Psychiatry (extra) important notes

Dr Sachin Arora
MBBS, MD (Psychiatry)
Consultant Psychiatrist
Dwarka, New Delhi
Anti-manics / mood stablizers
1.Lithium
2.Valproate
3.Carbamazepine
 LITHIUM : Page 194
Narrow therapeutic index: monitoring
(Therapeutic plasma levels of lithium):

Maintenance of bipolar disorder 0.5 – 0.8 mEq/L

Acute mania 0.8 – 1.2 mEq/L
Toxicity > 1.5 mEq/L
Hemodialysis is effective at > 4 mEq/L
 Page 195
Incidences of various side effects of lithium:

1 Overt hypothyroidism 7 – 10%

2 Reversible T wave flattening ~ 20%
3 Polyuria / Diabetes insipidus ~ 60%
4 Fine tremors 15 – 70%

• Normal dose: Fine tremors by lithium while Toxicity: Coarse tremors

• Frequency of fine tremors due to lithium – 8-12 Hz
• Teratogenic effect of lithium – Ebstein’s anomaly, Fetal goiter
Page 196
Adverse
effects of LITHIUM
(chart from kaplan)
Page 196
Lithium
Toxicity
Pg 197
Pg 197
VALPROATE
Pg 198
Pg 198
Pg 199
Carbamazepine
 DRUGS USED IN
DEADDICTION
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 Drugs used in alcohol deaddiction

Deterrent agents Anti craving agents

Disulfiram • Acamprosate
(Aversive therapy) • Naltrexone
Aldehyde dehydrogenase inhibitor
Not approved, but used:-
At least 12 hours off alcohol and • Topiramate
related products before starting it • Baclofen GABA B receptor agonist
• Fluoxetine
• Ondansetron
 DISULFIRAM
1. Aldehyde dehydrogenase inhibitor (irreversible)
2. Second stage metabolism inhibitor
3. Leads to accumulation of acetaldehyde (CH3CHO)
(NIMHANS 19)
4. Patient must be abstinent from last 12 hrs from
alcohol and related products
5. Hepatotoxic drug
6. Starting dose 250 mg/day (INICET)
7. Disulfiram ethanol reaction (can occur upto 2 weeks
also)
 ACAMPROSATE
1.NMDA ANTAGONIST (NIMHANS)
2.Mainly glutaminergic action,
can be started in withdrawal also
3. Cant be given in renal impairment
4. Suicidal risk is increased
5. Single tablet is 333 mg
6. serves as “artificial alcohol”
 Naltrexone
1.Mu receptor antagonist
2.Reduces craving and reduces
reward in response to drinking
3. Alcohol and opiod both (best)
4. Known to be hepatotoxic
5. Test dose is advised
6. Eosinophilic pneumonia
 FOR NICOTINE/ TOBACCO
DEADDICTION
1.VARENICLINE

2.BUPROPION
 VARENICLINE
1.alpha 4 beta 2 nicotine partial
agonist
2. Treatment is given initially for 12
weeks (NIMHANS)
3. Increases suicidal tendencies
4. START TAKING THE DRUG 1 WEEK
BEFORE QUIT DATE
5.MORE EFFECTIVE THAN BUPROPION
 BUPROPION
1. NDRI (Nor adr dopamine reuptake
inhibitor)
2. Anti depressant (very useful in bipolar)
3. Less maniac switch
4. Also used in hypoactive sexual desire
disorder, ADHD
5. DECREASES SEIZURE THRESHOLD
 FOR OPIUM DEADDICTION

1. NALTREXONE

2. BUPRENORPHINE

3. METHADONE
 Buprenorphine

1.Mu receptor partial agonist

2.Opiod substitution therapy (OST)
3.Given under supervision
4.Sublingual route
5.Itself has withdrawal symptoms
6.More useful in iv users (>3 m)
 Methadone

1. mu receptor agonist
2. Also has NMDA antagonist action
3. Opiod substitution therapy
4. Oral route
5. It also has withdrawal symptoms
6. Best in maintaining abstinence
Sleep stages identification
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DAMS Psychiatry
 Electrophysiology Of Sleep
Sleep Associated EEG pattern & characteristics
stage
Awake Beta waves (13-30cps) Active mental
concentration

Alpha waves(8-13cps) Relaxed with eyes

closed

Stage 1 ◼ Mixed frequency pattern Onset of sleep with

◼ Theta waves (4-8 cps) waves
slow rolling eye
movements
Lightest stage of sleep
↓ Pulse, respiration & BP
 Electrophysiology Of Sleep (Contd.)
Sleep stage Associated EEG pattern & characteristics
Stage 2 Sleep spindle & Largest % of sleep
K-complex Rapid eye movement
absent
Reduced EMG level
Disorders – Bruxism

Stage 3 Delta (0-4 cps) Deepest sleep

20% <δ< 50% (SWS) ↓ with age
Most relaxed stage
& Disorders-night
terror, sleep
Stage 4 walking & enuresis
δ >/= 50%
 Electrophysiology Of Sleep (Contd.)

Sleep stage Associated EEG pattern & characteristics

Bursts of 3 -5 Hz activity Dreaming, penile
NO EMG activity erection,
Saw tooth, beta, alpha, theta & vaginal lubrication
REM waves ↑ Pulse, respiration,
sleep BP & gastric
secretion
Muscle atonia
↓ with age
Peak REM - 5-6AM :
most of deaths due to
cardiac problems
Mental health care Act 2017
1. Rules of admission (30 days max : NEET)
2. Advanced directive (AIIMS) : Legal document
to be made before onset of illness, how he
wishes to be treated
3. Nominated representative
4. Prohibiting ECT for minors
5. Prohibiting direct ECT
6. Decriminalising SUICIDE 30
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