Anecdotal Use of Psychotropics

So…pretty much all eminence-based. In no particular order

Antidepressants

  • Makes fat and sleepy: mirtazapine, paroxetine
  • All other antidepressants activating
  • Less making fat: sertralines, (es)citaloptam
  • Coexisting pain syndrome: duloxetine
  • Coexisting anxiety: sertraline, fluvoxamine
  • Less sexual dysfunction: mirtazapine, duloxetine, fluvoxamine (avoid venlafaxine)
  • Has osteoporosis: mirtazapine, fluvoxamine, avoid other SSRIs
  • Nausea: mirtzapine
  • Heart disease: Sertraline is least cardiotoxic
  • Avoid in
    • Diarrhea: serttraline
    • Nausea: venlafaxine
    • Ulcers: SSRI/SNRI
    • Osteoporosis: SSRI
    • Urinary retension: mirtzapine, TCAs

Mood stabilisers

  • Lithium pretty good but avoid if noncompliance (incomplete course – manic relapse on discontinuation)
  • Valproate good for rapid cycling
  • Carbamazepine, lamotrigine

Antipsychotics

  • If patient has metabolic syndrome – aripiprazole, ziprasidone, amisulpride
  • Parkinson’s – olanzapine, quietiapine, aripiprazole, amisulpride
  • Falls – aripiprazole, amisulpride
  • Activating antipsyhotics – aripiprazole, amisulpride
  • Sedating antipsychotics – olanzapine, chlorpromazine,
  • Least QT effect – paliperidone, aripiprazole

Anxiety

  • Fluvoxamine – also has little weight gain
  • Mirtazapine – also sedating
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The Pharmacology of the Antipsychotics #1 – Basic Principles

The Dopamine Hypothesis

  • Theory derived from three points
    • Decrease of dopaminergic transmission by reserpine causes psychosis
    • Serendipitous discovery that chlorpromazine was effective for schizophrenia
    • Psychosis induced by drugs that increase dopamine (cocaine, amphetamines, L-dopa)
  • Does not explain
    • Cognitive affects of schizophrenia that appear to be due to decreased dopamine in the prefrontal cortex
    • Pyschotomimetic effects of drugs acting at other pathways (eg.  LSD)

Pathophysiology of Psychosis –   the Best Guesses

  • Common pathway of psychosis
    • Excessive dopamine in the the mesolimbic pathway
    • Drug effects on this pathway include:
      • Amphetamines – increased presynaptic DA release
      • Cocaine / amphetamine / methyphenidate – inhibition of presynaptic DA reuptake
      • L-dopa – increased DA availability
      • Ketamine / phencyclidine – antagonism of glutamate-mediated tonic inhibiton of DA release in the mesolimbic pathway
  • Positive and negative symptoms of schizophrenia
    • Glutamate NMDA-R stimulation results in
      • Tonic inhibition of mesolimbic DA release (presumed reason for positive symptoms)
      • Facilitation of mesocortical DA release (presumed reason for negative symptoms)
    • Schizophrenia simulated by infusion of NMDA antagonists
  • Psychosis related to delirium and dementia
    • Deficiency in cholinergic transmission
    • Neuronal loss

Dopamine Receptor Subtypes 

  • D1 receptor subfamily – D1 and D5
  • D2 receptor subfamily – D2, D3, D4

Central Dopamine Receptors

Subfamily Location Action
D1 & D2 substantia nigra

striatum

motor control
D1 & D2 limbic cortex information processing
D2 anterior pituitary inhibition of prolactin release

Peripheral Dopamine Receptors

Subfamily Location Action
D1 substantia nigra

striatum

motor control
D1 & D2 limbic cortex information processing
D2 anterior pituitary inhibition of prolactin release

 

Dopamine Pathways

  • Mesolimbic pathway
    • Positive symptoms of schizophrenia
    • Ventral tegmental area > nucleus accumbens
  • Mesocortical pathway
    • Negative symptoms of schizophrenia
    • Ventral tegmental area > prefrontal cortex
      • Dorsolateral prefrontal cortex – cognition / executive function
      • Ventromedial prefrontal cortex – emotions / affect
  • Nigrostriatal pathway
    • EPSE and tardive dyskinesia
    • Pars compacta of the substantia nigra > striatum
      • Motor planning pathway
  • Tuberoinfundibular pathway
    • Hyperprolactinemia
    • Arcuate + periventrucular nuclei of hypothalamus > infudibular region

Schizophrenia and Other Friends

Sticking with DSM IV TR because my uni still goes by that. You’re not my supervisor.

Diagnosis

  • DSM IV TR A
    • 2 or more of the following for >1/12 plus effects for 6/12
      • Delusions
      • Hallucinations
      • Disorganised speech (i.e. formal thought disorder)
      • Disorganised behaviour / catatonia
      • Negative symptom (affect blunted / avolition / apathy / alogia)
    • 1 of the following alone are sufficient for a diagnosis of schizophrenia
      • Bizarre delusion (a fixed, false belief which, unlike non-bizarre delusions, cannot possibly be true)
      • Auditory hallucination with 2 voices conversing or a voice giving a running commentary
    • Subtypes
      • Paranoid type
      • Disorganised (hebephrenic) – FTD + flattened affect
      • Catatonic
      • Undifferentiated
      • Residual – low intensity symptoms
    • Scheniderian first rank symptoms – mostly historical / used for showing off
      • Auditory hallucinations
      • Broadcasting of thought
      • Control of thought (delusions of control)
      • Delusional perception (normal perception, bizarre interpretation)

Differential Diagnosis

  • Schizoaffective disorder – mood disorder present with BUT NOT WITHOUT psychosis
  • Mood disorder with psychosis – psychosis present with BUT NOT WITHOUT mood disorder

Treatment

  • Antipsychotics
  • See future post on psychopharmacology
  • Basic principles
    • Start with atypical antipsychotics
      • Olanzapine / risperidone geenrally best tolerated
    • Clozapine is last line – effective but high side effects
    • Activating choices:aripiprazole,amisulpride
    • Sedating:olanzapine
    • Avoid in fat people: olanzapine

The Alcoholic Patient

Quand je bois du vin clairet,
Amis, tout tourne,
Aussi désormais
je bois Anjou ou Arbois.
Chantons et buvons,
à ce flacon faisons la guerre,
chantons et buvons,
mes amis, buvons donc.

Liver

  1. Good history and examination
  2. If the liver is failing, determine if decompensated or not
    1. Decreased synthetic function
    2. Hepatic encephalopathy
    3. Ascites
    4. Portal hypertension
  3. FBP + film
    1. Pancytopenia from blood cell suppression
    2. Premature destruction of RBC due to faulty synthesis
    3. Megaloblastic anaemia from folic acid deficiency
    4. Thrombocytopaenia
  4.  LFTs
    1. AST:ALT >2 is suggestive
    2. Isolated rise in GGT
    3. Albumin may be low
  5. Coags – INR is a marker of synthetic function
  6. Magensium – deficient

 

GIT concerns

  1. Mallory-Weiss tear
    1. Conservative management
  2. General nutritional defieincy

 

Alcohol Withdrawl

  1. Progresses through stages
    1. Agitation
    2. Hallucinations
    3. Tonic-clonic seizures
    4. Delirium tremens
  2. Manage with Alcohol Withdrawl Scale
    1. Titrate to symptoms
    2. Benzodiazepines
    3. Barbituates
    4. Propofol + tube

 

Neurological concerns

  1. Repeated falls + decreased synthetic function – subdural bleeds
    1. Full neurological exam
    2. CT head
    3. INR
  2. Wernicke-Korsakoff
    1.  Wernicke’s encephalopathy
      1. Opthalmoplegia
      2. Ataxia
      3. Confusion
    2. Korsakoff pyschosis
      1. Retrograde and atenrograde amnesia
      2. Confabulation prominent
    3. Thiamine
      1. Thiamine 500mg IV TDS for 3/7 then 250mg IV daily until clinical improvement ceases
      2. Prophylaxis: 100mg PO OD
      3. If giving glucose to alcoholic people, thiamine 200mg IV OD for 3/7 then switch to PO

Metabolic concerns

  1. Beer potomania
    1. Hyponatremia
    2.  Beer has little salt; coupled with minimal food intake, hypotonic fluid intake exceeds the ability of the kidneys to excrete dilute urine (maximal dilution to 50Osm/L)
    3. Fluid restrict
    4. Normal saline, follow the Rule of 6s (http://fluidtrials.org/correction-of-hyponatremia/)
  2. Folic acid defieincy
    1. Supplement as needed based on FBP
  3. Thiamine deficiency
    1. Due to inadequate intake
    2. Always supplement
    3. Special care if giving glucose
      1. Reduced enzme activity due to lack of cofactor -> excessive carbohydrate load -> toxic metabolites

 

Lung concerns

  1. Pneumonia
    1. Aspiration
    2. Alcohol related
      1. Klebsiella ‘currant-jelly sputum’
      2. Serratia – ESCAPPM organism
      3. Burkholderia pseudomallei
      4. Acinetobacter baumanii
  2. CXR
  3. Empirical antibiotics
    1. Aspiration – BenPen 1.2g IV QID + metronidazole 500mg IV BD
    2. Suspected complicated – consider ceftriaxone + gentamicin (TGA guidelines does not stratify)

 

Model plan for the undifferentiated alcoholic patient

  1. FBC
  2. LFT
  3. Coags
  4. UEC
  5. CXR
  6. CT head
  7. AWS
  8. Falls precautions
  9. Drugs and alcohol to see
  10. Social worker

 

ADHD and Autism

ADHD

Diagnosis

  • Characterised by (this is the simplified answer on the LMS lectures)
    • Inattention
    • Hyperactivity
    • Impulsivity
  • 1 and/or 2 and >6 months
  • 6 or more of ADHD DSM DX (quite proud of this mnemonic)
    • Absent-minded- forgetful in daily activities
    • Devil is in the details – overlooks details, inaccurate work
    • Hopeless at finding things – bit of forcing for the mnemonic
    • Derailable – starts things but gets sidetracked
    • Daily activities forgetfulness (chores, errands, appointments)
    • Sustained attention
    • Mind elsewhere when spoken to directly
    • Disorganised (sequential tasks, time maagement etc.)
    • Xternal stimuli is distracting
  • 6 or more of PPQRRSSTT
    • Pre-emptive conversation – doesn’t wait for appropriate turn in convos
    • Pushy – butts into conversations, doesn’t ask for permission, intrude into activities
    • Quiet play impossible
    • Restless – can’t stay still for long periods
    • Runs and climbs inappropriately
    • Squirms and fidgets
    • Seat leaving inappropriately
    • Taking turns is difficult
    • Talks excessively

Management

  • Dexamphetamine or methylphenidate
    • Must be prescribed specially certified psychiatrists of developmental paediatricians
  • Diet may help
  • Psychosocial training

 

Autism Spectrum

Diagnosis

  • Deficits in social communication and interactions
    • Reciprocity in coversation and social interaction
    • Non-verbal communication
    • Relationships
  • Restricted, repetitive behaviours as evidenced by 2 of:
    • Stereotyped/repetitive motor movements or speech
    • Insistence on sameness, adherence to ritual or routines
    • Focused, fixated interests that are abnormal in intensity
    • Hyper- or hypo-reactivity to sensory input

Management

  • Antipsychotics for symptomatic management of aggression only
  • Applied Behaviour Analysis

 

Attachment Disorders

Diagnosis

  • Reactive Attachment Disorder
    • A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers
    • A persistent social and emotional disturbance
    • A pattern of extremes of insufficient care
    • The disturbance is evident before age 5 years
    • The child has a developmental age of at least 9 months
  • Disinhibited Social Engagement Disorder
    • A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults in an impulsive, incautious, and overfamiliar way
    • The behaviors described in the first criterion are not limited to impulsivity but also include socially disinhibited behavior
    • A pattern of extremes of insufficient care
    • The child has a developmental age of at least 9 month

30 Things You Should Know About Psychiatry In No Particular Order

  1. In an exam, there is no prohibition against asking the patient what their diagnosis is

  2. Lithium dosing is to a maximum of 1800mg a day

  3. The therapeutic range of lithium is 0.8-1.2mmol/l; toxicity begins at >1.5mmol/l

  4. Chronic lithium toxicity presents with altered mental state, seizures, cerebellar sx, nephrogenic diabetes insipidus and hypothyroidism.

  5. Acute lithium poisoning tends to present as GI symptoms and rarely neurotoxicity (risk assessment: <25g is benign).

  6. Clozapine is started at 12.5mg a day and titrated up to a maximum of 900mg a day

  7. Clozapine levels of 250-350ng/ml are therapeutic

  8. The risk of neutropenia with clozapine is 3%, the risk of agranulocytosis is 1%.

  9. An obsession is defined as recurrent and persistent ego-dystonic thoughts that are intrusive or distressful and that are recognised as products of the patients own mind (i.e. not thought insertion). They cannot be excessive worry about a real-life problem and the patient must attempt to ignore, suppress or neutralise them through some action.

  10. A compulsion is defined as repetitive behaviours or mental acts that the patient feels compelled to perform in response to an obsession or to rigid rules. They must be aimed at reducing distress or preventing some dreaded event but are either clearly excessive or not connected in a realistic way to that which they are designed to neutralise.

  11. The handy mnemonic for the MMSE is ORAL Recall (Orientation, Registration, Attention, Language, Recall). Language can be remembered by Read, Write, Draw, Repeat the Stage Name (repeat a sentence, 3 stage command, name two items)

  12. The mini-cog is a fast, effective tool for dementia screening and is more sensitive and as specific as the MMSE. 3 word recall and clock-drawing comprise the mini-cog.

  13. Screen for borderline personality disorder by asking about relationships and identity in the developmental history.

  14. Screen for antisocial personality disorder while doing your forensic history

  15. Anxiety disorders hunt in packs. Ask about all 7 if you are making a diagnosis of one.

  16. Use the time when your patient is rambling on to fill in your mental state examination notes.

  17. The handy mnemonic for the MSE is All Borderline Subjects Are Tough Troubled Characters (Appearance, behaviour, speech, affect and mood, thought form, thought content, cognition)

  18. Fluoxetine, sertraline and venlafaxine are activating antidepressants

  19. Paroxetine, fluvoxamine and mirtazapine are sedating antidepressants

  20. Quetiapine is used for pretty much everything

  21. Address acute agitation with ‘10 and 2’ – 10mg of haloperidol and 2mg of lorazepam IM; alternatively 10mg of olanzapine

  22. The main antipsychotics you should know are olanzapine, risperidone, quetiapine, aripiprazole and clozpine

  23. Quetiapine and olanzapine are sedating, aripiprazole is activating. risperidone is the closest to FGA in terms of EPSE, olanzapine has the most prominent weight gain

  24. When discussing management with a SGA, always mention physical exercise and diet plan

  25. Benztropine and propanolol are useful adjuncts for the ADRs of antipsychotics

  26. When presenting your management plan, match your plan to your biopsychosocial formulation so that every factor is addressed. Giving psychotherapy and psychopharmacology is not good enough.

  27. Time criteria for DSM go in values of 1, 2 and 6

    1. MDD – 2 weeks; dysthymia – 2 years; BPAD – 1 week

    2. Panic disorder – 1 month; GAD – 6 months, PTSD – 1 month

    3. Schizophrenia – 1 month active + 5 months prodromal/residual = 6 months

  28. The mnemonic for your psychiatric review of symptoms is Psych Dep CASES for Psychosis, Depressive and mood, Cognitive, Anxiety, Somatoform, Substance, Eating

  29. The four modules of DBT are mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness

  30. Memorise this handy definition of CBT. CBT is a structured, short-term psychotherapy that addresses the dysfunctional beliefs and maladaptive information processing that cause inappropriate and psychopathological responses to stimuli by  encouraging patients to treat their beliefs as hypothesis to be tested and by guiding in doing so in a way that protect against biases and distortions inherent in specific psychological disorders