Alcohol withdrawal

Mechanism
chronic alcohol consumption enhances GABA mediated inhibition in the
CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate
receptors
alcohol ithdraal is thought to be lead to the opposite (decreased
inhibitory GABA and increased NMDA glutamate transmission)
!eatures
symptoms start at "-#$ hours
pea% incidence o& seizures at '" hours
pea% incidence o& delirium tremens is at ($ hours
Management
benzodiazepines
carbamazepine also e&&ecti)e in treatment o& alcohol ithdraal
phenytoin is said not to be as e&&ecti)e in the treatment o& alcohol
ithdraal seizures
Anorexia nervosa
Anore*ia ner)osa is the most common cause o& admissions to child and adolescent
psychiatric ards+
,pidemiology
-./ o& patients are &emale
predominately a&&ects teenage and young-adult &emales
pre)alence o& beteen #0#.. and #0$..
Diagnosis (based on the DSM-12 criteria)
person chooses not to eat - BM1 3 #(+4 %g5m6$7 or 3 84/ o& that e*pected
intense &ear o& being obese
disturbance o& eight perception
amenorrhoea 9 ' consecuti)e cycles
:he prognosis o& patients ith anore*ia ner)osa remains poor+ ;p to #./ o&
patients ill e)entually die because o& the disorder+
Anorexia nervosa: features
Anore*ia ner)osa is associated ith a number o& characteristic clinical signs and
physiological abnormalities hich are summarised belo
!eatures
reduced body mass inde*
bradycardia
hypotension
enlarged sali)ary glands
<hysiological abnormalities
hypo%alaemia
lo !S=7 >=7 oestrogens and testosterone
raised cortisol and groth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
lo :'
Antipsychotics
Antipsychotics act as dopamine D$ receptor antagonists7 bloc%ing dopaminergic
transmission in the mesolimbic pathays+ Con)entional antipsychotics are
associated ith problematic e*trapyramidal side-e&&ects hich has led to the
de)elopment o& atypical antipsychotics such as clozapine
,*trapyramidal side-e&&ects
<ar%insonism
acute dystonia (e+g+ torticollis7 oculogyric crisis)
a%athisia (se)ere restlessness)
tardi)e dys%inesia (late onset o& choreoathetoid mo)ements7 abnormal7
in)oluntary7 may occur in ?./ o& patients7 may be irre)ersible7 most
common is cheing and pouting o& @a)
:he Medicines and =ealthcare products Aegulatory Agency has issued speci&ic
arnings hen antipsychotics are used in elderly patients0
increased ris% o& stro%e
increased ris% o& )enous thromboembolism
Bther side-e&&ects
antimuscarinic0 dry mouth7 blurred )ision7 urinary retention7 constipation
sedation7 eight gain
raised prolactin0 galactorrhoea
neuroleptic malignant syndrome0 pyre*ia7 muscle sti&&ness
reduced seizure threshold (greater ith atypicals)
Aphonia
Aphonia describes the inability to spea%+ Causes include0
recurrent laryngeal ner)e palsy (e+g+ <ost-thyroidectomy)
psychogenic
External links
Summary article
<sychogenic aphonia
Atypical antipsychotics
Atypical antipsychotics should no be used &irst-line in patients ith
schizophrenia7 according to $..4 N1C, guidelines+ :he main ad)antage o& the
atypical agents is a signi&icant reduction in e*tra-pyramidal side-e&&ects+
Ad)erse e&&ects o& atypical antipsychotics
eight gain
clozapine is associated ith agranulocytosis (see belo)
:he Medicines and =ealthcare products Aegulatory Agency has issued speci&ic
arnings hen antipsychotics are used in elderly patients0
increased ris% o& stro%e (especially olanzapine and risperidone)
increased ris% o& )enous thromboembolism
,*amples o& atypical antipsychotics
clozapine
olanzapine
risperidone
Cuetiapine
amisulpride
Clozapine7 one o& the &irst atypical agents to be de)eloped7 carries a signi&icant ris%
o& agranulocytosis and &ull blood count monitoring is there&ore essential during
treatment+ !or this reason clozapine should only be used in patients resistant to
other antipsychotic medication
Ad)erse e&&ects o& clozapine
agranulocytosis (#/)7 neutropaenia ('/)
reduced seizure threshold - can induce seizures in up to '/ o& patients
External links
N1C,
Schizophrenia guidelines
Benzodiazepines
Benzodiazepines enhance the e&&ect o& the inhibitory neurotransmitter gamma-
aminobutyric acid (GABA)+ :hey there&ore are used &or a )ariety o& purposes0
sedation
hypnotic
an*iolytic
anticon)ulsant
muscle rela*ant
<atients commonly de)elop a tolerance and dependence to benzodiazepines and
care should there&ore be e*ercised on prescribing these drugs+ :he Committee on
Sa&ety o& Medicines ad)ises that benzodiazepines are only prescribed &or a short
period o& time ($-? ee%s)+
:he BN! gi)es ad)ice on ho to ithdra a benzodiazepine+ :he dose should be
ithdran in steps o& about #58 (range #5#. to #5?) o& the daily dose e)ery
&ortnight+ A suggested protocol &or patients e*periencing di&&iculty is gi)en0
sitch patients to the eCui)alent dose o& diazepam
reduce dose o& diazepam e)ery $-' ee%s in steps o& $ or $+4 mg
time needed &or ithdraal can )ary &rom ? ee%s to a year or more
1& patients ithdra too Cuic%ly &rom benzodiazepines they may e*perience
benzodiazepine ithdraal syndrome7 a condition )ery similar to alcohol
ithdraal syndrome+ :his may occur up to ' ee%s a&ter stopping a long-acting
drug+ !eatures include0
insomnia
irritability
an*iety
tremor
loss o& appetite
tinnitus
perspiration
perceptual disturbances
seizures
Body dysmorphic disorder
Body dysmorphic disorder (sometimes re&erred to as dysmorphophobia) is a mental
disorder here patients ha)e a signi&icantly distorted body image
Diagnostic and Statistical Manual (DSM) 12 criteria0
<reoccupation ith an imagine de&ect in appearance+ 1& a slight physical
anomaly is present7 the personDs concern is mar%edly e*cessi)e
:he preoccupation causes clinically signi&icant distress or impairment in
social7 occupational7 or other important areas o& &unctioning
:he preoccupation is not better accounted &or by another mental disorder
(e+g+7 dissatis&action ith body shape and size in Anore*ia Ner)osa)
Bulimia nervosa
Bulimia ner)osa is a type o& eating disorder characterised by episodes o& binge
eating &olloed by intentional )omiting
Management
re&erral &or specialist care is appropriate in all cases
cogniti)e beha)iour therapy (CB:) is currently consider &irst-line treatment
interpersonal psychotherapy is also used but ta%es much longer than CB:
pharmacological treatments ha)e a limited role - a trial o& high-dose
&luo*etine is currently licensed &or bulimia but long-term data is lac%ing
External links
Clinical Enoledge Summaries
,ating disoder guidelines
Cognitive behavioural therapy
Main points
use&ul in the management o& depression and an*iety disorders
usually consists o& one to to hour sessions once per ee%
should be completed ithin " months
patients usually get around #"-$. hours in total
Depression: selective serotonin reuptake inhibitors
Selecti)e serotonin reupta%e inhibitors (SSA1s) are considered &irst-line treatment
&or the ma@ority o& patients ith depression+
citalopram and &luo*etine are currently the pre&erred SSA1s
citalopram is use&ul &or elderly patients as it is associated ith loer ris%s o&
drug interactions
sertraline is use&ul post myocardial in&arction as there is more e)idence &or
its sa&e use in this situation than other antidepressants
SSA1s should be used ith caution in children and adolescents+ !luo*etine is
the drug o& choice hen an antidepressant is indicated
Ad)erse e&&ects
gastrointestinal symptoms are the most common side-e&&ect
there is an increased ris% o& gastrointestinal bleeding in patients ta%ing
SSA1s+ A proton pump inhibitor should be prescribed i& a patient is also
ta%ing a NSA1D
patients should be counselled to be )igilant &or increased an*iety and
agitation a&ter starting a SSA1
&luo*etine and paro*etine ha)e a higher propensity &or drug interactions
citalopram and sertraline and more suitable &or patients ith chronic
physical health problems as they ha)e a loer propensity &or drug
interactions+
1nteractions
NSA1Ds0 N1C, guidelines ad)ise Ddo not normally o&&er SSA1sD7 but i& gi)en
co-prescribe a proton pump inhibitor
ar&arin 5 heparin0 N1C, guidelines recommend a)oiding SSA1s and
considering mirtazapine
aspirin0 see abo)e
triptans0 a)oid SSA1s
!olloing the initiation o& antidepressant therapy patients should normally be
re)ieed by a doctor a&ter $ ee%s+ !or patients under the age o& '. years or at
increased ris% o& suicide they should be re)ieed a&ter # ee%+ 1& a patient ma%es a
good response to antidepressant therapy they should continue on treatment &or at
least " months a&ter remission as this reduces the ris% o& relapse+
Fhen stopping a SSA1 the dose should be gradually reduced o)er a ? ee% period
(this is not necessary ith &luo*etine)+ <aro*etine has a higher incidence o&
discontinuation symptoms+
Discontinuation symptoms
increased mood change
restlessness
di&&iculty sleeping
unsteadiness
seating
gastrointestinal symptoms0 pain7 cramping7 diarrhoea7 )omiting
paraesthesia
External links
N1C,
$..- Depression guidelines
Electroconvulsive therapy
,lectrocon)ulsi)e therapy is a use&ul treatment option &or patients ith se)ere
depression re&ractory to medication or those ith psychotic symptoms+ :he only
absolute contraindications is raised intracranial pressure+
Short-term side-e&&ects
headache
nausea
short term memory impairment
memory loss o& e)ents prior to ,C:
cardiac arrhythmia
>ong-term side-e&&ects
some patients report impaired memory
ypomania vs! mania
:he presence o& psychotic symptoms di&&erentiates mania &rom hypomania
<sychotic symptoms
delusions o& grandeur
auditory hallucinations
:he &olloing symptoms are common to both hypomania and mania
Mood
predominately ele)ated
irritable
Speech and thought
pressured
&light o& ideas
poor attention
Beha)iour
insomnia
loss o& inhibitions0 se*ual promiscuity7 o)erspending7 ris%-ta%ing
increased appetite
"euroleptic malignant syndrome
Neuroleptic malignant syndrome is a rare but dangerous condition seen in patients
ta%ing antipsychotic medication+ 1t carries a mortality o& up to #./ and can also
occur ith atypical antipsychotics
!eatures
more common in young male patients
onset usually in &irst #. days o& treatment or a&ter increasing dose
pyre*ia
rigidity
tachycardia
A raised creatine %inase is present in most cases+ A leu%ocytosis may also be seen
Management
stop antipsychotic
12 &luids to pre)ent renal &ailure
dantrolene may be use&ul in selected cases
bromocriptine7 dopamine agonist7 may also be used
#CD
<athophysiology
some research suggest childhood group A beta-haemolytic streptococcal
in&ection may ha)e a role
Associations
depression ('./)
schizophrenia ('/)
SydenhamDs chorea
:ouretteDs syndrome
anore*ia ner)osa
$arkinson%s disease: features
<ar%insonDs disease is a progressi)e neurodegenerati)e condition caused by
degeneration o& dopaminergic neurons in the substantia nigra++ :his results in a
classic triad o& &eatures0 brady%inesia7 tremor and rigidity+ :he symptoms o&
<ar%insonDs disease are characteristically asymmetrical
Brady%inesia
po)erty o& mo)ement also seen0 mas%-li%e &acies
di&&iculty in initiating mo)ement
:remor
most mar%ed at rest7 '-4 =z
typically Dpill-rollingD
Aigidity
lead pipe
cogheel0 due to superimposed tremor
Bther characteristic &eatures
&le*ed posture
short7 shu&&ling steps
micrographia
drooling o& sali)a
psychiatric &eatures0 depression is the most common &eature (a&&ects about
?./)G dementia7 psychosis and sleep disturbances may also occur
impaired ol&action
A,M sleep beha)iour disorder
Drug&induced parkinsonism has slightly di&&erent &eatures to <ar%insonDs disease0
motor symptoms are generally rapid onset and bilateral
rigidity and rest tremor are uncommon
$ost&concussion syndrome
<ost-concussion syndrome is seen a&ter e)en minor head trauma
:ypical &eatures include
headache
&atigue
an*iety5depression
dizziness
$ost&partum mental health problems
<ost-partum mental health problems range &rom the Dbaby-bluesD to puerperal
psychosis
%Baby&blues% $ostnatal depression $uerperal psychosis
Seen in around ".-
(./ o& omen
:ypically seen '-(
days &olloing birth
and is more common
in primips
Mothers are
characteristically
an*ious7 tear&ul and
irritable
A&&ects around #./ o& omen
Most cases start ithin a month and
typically pea%s at ' months
!eatures are similar to depression
seen in other circumstances
A&&ects appro*imately
.+$/ o& omen
Bnset usually ithin the
&irst $-' ee%s &olloing
birth
!eatures include se)ere
sings in mood (similar to
bipolar disorder) and
disordered perception (e+g+
auditory hallucinations)
Aeassurance and
support7 the health
)isitor has a %ey role
As ith the baby blues reassurance
and support are important
Cogniti)e beha)ioural therapy may
be bene&icial+ Certain SSA1s such as
sertraline and paro*etineH may be
used i& symptoms are se)ereHH -
hilst they are secreted in breast
mil% it is not thought to be harm&ul
to the in&ant
Admission to hospital is
usually reCuired
:here is around a $./ ris%
o& recurrence &olloing
&uture pregnancies
Hparo*etine is recommended by S1GN because o& the lo mil%5plasma ratio
HH&luo*etine is best a)oided due to a long hal&-li&e
$ost&traumatic stress disorder
<ost-traumatic stress disorder (<:SD) can de)elop in people o& any age &olloing
a traumatic e)ent7 &or e*ample a ma@or disaster or childhood se*ual abuse+ 1t
encompasses hat became %non as Dshell shoc%D &olloing the &irst orld ar+
Bne o& the DSM-12 diagnostic criteria is that symptoms ha)e been present &or
more than one month
!eatures
re-e*periencing0 &lashbac%s7 nightmares7 repetiti)e and distressing intrusi)e
images
a)oidance0 a)oiding people7 situations or circumstances resembling or
associated ith the e)ent
hyperarousal0 hyper)igilance &or threat7 e*aggerated startle response7 sleep
problems7 irritability and di&&iculty concentrating
emotional numbing - lac% o& ability to e*perience &eelings7 &eeling detached
&rom other people
depression
drug or alcohol misuse
anger
une*plained physical symptoms
Management
&olloing a traumatic e)ent single-session inter)entions (o&ten re&erred to as
debrie&ing) are not recommended
atch&ul aiting may be used &or mild symptoms lasting less than ? ee%s
military personnel ha)e access to treatment pro)ided by the armed &orces
trauma-&ocused cogniti)e beha)ioural therapy (CB:) or eye mo)ement
desensitisation and reprocessing (,MDA) therapy may be used in more
se)ere cases
drug treatments &or <:SD should not be used as a routine &irst-line treatment
&or adults+ 1& drug treatment is used then paro*etine or mirtazapine are
recommended
External links
N1C,
$..4 <:SD guidelines
'chizophrenia: epidemiology
Ais% o& de)eloping schizophrenia
monozygotic tin has schizophrenia 9 4./
parent has schizophrenia 9 #.-#4/
sibling has schizophrenia 9 #./
no relati)es ith schizophrenia 9 #/
External links
N1C,
Schizophrenia guidelines
'chizophrenia: features
SchneiderDs &irst ran% symptoms may be di)ided into auditory hallucinations7
thought disorders7 passi)ity phenomena and delusional perceptions0
Auditory hallucinations o& a speci&ic type0
to or more )oices discussing the patient in the third person
thought echo
)oices commenting on the patientDs beha)iour
:hought disorderH0
thought insertion
thought ithdraal
thought broadcasting
<assi)ity phenomena0
bodily sensations being controlled by e*ternal in&luence
actions5impulses5&eelings - e*periences hich are imposed on the indi)idual
or in&luenced by others
Delusional perceptions
a to stage process) here &irst a normal ob@ect is percei)ed then secondly
there is a sudden intense delusional insight into the ob@ects meaning &or the
patient e+g+ D:he tra&&ic light is green there&ore 1 am the EingD+
Bther &eatures o& schizophrenia include
impaired insight
incongruity5blunting o& a&&ect (inappropriate emotion &or circumstances)
decreased speech
neologisms0 made-up ords
catatonia
negati)e symptoms0 incongruity5blunting o& a&&ect7 anhedonia (inability to
deri)e pleasure)7 alogia (po)erty o& speech)7 a)olition (poor moti)ation)
Hoccasionally re&erred to as thought alienation
External links
N1C,
Schizophrenia guidelines
'chizophrenia: management
N1C, published guidelines on the management o& schizophrenia in $..-+
Eey points0
oral atypical antipsychotics are &irst-line
cogniti)e beha)ioural therapy should be o&&ered to all patients
close attention should be paid to cardio)ascular ris%-&actor modi&ication due
to the high rates o& cardio)ascular disease in schizophrenic patients (lin%ed
to antipsychotic medication and high smo%ing rates)
External links
N1C,
$..- Schizophrenia guidelines
'chizophrenia: prognostic indicators
!actors associated ith poor prognosis
strong &amily history
gradual onset
lo 1I
premorbid history o& social ithdraal
lac% o& ob)ious precipitant
External links
N1C,
Schizophrenia guidelines
'easonal affective disorder
Seasonal a&&ecti)e disorder (SAD) describes depression hich occurs
predominately around the inter months+ Bright light therapy has been shon to
be more e&&ecti)e than placebo &or patients ith SAD
'leep paralysis
Sleep paralysis is a common condition characterized by transient paralysis o&
s%eletal muscles hich occurs hen aa%ening &rom sleep or less o&ten hile
&alling asleep+ 1t is thought to be related to the paralysis that occurs as a natural part
o& A,M (rapid eye mo)ement) sleep+ Sleep paralysis is recognised in a ide
)ariety o& cultures
!eatures
paralysis - this occurs a&ter a%ing up or shortly be&ore &alling asleep
hallucinations - images or spea%ing that appear during the paralysis
Management
i& troublesome clonazepam may be used
'uicide
!actors associated ith ris% o& suicide &olloing an episode o& deliberate sel&
harm0
e&&orts to a)oid disco)ery
planning
lea)ing a ritten note
&inal acts such as sorting out &inances
)iolent method
:hese are in addition to standard ris% &actors &or suicide
male se*
ad)ancing age
unemployment or social isolation
di)orced or idoed
history o& mental illness (depression7 schizophrenia)
history o& deliberate sel& harm
alcohol or drug misuse
(ricyclic antidepressants
:ricyclic antidepressants (:CAs) are used less commonly no &or depression due
to their side-e&&ects and to*icity in o)erdose+ :hey are hoe)er used idely in the
treatment o& neuropathic pain7 here smaller doses are typically reCuired+
Common side-e&&ects
drosiness
dry mouth
blurred )ision
constipation
urinary retention
Choice o& tricyclic
lo-dose amitriptyline is commonly used in the management o& neuropathic
pain and the prophyla*is o& headache (both tension and migraine)
lo&epramine has a loer incidence o& to*icity in o)erdose
amitriptyline and dosulepin (dothiepin) are considered the most dangerous
in o)erdose
)ore sedative *ess sedative
Amitriptyline
Clomipramine
Dosulepin
:razodoneH
1mipramine
>o&epramine
Nortriptyline
Htrazodone is technically a Dtricyclic-related antidepressantD
+nexplained symptoms
:here are a ide )ariety o& psychiatric terms &or patients ho ha)e symptoms &or
hich no organic cause can be &ound0
Somatisation disorder
multiple physical SJM<:BMS present &or at least $ years
patient re&uses to accept reassurance or negati)e test results
=ypochondrial disorder
persistent belie& in the presence o& an underlying serious D1S,AS,7 e+g+
cancer
patient again re&uses to accept reassurance or negati)e test results
Con)ersion disorder
typically in)ol)es loss o& motor or sensory &unction
the patient doesnDt consciously &eign the symptoms (&actitious disorder) or
see% material gain (malingering)
patients may be indi&&erent to their apparent disorder - la belle indi&&erence -
although this has not been bac%ed up by some studies
Dissociati)e disorder
dissociation is a process o& Dseparating o&&D certain memories &rom normal
consciousness
in contrast to con)ersion disorder in)ol)es psychiatric symptoms e+g+
Amnesia7 &ugue7 stupor
dissociati)e identity disorder (D1D) is the ne term &or multiple personality
disorder as is the most se)ere &orm o& dissociati)e disorder
MunchausenDs syndrome
also %non as &actitious disorder
the intentional production o& physical or psychological symptoms
Malingering
&raudulent simulation or e*aggeration o& symptoms ith the intention o&
&inancial or other gain