Exam briefing

Wednesday , 14th december, 9-12.30pm

● Be there 8.30am
● Science lab
● Time and station
● Dont put sticker on your card
● Bring pen only
● Paper is given
● Bring clipboard
● Interview: 15 minutes
● QNA : 20 minutes
● 1 min (draw formulation chart ( straight away into the boxes), stressors, social problem,
bullying in school)
● 2 mint ( do your summary)
- Inform patient come to end
- Summarize the things patient tell me
- Patient will leave the station, say thank you
- Must have empathy
● 20 min
- Presentation
- Summary
- management
● Summary till formulation
● If i have time - if she has any psychotherapy - if no i i will consider
● Therapy: goal, purpose, who would you suggest this to,
● Minimum 3

Drugs therapy rules of thumb

- Tolerability
- Symptoms severity
- Previous response to treatment
- Pt’s preferences
Borderline personality disorder
Suicides
- Indication for hospitalization: imminent risk of suicide
 ● Only two medications, lithium15,16 and clozapine (Clozaril),17 have been shown to
reduce suicide rates over time.
50% - MDD
25%- substance abuse disorder
10%- psychotic disorder (schizophrenia)
Risk factors
Delirium
- Subtypes
● Hyperactive
- Classical delirium characterized by agitation
- Confused with psychotic illness
● Hypoactive
- More difficult to recognise
- Patient appear withdrawn & quiet
- Confused with depression
● mixed
- Recognition
● Fluctuating nature
● Mental state fluctuate over 24 h
● Get collateral from staff
● Agitation in the evening & at night
- Standardized assessment
● Confusion assessment
● Diagnosis 1,2 + either 3 or 4
- Acute onset & fluctuating course
- Inattention - difficulty focusing attention
- Disorganized thinking: appear incoherent? Rambling?
- Altered level of consciousness
● vigilant/ hypervigilant
● lethargic/ drowsy
 ● stupor/ difficult to arouse
● coma/ unrousable
- Causes “ I WATCH DEATH”

Delirium dementia depression

- Acute or sudden - Progressive - Change in mood

onset - Loss of brain cells
- Mental confusion - Decline of day to day
- Medical, social, env cognition &
- MMSE: vary from functioning
poor to good - Attempt to answer
- Fluctuating btw MMSE, not aware of
rational state & their mistakes
disorganized, - Gradual loss of
distorted thinking w cognition & ability to
incoherent speech problem solve & func
independently
- Last at least 2w
- Sadness, negativity,
loss of interest,
pleasure, decline with
func
- Give correct answers
on MMSE, but often
says “ i dont know”
- Indecisive & thoughts
highlight failure &
sense of hopelenss

- Delirium
● Good nursing care (manage in same room w consistency of staff
● Adequate hydration
● Reorientation

Paranoid symptoms and syndromes

Paranoid symptoms (not a diagnosis)

1) Ideas of reference
- Unduly self-conscious
2) Delusions of reference
- psychosis
3) Delusions of persecution
- Person, organization , power trying to kill him, harm
4) Delusions of grandeur
ABILITY
 - Special power
- Able to read people’s thoughts
- Solve problems beyond most people’s comprehension

IDENTITY
- Famous, rich, titled, related to prominent people

Paranoid personality disorder (predispose/ risk towards delusional disorder)

1) Extreme sensitivity to setbacks & rebuff
2) Suspiciousness
3) Tendency to misconstrue/ misinterpret the actions of others as hostile or contemptuous
4) Combative & inappropriate sense of personal rights
NO DELUSIONS (overvalued ideas), NO HALLUCINATIONS

Paranoid @ with psychiatric disorder

1) Organic disorder
- Delirium
- Dementia - persecutory delusion
- Focal brain lesion - tumor, stroke, trauma
- Learning disability
- Neurodevelopmental disorders
2) Substance misuse
- Amphetamines, cocaine, alcohol
- Alcohol misuse & morbid jealousy, 1-DOPA precipitate paranoid symptoms
3) Mood disorders
4) Schizophrenia
5) Schizophrenia-like syndromes
- ICD 10: acute and transient psychotic disorders

Persistent Delusional disorders

Subtypes
● Persecutory (commonest)
● Jealous
● Erotomanic
● Somatic
● Grandiose
● Mixed
● Unspecified
● ICD 10 has litigious and self-referential subtypes, other persistent delusional disorders (
delusional dysmorphophobia)

Specific Delusional Disorders

 ● Pathological jealousy
● Erotomania & erotic delusions
● Somatic delusional disorder
● Querulant delusions & reformist delusions
● Delusional misidentification syndrome
● Shared (induced) delusional disorder

Treatment in general (for paranoid symptoms & delusional disorder)

● High-potency, non-sedating antipsychotic
- risperidone
● Start with low dose
● For body dysmorphic disorder
- SSRI as first line
● psycho
- CBT: delusion in schizophrenia
- Individual never in group
Prognosis
● Delusional disorder- clinical poorer, but functional wise, better than psychotic disorders

Neurotic & anxiety disorders

ICD -10
● Panic disorder +- agoraphobia ( chronic or remitting)
● PTSD
● OCD
● Social phobia (inappropriate fear out of proportions, lead to avoidance)
● Specific phobia
● Acute stress disorder
● GAD (chronic or remitting)

GAD
● Functional impairment (self harm or suicide, comorbidity [substance misuse, personality
disorder, complex physical health problems, self-neglect]

PTSD Panic disorder

Hyperarousal Hyperarousal

Free floating anxiety: anxious ruminations [no specific theme/ endpoint, typical generalized
anxiety]

Citalopram
 ● SSRI
● 20mg od initial dose
● Or 10mg od in elderly

Clomipramine
● 2nd line
● OCD

Fluoxetine
● SSRI + long ½ life
● Higher doses in OCD & bulimia
Referral one

Questions
- HPC
- Anxiety = social / GAD / agoraphobia
- Ask re mood
- Did anything precipitate this?
- Rule out ADHD / ASD
- Found son being hyperactive / difficulty to relax
- Medical hx
- Family hx
- Personal
- Birth and developmental
- Milestones = delayed speech [ADHD / ASD]
- School
Opening, PC, biggest worries
“We received a GP letter asking to assess for this”

Mood, anxiety, psychotic symptoms

“I’ve heard a little bit about your son but if you could just tell me in your own words what has brought
you in to us”

“could you tell me when this all started?”

“would you notice anything that could have precipitated this?”

“have you noticed any other symptoms apart from the worry”

“before all this worry, how would you describe Tom”

“has anything helped with this worry or tummy pain”

“i just have a couple more questions, does he enjoy school”

“before school, how was the development and birth?”

“is there any medical problems or symptoms he's being experiencing”

“how does he get along with his brothers and sisters”

“Are there any other things that he's worried about?”

“that seems to be very tough for little Tom”

“is this something serious? well this is definitely something that we need to deal with and hopefully
support you and your family and Tom.”

“because of his worry, we would generally take a very conservative approach first especially with
children. so first we would start with some CBT and then take it from there. medication would be very
much down the line.”

Risk - abuse if there is a child involved - ask the child “how are things at home”, screen for depression

● Harm to self / others, self-neglect (showering, eating), substances

● Medical compliance: Did they take any medications? Did they stop any medications?

Functional impact

has Tom voiced to you any self-harm? have you seen them self-harm or seen any self-harm
wounds? Hasn’t been behaving, how would you discipline him? Any physical discipline him?

any history of suicide or self-harm?

Substance Use disorder

Men 17 SD, women 11 SD + 2-3 alc free days

ICD -10 Alcohol/ substance dependence syndrome (at least 3) (for alc, benzo, opiates)
● Compulsion - strong desire
- Do you have the strong desire to take it everyday?
● Loss of control- onset, termination, levels of use
- Can you control over the usage
● Withdrawal- physiological, repeated use, relief use
- What happen if you do not take it
● Tolerance effects
- Do you need to increase the amount to feel the same?
● Persistent use- despite aware of harmful effects
- Are you aware of the consequence of excessive use?
● Primary (salience)- neglect of interest/ responsibilities
- Has the drink taken over your priority over your responsibilities or hobbies

# narrowed repertoire
● Narrowing of repertoire. This refers to the gradual stereotyping of the heavy
drinker's pattern of alcohol consumption; he/she begins to drink in the same
pattern every day in order to ensure that a relatively high blood alcohol level is
maintained and alcohol withdrawal is avoided.
 ●
# rapid reinstatement- of use after abstinence

Harmful use
- Excess alcohol/ drug use
- Causes physical or mental damage
- in the absence of dependence
DDX
- delirium tremens
● Alc withdrawal 18-72 h after last drink
● Life-threatening
● Triad of
1) Clouding of consciousness/ confusion
2) Vivid hallucinations affecting every sensory modality
3) Marked tremor
- Paranoid delusions
- Agitation
- Sleeplessness
- Autonomic hyperactivity
● Tachycardia
● HTN
● Sweating
● fever
● Adjust benzo, haloperidol
- delirium-other cause

Wernicke’s encephalopathy
● Triad
- Ophthalmoplegia
- Ataxia
- confusion
● Symptoms
- Ataxia
- ophthalmoplegia/ nystagmus
 - Hypothermia, hypotension
- Memory disturbance
- Confusion
- coma
● treatment
- Pabrinex (4 ampoules) tds for 3-5 days
- PO Thiamine 200-300 mg daily
- IV rehydration

Korsakoff’s syndrome
● non-treatment/ late treatment
● Amnesia
● Disorientation
● Confabulation
● Lack of insight into memory difficulty
● Treat with thiamine

Hospitalization
- Severe dependence
- Severe withdrawal symptoms
- Past hx
- Current symptoms of delirium tremens/ seizures
- Failed outpatient detox
- Social difficulties
- Impaired community detox
- Cognitive impaired- wernicke’s/ korsakoffs
- Psychiatric comorbidity w suicide risk
- Comorbid physical illness
-
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tetrahydrocannabinol (THC) and cannabidiol (CBD)

Psychosis
- Not goal directed
- Loosened association
- Sequential thoughts unrelated topics
- Schizophrenia 30-50% risk in monozygotic twins
- Negative symptoms
● Apathy
● Avolition
 ● Amotivation
● Anhedonia
● Asociality
● Affective blunting
● Alogia
- Thought block
● Break in train of thought
- Thought broadcast
● Other people read or access your thoughts
- Neologisms- thought disorder

Schizoaffective disorder
- akathisia
● Subjective
● INNER RESTLESSNESS
● Mistaken as agitation
- Tardive dyskinesia
● First generation> second generation
● Irreversible
● s/e
- involuntary
- Repetitive movements of the
● Face
● Tongue
● Lips
● Other parts of body
- Extrapyramidal side effects
● Most common in 1st gen antipsychotics
● Caused by dopamine blockade
- Metabolic syndrome
● s/e
- Weight gain
- Hyperlipidemia
- Hyperglycemia
- More @ with 2nd generation antipsychotic (except amisulpride? Check
quiz)
-
- MSE
● Flat affect is more severe than blunted affect
Verbigeration - repetition of meaningless words & phrases
-
Olanzapine
● 2nd generation antipsychotic
● 5-10 mg initial dose
● Indication: adjunct for depression, mood stabilizer
● s/e : sedation, weight gain

2nd gen antipsychotic

● Quetiapine
● Aripiprazole: less metabolic side effect

Paliperidone
● Atypical antipsychotic
 ● Active metabolite of risperidone
● Extended release depot injections

Clozapine
● -ve symptoms
● Reduced risk of suicide
● Agranulocytosis- regular FBC monitoring to reduce risk
● Potentially fatal
● Blood clots

Haloperidol
● 1st generation antipsychotic
● Oral regular use
● Rapid tranquilisation
● IM for depot

Neuroleptic Malignant Syndrome

● Idiosyncratic
● Risk increased
- Rapid dose changes
- Males
- Comorbidity
- Lithium use
- Abrupt withdrawal of anticholinergic

Sudden cardiac death

● At risk in all pts with schizophrenia
● Increased by antipsychotic meds
● Regular ECG

Blood clots
● @ with first gen, clozapine, other second gen

Hyperprolactinemia
● s/e of 1st gen antipsychotic & risperidone

Mood disorders
● Depressive episode
- Nihilistic delusion
● Rotting organs

- Mild depressive episode (2A, 2B) - lasted 2 w

 ● A
- Depressed mood
- Loss of interest & enjoyment
- Increased fatigability
● B
-
- Moderate depressive episode (3A , ¾ B)
● A
● B
- Severe depressive episode without psychosis

● Distress or agitation
● Retardation
● B
- Loss of self-esteem
- Guilt
- suicide
- Severe depressive episode with psychosis
● psychosis
- Delusions (mood -congruent)
● Ideas of sin
● Ideas of poverty
● Imminent disasters
- Hallucinations
● Auditory
- Defamatory or accusatory voices
- +- rotting filth/ decomposing flesh
● Olfactory
- Depressive stupor
● Progress from severe psychomotor retardation

-
- management
● Optimize functioning
- Overall functioning of individual
- Target for recovery
 - Prevent further episodes
- Engage in exercise & social activity
- Try & improve confiding relationship
- Graded exercise in mild depression
- Explore obvious stressors
● Recent bereavement
● Financial difficulties
● Marital disharmony
● Risk of suicide/ self harm
- Risk to self
● Risk of self neglect
- Poor intake of food and drink

● Principle of management
- Psychological
# choice include psychological mindedness
● CBT
- 1st line for mild to moderate
● Cbt + AD
- Moderate to severe depression
● Interpersonal therapy

Antidepressants
● Lag time of 8 weeks
● But if 4 weeks no signs improvement, need to look at it
● Check other things that can influence this
● Increase dose up to maximum dose
● Augment with Li
● Or combined therapy

Sertraline
- SSRI used in pregnancy

Elderly at risk of hyponatremia

- s/e of SSRI

Venlafaxine
● SNRI

Mirtazapine
● NaSSA noradrenergic and specific serotonergic antidepressant
● s/e
- Sedation [H1]
- Weight gain
Lamotrigine
● Antiepileptic drug
 ● Mood stabilizer
● BAD, depressive episode
● s/e
- Steven-Johnsons syndrome

Lorazepam
● Benzodiazepine
● Rapid tranquilisation
● Doses: 2-4 mg PO/IM

● Mania
- Flight of ideas
● Has connections between sequential thoughts
● Endpoints keeps changing due to distractibility
● Connections based on WORDS SOUNDS not meaning
- Antidepressant can precipitate manic episode - so stop it
● Bipolar affective disorder
Hx

Li
 - Mood stabilizer
- Gold standard
- Narrow therapeutic index (margin)
- Reduce suicidal risk

Sodium valproate
- Antiepileptic drugs
- Mood stabilizer
- High risk of teratogenicity

● Mood changes Masked

- Irritability
- Excessive alc
- Hypotonic behavior
- Pre-existing phobic exacerbation
- Obsessional symptoms
- Preoccupied with hypochondriacal
● DDX
- Substance abuse
● To make the diagnosis of depression, they must be abstain the substance
at least 2 weeks
● Never make diagnosis of psychiatric illness under influence of
psychoactive substance
- Endocrine
● Adrenal disorders
● Thyroid disorders
● Hypopituitarism
- Infections
● Glandular fevers
● Syphilis
● AIDS
● encephalitis
- Neuro
● Stroke
● Parkinsons
● Multiple sclerosis
● Tumors
● lupus
- Carcinoma
● Paraneoplastic syndrome
- Pharmacological
● Statins
● Isotretinoin
● interferon
 - Nutritional
● Folate
● Nicotinamide
● Vitamin B 12 deficiency
● Vit B1 deficiency
● Vit B deficiency
- other
● Myocardial infarction
● Cerebral ischemia

●
Child psychiatry
Disconnected

Attachment behavior
● To protect at times of danger
● Instinctual response 1st year of life
● Attachment behavior focused on specific mother figure
- Secure
- Anxious
- Avoidant
- disordered/ dismissive

Strange situation test

● Ainsworth
● Attachment styles
- Secure 60%
● Parents leave upset, parents comes back calm
- Insecure 40%
● Ambivalent
- Ignore parent when comes back
● avoidant
- More upset when parent comes back
Child abuse
● Legislation

ADHD ? (ICD 10: hyperkinetic disorder)

- Neurobio
- Motor overactivity
● Insufficient dopaminergic activity
● Action on indirect pathway - hyperactivity, reduce inhibition from the cortex
- inattention,impulsivity
- Increased F-DOPA (right midbrain, left & medical PFC)
● Hyperactivity in ADHD: excess dopaminergic activity in striatum +_ nucleus
accumbens
- Cognitive symptoms
● Striatum (motor)- methylphenidate action lasted 7-8hr (only low dose needed)
- Behavioral symptoms
● Cortex - 2-3hr ( at high dose)
 - Less dopamine transporter in PFC, more in dorsal striatum
- Neuroleptic that enhance the +ve effects of methylphenidate

Communication
● Psychoeducation - shared understanding
● Treatment plan
● Less blame on parents

- Developmental
● Inappropriate levels of activity, impulsivity & inattention
- Commonest condition - 1 in 5 kids
- Most cases PERSISTENT across lifespan, depends on
● Severity
● Psychiatric comorbidity
● Parental psychopathology
- Inattention usually remain BUT HYPERACTIVITY declines with age

Based on DSM V
Criteria 1
● Inattention symptoms ( at least 6 symptoms)
- Lack of attention to details/ careless mistakes in school work
- Hard to sustain attention
- Don't seem to pay attention when talk to
- Don't follow instructions & failed to finish schoolwork, chores
- Hard to organize tasks & activities
- Avoid task that need sustained MENTAL EFFORT
- Lost things that are required for tasks or activities
- Easily distracted by extraneous (irrelevant) stimuli
- Forgetful in daily activities

Criteria 2
● Hyperactivity-impulsivity symptoms ( at least 6 symptoms)
- Hard to play or engage QUIETLY
- On the go or acts driven by a motor
- Excessive talk
- Blurt out answer (say things without thinking)
- Hard to wait in lines and turn
- Interrupt or intrudes on others
- Runs about or climbs inappropriately
- Fidgets with hands or feets or squirms in seat
- Leaves seat in classroom

Criteria 3
 ● Inattentive or hyperactive-impulsive symptoms present before 12 years old
● Symptoms present in 2 or > settings
- Home
- School
- Work
- With friends or relatives
- Other activities
● Interfere with functioning
● MUST NOT BE DURING COURSE OF SCHIZOPHRENIA/ OTHER PSYCHOTIC
DISORDER
● NOT EXPLAINED BY ANOTHER MENTAL DISORDER
- Mood disorder
- Anxiety disorder
- Dissociative disorder
- Personality disorder

Treatment
● No cure but control symptoms with drugs
● Psycho & social
- Parenting
- School support
- Attention span
● Brain training
● CBD (cannabidiol) - research does not support its efficacy in the child’s ability to pay
attention

●
Oppositional defiant disorder
● Milder variant of conduct disorder
● Before 9-10 yo
● Features

- Defiant挑衅
- Disobedient
- provocative
● ABSENT OF severe dissocial or aggressive acts that violate law or rights

Conduct disorder
● Repetitive & persistent > 1yr
● Violated basic rights
● Age appropriate societal norms/ rules broken
- Aggression
- Destruction of property
- Theft
- Serious risk behavior, substance use disorder, sexual behavior, running away,
truanting
● Prognosis
- poor
● Early onset, severity, frequency, range of symptoms pervasive across
situations, parental psychiatric disorder/ criminality & high hostility on child
● Delinquents 40$
● Adult delinquents w hx of conduct dis 90%
● Dissocial personality disorder in adulthood
- Increased mortality
- Offending
- Mental health problems
- Marital disharmony

Austic spectrum disorder

Triad of impairments
● Social interaction
● Communication
● Restricted, repetitive interests & behaviors
Onset : before 36 months

Gene + env
● Mz : dz
● Family with 1 child ASD, 20 times more likely to have another child with ASD
 ● Medical condition: tuberous sclerosis, PKU, congenital rubella, fragile x syndrome, 22q
deletion syndrome
● Perinatal complications/ abnormal brain MRI, EEG & serotonin
● Autism prevalence
- Real phenomenon
- Improved awareness
- Improved diagnosis
● Repetitive behavior
- Routine
- Obsessive interest (planes, titanic, spongebob)
- Rigid
- Rituals- very particular way of doing things
- Repetitive movements- spinning, hand flapping, rocking

DEV
Investigation
● Full blood count
- Prolonged self-neglect
● Lead to anemia, electrolyte disturbances, vitamin deficiencies
-
● Urea & electrolytes
● TFT
● LFT
● Vitamin B12 & folate levels
● Syphilis serology
● Urine pregnancy test ( promiscuity in mania)
● Urine blood toxicology screen (must rule out psychoactive substance use disorder before
diagnosing mania

Geriatrci psy

Referral 2

5 As of Alzheimers
- Amnesia
- Start losing short term memory and long term memory intact
- Apraxia
- Disorder of motor planning [e.g. hold cutlery back to front]
- Can’t perform ADLs
- Agnosia
- Lack of recognition of things / difficulty remembering familiar faces
- Aphasia
- Difficulty in language processing [repeat qs]
- Expressive = difficulty saying this
- Receptive = diff understanding others
- Affective changes
- Screen for depression / psychosis
Qs
 - HPC [done by minute 4]
- Mood / anxious
- Psychotic s/s = hearing or seeing things that aren’t there
- Past psych hx
- Medical hx
- Vascular - HTN / Stroke / TIA
- Medications
- Family hx
- Alcohol / substance
- Risk assessment
- Most worried about?
- When he mentions Alzheimer’s tell him you have heard of it but do not know anything
about it. Is there a treatment?
- We can give you medications to help slow the memory decline
- Can’t reverse progression
- We can link in with other teams to help make the home more safe for him
- We can arrange for home help to come in
- Blister pack for medications
- Make sure he is taking the meds
- “everyone loses brain cells as it gets older. In people with Alzheimer's this
process is more severe and rapid than normal aging. the part of the brain that
deals with memory and severely affected first and the person tends to get more
forgetful over time and difficulties processing new information and because of
this they find it difficult doing practical tasks like making meals, getting washed,
getting dressed”

Ddx
- Alzheimers
- Gradual decline
 - Vascular dementia
- More acute onset
History
- NB to do a risk assessment
- Risk of accidental injury / fire / flood [turning off tap]
- Risk to falls
- Risk of self neglect
- Risk of exploitation
- Risk of wandering

memory loss, behavior, mood, medical hx, family hx, organic causes

advice:

1 minute - each stations - ⅘ things you want to ask

eg. anxiety- symptoms , physical symptoms, mood and psychotic screening, risk assessment (Hx PC, past
psych + then depending on the complaint ½ other things, risk, family hx)

open question “what do you know of this”

then follow with closed qs - when did it start

“thank you so much for speaking to me, i will liaise with my team and get back to you. if you have any
questions my team will be in touch”

self harm/ suicide risk assessment

Onset

Duration

Physical signs and symptoms

Associated symptoms

relieving factors

Aggravating factors

screening - anxiety, depression, schizophrenia, substance abuse

“have you noticed them distracted and talking to themselves or to someone who wasn’t there?”

“everyone loses brain cells as it gets older. In people with Alzheimer's this process is more severe and
rapid than normal aging. the part of the brain that deals with memory and severely affected first and the
person tends to get more forgetful over time and difficulties processing new information and because of
this they find it difficult doing practical tasks like making meals, getting washed, getting dressed”

is he going to get aggressive towards my children

unfortunately this is a progressive condition and if they have a past history sometimes people do get
violent but we can look at that.

can be given an antipsychotic like quetiapine for agitation/ aggression - risk of stroke with that

can give risperidone as well

-might show up more on an MRI than a CT, might do a CT for a vascular dementia

Antipsychotics

Indications
● Schizophrenia
● Mania
● Rapid tranquilisation of acutely disturbed patient
● In combination with antidepressants in severe depressive episodes with psychosis

Choice of antipsychotic
● Safety, previous response, side effects, frequency of dosing (like if same doses, more
compliance), preference

titration / review
● After 4 weeks AT THERAPEUTIC DOSES
- Continue on the same dose for 6 to 8 weeks
- If NOT improved after 6 to 8 weeks
● Review diagnosis
● Check compliance
● Any evidence of illicit drug use
- Alternative antipsychotic
● Typical (dopamine receptor blockade)
- High propensity to block dopamine receptors, cause
extrapyramidal side effects, cause hyperprolactinemia
- Haloperidol
● High potency
● Binds well to dopamine
- Phenothiazines
● Chlorpromazine ( high risk for raised RBS)
● Thioridazine
● Trifluoperazine
- Thioxanthenes
 ● Flupenthixol
● zuclopenthixol
- Butyrophenones
● haloperidol
- Substituted benzamide
● sulpiride
● Atypical (serotonin + dopamine receptor blockade)
- Less propensity to cause EPS & hyperprolactinemia
- More serotonin: dopamine receptor binding ratios
- Increased efficacy to treat -ve symptoms
- Quetiapine
- Risperidone
- Olanzapine
- Amisulpride
- Aripiprazole
- clozapine

General Side effects

● Anti-adrenergic
- Postural hypotension
● Anticholinergic
- Dry mouth, blurred vision, constipation
● Cardiac
- Increased QTc
● GI
- Impaired glucose tolerance & weight gain
● COC
- Clozapine
- Olanzapine
- chlorpromazine
● Brain
- hyperprolactinemia
● Female
- Galactorrhea
- Menstrual irregularities
- infertility
● male
- Gynecomastia in men
- Decreased bone mineral density & OP ? ( long term)
● Skin reaction/ photosensitivity
- Chlorpromazine

Clozapine
● Most effective for schizophrenia
 - -ve symptoms
- Reduce in suicide rate
● Low incidence of eps
● Dont stimulate prolactin secretion
● Improves -ve & + ve symptoms
● Used in treatment resistant
● Careful monitoring in first 3 months
● Rebound psychosis when stop suddenly
● Risk of life threatening side effects
- Pulmonary embolism (blood clots)
- Myocarditis
- Blood dyscrasias
● Reversible neutropenia - agranulocytosis <1%)
- Watch out to stop if
- WBC < 3
- Neutrophils < 1.5
● Dose related
● High risk in older people & those with lower baseline white blood cell
counts

● Careful monitoring of WCC

● Side effects

dystonia parkinsonism akathisia Tardive dyskinesia

● H-d ● 1-6w ● 1-6w ● 6m-2 yr

● Typical ● Pill rolling tremor ● Unpleasant ● Serious, disfiguring,
● At early stages of therapy ● Affective physical & permanent
● Young adolescent male flattening psychologica movement disorder
● Torticollis, oculogyric crisis, ● Bradykinesia l ● 40-50% long term
tongue spasm ( painful) ● Festinating gait & restlessness therapy
● Tx: rigidity ● Older typical ● Pt coming on after
- procyclidine 5-10mg antipsychotic months- years
PO OR IM s ● Risk increased with
(anticholinergic) ● Difficult to age
- Dopamine agonists treat ● tx
● Unknown - Gradual
cause withdrawal
● tx the
- Dose antipsychoti
reduc cs
tion - Can give
benzo
- Cns
● Sedation
- First 4 weeks
● Seizures
- Increased risk when doses above 600 mgs daily used
●
- cvs
● Myocarditis & cardiomyopathy
● Tachycardia
- First 4 weeks
● Htn
 - First 4 weeks
- Often persists
●
- Resp
● PE
- 1 in 4500 patients
- Gi
● Hypersalivation
- First 4 weeks
- Troublesome at night
● Constipation
- persists
● Weight gain
- Dietary advice for clozapine
- Systemic
● fever
- First 4 weeks
- Must rule out infection secondary to emergent neutropenia
- Urinary
● Nocturnal enuresis
- Occur at any time
● Prep
- FBC: neutropenia
- Fasting lipid profile & glucose for metabolic syndrome
- ECG: risks of myocarditis
- Full CVS: risk of BP & tachycardia
● Start
- Starts at low dose
- Increased dose slowly to minimize risks of adverse effects
- Start 12.5 mg once per day
- 2nd day : Increased dose to 12.5 mgs BD
- If can be tolerated: increased dose by 25 mcg to 50 mgs a day
- Max 300-450 mgs (take 2-3 weeks)
- Plasma level: 350 mcg/L
● Monitor
- Bp & temp monitor 6 hourly
- Due to risk of hypotensive effect
- Blood
● 1st 18 w: FBC weekly
● 19th w onwards to 1 y: FBC every 2 weeks
● After 1 y: monthly FBC
● If wbc < 3000/ mm3 +_ neutrophil count < 1500/mm3
● Stop clozapine immediately
- Missed dose
 ● > 48 h- restart at 12.5- 25 mgs daily
● Then gradually built up to previous dose
● Psychosis therapy algorithm
1) Pt understanding & carer
- Can start atypical antipsychotic to reduce EPS
2) Titrate to minimum effective dose
- Adjust the dose based on the response & tolerability
- Assess response over 6- 8 weeks
3) Effective dose just continue as usual, if not effective- ensure diagnosis,
compliance, substance use, comorbidity are assessed
- If none happen, change the drug & follow back step 1 & 2
4) 2 trials- clozapine
5) Poor compliance, poor tolerability, poor insight
● Use depot
● Compliance therapy
- Motivational interviewing & cbt
- Involve the pt actively in their treatment
- Better than psychoeducational

● Compliance aids

Antidepressants
● Continue at therapeutic dose 6-9m after resolution of symptoms
● In elderly, continue 2 y or those with recurrent depressive episodes
● Indications
- moderate - severe depression
- Anxiety disorders
● Agoraphobia
● Social phobia
● Generalized anxiety disorder
● Obsessive compulsive disorders
● SSRI
- In depression the amount of serotonin in the synaptic cleft reduced
- Block the reuptake or resorption of serotonin into the presynaptic nerve terminal
- Increased the amount of serotonin in the synaptic cleft
- Side effects
● GI upsets (nausea, vomiting, diarrhea)
● Agitation , insomnia, headache
● Decreased libido, erectile dysfunction. Delayed orgasm, impaired
ejaculation
- generic
● Fluoxetine (prozac)
● Paroxeine ( aropax)
 ● Fluvoxamine (luvox)
● Sertraline (zoloft)
● Citalopram ( celexa)
● Escitalopram ( lexapro)
● TCA
- Amitriptyline (elavil)
- Dothiepin
- Clomipramine (anafranil)
- Lofepramine ( gamanil)
- s/e
● Anticholinergic
- Overflow incontinence

● SNRI
- Venlafaxine (venlalix)
- Duloxetine ( cymbalta)
● MOAI
- Phenelzine
- Tranylcypromine
- Moclobamide (reversible- so no diet restriction), unless given in high doses
- s/e
● Inhibit catabolism of dietary amines
● Hypertensive crisis when the pt consume tyramine
● Result in stroke/ cardiac arrhythmia
● Avoid red wine, cheese, bananas, milk chocolate

Associated syndrome
● Hyponatremia
- SIADH
- Risk factors
● Hyponatremia
● Old age
● Diuretics use
● DM & HTN
● Reduced renal function & Chronic obstructive airway disease?

1) Assess
- Severity of current illness
- Past response to treatment
- Patient preference
- Potential lethality in overdose
- discuss
● Therapeutic
● Adverse
 ● Discontinuation effects prior to commencing treatment
2) Start
- Start & titrate to recognised therapeutic dose
- Inform the latency of response to treatment
- Gradual relief from depressive symptoms over several weeks
- Assess effectiveness 4-6 weeks
3) Response
- Treat for 4-6 months at full treatment dose
- Consider longer term treatment in recurrent depression
- Reassess & confirm diagnosis
● Alternative diagnosis/ medical or psychiatric comorbid
● Poor compliance
● Poor tolerability
- Switch to different antidepressant
- Titrate to therapeutic dose
- Assess over 4-6 weeks
- Confirmed diagnosis & tolerability adequate- increased dose & assess
effectiveness over further 2 weeks
4) No effect
- NO EFFECT AFTER 8 WEEKS on increased dose, adequate tolerability &
compliance
- Switch to different antidepressant
- Titrate to therapeutic dose
- Assess 4-6 weeks
- Increase dose as necessary
5) Refractory depression
- Fail to respond to 2 adequate therapeutic trials of AD
- Treat with
● Li
● ECT
● Combination therapy

Mood stabilizers
Lithium

● Pharmacokinetics
- Rapid absorption from GI tract
- Long distribution phase
-
● indications
- Prophylaxis
● Manic & depressive relapse
● More effective in preventing manic relapse
- Acute mania & hypomania
- Treatment resistant unipolar depression
- NOT FOR ANXIETY OR PSYCHOTIC DISORDERS
● Communication with the patients
- s/e & symptoms of toxicity
- DO NOT Salt free diet
- Maintain hydration
- NEVER DOUBLED THE DOSE IF FORGET
 - Use adequate contraception
● Baseline investigation
- Blood
● RFT
● TFT
● Ca
● FBC
● ECG
-
● start
- 400 mg at night
- Lower in the elderly or in renal impairment
- Therapeutic range (0.6-1.0 mmol/L)
- Warning
● Intermittent lithium treatment can worsen the course
● Greater relapse in 1st few months after discontinuing Li in inpatients even
no symptoms for 5 years
● START LITHIUM, AND MUST CONTINUE FOR > 3 YEARS

● Monitoring
- Blood plasma level checked at 7 days
- Blood taken 12 hours after last dose
- Then measure serum level after 7 days, then 1 weeks, AFTER EACH DOSE
CHANGE
- Until desired level achieved
- Plasma level: 0.6-1.0 mmol/l
● Sides effects
- Gi
● Upset
- Skin
● Psoriasis
● Acne exacerbated by lithium
- Endocrine
● Fine tremor
● Hypothyroidism: treat with levothyroxine
● hyperPTH
● Hyperthyroidism
- Nephro
● Nephrotoxicity
- GFR reduction
- Interstitial nephritis
- Nephrogenic diabetes insipidus- thirst & polyuria
- Fetal
● teratogenic
 - Ebstein’s anomaly (10-20x increased risk)
- Period of maximum risk to fetus if 2-6 weeks after conception
● Dose-dependent side effects

0-1.2 mmol/L 1.2-2 mmol/L > 2 mmol/L

GI s/e Toxic range - Hyperreflexia

- Nausea, vomiting, - Coarse tremor - Limbs
diarrhea - Ataxia hyperextension
- Fine tremor, dry - Slurred speech - Convulsions
mouth, polyuria, - Drowsy - Syncope
polydipsia - Increased - Oliguria
- Vertigo, weight gain disorientation - Circulatory failure
- Dysarthria - Seizures
- Nystagmus - Coma
- Renal impaired - Death
- Anorexia
- Muscle weakness

● Drug-drug interaction
- NSAIDS
● Increased serum Li, precipitate toxicity
- Diuretics
● Increased serum Li
● Reduce clearance
● Thiazides- worst
● Use loop
- Haloperidol
● Neurotoxicity (low risk)
- Ssri
● Neurotoxicity
● Must check Li after starting SSRI
- Ace inhibitor
● Decreased Li excretion
● Precipitate renal failure
● Monitor serum creatinine & lithium

● Efficacy
- Acute mania
● 60-80% of acutely ill patients
- Bipolar prophylaxis
● mood swings in severe & recurrent bipolar disorder
● Commence based on frequency & severity of episodes
- Abrupt discontinuation
● Rebound mania
 ● Increased hospitalization
- Unipolar depression
● Augmentation
● Prognosis
- Poor in patients with mixed affective episodes
- / rapid cycling pattern ( 4 or more episodes in 1 year)

Eating disorders
Anorexia nervosa
● Most things low
● G & C raised
- Growth hormone
- Glucose
- Glands, salivary (hypersalivation)
- Cortisol
- Cholesterol
- carotinaemia
●

Geriatric pharmacology
● Principles
- Drug protein binding decreases with age
- Less albumin than younger adults
- Liver size reduced in elderly
- No reduction in metabolic capacity
- Decreased gut motility with age
● Slower drug absorption, slower onset
● Same amount of drug absorbed but slower rate
- Use drugs when needed
- AVOID THESE
● Polypharmacy
● Block alpha 1 adrenoreceptors ( lower bp)
● Anticholinergic s/e lead to confusion
● Sedative
● Potent inhibitors of hepatic metabolizing enzymes
- Start at low dose and titrate slowly up
- Choose better tolerated alternative

● Anticholinesterase (ACh E) inhibitors

- Slow cognitive decline
- drugs
● Reminyl (galantamine)
● Aricept (donepezil)- selective inhibitor of acetylcholinesterase
 ● Neostigmine ( neostigmine)
● Mestinon ( pyridostigmine)
● Elexon ( rivastigmine)
● Tacrine
● galantamine
- s/e
● Nausea and vomiting
● dizziness

● Alzheimer
- Donepezil + galantamine: selective inhibitor of Ach E (lower frequency of adverse
events)
- Rivastigmine- inhibit both acetylcholinesterase & butyrylcholinesterase
- Memantine- NMDA receptor antagonist for moderate to severe alzheimer
diagnosis
- Moderate
● Donepezil (metabolized by cytochromes 2D6 & 3A4)
- Start at 5 mg/day, increase to 10mg after 1 month
● Galantamine (metabolized by cytochromes 2D6 & 3A4)
● Rivastigmine ( no potential interaction)) ( least problematic)
- BD
- Start 1.5mg bd, increased to 3 mg bd after 2 w, to 4.5mg bd after 2
w
- Do not halt or reverse cognitive decline in alzheimer’s disease
● Adverse effects
- Excess cholinergic stimulation
● Nausea
● Vomiting
● Dizziness
● Insomnia
● diarrhea
- Urinary incontinence

● Drug tolerability
- Differ between anticholinesterase
- Affected by speed of titration
- Most adverse effects occur during trials of dose, so in elderly best do a slower
titration

Forensic
● Mental illness & violence
● Violence & symptoms
- Paranoid psychosis
 - Disorganized psychosis
- Command hallucinations
- Morbid jealousy
● CMH ? hos
● National forensic psychiatric service: high, medium, low security on campus
● Hospital based care
●
●
Women at childbearing age

Blues
- 50-60%
- Usually starts on 3rd day, lasts 72 hrs approx
- s/s → tearfulness, irritability, distress OR a brief high
- Significant if severe or prolonged
- Like PMS
- More common in women with mood swings on the pill or hx of bad PMS

Puerperal psychosis (6 weeks after childbirth)

- 1 in 500 [ 1 in 1000 first episode]
- 95% are affective dsrs mostly bipolar illness
- Onset can be immediate or day after [blues] or within 6 weeks
- s/s
- Agitation
- Mood congruent psychosis
- RF
- Hx of bipolar illness
- Fam hx of bipolar
- Prev PP = > 60% risk if not on med [if 2 episodes = 100%]
- Major life events in pregnancy
- Tx
- Assessment of illness and risks = suicide, infanticide
- Sleep space, low stimulation and demands
- Most admitted to hospital
- Meds = neuroleptics, mood stabilizers, ECT
- Advice, reassurance, support, psychological support / therapy : refer
- Social work / public health nurse
- Prevention
- Think of it when talking to a woman with hx of psychosis or bipolar illness
 - Assessment and appropriate tx of pre-existing RF / illness before and in after
pregnancy

Postnatal depression
- 11% of mothers
- Not a single homogenous dsr: A label
- Anxiety or depression or OCD
- Adjustment dsr
- Trauma: may be PTSD
- Mixture
- May be immediate - days - weeks
- 25% have symptoms of depression / anxiety in depression
- s/s
- Depression
- Anxiety [5% obsessional intrusive images]
- Insomnia - early morning waking
- Typical clinical symptoms of anxiety / depression or PTSD
- Hopelessness, helplessness, guilt, suicidal
- Only 20% have difficulty relating to the baby

- Lithium = ebstein's anomaly = 1 in 2000

Ect

Modified ECT
● Under GA + muscle relaxants
● Used sine wave- so high risk of cognitive side effects
● ? previously used as punitive/ punishment

Moa
● Seizure enhance DA, NA, 5 HT neurotransmission
 ● Release of hypothalamic pituitary hormones, restore dexamethasone suppression
● Neural growth/ plasticity : increased neuronal plasticity & neurogenesis

Indications
● 1st line if there is risk to life
- Pregnant woman
- Life threatening mania
- Worked before
● Catatonia
● Prolonged or severe manic episodes
● Severe depression, when other therapy failed, rapid response required
● Moderate depression in treatment resistant
● PD with depression
● Refractory mania or psychosis

Contraindications

absolute relative

NONE ● unstable/ severe cvs

- Recent MI
- CHF
- Severe valvular cardiac
● aneurysm / vascular malformation
- Susceptible to rupture +
increased bp
● Raised ICP, brain tumors or space
occupying lesion
● Recent cerebral infarction
● Pulmonary : severe COPD, asthma,
pneumonia
● High risk for anesthesia

Steps
● Fitness for ECT with anesthetist
● Medical check
- Medical hx
- Fam hx
- Blood
- Ecg
- cxr
● Capacity
- Consent
- Prescription
 - monitor
● MOCA
● Rating scale
● Meds
- Increased seizure threshold
● Diazepam/ antiepileptic drugs
- Decreased seizure threshold
● Antipsychotics (clozapine)
- So need to wait for 12 hours before GA

- Stop temazepam before ECT

● Prep
- Anesthesia
● Short GA less than 10 minutes w mm relaxant
- Propofol + suxamethonium (relaxant)
- Tooth guard to protect teeth
- Give o2 when necessary
- Conduction gel placed on electrodes
● Deliver
- Bilateral or unilateral electrical stimulus
- Bi
● Centre of electrode 4 cm above & perpendicular to the midpoint of a line
btw the lateral angle of the eye & external auditory meatus
● Bitemporal ECT
- Uni
● Temporoparietal position
- Electrode on parietal arc
● Electrode on non dominant hem (right side 99%)
● Placement
- Unilateral: half-way

● Duration
- Pt feet (twitching of toes)
● Monitor
- BP, HR, oxygen saturation
● Recovery
 - Reorientation time
● Course
- 12 sessions (twice a week)
- Assess cognition after finishing course of ECT
- Cognitive assessment after 8 weeks after finishing course
● Stimulus dosing
- Dose above the seizure threshold
- Start 50mC— to 75mC— to 150mC(suprathreshold)
- Minimum electrical dose to induce required cerebral seizure
● High threshold
- Male
- Age
- Cumulative number of therapy
- Bilateral placement
- Benzodiazepines
- anticonvulsants
● Subsequent sessions
- 50% higher stimulus dose for bilateral ECT
● Seizure threshold 100- give 150mC (50% of 100 is 50 so
100+50= 150)
- 200% higher for unilateral ECT
- eeg
● Latent phase
- Low amplitude
- High frequency polyspike activity
- No convulsions
- Then increasing amplitude of polyspike activity & slowing of
frequency
● Prolonged clonic phase of convulsion
- 3 Hz spike & wave activity

-
● Post ictal suppression
- Gradual loss of spike & wave pattern
● Lower amplitude & frequency
● Tonic clonic/ grand mal, convulsion
● Side effects
- s/e anesthetic
- Short term
● Headaches
● Muscle aches
● Nausea
● confusion
- Cognition
● short term memory & executive function
- Impacted during the course
- Improve post ect
● Long term cognitive function
- Anterograde memory loss
● Cognition side effects more common in bilateral vs unilateral
- Cannot drive home after
LAW
Personality disorder
Antisocial personality disorder
● Traits
 - Impulsivity
- High negative emotion
- Low conscientiousness
- behaviors
● Irresponsible
● Exploitative
● Recklessness
● deceitfulness
● Disregard the consequences of their behavior & feelings on others

INsomnia
● Zaleplon
● Zolpidem
● Zopiclone