sinuous, continual) Rhythmic movements (stereotypes)Rhythmic movements (stereotypes)

Peri-Oral movements most common : Darting, twisting, protruding movements of Peri-Oral movements most common : Darting, twisting, protruding movements of the tongue (lip-licking, sucking, smacking, “fly-catching tongue), Chewing and the tongue (lip-licking, sucking, smacking, “fly-catching tongue), Chewing and lateral jaw movements, Lip puckering and Puffing cheekslateral jaw movements, Lip puckering and Puffing cheeks

Other movements : Trorticollis, retrocollis, Trunk twisting, rocking, hand Other movements : Trorticollis, retrocollis, Trunk twisting, rocking, hand clenching, facial grimacing, blinking etcclenching, facial grimacing, blinking etc

There is no specific treatment once TD appears. Delaying its appearance and There is no specific treatment once TD appears. Delaying its appearance and prevention are the only options : using atypical antipsychotics, using lowest prevention are the only options : using atypical antipsychotics, using lowest possible dose are some strategies. possible dose are some strategies.

Addressing Extrapyramidal Side effectsAddressing Extrapyramidal Side effects

Managing Managing Tardive DyskinesiaTardive Dyskinesia: :

Note :Note :

Clozapine’s greater efficacy as an Clozapine’s greater efficacy as an antipsychotic drug may be related to its higher antipsychotic drug may be related to its higher affinity for the D4 than the D2 receptor. No affinity for the D4 than the D2 receptor. No typical neuroleptic has a similar D4/D2 ratio. typical neuroleptic has a similar D4/D2 ratio. This different mechanism of action may also This different mechanism of action may also account for its beneficial effect in treating TD account for its beneficial effect in treating TD

Clozapine is the drug of choice in refractory Clozapine is the drug of choice in refractory schizophrenia schizophrenia ( i.e.; after no response to two ( i.e.; after no response to two different antipsychotic agents)different antipsychotic agents)

PTSDPTSD

PTSDPTSD After a traumatic event normal individuals may After a traumatic event normal individuals may

experience symptoms for a short period such as: experience symptoms for a short period such as: Nightmares, Flashbacks, Anxiety attacks , Startle Nightmares, Flashbacks, Anxiety attacks , Startle reactions , Insomnia, Irritability, Anger, reactions , Insomnia, Irritability, Anger, Depressed mood, Guilt & Poor appetite. If they Depressed mood, Guilt & Poor appetite. If they last more than 1 month last more than 1 month PTSD. PTSD.

Recurrent symptoms of Flashbacks and Hyper Recurrent symptoms of Flashbacks and Hyper vigilance are characteristic to PTSD ( No vigilance are characteristic to PTSD ( No flashbacks with Adjustment disorder)flashbacks with Adjustment disorder)

Time course : < 1 mo: acute stress disorderTime course : < 1 mo: acute stress disorder, > 1 month , > 1 month PTSD PTSD

Spontaneous recovery from acute stress disorder Spontaneous recovery from acute stress disorder is common (>50%), is common (>50%), but a high level of symptoms but a high level of symptoms during the first month is a risk factor for PTSDduring the first month is a risk factor for PTSD

PTSD - ManagementPTSD - Management

Non – Pharmacological TherapyNon – Pharmacological Therapy Cognitive-behavioral therapy, exposure therapy, and Cognitive-behavioral therapy, exposure therapy, and

trauma-related anxiety management. Group therapy also trauma-related anxiety management. Group therapy also usefuluseful

Drug Rx :Drug Rx : SSRIs SSRIs Start with low dose and titrate up to maximum Start with low dose and titrate up to maximum

effect.effect. Switch to different agents or add adjuncts if response to Switch to different agents or add adjuncts if response to

SSRI is inadequate.SSRI is inadequate. Trazadone and sedating TCAs may be used as adjuncts Trazadone and sedating TCAs may be used as adjuncts

to SSRIs, particularly for insomniato SSRIs, particularly for insomnia In difficult cases, consider Phenelzine. In difficult cases, consider Phenelzine.

ENDEND

Anxiety DisordersAnxiety Disorders

Generalized Anxiety DisorderGeneralized Anxiety Disorder Panic DisorderPanic Disorder

Personality Personality disordersdisorders

Borderline personality DisorderBorderline personality Disorder Obsessive compulsive personality Obsessive compulsive personality

DisorderDisorder

Borderline Personality DisorderBorderline Personality Disorder

Obsessive – compulsive Obsessive – compulsive disorderdisorder

Panic DisorderPanic Disorder

Generalized Anxiety Generalized Anxiety DisorderDisorder

Bipolar disorderBipolar disorder