‫صدقة جارية لي و الهلي‪ ,‬أرجوكم ال تنسونا من‬

‫صالح دعائكم‬
‫‪Please Grace us with your good prayers‬‬

‫يوسف معيوف‬
‫‪Youssef Maayouf‬‬
What is the term that we use for patients who
have Symptoms without organic disease?
• Symptoms without organic disease: there are a wide variety of
psychiatric terms for patients who have symptoms for which no
organic cause can be found

• Somatisation = Symptoms

• HypoChondria = Cancer
Drug therapy of different psychiatric
conditions:
• Post traumatic stress disorder: (TL depression): SSRIs NassIs (Paroxetine
• Cataplexy: (TL depression): fluoxetine clomipramine
• Post natal depression: (TL depression): Sertraline
• Bulemia nervousa: (TL depression): fluoxetine
• Chronic fatigue syndrome: (TL depression): but TCA instead of SSRIs for the pain Amitryptyline
• Alcohol withdrawal: Treat like insomnia( benzo)and epilepsy (Carpamazepine)
• Sleep paralysis: Treat like insomnia (Clonazepam)
• Narcolepsy: Methylphenidate , Mofanedil
• Restless leg syndrome: (TL Parkinson): Ropinirol or sedate with Benzos
Side effects of Antipsychotics

• Atypical antipsychotics make you fat, insulin resistant, and give you
clots (Risperidone and olanzapine in elderly)
• Clozapine is dangerous cause it causes agranulocytosis, liability to
seizures
Side effects of SSRIS

• GIT Bleeding
How to prescribe SSRIS

• Elderly or have a disease or taking other drugs safest are Citalopram

or Sertraline
• A child: Fluoxetine
• Do not give SSRIs with heparin or warfarin and give NassIs
Mertazapine
What are Somatisation disorder?

• Multiple physical SYMPTOMS present for at least 2 years

• Patient refuses to accept reassurance or negative test results

What is Hypochondrial disorder?

• Persistent belief in the presence of an underlying serious DISEASE, e.g.

Cancer

• Patient again refuses to accept reassurance or negative test results

What is Conversion disorder?

• Typically involve loss of motor or sensory function

• Some patients may experience secondary gain from loss of function

• Patients may be indifferent to their apparent disorder

• Psychogenic aphonia is a form of conversion disorder: not speaking after a

shocking event.
What is Dissociative disorder?

• Dissociation is a process of 'separating off' certain memories from

normal consciousness

• In contrast to conversion disorder involves psychiatric symptoms e.g.

Amnesia, fugue, stupor

• Dissociative identity disorder (DID) is the new term for multiple

personality disorder as is the most severe form of dissociative disorder
What is Munchausen's syndrome?

• Also known as factitious disorder

• The intentional production of physical or psychological symptoms

What is Malingering?

• Fraudulent simulation or exaggeration of symptoms with the

intention of financial or other gain
What is Body dysmorphic disorder?

• Body dysmorphic disorder (sometimes referred to as dysmorphophobia) is a

mental disorder where patients have a significantly distorted body image
What are the features of patients with Body
dysmorphic disorder?
• Preoccupation with an imaginary defect in appearance. If a slight physical
anomaly is present, the person’s concern is markedly excessive

• The preoccupation causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning

• The preoccupation is not better accounted for by another mental disorder (e.g.,
dissatisfaction with body shape and size in Anorexia Nervosa)
What is Seasonal affective disorder (SAD)?

• Seasonal affective disorder (SAD) describes depression which occurs

predominately around the winter months.

• Bright light therapy has been shown to be more effective than placebo for
patients with SAD
What is Post-traumatic stress disorder
(PTSD)?
• Post-traumatic stress disorder (PTSD) can develop in people of any age following
a traumatic event, for example a major disaster or childhood sexual abuse.

• It encompasses what became known as 'shell shock' following the First World
War.
• One of the DSM-IV diagnostic criteria is that symptoms have been present for
more than one month
What are the features of Post-traumatic stress
disorder (PTSD) (Symptoms are there for more
than a Month)?
• Re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
• Avoidance: avoiding people, situations or circumstances resembling or associated with
the event
• Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems,
irritability and difficulty concentrating
• Emotional numbing - lack of ability to experience feelings, feeling detached from other
people
• Depression
• Drug or alcohol misuse
• Anger, Unexplained physical symptoms
What is the management of Post-traumatic
stress disorder (PTSD)?
• Following a traumatic event single-session interventions (often referred to as debriefing)
are not recommended

• Watchful waiting may be used for mild symptoms lasting less than 4 weeks

• Trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation

and reprocessing (EMDR) therapy may be used in more severe cases
• Drug treatments for PTSD should not be used as a routine first-line treatment for
adults.

• If drug treatment is used then paroxetine or mirtazapine are recommended

What is Post-concussion syndrome?

• Post-concussion syndrome is seen after even minor head trauma

• Typical features include
• Headache
• Fatigue
• Anxiety/depression
• Dizziness
How to differentiate Mania from
Hypomania?
• Presence of psychotic symptoms differentiates mania from hypomania

• Psychotic symptoms (Delusions of grandeur, Auditory hallucinations)

Which symptoms are common to both
hypomania and mania?
• Mood: Predominately elevated, Irritable

• Speech and Thought: Pressured, Flight of ideas, Poor attention

• Behavior:
• Insomnia
• Loss of inhibitions: sexual promiscuity, overspending, risk-taking
• Increased appetite
What is Sleep paralysis?

• Sleep paralysis is a common condition characterized by transient paralysis of

skeletal muscles which occurs when awakening from sleep or less often while
falling asleep.

• It is thought to be related to the paralysis that occurs as a natural part of REM

(rapid eye movement) sleep.

• Sleep paralysis is recognised in a wide variety of cultures

What are the features of Sleep paralysis (due
to natural part of REM )?
• Paralysis - this occurs after waking up or shortly before falling asleep

• Hallucinations - images or speaking that appear during the paralysis

What is the management Sleep paralysis?

• if troublesome clonazepam may be used

What is narcolepsy?

• narcolepsy with symptoms of excessive daytime somnolence,

hypnological hallucinations and sleep paralysis.
• Cataplexy is usually associated
• There is a genetic predisposition to narcolepsy and it is strongly
associated with HLA-DR2.
• The diagnosis is supported by overnight sleep studies and a multi-
sleep latency test.
What is the management of narcolepsy?

• The patient should first try non-pharmacological therapies such as

creating a sleep timetable and decreasing alcohol intake.
• Clomipramine and fluoxetine are used to treat symptoms of
cataplexy.
• Central nervous system stimulants such as methylphenidate are
used to treat narcolepsy.
What are the Post-partum mental health
problems ?
• Post-partum mental health problems range from the 'baby-blues' to
puerperal psychosis
What are the features of 'Baby-blues' ?

• Seen in around 60-70% of women

• Typically 3-7 days following birth and more common in primips
Mothers

• Characteristically anxious, tearful and irritable

What is the management of 'Baby-blues'?

• Reassurance and support, the health visitor has a key role

What are the features of Postnatal
depression?
• Affects around 10% of women

• Most cases start within a month and typically peaks at 3 months

• Features are similar to depression seen in other circumstances

What is the management of Postnatal
depression?
• As with the baby blues reassurance and support are important

• Cognitive behavioural therapy may be beneficial.

• Certain SSRIs such as sertraline may be used if symptoms are severe (fluoxetine is
best avoided due to a long half-life) whilst they are secreted in breast milk it is
not thought to be harmful to the infant
What are the features of Puerperal
psychosis?
• Affects approximately 0.2% of women

• Onset usually within the first 2-3 weeks following birth

• Features include severe swings in mood (similar to bipolar disorder) and

disordered perception (e.g. auditory hallucinations)
What is the management of Puerperal
psychosis?
• Admission to hospital is usually required

• There is around a 20% risk of recurrence following future pregnancies

What is OCD?

• Obsessive–compulsive disorder (OCD) is an anxiety disorder characterized

by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by
repetitive behaviors aimed at reducing the associated anxiety; or by a
combination of such obsessions and compulsions
What is the pathophysiology of Obsessive
compulsive disorder (OCD)?
• some research suggest childhood group A -hemolytic streptococcal
infection may have a role
What are the diseases associated with
Obsessive compulsive disorder (OCD)?
• Depression (30%)
• Schizophrenia (3%)

• Sydenham's chorea

• Tourette's syndrome
• Anorexia nervosa
What is the classification of Schizophrenia
symptoms?
• Schneider’s first rank symptoms may be divided into auditory
hallucinations, thought disorders, passivity phenomena and delusional
perceptions
Describe the Auditory hallucinations
Associated with Schizophrenia?
• Auditory hallucinations of a specific type:

• Two or more voices discussing the patient in the third person

• Thought echo

• Voices commenting on the patient's behaviour

Describe the Thought disorder Associated
with Schizophrenia?
• Thought disorder (occasionally referred to as thought alienation):
• Thought insertion
• Thought withdrawal
• Thought broadcasting
Describe the Passivity phenomena:
Associated with Schizophrenia?
• Bodily sensations being controlled by external influence

• Actions/impulses/feelings - experiences which are imposed on the individual or

influenced by others
Describe the Delusional perceptions
Associated with Schizophrenia?
• A two stage process:

• where first a normal object is perceived then secondly there is a sudden intense
delusional insight into the objects meaning for the patient

• e.g. 'the traffic light is green therefore i am the king'.

What are the features of Schizophrenia?

• Impaired insight
• Incongruity/blunting of affect (inappropriate emotion for circumstances)
• Decreased speech
• Neologisms: made-up words
• Catatonia
• Negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive
pleasure), alogia (poverty of speech), avolition (poor motivation)
What are the Factors associated with poor
prognosis of schizophrenia?
• Strong family history
• Gradual onset
• Low IQ
• Premorbid history of social withdrawal

• Lack of obvious precipitant

what are the Risk factors of developing
schizophrenia?
• Monozygotic twin has schizophrenia = 50%

• Parent has schizophrenia = 10-15%

• Sibling has schizophrenia = 10%

• No relatives with schizophrenia = 1%

What is Concrete thinking?

• When a patient cannot use abstraction to understand the meaning of a sentence.

• It is more common in schizophrenia.

• Literal thinking is of course a feature of autism.

What are the milestones in Alcohol
withdrawal process?
• Symptoms: 6-12 hours

• Seizures: 36 hours

• Delirium tremens: 72 hours

What is the mechanism of Alcohol withdrawal?

• Chronic alcohol consumption enhances GABA mediated inhibition in the CNS

(similar to benzodiazepines) and inhibits NMDA-type glutamate receptors

• Alcohol withdrawal is thought to lead to the opposite ( inhibitory GABA and

NMDA glutamate transmission)
What are the features of Alcohol withdrawal?

• Symptoms start at 6-12 hours

• Peak incidence of seizures at 36 hours

• Peak incidence of delirium tremens is at 72 hours

What is the management of Alcohol
withdrawal?
• Benzodiazepines

• Carbamazepine also effective in treatment of alcohol withdrawal

• Phenytoin is said not to be as effective in the treatment of alcohol withdrawal

seizures
What is Bulimia nervosa?

• Bulimia nervosa is a type of eating disorder characterized by episodes

of binge eating followed by intentional vomiting
What is the management of Bulimia
nervosa?
• Referral for specialist care is appropriate in all cases

• Cognitive behaviour therapy (CBT) is currently consider first-line treatment

• Interpersonal psychotherapy is also used but takes much longer than CBT
• Pharmacological treatments have a limited role - a trial of high-dose fluoxetine is
currently licensed for bulimia but long-term data is lacking
What are the features of Anorexia Nervosa?

• A phobic avoidance of normal weight, Relentless dieting

• Self-induced vomiting, Laxative abuse
• Excessive exercise, Amenorrhoea
• Lanugo hair
• Hypotension
• Denial, Concealment, Overperception of body image
• Enmeshed families.
• Impaired glucose tolerance
What could be a useful test to check for
Anorexia Nervosa?
• Mid-arm muscle circumference and skin-fold thickness
Can you give an easy way to remember the
physiological values with Anorexia nervosa?

•G's and C's raised: growth hormone, glucose, salivary glands, cortisol,
cholesterol, carotinemia
What are the features of Anorexia Nervousa?

• Loss of axillary and pubic hair

• Bradycardia, Hypotension
• Enlarged salivary glands
• Hypokalemia
• Low FSH, LH, estrogens and testosterone, Raised cortisol and growth hormone
• Impaired glucose tolerance, Hypercholesterolemia
• Hypercarotinemia
• Low T3
What are the Laboratory picture of Anorexia
Nervousa?
• Laboratory studies that support the diagnosis include a normocytic
normochromic anaemia due to bone marrow suppression,
• Hypokalaemia from laxative abuse, metabolic alkalosis resulting from vomiting
and the gastrointestinal loss of HCl,
• Hypocalcaemia from dietary deficiency and the associated protein deficiency,
and
• Increased serum amylase level from frequent vomiting.
What is the problem of Nasogastric feeding
for a patient with Anorexia Nervousa?
• Hospitalized patients with AN and NGT feeding are at risk of
refeeding syndrome, which can lead to profound hypophosphatemia
What is most common cause of admissions to
child and adolescent psychiatric wards?
• Anorexia nervosa is the most common cause of admissions to child
and adolescent psychiatric wards.
What is the Epidemiology of Anorexia
Nervosa (Most common cause of admission to
child psychiatric ward)?
• 90% of patients are females

• Predominately affects teenage and young-adult females

• Prevalence of between 0.5-1%

How to diagnose Anorexia Nervosa?

• (based on the DSM-IV criteria)

• Person chooses not to eat - BMI < 17.5 kg/m2, or < 85% of that expected
• Intense fear of being obese
• Disturbance of weight perception
• Amenorrhoea = 3 consecutive cycles
What is the prognosis of Anorexia Nervousa?

• The prognosis of anorexia nervosa remains poor. 10% of patients will

eventually die.
What are the factors associated with risk of
suicide following an episode of deliberate self
harm?
• Efforts to avoid discovery
• Planning
• Leaving a written note
• Final acts such as sorting out finances
• Violent method
What are the standard risk factors for suicide?

• Female sex
• Increased age
• Unemployment or social isolation
• Divorced or widowed
• History of mental illness (depression, schizophrenia)
• History of deliberate self harm
• Alcohol or drug misuse
Employment is a protective factor against
suicide, T/F?
• True
When is the diagnosis of Chronic Fatigue
Syndrome is made?
• Chronic Fatigue Syndrome: diagnosed after at least 4 months of disabling fatigue
affecting mental and physical function more than 50% of the time in the absence
of other disease which may explain symptoms
What is the epidemiology of chronic fatique
syndrome?
• More common in females

• Past psychiatric history has not been shown to be a risk factor

What are the features of chronic fatigue
syndrome other than the Fatigue?
• Sleep problems, such as insomnia, hypersomnia, unrefreshing sleep, a disturbed
sleep–wake cycle
• Muscle and/or joint pains, Headaches
• Painful lymph nodes without enlargement, Sore throat
• Cognitive dysfunction, such as difficulty thinking, inability to concentrate,
impairment of short-term memory, and difficulties with word-finding
• Physical or mental exertion makes symptoms worse
• General malaise or ‘flu-like’ symptoms, Dizziness, Nausea, Palpitations
What are the investigations that you should
do in Chronic fatigue syndrome?
• NICE guidelines suggest carrying out a large number of screening blood tests to
exclude other pathology e.g. FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK,
ferritin*, coeliac screening and also urinalysis
What is the management of Chronic fatigue
syndrome?
• CBT - very effective, number needed to treat = 2

• Graded exercise therapy - a formal supervised program, do not advise to go to

the gym
• 'Pacing' - organising activities to avoid tiring
• Low-dose amitriptyline may be useful for poor sleep
• Referral to a pain management clinic if pain is a predominant feature
Chronic Fatigue syndrome has a worse
prognosis in children, T/F?
• False

• Better prognosis in children

What is Serotonin Syndrome?

• Serotonin Syndrome: is a potentially life-threatening adverse drug reaction that

may occur following therapeutic drug use, inadvertent interactions between
drugs, overdose of particular drugs, or the recreational use of certain drugs.
• Serotonin syndrome is not an idiosyncratic drug reaction; it is a predictable
consequence of excess serotonergic activity at CNS and peripheral serotonin
receptors.
• For this reason, some experts strongly prefer the terms serotonin toxicity or
serotonin toxidrome because it is a form of poisoning.
What are the other names of Serotonin
Syndrome?
• It may also be called serotonin sickness, serotonin storm, serotonin poisoning,
hyperserotonemia, or serotonergic syndrome.
What are the features of Serotonin
Syndrome?
• Agitation
• Hyperthermia
• Tachycardia
• Labile BP

• Hyperreflexia and tone

What are the drugs that may cause Serotonin
Syndrome?
• SSRI

• MAOI (e.g. Moclobemide)

What is the management of Serotonin
Syndrome?
• Remove the causative factor

• Supportive measures
What is Restless legs syndrome (RLS)

• Restless legs syndrome (RLS) is a syndrome of spontaneous, continuous lower

limb movements that may be associated with paraesthesia.

• It is extremely common, affecting between 2- 10% of the general population.

• Males and females are equally affected and a family history may be present
What are the features of Restless legs
syndrome (RLS) (Males affected as
females)
• Uncontrollable urge to move legs (akathisia). Symptoms initially occur at night
but as condition progresses may occur during the day.

• Symptoms are worse at rest

• Paraesthesias e.g. 'Crawling' or 'throbbing' sensations

• Movements during sleep may be noted by the partner - periodic limb movements
of sleeps (PLMS)
What are the causes of Restless legs
syndrome (RLS)
• There is a positive family history in 50% of patients with idiopathic RLS

• Iron deficiency anaemia

• Uraemia

• Diabetes mellitus
• Pregnancy
How to diagnose Restless legs syndrome
(RLS)
• The diagnosis is clinical although bloods to exclude iron deficiency
anaemia may be appropriate
What is the management of Restless legs
syndrome (RLS)
• Simple measures: walking, stretching, massaging affected limbs

• Treat any iron deficiency

• Dopamine agonists are first-line treatment (e.g. Pramipexole, ropinirole)

• Benzodiazepines
• Gabapentin
What do you know about cognitive
Behavioral Therapy?
• It is an approach which addresses dysfunctional emotions, maladaptive behaviors
and cognitive processes, and contents through a number of goal-oriented, explicit
systematic procedures

• Useful in the management of depression and anxiety disorders

• Usually consists of one to two hour sessions once per week
• Should be completed within 6 months
• Patients usually get around 16-20 hours in total
What are Antipsychotics?

• act as dopamine D2 receptor antagonists, blocking dopaminergic transmission in

the mesolimbic pathways.

• Conventional antipsychotics are associated with problematic extrapyramidal side-

effects which has led to the development of atypical antipsychotics such
as clozapine
What are the Extrapyramidal side effects of
Antipsychotics (Due to dysfunction of the
extrapyramidal system)?
• Parkinsonism
• Acute dystonia (e.g. Torticollis, oculogyric crisis)
• Akathisia (severe restlessness)

• Tardive dyskinesia (late onset of choreoathetoid movements, abnormal,

involuntary, may occur in 40% of patients, may be irreversible, most common is
chewing and pouting of jaw)
What are the non Extrapyramidal side
effects of Antipsychotics?
• Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation

• Sedation, weight gain

• Raised prolactin: galactorrhoea
• Neuroleptic malignant syndrome: pyrexia, muscle stiffness

• Decrease seizure threshold (greater with atypicals)

Are Antipsychotics addictive?

• No
• Antipsychotics are not addictive
What are Atypical antipsychotics?

• Atypical antipsychotics should now be used first-line in patients with

schizophrenia, according to 2005 NICE guidelines.

• The main advantage of the atypical agents is a significant reduction in extra-

pyramidal side-effects.
What are the actions of Olanzapine?

• Olanzapine, like other atypical antipsychotics, is known to block

serotonin receptors (especially 5-HT2 subtype) as well as D2
dopamine receptors
What are the Adverse effects of atypical
antipsychotics?
• Weight gain

• Increased risk of venous thromboembolism

• Olanzapine and risperidone are associated with an increased risk of stroke in
elderly patients

• Clozapine is associated with agranulocytosis (see below)

Give Examples of atypical antipsychotics

• Clozapine
• Olanzapine

• Risperidone (affinity for serotonin 5-HT2A receptor > D2 receptors)

• Quetiapine
• Amisulpride
What is clozapine?

• Clozapine, one of the first atypical agents to be developed, carries a significant

risk of agranulocytosis and full blood count monitoring is therefore essential
during treatment.

• For this reason clozapine should only be used in patients resistant to other
antipsychotic medication
What are the Adverse effects of clozapine?

•Agranulocytosis (1%), neutropaenia (3%)

•Decrease seizure threshold - can induce seizures in up to 3% of patients

What is the relationship between
antipsychotics and Diabetes mellitus?

• Clozapine is associated with around a 7 fold increase in cases of diabetes

mellitus after 12 months use.
• In contrast for olanzapine the increase is around 3 fold, this is similar to the
increase seen for low potency traditional neuroleptics.
• Olanzapine and clozapine lead to increased insulin resistance and are associated
with weight gain; this may accelerate the development of impaired glucose
tolerance.
What is Neuroleptic Malignant Syndrome?

• Neuroleptic Malignant Syndrome is a rare but dangerous condition seen in

patients taking antipsychotic medication.

• It carries a mortality of up to 10% and can also occur with atypical antipsychotics
What are the features of Neuroleptic
Malignant Syndrome?
• More common in young patients

• Onset usually in first 10 days of treatment or after increasing dose

• Pyrexia
• Rigidity
• Tachycardia
• A raised creatine kinase is present in most cases. A leukocytosis may also be seen
What is the management Neuroleptic
Malignant Syndrome?

• Bromocriptine, dopamine agonist, First line

• Stop antipsychotic
• IV fluids to prevent renal failure

• Dantrolene may be useful in selected cases

What do you know about selective serotonin
reuptake inhibitors ?

• Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment

for the majority of patients with depression
• Citalopram and fluoxetine are currently the preferred ssris
What are the side effects of selective serotonin
reuptake inhibitors?

• Gastrointestinal symptoms are the most common side-effect

• There is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A

proton pump inhibitor should be prescribed if a patient is also taking a NSAID

• Patients should be counseled to be vigilant for increased anxiety and agitation

after starting a SSRI
Which SSRIS are most likely to cause drug
interactions?

• Fluoxetine and paroxetine have a higher propensity for

drug interactions
Which SSRIS are best given to patients with
Physical health problems (MI and so on)

• Citalopram and sertraline and more suitable for

patients with chronic physical health problems as they have a lower
propensity for drug interactions.
If you had to give a child a SSRI, which one
would u give?

• SSRIs should be used with caution in children and adolescents.

Fluoxetine is the drug of choice when an antidepressant is
indicated
Which SSRIS are best given to patients with
Physical health problems (Less Drug
interactions)
• Citalopram is useful for elderly patients as it is associated with
lower risks of drug interactions
• Sertraline is useful post myocardial infarction as there is more
evidence for its safe use in this situation than other antidepressants
What are the drug interactions of selective
serotonin reuptake inhibitors?
• NSAIDs: NICE advised 'do not normally offer SSRIs', but if given co-prescribe a
proton pump inhibitor

• Warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering

mirtazapine

• Aspirin: see above

• Triptans: avoid SSRIs
What are the guidelines when initiating the
administration of selective serotonin reuptake
inhibitors?
• Following the initiation of antidepressant therapy patients should normally be
reviewed by a doctor after 2 weeks.

• For patients under the age of 30 years or at increased risk of suicide they should be
reviewed after 1 week.

• If a patient makes a good response to antidepressant therapy they should continue

on treatment for at least 6 months after remission as this reduces the risk of
relapse.
What are the guidelines when discontinuing
the administration of selective serotonin
reuptake inhibitors?
• When stopping a SSRI the dose should be gradually reduced over a 4 week period
(this is not necessary with fluoxetine).

• Paroxetine has a higher incidence of discontinuation symptoms.

What are the symptoms of discontinuing
selective serotonin reuptake inhibitors?
• Increased mood change

• Restlessness, Difficulty sleeping

• Unsteadiness
• Sweating
• Gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
• Paraesthesia
What are Tricyclic antidepressants used
for?
• Tricyclic antidepressants (TCAs) are used less commonly now for depression due
to their side-effects and toxicity in overdose.

• They are however used widely in the treatment of neuropathic pain,

where smaller doses are typically required.
What are the common side effects of
Tricyclic antidepressants (Anticholinergic
effect)?
• Drowsiness
• Dry mouth

• Constipation
• Urinary retention

• Blurred vision
How to choose between Tricyclic
antidepressants?
• Low-dose amitriptyline is commonly used in the management of neuropathic
pain and the prophylaxis of headache (both tension and migraine)

• Lofepramine has a Lower incidence of toxicity in overdose

• Amitriptyline and dosulepin (dothiepin) and considered the most dangerous
in overdose
Which Tricyclic antidepressants has a
more sedative effect (CDAT/Sedative)?

• Clomipramine
• Dosulepin
• Amitriptyline
• Trazodone
Which Tricyclic antidepressants has a less
sedative effect?
• Imipramine

• Lofepramine
• Nortriptyline
What is Electroconvulsive therapy?

• Electroconvulsive therapy is a useful treatment option for patients with severe

depression refractory to medication or those with psychotic symptoms.

• The only absolute contraindication is raised intracranial pressure.

What are the short-term side effects of
Electroconvulsive therapy?
• Headache
• Short term memory impairment

• Memory loss of events prior to ECT

• Cardiac arrhythmia
• Physical complications: fractures, dislocations etc
What are the long-term side effects of
Electroconvulsive therapy?
• Some patients report impaired memory
Clozapine (new antipsychotic agent) is associated with
agranulocytosis and granulocytopenia in approximately 1-2%
of patients, which can result in fatal sepsis. The mechanism
through which this happens remains unclear. T/F?
• True
What is the treatment of restless leg
syndrome?
• Treatment depends on the severity of the problem and the most appropriate
treatment here would be ropinirole, which is the one agent, in the options,
licensed for this purpose.

• Pramipexole and rotigotine are also licensed for moderate to severe restless leg
What is Capgras syndrome?

• Capgras syndrome refers to a disorder in which a person holds a

delusion that a friend or partner has been replaced by an identical-
looking impostor.
What is Cotard syndrome?

• Cotard syndrome is a nihilistic delusion seen in severely depressed

people where they believe that they, or a part of their body is dead.
What is the management of Cotard
syndrome?

• Electroconvulsive therapy
• In delusional depression tricyclic antidepressants, SSRIs and major
tranquilisers are less successful than Electroconvulsive therapy ECT.
What is Fregoli syndrome?

• In Fregoli syndrome, the patient believes that an individual (who is

almost always a persecutory figure and someone close to them) has
taken on many different guises.
• This syndrome is named after an artist called Leopoldo Fregoli
renowned for his ability to change costumes very quickly. A person
with Fregoli syndrome will identify several different strangers as
being the persecutor in disguise.
What is Charles Bonnet syndrome?

• This condition is described as visual hallucinations in a patient with a profound

visual field defect.
• Normally the visual hallucinations subside after 12-18 months, and there is no
specific treatment required.
• Often patients are very stubborn that they are able to see the objects concerned,
although screening with a mini- mental state test for dementia is normal.
What is Borderline personality disorder?

• Repeated episodes of difficulty dealing with the stresses of life such as

relationship difficulties, holding down a job etc, coupled with repeated self harm
are typical of borderline personality disorder.
• No specific pharmacological intervention is required in this case, but a risk
assessment should be carried out with respect to suicidal intent, and assessing
possible triggers to this type of repeated behaviour.
What is Tourette syndrome?

• Gilles de la Tourette syndrome presents with multiple tics, including sniffing,

snorting, involuntary vocalisations.
• Some patients display repetitive and annoying motor behaviour. An attention
deficit hyperactivity disorder and obsessive–compulsive traits are associated at
some point of time in the course of the illness. Intelligence does not deteriorate.
• Dopamine (particularly D2)-receptor blockers like haloperidol are an effective
treatment supporting the concept of dopaminergic abnormality in the basal
ganglia; more so in the caudate nucleus