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Title: Psychiatry lecture notes
Description: A detailed and comprehensive set of psychiatry lectures notes. Covers all aspects of mental health. Diagrams included to aid learning. Very useful for medical students.
Description: A detailed and comprehensive set of psychiatry lectures notes. Covers all aspects of mental health. Diagrams included to aid learning. Very useful for medical students.
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PSYCHIATRY REVISION NOTES
PSYCHIATRIC HISTORY TAKING
Information from patient and other informants (collateral history):
• Presenting complaint and history of presenting complaint: SOCRATES: Affective (mood)
disorder (mania or depression) – how is you mood? Is it up or down? Psychotic disorder
(psychosis) – any strange thoughts or feelings? Any strange voices or images? Personality
disorder? Alcohol/drug dependency? Self harm? Anxiety – do you every worry about stuff?
Do a psychiatric systematic enquiry to screen for all the major diorders
...
Previous alcohol or drug
problems
...
g
...
Technical description of the following factors should be documented:
• Appearance: age, facial expressions, activity (e
...
fidgeting or sitting still), posture, clothing,
effort with appearance, evidence of self neglect, evidence of self harm, evidence of drug
abuse or alcohol dependency, signs of physical ill health, signs of weight loss, signs of
malnutrition
• Behaviour: describe what the patient is doing and the appropriateness for the situation, eye
contact, attitude/rapport, cooperative/uncooperative, hostile, guarded, suspicious, anxious,
psychomotor agitation (unintentional and purposeless motions that stem from mental
tension and anxiety of an individual), psychomotor retardation (involves a slowing-‐down of
thought and a reduction of physical movements in an individual), other abnormal
movements (e
...
choreiform, tics, myoclonics, bradykinesia, hyperkinesia)
•
•
•
Speech: volume, rate, tone, articulation, accent, vocabulary, sudden silences, poverty of
speech (minimal verbal communication), echolalia (repetition of another person's words)
Mood and affect (including suicidality)
! Mood: subjective description using patients own words (can rate mood on a
scale) e
...
neutral, euthymic, dysphoric, euphoric, anxious, angry, apathetic,
irritable, suicidal ideation or self-‐harm
...
g
...
Also
include doctors objective description of mood e
...
appeared anxious due to
sweating and fidgeting
! Suicidality: very important to ask, “Have you ever thought about harming
yourself?” If so then further enquire into plan, reasons to die, reasons to live etc
...
g
...
g
...
g
...
g
...
Neuropsychiatric examination: The MSE may include a brief neuropsychiatric examination in
some situations e
...
to assess for basal ganglia pathology in suspected PD (bradykinesia,
rigidity, tremor, postural instability) or cerebellar disease (“DANISH PT”)
DEPRESSED MOOD
Depressed mood is not necessarily a psychiatric disorder
...
g
...
g
...
It is often one of the early symptoms of
hypothyroidism) – organic low mood – MUST ALWAYS RULE OUT
• A side effect of some drugs or medical treatments
• Must always rule out organic causes before diagnosing psychiatry cause!
Clinical depression
• Clinical depression (major depressive disorder MDD) is a psychiatric disorder characterized
by a pervasive and persistent low mood which is accompanied by a variety of symptoms
such as low energy (anergia), loss of interest or pleasure in normally enjoyable activities
(anhedonia), low self esteem, disturbed sleep, weight loss and if severe – psychosis, ideas of
self harm and suicide
...
g
...
The model specifies that depression
results when a pre-‐existing vulnerability (e
...
genetics, early adverse life experiences,
personality traits) is activated by stressful life events
• Always consider BIOPSYCHOSOCIAL FACTORS
• Pathophysiology: Due to the clinical and etiological heterogeneity of major depressive
disorder, it has been difficult to elucidate its pathophysiology
...
These substances are serotonin
(5HT), norepinephrine (noradrenaline NA), and dopamine (DA)
...
Most antidepressant medications increase the levels
of one or more of the monoamines: the neurotransmitters serotonin, norepinephrine and
•
•
•
dopamine, in the synaptic cleft between neurons in the brain
...
Very complicated pathophysiology – not fully understood
...
g
...
If suicidal => severe
...
Have you had any strange thoughts or feelings? Have
you seen or heard anything that no one else has?
Physical symptoms
Pseudodementia (decrease in cognitive ability)
Self harm and suicide (always enquire about) – specifically ask about thought of harm or
suicide
...
Plans etc
...
Reasons to live
...
MSE
The MSE is important for fully assessing the patient and most importantly assessing for evidence of
self harm, suicidal thought and drug/alcohol abuse
...
g
...
The triad
involves negative thoughts about:
• The self (e
...
the self is worthless, helpless and/or unlovable)
• The world/environment (e
...
the world is unfair)
• The future (e
...
the future is hopeless)
...
Subtypes of clinical depression
The DSM-‐IV-‐TR recognizes five further subtypes of major depressive disorder (clinical depression),
called specifiers:
• Melancholic depression is characterized by a loss of pleasure in most or all activities, a
failure of reactivity to pleasurable stimuli, a quality of depressed mood more pronounced
than that of grief or loss, a worsening of symptoms in the morning hours, early-‐morning
waking, psychomotor retardation, excessive weight loss (not to be confused with anorexia
nervosa), or excessive guilt
...
• Atypical depression is characterized by mood reactivity (paradoxical anhedonia) and
positivity, significant weight gain or increased appetite (hyperphagia, comfort eating),
excessive sleep or sleepiness (hypersomnia), a sensation of heaviness in limbs known as
leaden paralysis, and significant social impairment as a consequence of hypersensitivity to
perceived interpersonal rejection
...
May respond better to MAO-‐A
inhibitors e
...
meclobemide
...
Here the person is mute and almost stuporous
(decreased consciousness), and either remains immobile or exhibits purposeless or even
•
•
bizarre movements
...
Indication for ECT
...
Postpartum depression has an incidence rate of
10–15% among new mothers
...
It has been said
that postpartum depression can last as long as three months
...
Seasonal affective disorder (SAD) is a form of depression in which depressive episodes come
on in the autumn or winter, and resolve in spring
...
Atypical Depression
Diagnostic criteria requires two (or more) of the following
• Paradoxical anhedonia (mood reactivity) e
...
improved mood in response to positive events
(reactive affect, rather than blunted)
• Significant weight gain or increase in appetite -‐ hyperphagia (comfort eating)
• Hypersomnia (excessive sleepiness)
• Leaden paralysis (that is, heavy, leaden feelings in arms or legs)
• Long-‐standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood
disturbance) that results in significant social or occupational impairment
Depression differential diagnosis
There are many psychiatric and medical (organic) conditions that may mimic some or all of the
symptoms of clinical depression, or may occur co-‐morbid to it
...
g
...
g
...
g
...
g
...
g
...
They include
depressions due to physical organic illness (directly or indirectly), chronic pain, medications, and
substance abuse
...
This condition is determined based on history, laboratory findings, or physical
examination
...
In
such cases, a substance is judged to be aetiologically related to the mood disturbance
...
Low
mood or loss of interest (anhedonia) must be present and delusions and hallucinations are absent
...
While this disorder may interfere with social or occupational functioning, the disturbance is not
severe enough to qualify for a diagnosis of major depressive disorder (clinical depression)
...
Also, people with only partial recovery from a major depression are not classified as
dysthymic
...
The symptoms are not as severe as those for major depression,
although people with dysthymia are vulnerable to secondary episodes of major depression
(sometimes referred to as double depression)
...
Older people were sometimes misdiagnosed as having dementia
when further investigation showed they were suffering from a major depressive episode
...
•
•
•
It has long been observed that in the differential diagnosis between dementia and
pseudodementia, depressive pseudodementia appears to be the single most difficult
disorder to distinguish from "organic" categories of dementia, especially degenerative
dementia of the Alzheimer type
...
Investigations such as SPECT imaging of the brain show reduced blood flow in areas of the
brain in people with Alzheimer's disease, compared with a more normal blood flow in those
with pseudodementia
Complex pathophysiology
•
Management of depression
The three most common treatments for depression are:
• Psychotherapy e
...
CBT (first line management; CBT has the greatest evidence base for
effectiveness)
• Medication: SSRIs usually first line medication due to relatively mild side effects; often used
in conjunction with psychotherapy
• Electroconvulsive therapy (last resort or for emergencies e
...
Tx resistant severe depression
or catatonia)
ECT
• Electroconvulsive therapy (ECT) is a procedure whereby pulses of electricity are sent through
the brain via two electrodes, usually one on each temple, to induce a seizure while the
person is under a brief period of general anaesthesia
...
• Can also be used for catatonic states
• ECT can have a quicker effect than antidepressant therapy and thus may be the treatment of
choice in emergencies such as catatonic depression where the person has stopped eating
and drinking, or where a person is severely suicidal
...
However, when ECT is used on its own, the relapse rate within the first six
months is very high (a recent controlled trial found rates of 84% even with placebos)
...
• Although memory disturbance after ECT usually resolves within one month, ECT remains a
controversial treatment, and debate on its efficacy and safety continues
...
Care is usually given on an outpatient basis, whereas
treatment in an inpatient unit is considered if there is a significant risk to self or others
Bipolar affective disorder
• Bipolar disorder, also known as bipolar affective disorder, manic-‐depressive disorder, or
manic depression, is a mental illness classified by psychiatry as a mood (affective) disorder
...
• Bipolar disorder is characterized by two or more episodes
• Mania/hypomania is the defining feature of bipolar disorder (and must occur at least once
out of the two defining episodes)
• Repeated episodes of hypomania or mania only are still classified as bipolar disorder – a
depressive episode is NOT required to meet the diagnostic criteria
• Mean age of onset 21 years
• Types:
! Bipolar type 1 (mania): prevalence 1%
! Bipolar type 2 (hypomania): prevalence 1
...
g
...
g
...
g
...
Substance abuse may predate the appearance of
bipolar symptoms, further complicating the diagnosis
...
• Mania can occur with different levels of severity
...
• As mania becomes more severe, individuals begin to behave erratically and impulsively,
often making poor decisions due to unrealistic ideas about the future, and may have great
difficulty with sleep
...
People with bipolar disorder exhibiting psychotic symptoms can
sometimes be misdiagnosed as having schizophrenia
...
Manic and depressive episodes last from a few days to several months
...
Generally, hypomania does not inhibit
functioning (in contrast to mania)
...
•
Hypomania has same symptoms as mania but often milder e
...
• Mild elevation of mood
• Pressure of speech and activity
• Feelings of wellbeing and efficiency
• Increased energy and activity
• Sometimes irritability
• Some disturbance of function
• NO PSYCHOSIS
Depressive phase
Signs and symptoms of the depressive phase of bipolar disorder include:
• Depressed (low mood)
• Anhedonia
• Anergia
• Loss of appetite
• Sleep disturbance
• Loss of interest in sexual activity
• Morbid suicidal thoughts
...
These symptoms include delusions or, less commonly,
hallucinations, usually unpleasant
...
Lamotrigine is a useful second line agent for pts who have depression predominant bipolar
...
Mixed Affective State
• In the context of bipolar disorder, a mixed affective state is a condition during which
symptoms of mania/hypomania and depression occur simultaneously
...
• Individuals may also feel very frustrated in this state, for example thinking grandiose
thoughts while at the same time feeling like a failure
...
Diagnosis
• History
• We can use MSE to clinically evaluate suspected bipolar patients
...
• There is no simple physiological test to confirm the disorder
...
In particular, it can be difficult to distinguish depression caused by bipolar
disorder from pure unipolar depression
...
The criteria takes into
account the presence and duration of certain signs and symptoms
...
g
...
Very important to fully asses sot including blood and potentially imaging
...
Although there are no
biological tests, which confirm bipolar disorder, tests may be carried out to exclude medical
(organic) illnesses such as hypo-‐ or hyperthyroidism, metabolic disturbance, a systemic infection
or chronic disease, and syphilis or HIV infection (which may be the cause or exacerbator of the
psychiatric presentation)
...
Investigations are not generally repeated for relapse unless there is a specific
medical indication
...
• These disorders range from bipolar type 1 disorder (featuring full-‐blown manic episodes)
to cyclothymia (featuring less prominent hypomanic episodes) to bipolar type 2 disorder
(featuring hypomanic episodes)
...
Criteria and subtypes: DSM classification
• Bipolar type I disorder: One or more manic episodes
...
This is the most severe bipolar with the
worse prognosis
...
• Cyclothymia: A history of hypomanic episodes with periods of depression that do not meet
criteria for major depressive episodes
...
Cyclothymia is a mild
form of bipolar disorder, however, the symptoms do not meet the diagnostic requirements
for any other type of bipolar disorder
...
These include schizophrenia, schizoaffective disorder, attention deficit
hyperactivity disorder (ADHD), delirium, non-‐bipolar psychosis, and some personality
disorders, including borderline personality
...
g
...
Schizoaffective disorder
• Episodic disorders
• Schizophrenic symptoms (e
...
First rank symptoms) and mood symptoms present to the
same degree in the same episode -‐ at same time or within days of each other
• In contrast, acute episodes of schizophrenia are NOT normally associated with affective
(mood symptoms) at the same time
• More discussion in schizophrenia lecture
Management of bipolar
• Psychosocial e
...
CBT
•
Medication e
...
lithium (often first line), sodium valproate (good for mania predominance),
and lamotrigine (good for depressive predominance)
A number of medications are used to treat bipolar disorder
...
Lithium reduces the risk of suicide, self-‐harm, and
death in people with bipolar disorder
...
THE NEUROBIOLOGY OF MOOD DISORDERS
Appetitive/Approach Systems: Reward system
This system functions to mediate seeking and approach behaviours (including pleasure) e
...
reward
pathways
...
DA projections are selectively confined to specific parts of brain
...
g
...
The major part of this system is the noradrenaline and ascending serotonin systems
...
Components include:
• Cortex
• Limbic system:
! Central nucleus of amygdale (activates hypothalamus to generate flight or fright
response)
! Hippocampus
! Hypothalamus (actives ANS for flight or fright response)
• Periaqueductal gray matter
Neurobiology of Depression
Clinical features of Major Depressive disorder
Core symptoms:
• Low (depressed) mood
• Anhedonia (lack of pleasure)
• Anergia (lack of energy)
Other symptoms (ICD 10):
• Disturbed sleep
• Diminished appetite
• Reduced concentration and attention
•
•
•
•
Reduced self esteem and self confidence
Ideas of guilt and unworthiness
Bleak and pessimistic views of the future
Ideas or acts of self harm or suicide (never forget to enquire about suicide and self harm:
both in the past, present, or thoughts about future)
Linking neurobiology to depressive symptoms
• Dysfunction of the aversive/defensive systems is the main thing associated with depression,
and
these
systems
are
primarily
mediated
by
serotonin
(and
noradrenaline/norepinephrine)
...
• Increasing serotonin in the synapse itself doesn’t appear to be the direct way that SSRIs treat
depression (takes about 16 hours for an SSRI to increase the serotonin level, but 2-‐6 weeks
for it to work) but changes in serotonin receptors as a result of the increase in serotonin,
which may then affect secondary messengers and in turn gene expression, seem to be
involved
...
g
...
• Such atrophy is centred in a brain region called the hippocampus
...
g
...
• The hippocampus belongs to the limbic system and plays important roles in the
consolidation of information from short-‐term memory to long-‐term memory and spatial
navigation
...
Bipolar Disorder neurobiology
Linking neurobiology to mania symptoms
• Mania/Hypomania symptoms can be explained by disordered appetitive/approach (reward
system: dopamine pathways) functioning AND disordered aversive/defensive (serotonin
and noradrenaline pathways)
...
• PSYCHOLOGICAL AND PHYSICAL COMPONENT
• Anxiety can be a normal response to a threat (therefore not an anxiety disorder)
• Psychological component: fear, dread, unease, avoidance, worry, panic
• Physical component: dry mouth, globus pharyngeus, chest tightness, SOB, tingling, urinary
and bladder dysfunction, muscle tightness, tremor, palpitations
•
Anxiety is a bio-‐psycho-‐social state with the following elements:
• Bodily responses: autonomic (increased sympathetic activity due to flight or fright response)
and hormonal (e
...
increased cortisol due to stress)
• Psychological: thoughts and emotions such as unease, fear or dread, panic (which are
disproportionate to the situation)
• Social: Impact upon interaction in the environment e
...
facial expressions, speech, coughing,
swallowing, avoidance of situations
Normal response to threat
The amygdala plays a central role in responding to threat
...
g
...
e
...
Aberrant overactivity in the amygdala may well play an important role in anxiety disorders
...
Cognitive-‐Behaviour theory: Behavioural theory => anxiety is a conditioned response to specific
environmental stimuli
...
Patients with anxiety disorders overestimate the degree of danger and
probability of harm in a given situation underestimate their own ability to cope with perceived
threats
...
Types of anxiety disorder (DSM IV)
• Generalised Anxiety Disorder: Remember that anxiety is a mood
...
There are no specific identifiable triggers in GAD
...
• Anxiety Disorder due to a general medical condition (anxiety can be a symptom of many
medical conditions -‐ don’t forget about hyperthyroidism, Cushings, hypercalcaemia)
• Substance-‐induced anxiety disorder e
...
cannabis
• Panic disorder: The individual experiences recurrent panic attacks (severe brief episodes of
anxiety – psychological and physical manifestations) that are not consistently associated
with a specific situation or object, and which often occur spontaneously
...
May occur with agrophobia (agoraphobia with panic disorder)
• Social phobia: Marked fear or avoidance of being the focus of attention or of behaving in a
way, which will be embarrassing or humiliating
...
However note that
the individual wants to be social, but it causes fear
...
g
...
Associated with anxiety symptoms and emotional distress and recognition
that symptoms are excessive/unreasonable
...
Specific phobia: Marked fear or avoidance of a specific object or situation not included in
agoraphobia or social phobia
...
g
...
g
...
g
...
g
...
g
...
g
...
g
...
g
...
g
...
There is future
potential for the other mediators and receptors, especially for possible repair in CNS
...
Cholinergic system
• NT= Acetylcholine (ACh) -‐ monoamine NT
• Receptors: nicotinic (ligand gated ion channels: ionotropic) and muscarinic (metabotropic
GPCR)
• In the CNS: Important for motor control, learning and memory, and attentional processes
• In the ANS: important for both sympathetic (presynaptic release of ACh) and
parasympathetic (both pre-‐ and post-‐synaptic release) components
• In the PNS important for NMJ transmission (nicotinic ion channel)
• Main projecting nuclei = Nucleus basalis of Meynert
Unlike the amino acid neurotransmitters (GABA and glutamate) and NA/5HT, it has a much more
localised distribution in the CNS
...
g:
• Striatum (caudate nucleus and putamen) in basal ganglia: role in motor control which is
relevant to some treatments for Parkinson’s disease, where anti-‐cholinergics can be used to
decrease ACh activity => increase relative concentration of DA in basal ganglia system
• Hippocampus: role in learning & memory (relevant to Alzheimer’s disease)
• Longer projection systems from the nucleus Basalis of Meynert (degeneration of this ACh
rich structure is also implicated in Alzheimer’s disease => acetylcholinesterase inhibitors can
be used in AD e
...
Rivastigmine, donepezil and galantamine) to cortex, thalamus and
amygdale: roles in attention and cognitive function
Noradrenergic system
• NT= Noradrenaline (NA) / Norepinephrine (NE) -‐ monoamines
• Receptors: α and β-‐adrenoceptors (metabotropic GPCRs)
• Important for arousal and emotion
• Aversive/defensive system
• Two main projecting nuclei in: (i) locus coeruleus (LC) and (ii) brain stem (pons/medulla)
• Each noradrenaline (NA) containing neurone has many terminals and innervates many other
cells (diffuse projections)
• LC neurones may be involved in arousal (silent during sleep) and mood regulation
• Control of blood pressure through NA synapses in the medulla (CV centre)
• NA neurotransmitter is also found in the sympathetic nervous system (postsynaptic
neurones release NA; except with sympathetic nerves innervating the adrenal gland which
are presynaptic cells and release ACh)
Dopaminergic system
• NT= Dopamine (DA) -‐ monoamine
• Receptors: D1 and D2 family
• Appetitive/approach (reward) system
• Important for motor control, motivation, and reward
• Also important for inhibition of prolactin release -‐ thus antipsychotics (dopamine
antagonists) are potent stimulants of prolactin release and can cause hyperprolactinaemia
• Nigrostriatal pathway (in the basal ganglia) contains 70% of all brain dopamine and is
involved in motor control
...
• Mesocortical/mesolimbic involved in motivation/reward, emotion, and cognitive functions
• Minor projection to pituitary to control hormone release: (i) Major inhibitor of prolactin
(under constant inhibition) release (ii) Minor inhibition of GH
Serotonergic (5HT) system
•
•
•
•
•
•
•
•
NT= Serotonin (5-‐hydroxytryptamine 5HT) -‐ monoamine
Aversive/defensive system – major NT involved
Receptors: many subtypes 5HT1, 5HT2, 5HT3 (most of them G-‐protein linked apart from the
5-‐HT3 receptor)
Best known as a transmitter in several brain areas: (i) sleep regions, (ii) limbic system and
mood control regions and (iii) pain suppression system
Diffuse projections
Important NT for: mood, memory, sleep, cognition, feeding behavior, sensory perception
and analgesia
May play an important role in hallucinations
Happy NT? Ecstasy?
•
•
Nuclei confined almost exclusively to the Raphe nucleus of the brain stem (RS = Raphe
nucleus and serotonin)
Virtually every neuron in the brain may be contacted by a serotonergic fibre
Neuropeptides
•
•
•
•
•
Small proteins that can act as neurotransmitters
Synthesized in the nucleus and then transported down axonal transport system to synaptic
terminal
...
Packaged in large dense core vesicles
Substance P and opioid peptides (enkephalins) found in spinal cord and higher brain
centres
Play a role in perception of pain
Synaptic transmission (chemical)
Common mechanisms:
•
•
•
•
•
Formation:
! Non-‐peptides (e
...
ACh, DA, NA, 5HT) are formed in the nerve terminal
...
g
...
Storage: inside vesicles (with the help of VMAT), small synaptic or dense core
Release: an action potential invades the terminal and causes Ca2+ influx and a rise in
intracellular calcium => the vesicles fuse with the terminal membrane to allow the
neurotransmitter into the synaptic space
...
Occasionally there is metabolism in the synaptic cleft e
...
by MAO enzymes
Targets for drug action
•
•
•
•
Ion channels
Receptors
Enzymes
Transport proteins
Drugs normally interact with protein molecules in or on neurones in order to alter synaptic
transmission e
...
presynaptic receptor, postsynaptic receptor, transporter, OR by acting on
metabolic chemicals e
...
acetlycholinesterase
...
g
...
g
...
Entry of drugs into brain and the BBB
•
•
•
•
•
BBB (astrocytes) is protective e
...
protects unwanted disruption of brain activity
In general, lipid soluble (liophillic or hydrophobic) drugs get in, and water soluble
(hydrophilic or liphophobic) drugs kept out
...
Brain penetration predicted by oil/water partition coefficient
...
Specific transporters or carrier molecules present
Classification of drugs
•
•
•
By structure e
...
benzodiazepine (BDZs)
By pharmacological action e
...
monoamine oxidase inhibitor (MOI)
By clinical action e
...
antipsychotic
PHARMACOLOGY OF ANTI-‐DEPRESSANTS AND MOOD STABALISERS
Types of Antidepressant drugs
There are various types of Anti-‐depressants (ADs):
•
•
•
Monoamine reuptake inhibitors: (i) Tricyclics (TCA) & related, (ii) Selective serotonin
reuptake inhibitors (SSRI), (iii) Other non-‐selective and selective reuptake inhibitors e
...
SNRIs (venlafaxine) and NaSSA (e
...
mirtazapine)
Monoamine oxidase inhibitors (MAO inhibitors) e
...
meclobemdie
Atypical drugs (post-‐synaptic receptor effects)
Most of the drugs used have a similar efficacy but different profile of side effects
...
g
...
g
...
This is accomplished by
vesicular monoamine transporter (VMAT) in the lipid bilayer of the vesicle
...
•
•
•
•
Extracellular uptake of NA into the cytosol is done either presynaptically (uptake 1) or by
non-‐neuronal cells in the vicinity (uptake 2)
...
Reserpine irreversibly blocks the vesicular monoamine transporter (VMAT)
...
Unprotected neurotransmitters are metabolized by MAO (as well as by
COMT) in the cytoplasm and consequently never excite the post-‐synaptic cell
...
As the result of decreased dopamine activity, reserpine can be used to treat psychosis
(reserpine is an anti-‐psychotic), however it can cause drug-‐induced Parkinson's disease
...
Serotonergic (5HT) system
•
•
•
•
•
•
•
•
•
•
•
•
•
•
NT= Serotonin (5-‐hydroxytryptamine/5HTP) – monoamines
Aversive/defensive system – DOMINANT NT
Receptors: many subtypes 5HT1, 5HT2, 5HT3 (Many subtypes of receptor, most of them G-‐
protein linked apart from the 5-‐HT3 receptor)
Best known as a transmitter in several brain areas: (i) sleep regions, (ii) limbic system and
mood control regions and (iii) pain suppression system
Important NT for: mood, memory, sleep, cognition, feeding behavior, sensory perception
and analgesia
Nuclei confined almost exclusively to the Raphe nucleus of the brain stem
...
Serotonin transporters (SERT) transport serotonin back into presynaptic terminal
Monamine oxidases (MAO) degrade serotonin in the cytoplasm and synaptic cleft => MAO
inhibitors can increase 5HT in synaptic cleft
Reserpine
•
•
•
•
•
•
Anti psychotic (as decreases DA levels => puts brake on disordered appetitive/approach DA
system)
Resperine is a drug which irreversibly blocks the vesicular monoamine transporter (VMAT)
e
...
reserpine is a VMAT inhibitor
VMATs primary function is to transport free norepinephrine, serotonin, and dopamine from
the cytoplasm of the presynaptic nerve terminal into storage vesicles for subsequent release
into the synaptic cleft ("exocytosis")
...
Unprotected
neurotransmitters are metabolized by MAO (monoamine oxidase) in the cytoplasm and
consequently never reach the synapse
...
As the result of above, reserpine can cause drug-‐induced Parkinsonism (due to decreased
DA activity) and drug induced low mood (due to decreased 5HT)
Monoamine oxidase inhibitors (MAOI)
There are two different subtypes of MAO with a slightly different substrate preference:
•
•
•
•
•
•
•
They are found bound to the outer membrane of mitochondria in most cell types in the
body
MAOs have a vital role in the inactivation of neurotransmitters, therefore MAO dysfunction
(too much or too little MAO activity) is thought to be responsible for a number of psychiatric
and neurological disorders
MAOA (expressed in NA neurons) – selective for NA, 5-‐HT, DA, tyramine, tryptamine
MAOB (expressed in 5-‐HT neurons) – selective for DA, tyramine, tryptamine
Appreciate that both subtypes are selective for: DA, tyramine, tryptamine
Appreciate that MAO expressed in 5-‐HT neurons (MAOB) doesn’t actually break down 5-‐HT
...
Compounds that enter neurons can be toxic/halllucinogenic – one of the reasons MAO is
there to protect neuron from other substances it may get in
...
•
MAO inhibitors can result in (i) excessive levels of catecholamines (epinephrine, norepinephrine,
and dopamine; particularly in MAO-‐A inhibitors e
...
meclobemide) which may lead to a hypertensive
crisis or (ii) excessive levels of serotonin which may lead to serotonin syndrome
...
•
•
MAO-‐A inhibitors (e
...
meclobemide) act as antidepressant and antianxiety (anxiolytic)
agents (as can boost 5HT, NA and DA levels)
MAO-‐B inhibitors are used alone or in combination to treat Alzheimer’s and Parkinson’s
diseases e
...
Selegiline used for Parkinson’s (can boost dopamine levels)
MAJOR COMPLICATIONS = HT CRISIS (catecholamine driven) and SEROTONIN SYNDROME
MAO inhibitors: mechanism of action
Site of action: MAO inhibitors inhibit the action of MAO primarily found on the mitochondrial outer
membrane
...
Therefore, this results in inhibition of
NT breakdown => increase levels of NT long term => increasing function at synapse
...
g
...
g
...
g
...
g
...
Food interactions may cause hypertensive crisis: Interactions with foodstuffs containing
tyramine (e
...
cheese, pickled herrings, marmite)
...
Excessive tyramine can produce a hypertensive crisis (as stimulates sympathetic system)
...
Therefore patients should have a low tyramine diet
...
g
...
g
...
g
...
g
...
Excessive levels of serotonin produce a spectrum of
specific symptoms including cognitive, autonomic, and somatic effects
...
Because of potentially lethal dietary and drug interactions, monoamine oxidase inhibitors
have historically been reserved as a last line of treatment, used only when other classes of
antidepressant drugs (for example selective serotonin reuptake inhibitors and tricyclic
antidepressants) have failed
...
They are named by structure not target (unlike monoamines)
...
g
...
They are also used to treat a wide variety of other medical conditions (e
...
neuropathic pain
and migraine prophylaxis) and psychiatric disorders
...
This results in an elevation of the synaptic concentrations of these
neurotransmitters, and therefore an enhancement of neurotransmission (particularly useful
in treating MDD; as these monamines are closely linked to the disorder e
...
disordered
appetitive/aversive system)
...
•
Due to the non-‐specificity of reuptake => they therefore have many more side effects in
comparison to SNRIs such as venlafaxine (which is SELECTIVE)
•
Notably, the TCAs have negligible affinity for the dopamine transporter (DAT), and therefore
have no efficacy as dopamine reuptake inhibitors (DRIs) => not used in PD or related
conditions
...
•
Anti-‐cholinergic (anti-‐muscarinic) and anti histamine properties: The TCAs also have
varying but typically high affinity for antagonising the H1 and H2 histamine receptors, as well
as the muscarinic (acetylcholine) receptors
...
These properties are generally
undesirable in antidepressants, however, and likely contribute to their large side effect
profiles
...
! Anti muscarinic effects include dry eyes, dry eyes, urinary retention, constipation,
blurred vision
•
Most, if not all, of the TCAs also potently inhibit sodium channels and L-‐type calcium
channels, and therefore act as sodium channel blockers and calcium channel blockers,
respectively
...
OD is Tx with
bicarbonate
...
•
In OD: supportive therapy is given if necessary, including respiratory assistance,
maintenance of body temperature, and administration of intravenous sodium bicarbonate
as an antidote, which has been shown to be an effective treatment for resolving the
metabolic acidosis and cardiovascular complications of TCA poisoning
...
g
...
e
...
For
this reason they are not commonly used to treat depression (suicide risk) due to newer drugs (e
...
SSRIs) with less toxicity
...
•
SSRIs are also frequently prescribed for anxiety disorders, such as social anxiety disorder,
panic disorders, obsessive compulsive disorder (OCD), eating disorders, chronic pain and
occasionally, and for post-‐traumatic stress disorder (PTSD)
...
For clinical depression, SSRIs are
recommended by NICE over tricyclic’s (TCAs) due to their superior tolerability and less
toxicity
...
•
SSRIs are believed to increase the extracellular level of the neurotransmitter serotonin by
inhibiting its reuptake into the presynaptic cell, increasing the level of serotonin in the
synaptic cleft available to bind to the postsynaptic receptor
...
•
SSRIs inhibit the reuptake of the neurotransmitter serotonin (5-‐hydroxytryptamine or 5-‐HT)
into the presynaptic cell, increasing levels of 5-‐HT within the synaptic cleft
...
Activation of the autoreceptors (by agonists like serotonin) triggers a throttling back
of serotonin production => initial serotonin deficiency (can initially increase anxiety levels)
...
The body adapts gradually to this situation by
lowering (downregulating) the sensitivity of the autoreceptors
...
SSRIs include:
•
•
•
•
Citalopram
Fluoxetine (prozac) – used in children (children get FLU all the time) and in pregnancy
Paroxetine -‐ used in breast feeding (parrot on the breasts)
Sertraline (dont confuse with the MAO-‐B inhibitor selegiline used in PD to increase DA
levels)
Improvements over MAOIs & tricyclics (TCAs)
Non sedative (less anti-‐histamine effects)
Less anti-‐muscarinic effects (e
...
less dry mouth, less bradycardia, less visual problems, less
constipation and less urinary retention)
• Less cardiac effects
Adverse effects
• GI: Nausea/diarrhoea/indigestion (high presence of serotonin and serotonic receptors in GI
tract)
• Headache
• Insomnia
• Sexual dysfunction (increased levels of serotonin in brain results in decreased levels of
dopamine and NA which can result in sexual dysfunction)
• Hyponatremia
• Suicidal behavior?
• Initial anxiety
•
•
General side effects are mostly present during the first one to four weeks while the body adapts to
the drug (with the exception of sexual side effects, which tend to occur later in treatment)
...
Serotonin-‐norepinephrine reuptake inhibitor (SNRI)
•
•
•
Dual reuptake inhibitors e
...
venlafaxine
Mode of action: Block the reuptake of monoamines (noradrenaline and 5-‐HT) into
presynaptic terminals
...
g
...
g
...
ONLY EVER GIVE AD TOGETHER WITH A MOOD STABALISER
...
Stabilize mood and prevent recurrence (prophylaxis)
•
•
Lithium salts – good for preventing mania in particular
Anticonvulsants (e
...
sodium valproate and lamotrigine and carbamazepine)
! Sodium valproate very good for mania predominance
! Lamotrigine very good for depressive predominance
Lithium therapy
Lithium carbonate is used to treat mania, the elevated phase of bipolar disorder
...
g
...
g
...
g
...
g
...
g
...
g
...
All adults are presumed to have sufficient
capacity to decide on their own medical treatment unless there is significant evidence to suggest
otherwise
...
The impairment or disturbance means the person is unable to make a decision at the current
time
...
g
...
•
•
Emergency Detention (section 36)
Short Term Detention (section 44)
Criteria for Emergency Detention (section 36)
1) Likely to have a mental disorder
2) Significantly impaired decision-‐making ability regarding treatment, due to mental disorder
3) Detention in hospital is necessary as a matter of urgency to determine what treatment is needed
4) Risk to health, safety or welfare of the person, or safety of others
5) Making arrangements for section 44 would involve undesirable delay
Criteria for Short Term Detention (section 44)
1) Has a mental disorder
2) Significantly impaired decision-‐making ability regarding treatment, due to mental disorder
3) Detention in hospital is necessary for assessment or treatment (but non-‐urgent)
4) Risk to health, safety or welfare of the person, or safety of others
5) Cannot be treated voluntarily
Note: MHA is used for detention! If pt needs treated for a medical disorder, and they lack
capacity, but they don’t need detention then can use AWI
...
Under 16’s can consent to medical treatment on their own behalf if they have capacity to
do so in the opinion of a qualified medical practitioner attending them e
...
a 12 year old
may have the capacity to consent to an injection but not surgery
EASTING DISORDERS
•
•
•
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Aetiology of eating disorders
•
Genetics:
! Influence of genes on control of appetite and feeding via hypothalamus (leptin,
ghrelin)
! Personality type
! 10 x risk in families with affected individual
•
Environmental
! In utero nutrition
! Childhood adverse experiences
! Developmental
! Puberty
•
Brain chemistry
Anorexia Nervosa
•
Anorexia nervosa is an eating disorder characterized by:
! Low body weight (low BMI < 17
...
This restriction of food intake causes metabolic and hormonal disorders
...
•
It is a serious mental illness with a high incidence of comorbidity and similarly high mortality
rates to serious psychiatric disorders
...
The high levels of ghrelin suggests
that their bodies are desperately trying to make them hungry; however, that hunger call is
being suppressed, ignored, or overridden
...
•
Note: leptin is the hunger suppressant hormone
Clinical features
History
•
•
•
Weight loss (BMI < 17
...
g
...
g
...
Physical Signs
•
•
•
•
•
•
•
•
•
Low BMI (<17
...
5 or less
Self-‐induced weight loss (strict dieting, vomiting, excessive exercise, medication)
Body image disturbance (dysmorphobia)
Fear of fatness
Hypothalamic dysfunction (hormone dysfunction): Amenorrhoea (females) or loss of libido
(males)
NB: loss of appetite is NOT generally a feature of anorexia nervosa
Starvation Effects on Brain
•
•
•
•
•
Loss of grey and white matter resulting in Brain atrophy
Hypothalamic dysfunction resulting in hormonal imbalances e
...
amenorrhoea
Increased compulsive behaviour
Reduced attention and memory (pseudodementia)
Poor concentration and decision making
These effects will improve with re-‐feeding
...
g
...
g
...
5
• Moderate risk: BMI=15-‐16
• High risk: 13-‐14
...
0
• Weigh loss> 1kg/week
• Prolonged QT
• HR<40
• SBP < 80
• Core temp < 34C
• Unable to rise from squat without using arms for leverage
• Cognitive impairment
Treatment
•
•
•
•
•
Family therapy beneficial in adolescents
Psychological therapies e
...
CBT
Dietician
Medical monitoring
Inpatient treatment for high risk (mental health act if refuse Tx): Re-‐feeding (beware of
refeeding syndrome – hypophosphatemia and hypokalemia)
Mental Health Act (Care and Treatment) (Scotland) 2003
This act allows for treatment of mental disorder or physical consequences of mental disorders in
someone without capacity to consent to treatment e
...
for treatment of anorexia (mental health
disorder) or any of its physical complications (in a patient who refuses treatment)
•
•
Emergency Detention (section 36) e
...
for life threatening long QT syndrome or life
threatening electrolyte imbalance (in a pt who needs detained as they refuse to stay)
Short Term Detention (section 44) e
...
for non life threatening complications and high risk
patients (in a pt who needs detained as they refuse to stay)
MARSIPAN
•
•
•
Management of really sick patients with anorexia nervosa
RCPsych and RCPhysicians
Aim to reduce mortality of starved patients admitted to medical wards
Refeeding Syndrome
•
Caused by depletion of already inadequate stores of nutrients e
...
magnesium, potassium,
phosphate which are quickly used up as body starts to repair itself
...
Phosphate levels are
normally the worse affected
...
•
It is generally a result of an extensive concern for body weight e
...
a fear of becoming fat
...
•
Many individuals with bulimia nervosa also have an additional psychiatric disorder
...
Patients may also cycle between bulimia and anorexia
•
Antidepressants, especially SSRIs (fluoxetine), are widely used in the treatment of bulimia
nervosa
...
g
...
•
•
•
Parotid hypertrophy
Dental caries (due to acid regurgitation)
Normal weight (usually)
Medical Complications
• Oesophageal reflux => caries (decay)
• Oesophageal tears/rupture e
...
Mallory–Weiss tear
• Hypokalaemia due to excessive vomiting (may cause cardiac arrhythmias)
...
• Metabolic alkalosis due to excessive vomiting of HCl
• Subconjunctival haemorrhage (due to strain of retching)
• Nutritional deficiencies
• Dehydration
• Seizures due to metabolic abnormalities
Treatment
• Guided self-‐help
• CBT
• SSRI e
...
citralopram, fluoxetine, paroxitine, sertraline (don’t get this confused with
selegiline which is a MAO-‐B inhibitor used in PD to increase DA activity)
MEDICALLY UNEXPLAINED SYMPTOMS
Terminology
•
The terminology is confusing in this area, as many terms are used interchangeably
...
•
It is possible for one patient to fulfil diagnostic criteria for several somatoform disorders at
one time (e
...
, somatoform pain disorder and dissociative disorder) which has led to
criticism of current diagnostic systems, and it is likely that future versions of ICD/DSM will
change how such disorders are defined
...
Take, for example, a woman who suffers from
a wide number and range of symptoms for which no adequate pathological cause has been
found
...
The woman’s medically unexplained symptoms include fatigue,
dizziness, headache, subjective limb weakness and painful joints
...
In the field of the
somatoform disorders, the labels often say more about the specialty of the person
applying them than any underlying pathology
...
•
Failure to identify a pathology can lead to frustration and uncertainty, from both the doctor
and the patient
...
e
...
“Functional disorders” with no known organic pathology
They cannot be explained fully by a general medical condition or by the direct effect of a
substance, and are not attributable to another mental disorder
...
The main feature of somatoform disorders is repeated presentation of physical symptoms,
together with persistent requests for medical investigations, in spite of repeated negative
findings and reassurances by doctors that the symptoms have no physical basis
...
Somatoform disorders are not the result of conscious malingering (fabricating or
exaggerating symptoms for secondary motives e
...
external gain such as monetary gain) or
conscious factitious disorders (deliberately producing, feigning, or exaggerating symptoms -‐
to play the “sick patient” and receive attention – for internal gain)
...
Key features
There are 3 central features of somatoform disorders:
• Physical complaints without identifiable organic basis (“functional” disorders)
...
•
The main features are multiple, recurrent, and frequently changing physical symptoms
...
•
Marked depression and anxiety are frequently present and may justify specific treatment
...
Somatization disorder ICD10 diagnostic criteria
•
•
•
Physical symptoms suggesting a physical disorder but with no evidence of organic disease
At least 2 years of multiple and variable physical symptoms for which no adequate physical
explanation has been found;
Symptoms linked to psychological factors/conflicts – may manifest subconsciously as
physical symptoms
Conversion disorder
•
A conversion disorder causes patients to suffer from neurological symptoms, such as
numbness, blindness, paralysis, or fits without a definable organic cause
...
Conversion disorder is considered a psychiatric disorder in the Diagnostic
and Statistical Manual of Mental Disorders fifth edition (DSM-‐5)
...
•
Can use Hoovers test of lower limbs to assess for functional or organic leg weakness
How common are somatoform disorders?
•
•
•
33% of new Neurology outpatients => VERY COMMON
50% of patients admitted to hospital with apparent Status Epilepticus (who are actually
having a psychogenic seizure)
5% of new referrals to Movement disorder clinics
Aetiology of Somatoform Disorders
•
•
Predisposing e
...
genetics, adverse childhood experiences, temperaments
Precipitating e
...
stressful life events, physical health disorder, psychiatric illness
Perpetuating e
...
over-‐investigation of patient can perpetuate the disorder by causing
anxiety and helplessness
Management
•
Management will depend on the patient
...
g
...
The sign relies on the principle of synergistic contraction
...
It has been neglected, although it is a useful clinical test
...
If you feel pressure from the weak leg, the weakness is
likely non organic (e
...
functional)
...
If no pressure is felt, this is more likely organic limb weakness
...
Summary
•
•
•
•
•
•
•
•
•
Somatoform disorders are characterized by bodily symptoms without any identifiable
organic (physical) cause
May be heightened sense of awareness of normal “symptoms”
May be normal functional processes functioning abnormallye
...
altered physiology
Very complex pathophysiology
Five major types of somatoform disorders:
! Conversion disorder (unexplained neurological symptoms)
! Pain disorder (unexplained pain symptoms)
! Somatization disorder (many unexplained symptoms from different bodily
systems over at least 2 years)
! Body dysmorphic disorder (excessive concern about and preoccupation with a
perceived defect of their physical appearance)
! Hypochondriasis (excessive preoccupancy or worry about having a serious illness)
Remember: symptoms might be exaggerated and irrational for us, but they are REAL for the
patients
Treat the concomitant psychiatric problem
Focus on anxiety reduction, not physical symptoms
Treat the dominant symptom(s) e
...
amitriptylline for pain and a SSRI for anxiety
PSYCHIATRIC GENETICS
Huntington’s disease (HD)
•
•
•
•
•
•
•
Huntingtons disease is a genetic disorder – neuropsychiatric
Autosomal dominant
Huntingtin gene codes for huntingtin protein
HD occurs due to expansion of the CAG triplet repeat
CAG is code for the amino acid glutamine, so more CAG repeats causes a longer chain of
glutamines in the protein, which causes the huntingtin protein to be misshapen
...
Anticipation = earlier onset in each generation
Motor symptoms
•
•
•
•
•
Choreiform movements: Brief, semi-‐directed, irregular movements that are not repetitive or
rhythmic, but appear to flow from one muscle to the next (“dance like”) which occurs due to
basal ganglia dysfunction
Rigidity (non-‐spastic hypertonia) due to basal ganglia dysfunction
Problems chewing, swallowing, and speaking
Gait disturbance
All actions requiring muscle control can become impaired
Psychiatric symptoms
•
•
•
•
•
•
Depression (depression and/or anxiety can be first signs)
Anxiety
Psychosis (patient may present as if they have schizophrenia)
Aggression and other behavioural disturbances
Suicidality
Compulsions
Cognitive symptoms
•
•
•
Decline in executive function (planning, abstract thinking, cognitive flexibility)
Short and long term memory deficits
Dementia (progressive decline in global cognition)
Genetics of Huntington’s
•
•
•
Autosomal dominant
Usually asymptomatic until adulthood (>35s)
Slow onset neurological and psychological symptoms
•
•
•
•
Currently irreversible and unstoppable
Only symptomatic treatment is possible
Very easy genetic test
Does the patient want a genetic test? Genetic counseling is required to help them reach
this decision
...
• Life expectancy average 7 years after diagnosis
...
Tau protein involved in the microtubules (important for
structure of neuron and intracellular transport) is hyperphosphorylated and causes the
tangles
...
We do know that one of the first areas affected by Alzheimers disease is the nucleus basalis
of Meynert, in the basal forebrain, which is where most of the cholinergic pathways in the
brain start
...
Increasing cholinergic transmission with cholinesterase inhibitors (e
...
rivastigmine, galantamine and donepezil RGD) seems to slow the decline in Alzheimer’s
disease, but does not affect the actual neuropathology, and so cannot stop or reverse the
disease
...
• Early onset familial AD (EOFAD) mutations (believed to be autosomal dominant) may be
found in PSEN1 (presenilin 1), PSEN2 (presenilin 2) or APP (amyloid precursor protein)
genes
...
g idiopathic AD, MDD and bipolar
Monogenic disease e
...
•
OCD is an anxiety disorder characterized by intrusive thoughts (obsessions) that produce
anxiety, uneasiness, apprehension, fear, or worry; and/or repetitive behaviours
(compulsions) aimed at reducing the associated anxiety; or by a combination of such
obsessions and compulsions
...
These symptoms
can be alienating and time-‐consuming, and often cause severe emotional and financial
distress
...
To be diagnosed by OCD the obsession and/or compulsions must be a cause of anxiety and
there must be other features
Aetiology of OCD
• Genetics: MZ‘v’DZ twins: 63-‐87% ‘v’ 15-‐45% (suggesting genetics plays a role)
• Autoimmunity: beta haemolytic (complete haemolysis) Streptococcal infection (GAS e
...
Strep pyogenes) & generation of autoantibodies to basal ganglia (some researchers also
believe this play a role in Tourettes syndrome); which may be associated with Rheumatic
fever
• PANDAS: There is gradually accumulating evidence that there are some children who
experience sudden onset of a neuropsychiatric disorder (usually obsessive-‐compulsive
disorder (OCD) or tics) following a Group A beta-‐haemolytic streptococcal infection (GABHS)
...
! Syndenhams chorea – major diagnostic criteria for Rheumatic fever
! OCD
! Tic disorders
•
Obsessions
•
•
•
•
•
Recurrent, intrusive and distressing thoughts, ideas, images, memories, impulses
Unwanted
Usually resisted
Recognised as originating from own mind
Associated with the emergence or increase of anxiety
Common obsessions in OCD
•
•
•
•
•
•
•
•
Contamination from dirt, germs, viruses, bodily fluids or faeces, chemicals, sticky substances,
dangerous material etc
Fear of harm e
...
door locks are not safe
Excessive concern with order or symmetry
Obsessions with body or physical symptoms
Religious, sacrileligious, or blasmphemous thoughts
Sexual thoughts
Urge to hoard useless or worn out items
Thoughts of violence or aggression
Compulsions
•
•
•
•
•
Repetitive, seemingly purposeful behaviours that individual feels driven to perform
Can include physical and mental rituals
Carrying out compulsions tends to reduce anxiety (which occurs as a result of obsessions)
e
...
handwashing
Resistance to performing a compulsion increases anxiety
Usually recognised as ‘irrational’
Common compulsions in OCD
•
•
•
•
•
•
•
Checking e
...
doors and gas taps
Cleaning and washing
Repeating acts
Mental compulsions e
...
special words or prayers repeated in a set manner
Ordering, symmetry or exactness
Hoarding and collecting
Counting
OCD diagnostic criteria (ICD 10)
For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on
most days for at least 2 successive weeks and be a source of distress (anxiety) or interference with
activities
...
Persons with OCPD are
usually inflexible and controlling
...
In contrast to people with obsessive-‐compulsive disorder (OCD), behaviours are
rational and desirable to people with OCPD (egosyntronic)
...
Perfectionism interfering with task completion
Excessive devotion to work
Overconscientious, scrupulous and inflexible
Unable to discard worthless objects
Reluctance to delegate, need to be in control
Rigidity and stubbornness
OCD is often confused with the separate condition obsessive compulsive personality disorder
(OCPD)
...
Because ego dystonic disorders go against a person's self-‐concept, they tend to cause much
distress
...
As a result, people with OCD are often aware that their behaviour is not rational, are unhappy about
their obsessions but nevertheless feel compelled by them, and may be ridden with anxiety
...
OCD sufferers are more likely to meet criteria for a personality disorder (PD) than controls however,
this would more likely be dependent, avoidant, histrionic or mixed PD
...
g
...
g
...
If patient doesn’t respond to first SSRI
then try a different SSRI
...
OCD is strikingly responsive to SSRIs but not much else
...
CBT for OCD: exposure and response prevention (desensitisation)
•
•
•
Deliberate exposure to obsessional stimuli
Prevention of compulsions typically used to lessen the distress associated with feared stimuli
Repeated exposure to the obsessional cues whilst employing strict response prevention
leads to habituation
Five screening questions to help identify OCD:
1
...
Do you check things a lot?
3
...
Do your daily activities take along time to finish?
5
...
g
...
The locus coeruleus is the principal site for brain
synthesis of norepinephrine (noradrenaline)
...
But serotonin is believed to be a key regulatory
mechanism of this system (e
...
regulates fear, pain and anxiety etc)
...
Indeed SSRIs can cause increased anxiety in the initial few days before becoming
effective anti anxiety (anxiolytic) agents
...
Serotonin is thought to have a role in
regulating anxiety
...
It is hypothesized that the
serotonin receptors of OCD sufferers may be relatively understimulated
...
•
It seems unlikely that a solitary disturbance in serotonin function can fully account for the
pathophysiology of obsessive compulsive disorder
...
Additional studies are needed to more directly evaluate dopamine
function in patients with obsessive compulsive disorder
...
g
...
g
...
g
...
g
...
g
...
g
...
For people who have experienced this response: they may be riddled
with guilt for not having fought courageously or not saved someone
...
The limbic brain: Feeling brain (Lizard brain)
• Hippocampus: important for forming new memories (anterograde memories) and locating
memories in the right time, place and context
• Amygdala: stores emotionally charged memories
...
The amygdala is also
important for controlling autonomic, emotional and sexual behaviours
• There are many other connections from limbic brain to prefrontal cortex
• Important for survival instincts
• Sense of danger overrides logic
Amygdala
• The amygdala stores emotionally charged memories
...
The amygdale is also
important for controlling autonomic, emotional and sexual behaviours
...
It stores emotionally charged
memories: good and bad
...
Post-‐traumatic reactions
• Acute stress disorder (2 hours – 28 days after trauma)
• Simple (type 1: single incident) PTSD (from 28 days to 3 months after trauma)
• Complex (type 2: multiple incidents) PTSD (from 28 days to 3 months after trauma)
• Chronic PTSD (greater than 3 months after trauma)
• Dissociative disorders
Acute Stress Disorder
•
Occurring within 1 month of the trauma and lasting at least 2 days
...
Post-‐traumatic stress disorder (PTSD)
• Posttraumatic stress disorder (PTSD) is a severe condition that may develop after a person is
exposed to one (simple: type 1) or more (complex: type 2) traumatic events, such as sexual
assault, serious injury or the threat of death (e
...
assault or health condition)
...
•
Posttraumatic stress disorder is classified as an anxiety disorder
...
Typically the
individual with PTSD persistently avoids all thoughts, emotions and discussion of the stressor
event and may experience amnesia for it
...
•
Most people who experience a traumatizing event will not develop PTSD
...
Children are less likely to experience PTSD after trauma than adults,
especially if they are under 10 years of age
...
•
PTSD symptoms may result when a traumatic event causes an over-‐reactive adrenaline
response, which creates deep neurological patterns in the brain
...
•
During traumatic experiences the high levels of stress hormones (cortisol) secreted suppress
hypothalamic activity, which may be a major factor towards the development of PTSD
...
Most people with PTSD show a low secretion of
cortisol (adrenal burnout) and high secretion of catecholamines in urine (hypervigilent
flight or fright state)
...
We have
raised catecholamines (e
...
adrenaline) as the body is still in a high alert mode (fight or
flight sympathetic activation)
•
Why low cortisol? It is proposed that it is due to Adrenal exhaustion due to prolonged and
persistent overactivity of the stress response
...
Hippocampus: during high stress times the hippocampus is suppressed
...
In PTSD the
event fails to get stored away in long term memory because the limbic brain/emotional
brain keeps on getting triggered
...
These are not conscious worries or ruminations
They seem to intrude and engulf the person
They are unwelcome , painful and unpleasant
They often lead to fear, panic, anger, rage, sadness, guilt shame and increased sense of
vulnerability
Nightmares
•
•
These occur commonly
Patients often describe wakening up shouting, screaming and drenched in sweat or hot and
trembling
Increased arousal
•
•
•
•
•
Hypervigilance: constantly on guard, scanning their environment for potential threat
...
The person may feel like they are observing themselves from above
...
Dissociative flashbacks
Dissociative identity disorder
Amnesia
Physical clinical features of stress disorders
Clinical features are anxiety symptoms due to increased sympathetic nervous system activity:
•
•
•
•
•
Muscle tension
Headaches
Nausea
Shakes and tremors
Choking sensation
•
•
Palpitations
Dizziness
Outcome of mental trauma
Mental trauma can result in:
•
•
•
•
•
•
•
•
•
•
•
•
Acute stress disorder: 2 hours to 28 days (at least two days)
Simple (type 1) PTSD: 28 days to 3 months
Complex (type 2) PTSD: 28 days to 3 months
Chronic PTSD: >3months
Dissociative disorders
Adjustment disorder: occurs when an individual is unable to adjust to or cope with a
particular stressor, like a major life event (not as potent a stressor as is seen in PTSD)
Depression
Anxiety disorder including panic disorder
BPD
Somatisation
Enduring personality change
Or a combination of any of the above
DSM Diagnostic criterion for PTSD
A
...
The traumatic event is persistently re-‐experienced (e
...
re-‐collections, dreams/nightmares, and
feelings)
C
...
These are all physiological
response issues, such as difficulty falling or staying asleep, or problems with anger, concentration, or
hypervigilance
...
E: Duration of symptoms which continue for more than 4 weeks after the last traumatic incident
...
Specify if:
•
•
Acute: if duration of symptoms is less than three months after the stressor
Chronic: if duration of symptoms is more than three months after the stressor
•
Delayed onset: if onset of symptoms is at least six months after the stressor
Management
•
•
•
•
Psychological
Medication
If trauma symptoms are mild and present for less than 4 weeks: watchful waiting should be
implemented with review within one month
Remove or manage continuing threat
Psychological interventions
•
•
•
•
•
Trauma focused CBT is generally the first line management: There may be avoidance of
trauma memories as they are distressing
...
EMDR (eye movement desensitization and reprocessing)
Exposure therapy (technique in behaviour therapy) -‐ desensitisation
If depression is also present treat PTSD first
Non trauma focused interventions such as relaxation or non directive therapy which do not
address trauma symptoms should not routinely be offered to those suffering from PTSD
Medications
When symptoms persist pharmacological treatment in addition to psychotherapy is required:
SSRIs are considered to be a first-‐line drug treatment
...
• Alternative class of antidepressant should be considered if SSRIs not helping
• Olanzapine (atypical antipsychotic) can be used as an adjunct to antidepressant medication
PHARMACOLOGY OF ANXIOLYTIC DRUGS
•
Drugs used to treat anxiety
•
•
•
•
Benzodiazepines (BDZs) – short term use only
Antidepressant drugs
Pregabalin (AED)
β-‐blockers (propanolol) – for somatic sympathetic NS symptoms
Benzodiazepines
•
•
•
•
•
•
•
Benzodiazepines can be used as minor tranquilizers, anxiolytics, hypnotics, and sedatives
(NOT ADs)
Should not be used long term due to addictive properties
Many types (“pam”) e
...
midazolam, lorazepam, temazepam, nitrazepam, diazepam (valium)
etc
Choice usually depends on half life
Majority can be used for sedation at low dose
Higher dose for sleep
Don’t want to use one with a long half life to induce sleep as sleep will have a long duration
Pharmacological effects of benzodiazepines
Reduce anxiety and aggression
Hypnosis/sedation
Muscle relaxation
Anticonvulsant effect
Anterograde amnesia
Some may produce one or other to a different degree, but all produce these effects
•
•
•
•
•
The choice of drug is determined by duration of action
...
Gamma amino butyric acid (GABA)
•
•
•
•
•
GABA is the main inhibitory NT in the brain
GABA is a CNS depressant
Widespread distribution (found in all neurons unlike monoamines)
GABA causes hyperpolarisation (Cl-‐ influx to make Em more -‐ve) of target cells e
...
stabilizes cells and inhibits AP’s from firing
NB: Glycine is another major inhibitory NT restricted to spinal cord and brain stem
GABA Receptors
•
•
GABA (A) = ionotropic ligand gated ion channel (main target for benzodiazepines)
GABA (B) receptor = GPCR
GABA (A) receptor
•
•
Main target for benzodiazepines (BDZs)
Ionotropic ligand gated ion channel
•
•
•
Multi unit receptor linked to chloride channel
When GABA binds => conformational change => chloride ions flow in => inside cell more
negative => hyperpolarised => neurone less likely to fire an AP
Therefore we can appreciate that GABA is inhibitory (stabalises neurones)
Action of BDZs
•
•
•
•
BDZs act at a different site separate from GABA binding site
They have no activity until the natural ligand (GABA) also binds to its binding site
When GABA binds => increase in openings => increase in Cl-‐ influx => increased
hyperpolarisation
We get more activity than you would without the BDZ being bound to GABA (A) receptor =>
enhance GABA effects
Clinical uses of benzodiazepines
Acute treatment of extreme anxiety
Rapid tranquillisation e
...
in aggressive or highly agitated patient
Mania
Delirium
Status epilepticus (as benzos are muscle relaxant and AED)
Premedication before surgery or during minor procedures
Alcohol withdrawal -‐ chlordiazepoxide
Hypnosis
Benzos should only be used acutely, never chronically or long term (due to addictive properties)
...
•
•
•
•
•
•
•
•
Other modulators
•
•
•
The GABA receptor (A) has a lot of different modulating sites
Barbiturates act on the barbiturate site
...
Similar end point in terms of action but they increase
time duration the channel stays open for
...
g
...
Withdrawal results in anxiety/convulsions possibly due to decreased
density of BDZ receptors, which results in decreased inhibition of electrical activity => increased
glutamate stimulation
...
Rapid withdrawal of a benzodiazepine may cause:
•
•
•
•
•
•
•
•
Confusion
Toxic psychosis
Convulsions
Insomnia
Anxiety
Loss of appetite
Tremor
Perceptual disturbances
How to withdraw benzodiazepines: Titrate down slowly
1
...
Reduce dose every 2–3 weeks in steps of 2 or 2
...
Reduce dose further, if necessary in smaller steps; it is better to reduce too slowly rather
than too quickly
4
...
The increased NTs in the limbic
system is associated with negative mood states/stress
...
BDZs can act on GABA
(A) receptors to stop neurons from firing off in stressful event resulting in decreased release of
5HT and NA
...
How do antidepressants help?
•
•
Acutely SSRIs increase extracellular 5-‐HT and have anxiogenic properties however after
several weeks the anxiolytic properties appear
Mechanisms not understood
...
g
...
g
...
g
...
For example many individuals who suffer from
agoraphobia (fear of public places) also suffer from panic disorder
...
In addition, anxiety disorders are commonly comorbid to other conditions such as depression and
bipolar
...
g
...
g
...
g
...
Psychotherapy primarily targets deep rooted issues and fears etc and focuses on changing
behaviour and thought process/content in the attempt to offer a long term solution to the
problem
...
In severe cases, pharmacological measures will almost certainly be required
...
GAD management
Step 1: Provide Education and options for treatment
...
g
...
g
...
Desensitisation is also called exposure therapy
...
Characterised by:
•
•
•
•
The person fears that he/she will appear anxious, embarrassed or be humiliated in social
situations
The person recognises that the fear is unreasonable or excessive
There is avoidance of people and situations
Social phobia can possibly progress to panic attacks
Common symptoms:
•
•
•
Reluctance to speak in public
Inability to write, eat or use public conveniences
Blushing
•
Anxiety symptoms e
...
headache, dizziness, light headedness, dry mouth, palpitations,
racing heart, chest pain or discomfort, SOB, tremor, nausea, sweating, trembling
Management:
•
•
•
CBT
Desensitisation (a form of behaviour therapy which involves being gradually exposed over a
period of time to the object or situation of your fear so that you start to feel less anxious
about it)
...
Medication e
...
SSRI, beta blockers
Agoraphobia
Agoraphobia is an anxiety disorder characterized by anxiety in situations where the sufferer
perceives certain environments as dangerous or uncomfortable, often due to the environment's vast
openness or crowdedness
...
Agrophobia may or may not result in panic attacks
...
This is also
sometimes called 'social agoraphobia' which may be a type of "social phobia"
...
Some agoraphobics have only a fear of open spaces
...
Desensitisation is also called exposure therapy
...
g
...
•
Physical symptoms (sympathetic NS) of panic attacks include: headache, dizziness, light
headiness, dry mouth, syncope, palpitations, increased heart rate, pounding heart, sweating,
shaking, trembling, spasm, SOB, nausea, tingling, chills, hot flushes, chest pain or chest
discomfort
•
Mental symptoms of panic attacks include: restlessness or feeling on edge, irritability, mind
going blank, sleep disturbance, poor concentration, feeling out of control or detached, fears
of ‘going mad’, feeling of impending doom, avoidance of situations
•
Appreciate that the physical symptoms of panic attacks are anxiety symptoms (as a result of
overactive sympathetic nervous system)
...
g
...
g
...
Treatment for panic disorder
NICE recommends CBT should be used as first line management
...
g
...
g
...
g
...
Obsessions:
•
•
•
•
•
Recurrent and persistent thoughts, impulses or images; which are intrusive and
inappropriate & cause anxiety or distress
These are not simply related to real life problems
The person attempts to ward them off, attempting to ignore or suppressing them
He/she may also try and neutralize them with another thought or action e
...
compulsions
The obsessions and compulsions are recognised as coming from the persons own mind
Compulsions:
•
•
Repetitive behaviours (e
...
cleaning and washing hands) or mental acts (e
...
counting,
praying, repeating words) that the person feels driven to perform in response to an
obsessional thought
These behaviours serve to reduce the distress associated with the obsessional
thought/image
NICE Guidance for OCD
1
...
These include brief individual CBT (with exposure and response prevention ERP) and group CBT
(ERP)
2
...
g
...
Adults with OCD with moderate functional impairment should be offered either:
• SSRI
• More intensive CBT (more than 10 therapist hours)
Both of the above are similarly efficacious
...
g
...
g
...
CBT should also aim to identify any possible core underlying beliefs which may be playing a
role in the pathophysiology e
...
which may be linked to an overvalued sense of responsibility
or guilt
Self monitoring using a thought record diary
Re-‐labelling the thought for what it really is
Incorporating anxiety management
MANAGEMENT OF MOOD (AFFECTIVE) DISORDERS
1
...
g
...
Assess severity
...
General measures
• Psychoeducation
• Mood charting
• Sleep hygiene
4
...
•
•
•
•
Psychoeducation
CBT
Medications
Electroconvulsive therapy (ECT)
Pharmacological management for MDD
•
•
•
•
For moderate to severe depression: Start on SSRI (first line) +/-‐ CBT and monitor response
If no response after 4 weeks at “adequate dose” then consider switch to alternative SSRI
If still no response consider alternative SSRI, venlafaxine (SNRI) or mirtazapine (NaSSA –
NASA to mars!)
If still no suitable response then consider TCA (amitriptyline, imipramine, clomipramine) or
MAO inhibitor (e
...
meclobemide): these drugs are last line due to toxicity
Pharmacological management for mania/hypomania
•
•
•
Review medication: stop antidepressant (if relevant)
Prescribe anti-‐manic drug or up the dose e
...
lithium carbonate, sodium valproate, or
antipsychotic
Review frequently and titrate dose to response
Antidepressants (ADs)
•
•
•
•
•
•
•
•
•
•
ADs do not make non depressed people happier
AD drugs take 2-‐3 weeks to work, but they increase post-‐synaptic serotonin from the first
dose
ADs probably share mechanisms of action which may involve: modulation of emotional
processing and altering activity in limbic and prefrontal circuitry
AD do not insert emotions which aren’t there, but change the balance of emotional tone to
facilitate emotional-‐cognitive processing and learning from behavioural feedback
Antidepressant drugs can be dangerous in overdose (TCAs are particularly dangerous =>
cardiac arrhythmias can occur)
AD drugs are NOT addictive
Stopping antidepressant drugs can result in withdrawal effects
...
The presence of
withdrawal symptoms does NOT imply addiction
...
g
...
Management of mild MDD:
CBT or other non pharmacological intervention – first line
Consider AD (antidepressant) if depression persists after other interventions
For moderate to severe MDD:
• Combination of AD medication (SSRI usually first line) and a high intensity psychological
intervention (CBT or Interpersonal therapy IPT)
•
•
Choice of antidepressant
When an antidepressant is to be prescribed, it should normally be an SSRI in a generic form because
SSRIs are equally effective as other antidepressants and have a favourable risk–benefit ratio
...
g
...
g
...
The medication with the best evidence
is lithium, which is effective in treating acute manic episodes, and preventing relapses
(prophylaxis), more so for manic than for depressive episodes
...
Sodium valproate has become a commonly
prescribed treatment, and is effective in treating manic episodes
...
g
...
g
...
g
...
g
...
The
terms 'antimanic agent' or 'antimanic medication' are used for treatment of an acute episode, and
'prophylactic agent' or 'prophylactic medication' for long-‐term maintenance treatment
...
The choice should depend on:
• Response to previous treatments
• The relative risk, and known precipitants, of manic versus depressive relapse
• Physical risk factors (particularly renal disease, obesity and diabetes)
• The patient’s preference and history of adherence
• Gender (valproate should not be prescribed for women of child-‐bearing potential, as is
tetrogenic and can cause neural tube defects)
Lithium has the best evidence and is the most effective drug in the prophylactic treatment of
Bipolar disorder
...
In addition, lithium can
cause renal damage (e
...
nephrogenic DI) => also important to monitor kidney function –
There are high rates of adverse effects and risk of inadvertent toxicity
Lithium treatment requires regular blood monitoring: renal function (U&Es), CrCl, thyroid
function (TFTs), lithium level, and calcium level
Side effects of lithium therapy
•
•
•
•
•
•
•
•
Nausea, vomiting, anorexia, diarrhea (GI effects)
Tremor
Visual changes
Renal effects: polydipsia, polyuria – can cause nephrogenic DI => monitor U&Es
Hypothyroidism and hyperparathyroidism (can cause hypercalcaemia) => monitor TFTs and
calcium
Lithium toxicity (GI symptoms, drowsiness, ataxia and confusion) => monitor lithium levels
Neurotoxic in overdose
Blood levels must be monitored (particularly U&Es, CrCl and TFTs and lithium levels)
Lithium levels
•
•
•
•
•
•
Normally aim for level of 1
...
6-‐1
...
Toxicity can occur >1
...
Concurrent use of diuretics that inhibit
the uptake of sodium by the distal tubule (e
...
thiazides) is hazardous and should be avoided
because this can cause increased resorption of lithium in the proximal convoluted tubule,
leading to elevated, potentially toxic levels
...
Plasma concentrations in excess of 2
...
g
...
Anticonvulsants are also increasingly being used in the treatment of bipolar disorder, since many
seem to act as mood stabilizers
...
The key characteristic of an anticonvulsant is to suppress the rapid and
excessive firing of neurons that start a seizure
...
g
...
g
...
Non-‐pharmacological management of mood disorders
Psychoanalysis
•
•
•
•
•
•
One of the first forms of therapy constructed by Freud
His model states that people are driven by their basic instincts e
...
sex and aggression
...
In other words we are driven by unconscious motivations to satisfy/regress sexual urges or
aggression
...
We are
driven by our unconscious
...
g
...
Our response system brings
about particular consequences (behaviours)
...
Depending on our learnt behaviours we interpret information in different ways
...
•
•
•
Therefore behaviorists do not look at behaviour disorders as something a person has; they
see them as a reflection of how learning has influenced certain people to behave in a certain
way in certain situations
...
Those who practice
behaviour therapy tend to look more at specific, learned behaviours and how the
environment has an impact on those behaviours
...
A schema is the fundamental underlying ways in which people process information, about
the self, the world or the future
...
It can also be described as a mental structure of preconceived ideas, a framework
representing some aspect of the world, or a system of organizing and perceiving new
information
Depressed people acquire such schemas through a loss of a parent, rejection by peers,
bullying, criticism from teachers or parents, the depressive attitude of a parent and other
negative events
...
Therefore this theory says that depression is brought on by
environmental triggers
...
Once those thoughts have been challenged, one's feelings about the subject
matter of those thoughts are more easily subject to change
...
The therapist initially tries to highlight these distortions, and then encourages
the patient to change his or her attitudes
...
Beliefs and schemas (the way we think and interpret information) drives behaviour and
controls our feelings and emotions (cognitive theory)
Our (learnt) behaviour brings about consequences which changes the way we think and
changes moods and physical feelings (behavioural theory)
Educational therapy which teaches the patient to think and interpret information differently
Also teaches self control
Strong evidence base
AD’s make the patient more open and more susceptible to CBT therapy
...
They can result in dysfunctional
assumptions which can drive negative thoughts
...
ECT clearly works
...
ECT is very useful for depression (without psychosis) which has not responded to AD
(treatment resistant MDD)
ECT is also very useful for depression with psychotic symptoms (e
...
hallucinations and
delusions)
Useful for catatonic states
Common side effects include: confusion, headache and memory impairment (short term)
Long term memory problems can also occur
Can be performed as out patient (under GA)
Further Tx (e
...
CBT, medication and/or ECT) is required after to prevent relapses
SUICIDE
•
Suicide is the act of intentionally causing one's own death
...
Stress factors such as financial
difficulties or troubles with interpersonal relationships often play a role
...
The leading methods in different
regions include hanging, pesticide poisoning, and firearms
...
•
Efforts to prevent suicide include limiting access to firearms, treating mental illness and drug
misuse, and improving economic development
...
Parasuicde = apparent attempted suicide without the actual intention of killing oneself
(e
...
DSH)
Other researchers also include those who attempt suicide with the intent to kill themselves
in the definition of parasuicide
...
Studies have found that about half of those who complete suicide have a history of
parasuicide => DSH and parasuicide are major risk factors for future suicide
Suicide risk factors
Factors that affect the risk of suicide include:
•
•
•
•
•
•
•
•
•
Previously attempted suicide
Previous DSH
Psychiatric disorders e
...
major depression (MDD), bipolar (BPD), psychosis, schizophrenia
and personality disorders
Medical problems
Drugs and alcohol misuse
Psychological states e
...
hopelessness, depression, anhedonia and anxiousness
Cultural, family and social situations e
...
single with reduced support network
Genetics
Male
Pathophysiology
•
There is no known unifying underlying pathophysiology for suicide
...
•
Low levels of brain-‐derived neurotrophic factor (BDNF) are both directly associated with
suicide and indirectly associated through its role in major depression, post-‐traumatic stress
disorder, schizophrenia and obsessive–compulsive disorder
...
•
Serotonin is believed to be low in those who commit suicide
...
Other evidence includes reduced
levels of a breakdown product of serotonin, 5-‐Hydroxyindoleacetic acid (5-‐HIAA), in the
cerebral spinal fluid
...
Suicide prevention
•
•
•
•
•
•
Identifying at risk patients and offering help
Treatment of psychiatric conditions
Treatment of drug and alcohol addiction
CBT therapy for individuals at risk
Efforts to increase social connection and support network
Reducing access to certain methods, such as firearms or toxins reduces the risk
Determining a patient's risk of suicide
•
•
•
•
•
•
History of DSH or “attempted” suicide
Suicidal intent has been found to be a good predictor of subsequent attempts
...
The most widely used
scales are the Pierce Suicide Intent Scale and Beck's Suicidal Intention Scale
...
g
...
You may need to consider referral to local mental
health services for further follow-‐up
...
If you are
unsure then seek advice from mental health specialists
...
SELF HARM AND RISK ASSESSMENT
Deliberate Self Harm (DSH)
•
Self-‐harm (SH) or deliberate self-‐harm (DSH) includes self-‐injury and self-‐poisoning and is
defined as direct injuring of body tissue most often done without suicidal intentions
...
Behaviours associated with substance abuse and eating
disorders are usually not considered self-‐harm because the resulting tissue damage is
ordinarily an unintentional side effect
...
However patients with other diagnoses may also self-‐harm, including those with depression,
anxiety disorders, substance abuse, eating disorders, post-‐traumatic stress disorder,
schizophrenia, and several personality disorders
...
Self harm is also often
associated with drug or alcohol abuse
...
•
The motivations for self-‐harm vary and it may be used to fulfill a number of different
functions
...
Selfharm may also be a cry for help
...
Many self-‐harmers are very self-‐conscious of their wounds
and scars and feel guilty about their behaviour leading them to go to great lengths to
conceal their behaviour from others
...
However, some individuals may be self harming
as a cry for help (which is not “attention seeking” used in the context which it is usually used
in)
...
People who self-‐harm are not usually
seeking to end their own life; it has been suggested instead that they are using self-‐harm as
a coping mechanism to relieve emotional pain or discomfort or as an attempt to
communicate distress
...
Neurobiology
•
•
•
•
Patients with Hx of deliberate self harm (DSH) have lower 5-‐HIAA (main metabolite of
serotonin) in CSF (in comparison to controls)
Low levels of brain-‐derived neurotrophic factor (BDNF)
Low serotonin (low 5HIAA) correlated with DSH, attempted suicide, assaultiveness,
instability, aggression & impulsiveness
Reduced binding to 5-‐HT transporter sites in Ventral PreFrontal Cortex
Suicide & Genetics
•
•
•
MZ twins (identical): concordance rate 13
...
7%
This is suggestive of a genetic link
Signs and symptoms of DSH
•
•
•
•
Eighty percent of self-‐harm involves stabbing or cutting the skin with a sharp object
...
The locations of self-‐harm are often areas of the body that are easily hidden and concealed
from the detection of others
...
Aetiology
•
Mental illness
•
•
•
Drugs and alcohol: Substance misuse, dependence and withdrawal are associated with self-‐
harm
...
Factors such as war, poverty, and unemployment may also contribute
...
This is so we can
identify patients at moderate to high risk of suicide and treat them accordingly
...
g
...
Risk of suicide in 12 months after DSH = 1%
Enquire about suicidal ideations, thoughts, plans, and motivations (including previous
attempts and DSH)
Psychiatric conditions and alcohol/drug abuse are also major risk factors
Enquire and take into account all major risk factors
Hopelessness is a robust predictor of eventual fatal self-‐harm (include hopelessness in your
MSE)
Management of DSH
Immediate management
•
•
•
Calm the patient
Crisis cannot usually be resolved without some release of emotion
Direct the interview e
...
privacy and deep breathing
•
•
•
•
Ask about: background, the episode of self-‐harm and mental state then & now
Perform a risk assessment and assess if the patient has low, moderate or high risk of suicide
or fatal DSH
Who else needs to be involved? (depends on risk)
Arrange & explain follow-‐up if this is indicated e
...
psychiatry/psychology, counselling (e
...
Rape Crisis, Womens’ Refuge), Social work and Samaritans
SELF HARM TUTORIAL CASES
Case 1
A 44 year old man is brought to Carseview by the police for emergency assessment after attempting
to jump off the Tay Bridge
...
He has a diagnosis of paranoid schizophrenia and is
under the care of the community mental health team and the clozapine clinic
...
He also has significant negative symptoms
...
He has not been employed since being diagnosed
with schizophrenia nearly 20 years ago and has little contact with his family
...
What are negative symptoms?
Things that would normally be present in a patient but are absent in schizophrenia: withdrawal and
social isolation, flat/blunt affect, anhedonia, apathy (lack of interest) etc
2
...
What might you find on mental state examination?
Positive or negative symptoms
Formal thought disorder, hallucinations, delusions, flat affect, low mood, odd behaviours, cognitive
impairment
4
...
She is unemployed and has little contact with other people
...
She has difficulty
relating to people and trusting them
...
” She finds herself becoming very anxious and
describes physical symptoms including heart racing, sweatiness and headache
...
She also takes alcohol with the
paracetamol at times
...
Sometimes her overdoses don’t come to anyone’s attention but at other
times she realises she has taken more than the prescribed amount, tells her sister and she takes her
to A+E
...
1
...
What is going on physiologically in her body when she is watching this?
Panic attack: excessive activation of sympathetic nervous system
3
...
Why do you think she takes the paracetamol?
Form of deliberate self-‐harm
5
...
g
...
• However, the event is commonly relived by the individual through intrusive,
recurrent recollections, flashbacks and nightmares
6
...
Stigma may then be affixed to such a person, by the greater society, who differs from their
cultural norms
...
Attributes
associated with social stigma often vary depending on the geopolitical and corresponding
sociopolitical contexts employed by society, in different parts of the world
...
•
Psychosis is a description of symptoms (a syndrome) rather than a diagnosis
...
•
Psychosis is generally given to noticeable deficits in normal behaviour (negative signs) and
more commonly to positive signs such as diverse types of hallucinations or delusional
beliefs (e
...
grandiosity, delusions of persecution)
...
g
...
g
...
g
...
g
...
g
...
g
...
Put simply,
delusions are false beliefs, outwith the social and cultural norms of the pt, which a person
holds on to with absolute conviction, without adequate evidence
...
•
It may be difficult to change the belief even with evidence to the contrary
...
However, they are of particular diagnostic
importance in psychotic disorders including schizophrenia, manic episodes of bipolar
disorder, and depression with psychosis
...
Non-‐bizarre delusion: A delusion that, though false, is at least possible, e
...
the affected
person mistakenly believes that he is under constant police surveillance
...
g
...
Common themes of delusions are:
•
•
•
•
•
Persecutory (person believes that others are out to harm him/her)
Grandiose (person believing that he or she has special powers or skills, or, is god),
Poverty – person believes that they are poor when they are not
Sin
Guilt
•
•
Nihilism (persistent beliefs that a person does not exist or is dead or is dying)
Self reference – person believes things are related to them
Depressed persons may have delusions consistent with their low mood e
...
delusions that they have
sinned, or have contracted serious illness etc
...
g
...
g
...
These sorts of delusions are called secondary delusions
...
They feel like they are coming from outside of
me"
...
However these inner experiences may lead onto delusions and a patient may start to think
"they are being transmitted by the Mafia"
...
Self-‐referential experiences
•
•
•
•
The belief that external events are related to oneself
...
In particular, the dopamine hypothesis of psychosis has been influential and states that
psychosis results from an overactivity of dopamine function in the brain, particularly in the
mesolimbic pathway
...
e
...
However, increasing evidence in recent times has pointed to a possible dysfunction of the
excitory neurotransmitter glutamate, in particular, with the activity of the NMDA receptor
...
g
...
g
...
g
...
If present in psychotic phase => suggestive
of schizoaffective disorder
Third person delusions are characteristic (e
...
voices talking about the individual)
Visual hallucinations are NOT normally a feature (these are suggestive of delirium or DLB)
Drug induced Psychosis
•
•
•
May be florid symptoms or chronic symptoms but tend to be short lasting if access to the
psychoactive substance is removed
...
g
...
g
...
g
...
g
...
g
...
g
...
g
...
g
...
g
...
He has also tried to buy a Porsche on credit
...
He feels full of energy and new ideas and can’t see that he has done anything wrong
...
So a new-‐onset
episode of psychosis cannot be considered to be a sign of a psychiatric disorder until other
relevant and known (medical/drug) causes of psychosis are properly excluded, or ruled out
...
g
...
Illicit substance-‐induced psychosis should also be ruled out
...
! B12/Folate assay
Other investigations which may be performed include:
• EEG to exclude epilepsy and encephalitis
• MRI or CT scan of the head to exclude brain lesions
SCHIZOPHRENIA
What is schizophrenia?
•
•
•
•
•
A group of brain disorders
Chronic disorder resulting in positive and negative symptoms resulting in problems with
dealing with reality and functioning
Characteristic features are distortions of:
! Thought process (thought disorder)
! Thought content (delusions)
! Perception (hallucinations)
! Behaviour
! Emotion
No pathognomonic symptoms (e
...
no symptoms specific to schizophrenia, although third
person hallucinations are suggestive)
Aetiology= Neurodevelopmental + Genetic + Environment (Biopsychosocial)
Key clinical features
Delusions
Hallucinations
Thought disorder
Negative symptoms: apathy, anhedonia, blunted affect, social isolation and withdrawal
Emotional disorder
Motor and behavioural disorder
Cognitive dysfunction
Positive and negative symptoms
•
•
•
•
•
•
•
•
•
•
•
•
•
In describing mental disorders, especially schizophrenia, symptoms can be divided into
positive and negative symptoms
...
Examples of positive symptoms include hallucinations, delusions, and bizarre behaviour
(Tx with anti dopaminergics which block DA in the mesolimbic pathway)
Negative symptoms are functions that are normally found in healthy persons, but that are
diminished or not present in affected persons
...
Examples of negative symptoms are social withdrawal, apathy (lack of interest),
flat/blunted affect (no emotion in response to something that would normally illicit an
emotion), inability to experience pleasure (anhedonia) and defects in attention control
...
•
•
•
•
The mesolimbic pathway is a dopaminergic pathway in the brain
...
The mesolimbic dopamine system is widely believed to be a "reward" pathway
...
The mesocortical pathway is a neural pathway that
connects the ventral tegmentum (VTA) to the cerebral cortex, in particular the frontal lobes
(PFC)
...
It is essential to the
normal cognitive function of the dorsolateral prefrontal cortex (part of the frontal lobe), and
is thought to be involved in cognitive control, motivation, and emotional response
...
Anti-‐psychotics are good at Tx positive symptoms but not so good at Tx negative
symptoms
...
Positive symptoms
•
•
•
Delusions: standard delusions, delusions of control (pasitivity phenomenon), thought
interference, delusional perception
Hallucinations: third person, thought echo, running commentary
Formal thought disorder (which manifests as disorganised speech) e
...
knights move
thinking (loosening of associations), neologism, and thought interference
(blocking/insertions/broadcasting)
Negative symptoms
•
•
•
•
•
Apathy and flat affect
Anhedonia
Lack of volition
Social withdrawal
Cognitive impairment
Schneider’s First Rank Symptoms
Schneider's first-‐rank symptoms of schizophrenia are symptoms, which, if present, are strongly
suggestive of schizophrenia
...
g
...
The individual feels that some
external agent is controlling them to feel emotions, to desire to do things, to
perform actions or to experience bodily sensations
...
This six-‐month period must
include at least one month of symptoms as stated above (or less, if symptoms remitted with
treatment)
...
Psychotic symptoms may be present in several other mental disorders, including bipolar
disorder, borderline personality disorder, and MDD
...
•
•
•
•
A small number of people withdrawing from benzodiazepines experience a severe
protracted withdrawal syndrome which can resemble schizophrenia and be misdiagnosed as
such
...
It may be necessary to rule out a delirium, which can be distinguished by visual
hallucinations, acute onset and fluctuating level of consciousness, and indicates an
underlying medical illness
...
Schizophreniform disorder (DSM)
•
•
•
•
•
•
Schizophreniform disorder is a mental disorder diagnosed when symptoms of schizophrenia
are present for a significant portion of the time within a one-‐month period, but signs of
disruption are not present for the full six months required for the diagnosis of
schizophrenia (DSM IV criteria)
The symptoms of both disorders can include delusions, hallucinations, disorganized speech,
disorganized or catatonic behavior, and social withdrawal
...
While the onset of schizophrenia is often gradual over a number of months or years, the
onset of schizophreniform disorder can be relatively rapid
...
g
...
) designed to reduce the social and emotional impact of the illness
...
Schizoaffective disorder
•
•
•
Schizoaffective disorder is a mental disorder characterized by psychosis and abnormal
emotional/affective responses (mood disorder) – in the same time period (separated by at
least 2 weeks)
Common symptoms of psychosis include auditory hallucinations, paranoid delusions, and
disorganized speech and thinking
...
The
bipolar type is distinguished by symptoms of mania, hypomania, or mixed episodes; the
depressive type by symptoms of depression exclusively
...
When there is risk to self or
others, usually early in treatment, brief hospitalization may be necessary
...
g
...
In DSM-‐5 and ICD-‐10 (which is being revised to ICD-‐11, to be published in 2015),
schizoaffective disorder is in the same diagnostic class as schizophrenia, but not in the same
class as mood disorders
...
Only when a psychotic condition lasts
two-‐weeks continuously or longer without mood symptoms, is the diagnosis either
schizophrenia or schizoaffective disorder
...
Positive symptoms include hallucinations, delusions, passivity phenomenon, and thought
interference, and are often the most responsive to anti-‐psychotic treatment
...
In addition to positive, negative, aggressive and cognitive symptoms, patients with
schizophrenia often exhibit affective disorders, including depression and anxiety
...
There is substantial overlap among these different symptom domains and it can be
particularly difficult to distinguish negative symptoms from affective symptoms (including
depression and anxiety)
The comorbidity of affective symptoms, especially depression, can have dire consequences
for the quality of life and life span of those with schizophrenia; thus it is important that
affective symptoms are properly diagnosed and treated optimally
...
If
affective symptoms are present they are not generally severe
...
However in the lifelong course of schizophrenia, depressive symptoms are common -‐ not
necessarily as part of a psychotic relapse as they can occur at any time and do not have to be
related to psychotic symptoms
...
The issue of schizoaffective disorder is complex and a little controversial -‐ the best way to
think of it, without getting into the complex arguments is to say that although "pure"
schizophrenia is recognisable in many patients, and "pure" BPD/MDD is recognisable in
many others, there are also many patients who have features of both schizophrenia and
BPD/MDD and for whom it is impossible to say they have one or the other -‐ they have
features of both
...
Schizoaffective disorder can
be classified as depressive or bipolar type
...
• Schizophrenia and schizoaffective disorder are lifelong chronic illnesses which relapse and
remit
• Schizophreniform disorder is a mental disorder diagnosed when symptoms of
schizophrenia are present for a significant portion of the time within a one-‐month period,
but signs of disruption are not present for the full six months required for the diagnosis of
schizophrenia (DSM IV criteria)
...
g
...
g
...
g
...
dendrites and glial cells) and not
neuron loss
Consistent reductions
•
•
•
Temporal cortex (especially superior temporal gyrus)
Medial temporal lobe (especially hippocampus)
Variable reductions
•
•
•
Orbitofrontal cortex
Parietal cortex
Basal ganglia
In patients with poor prognosis
•
•
Reduced frontal lobe volume
Reduced frontal lobe grey matter
•
•
Enlarged lateral ventricle volume
White matter abnormalities
What causes the brain pathology?
•
•
Identified gene alterations: neuregulin, dysbindin, DISC-‐1
Glutamatergic hypothesis: altered NMDA receptor subunit expression (ketamine is an NMDA
receptor antagonist and can also induce psychotic symptoms) results in decreased glutamate
activity
DA hypothesis of schizophrenia
It is assumed there is overactivity of certain DA pathways (in particular the mesolimbic) in the
brain
...
g
...
• Amphetamine can make schizophrenics worse
• Dopamine receptor antagonists (anti-‐psychotics) are used to treat the positive symptoms
of schizophrenia and psychosis
...
Dopamine receptors are implicated in many neurological processes, including motivation,
pleasure, cognition, memory, learning, and fine motor control, as well as modulation of
neuroendocrine signaling
...
Thus, dopamine receptors are common neurologic drug
targets
...
Is the dopamine system dysfunctional in SZ?
Reformulation of dopamine hypothesis:
•
•
Subcortical (mesolimbic pathway) DA hyperactivity leads to psychosis and hallucinations
(positive symptoms)
Mesocortical DA hypoactivity leads to negative and cognitive symptoms
This is based on evidence that negative and cognitive symptoms persist despite D2 blockade with
antipsychotics
...
•
Anti-‐psychotics = dopamine antagonists (dopamine receptor blockers) – but have a range of
NT channel profiles
Typical antipsychotics
Vague definition, which describes the drugs originally developed or even drugs that do not have
atypical properties:
•
•
•
Haloperidol
Chlorpromazine
Significant extra-‐pyramidal symptoms (due to DA blockade in the basal ganglia)
Atypical (2nd generation) antipsychotics
•
•
•
•
•
•
Less likely to induce EPS (extra-‐pyramidal basal ganglia symptoms)
High 5-‐HT2A to D2 receptor ratio
Better efficacy against negative symptoms
However greater risk of metabolic syndrome: weight gain, DM, hyperlipidaemia
Effective in patients unresponsive to typical drugs
Atypicals include clozapine, olanzapine, and risperidone (“ROC”)
Remember: Risperidone can be given as depot
Anti-‐psychotics: mechanism of action
• All antipsychotic drugs tend to block D2 receptors in the dopamine pathways of the brain
...
• In addition of the antagonistic effects of dopamine, antipsychotics (particular atypical
antipsychotics) also block serotonin receptors
...
Blocking D2 receptors in these
•
•
other pathways is thought to produce some of the unwanted side effects that the typical
antipsychotics can produce (e
...
extra-‐pyramidal motor symptoms and prolactin
hypersecretion -‐ hyperprolactinaemia)
...
5-‐HT2A
antagonism also increases dopaminergic activity in the nigrostriatal pathway, leading to a
lowered extrapyramidal side effect liability among the atypical antipsychotics
...
They also have a lower
propensity for causing extrapyramidal side effects
...
In addition,
many atypical antipsychotics are compared to haloperidol (a traditional antipsychotic that
yields numerous extrapyramidal side effects) and therefore it is not surprising that the
atypical antipsychotics have an improved extrapyramidal side effect profile in comparison
...
Key points
• Anti-‐psychotics = dopamine (D2) blockers
• Typicals (haloperidol, chlorpromazine) are not particularly selective and also block DA in the
nigrostratial pathway leading to EPS e
...
Parksinonian symptoms)
...
• In addition of the antagonistic effects of dopamine, antipsychotics (particular atypical
antipsychotics) also block serotonin receptors
...
Atypical antispyschotics are
better at treating negative symptoms in addition to positive symptoms
...
5-‐HT2A antagonism also
increases dopaminergic activity in the nigrostriatal pathway, leading to a lowered
extrapyramidal side effect liability among the atypical antipsychotics
...
g
...
! In pt with Parkinsonism => atypical
! In pt with CVD and multiple CV risk factors => typical
Relative receptor binding profiles
Anti psychotics not only bind to dopamine receptors but they can also bind to:
•
•
•
•
Serotonin receptors
Adrenergic receptors
Histamine receptors
Cholinergic (muscarinic) receptors
Different anti-‐psychotics have different receptor binding profiles
Adverse effects of Anti-‐Psychotics
Dopamine D2 receptor blockade: more prominent in typicals
•
•
Hyperprolactinaemia (as dopamine acts to suppress prolactin release) which may cause
galactorrhoea, gynaecomastia, sexual dysfunction (in both sexes) and osteoporosis
Extra-‐pyramidal side effects (EPSE) due to disruption of dopamine signalling (nigrostriatal
pathway) in the basal ganglia system which may result in dystonia (inc oculogyric crisis),
bradykinesia, tremor, muscle rigidity (non spastic hypertonia), parkinsonism, Akathisia,
tardive dyskinesia, etc
...
g
...
The more common include extreme constipation, bed-‐
wetting, night-‐time drooling, muscle stiffness, sedation, tremors, orthostatic hypotension,
hyperglycemia, and weight gain (e
...
the more common side effects are due to anti-‐
dopamine, anti-‐histamine and anti-‐cholinergic effects)
Clozapine also has a risk of causing serious side effects such as agranulocytosis, CNS
depression, seizure disorder, bone marrow suppression, dementia, hypotension, and
myocarditis
...
It is, however, one of
the very effective anti-‐psychotic treatment choices
...
Typically C-‐reactive protein (CRP) increases with the onset of fever and rises in the cardiac
enzyme, troponin, occur up to 5 days later
...
If spreads to pericardium resulting in pericarditis then O/E we may observe a pericardial rub
Perform ECG if suspected myocarditis/pericarditis
MANAGEMENT OF SCHIZOPHRENIA
•
The primary treatment of schizophrenia is antipsychotic medications, often in combination
with psychological and social supports
...
Long-‐term hospitalization is
uncommon since deinstitutionalization beginning in the 1950s, although it still occurs
...
•
Some evidence indicates that regular exercise has a positive effect on the physical and
mental health of those with schizophrenia
...
Antipsychotics, however, fail
to significantly ameliorate the negative symptoms and cognitive dysfunction
...
•
The choice of which antipsychotic to use is based on benefits, risks, and costs
...
Both have
equal drop-‐out and symptom relapse rates when typicals are used at low to moderate
dosages
...
•
KEY POINT: With respect to side effects typical antipsychotics are associated with a higher
rate of extrapyramidal side effects (and hyperprolactinaemia) while atypicals are
associated with considerable weight gain, diabetes and risk of metabolic syndrome
...
It remains
unclear whether the newer antipsychotics reduce the chances of developing neuroleptic
malignant syndrome, a rare but serious neurological disorder
...
Aggression can take a variety of forms and can be physical or be communicated verbally or
non-‐verbally
Remember that their may be an organic cause of aggression so check patients vital signs,
assess for infections etc
Management of Aggressive Behaviour
•
•
•
•
•
•
•
•
•
Prediction e
...
body language and verbal cues
Prevention: de-‐escalation, reasoning, compromise, observations, room lay out etc
Intervention: restraint, seclusion, rapid tranquillisation
Level of observations: physical and psychiatric
May wish to observe medication free initially
Immediate treatment include management of withdrawals, management of disturbed or
aggressive behaviour
Physical fluid balance, food charts, sleep charts etc
Check SEWS – may be caused by acute illness, hypoxia etc
Don’t forget that hypoxia can cause change in behaviour!
Mental Health Act Legislation
•
•
Applies to a "patient" who has or appears to have a mental disorder
Mental disorder:
! Any mental illness
! Any personality disorder
! Any learning disability (NOT learning disorder)
Emergency Detention
•
•
•
•
•
•
Mental Health (Care and Treatment) (Scotland) Act 2003: Allows for treatment of mental
disorder or physical consequences of mental disorder in someone without capacity to
consent to treatment
...
Short term detention is section 44
Applied by AMP (approved medical practitioner)
Requires MHO (mental health officer) for consent
More rights for patient and named person
Authorises treatment
Lasts for maximum of 28 days (one month) – after this CTO required
Right of appeal to Tribunal and Mental Welfare Commission
Criteria for short term detention:
•
•
•
•
•
The patient has mental disorder
Significantly impaired decision-‐making ability regarding treatment, due to mental disorder
Detention in hospital is necessary for assessment or treatment
Risk to health, safety or welfare of the person, or safety of others
Cannot be treated voluntarily
Compulsory Treatment Order (CTO)
•
•
•
•
•
•
•
•
•
•
Application made by MHO supported by two medical reports
One MUST be from an AMP
Other report usually from patient’s GP
Right of appeal, may have legal representation
Authorises treatment
Requires to have tribunal hearing
Care Plan prepared by MHO (in consultation with team) can impose conditions ie residency,
attendance at services
Last for up to 6 months
Patient can be in hospital or community
Replaced section 18 MH(S)A 1984
Tayside Rapid Tranquillisation Policy
1
...
If history unknown, cardiac disease (haloperidol is contraindicated), no history of typical
antipsychotics, or current illicit drug use then:
• Consider oral Lorazepam (BDZ) 1-‐2mg (BDZ are sedatives)
• If oral unsuccessful or an effect required within 30 minutes then consider injection
(Lorazepam 1-‐2mg intramuscular)
• Wait 30 minutes: Repeat lorazepam injection once IM if necessary
• If no response to second injection seek advice from senior experienced doctor
3
...
e
...
Do not mix in same syringe
...
g
...
g
...
g
...
Delirium represents an organically caused acute decline from a
previously attained baseline level of cognitive function
...
It typically involves other cognitive deficits, changes in arousal (hyperactive, hypoactive, or
mixed), perceptual deficits, altered sleep-‐wake cycle, and psychotic features such as
hallucinations (inparticular visual or auditory) and delusions
...
Delirium is most often caused by a disease
process outside the brain that nonetheless affects the brain
•
It is a corollary of the criteria that a diagnosis of delirium cannot be made without a previous
assessment, or knowledge, of the affected person's baseline level of cognitive function
...
Therefore collateral history is essential
•
Treatment of delirium requires treatment of the underlying organic cause(s)
...
Tranquilization with BDZs may also be justified
...
It affects 10-‐20% of all hospitalized adults, and 30-‐40% of elderly hospitalized
patients and up to 80% of ICU patients
...
g
...
g
...
g
...
Clinical environments can also precipitate delirium, and optimal
nursing and medical care is a key component of delirium prevention
...
alcohol, benzodiazepines
Substance intoxication
Traumatic head injury
VINDICATE: Mnemonic for differential diagnosis and aetiology
Differential diagnosis is the systematic method by which diseases of similar presentation are
distinguished by considering their various features
...
VINDICATE
stands for
•
•
•
•
•
•
•
•
•
V – Vascular
I – Inflammatory
N – Neoplastic
D – Degenerative / Deficiency
I – Idiopathic, Intoxication
C – Congenital
A – Autoimmune / Allergic
T – Traumatic or toxic
E – Endocrine or metabolic
PERONALITY DISORDERS AND BEHAVIOURAL PROBLEMS IN ADULTS
Personality disorders
•
Personality disorders are a class of social disorders characterised by enduring maladaptive
patterns of behavior, cognition and inner experience, exhibited across many contexts and
deviating markedly from those accepted by the individual's culture
...
•
There are many issues with classifying a personality disorder -‐ is it really a disorder, or just
difficulties getting on socially?
Clinical Personality Assessment
•
•
MSE
•
Detailed history of problem behaviour and psychological history
...
Stable and long duration (late childhood / adolescence)
...
Organic causes need to be excluded
...
g
...
g
...
Is PD present?
•
•
•
•
Long term pattern of poor interpersonal functioning and relationships with others
Can occur at any age
Is not part of another mental disorder or organic cause
Leads to impairment or distress to self or others
2
...
How can it be described?
•
•
•
•
Schizoid PD (negative symptoms): detached e
...
lack of interest in social relationships, a
tendency towards a solitary lifestyle, loner, secretiveness, emotional coldness, and apathy
Schizotypal (negative symptoms + strange thoughts): A need for social isolation (or being
alone), and often unconventional or out of the ordinary thoughts (schizotypal is typical of
schizophrenia, with abnormal thoughts)
Anti-‐social PD (dissocial PD): dissocial, lack of empathy, crime, violence
Anankastic (Obsessive compulsive PD): rules, orderly, strict, inflexible, ego-‐syntronic
Schizotypal and schizoid PD: Cluster A
•
Schizoid: Lack of interest towards a social lifestyle, bottled emotions, detached, emotional
coldness, apathy (lack of interest)
•
Schizotypal: A need for social isolation (or being alone), and often unconventional or out of
the ordinary thoughts (typical of schizophrenia)
•
They are similar in the way that they both reflect social isolation, but schizotypal is to
'strange' thoughts as schizoid is to unshared thoughts
...
There
may be an impoverished moral sense or conscience (lack of empathy) and a history of crime, legal
problems, impulsiveness and aggressive behaviour
...
What is the difference between a sociopath and a psychopath? It depends who you ask
...
•
Mental health professionals disagree about which term to use, which unfortunately only
confuses the public
...
Some people say psychopath describes personality traits and sociopath describes
behaviour
...
At least three symptoms
of impulsive type (e
...
impulsiveness, explosive, emotionally unstable) and at least 2 of the following
must be present:
•
•
•
Self-‐harm
Poor self image
Relationship crisis
•
•
Fear of abandonment
Feelings of emptiness
Narcissistic PD: Cluster B
At least five of the following must be present:
Grandiose (feelings of being superior)
Arrogant
Self-‐opinionated
High ideals
Needs admiration
Expects privilege
Exploits others
Lacks empathy
Envy
Avoidant (anxious) PD: Cluster C
• Avoidant personality disorder (also known as anxious personality disorder), is afflicting
persons when they display a pervasive pattern of social inhibition, feelings of inadequacy,
extreme sensitivity to negative evaluation, and avoidance of social interaction
...
OCD on the other hand, is characterised by ego-‐dystronic thoughts and behaviour e
...
obsessions
and compulsions are in conflict with the needs and goals of the ego, or, further, in conflict with a
person's ideal self-‐image
...
g
...
g
...
e
...
g
...
g
...
It does not infer a
particular aetiology
...
It is important to
understand that it is different from mental illness – a person with a learning disability can also
develop mental illness
...
g
...
Prevalence of people with learning disability is 1-‐2%,
What it is not
•
•
•
•
Dyslexia and any other educational difficulties
Adult acquired head injury
Cognitive decline due to chronic psychosis, substance abuse, neurological condition, or other
organic cause etc
Learning difficulty ≠ learning disability
Severity of LD
•
•
•
•
•
•
Severity
Borderline LD
Mild LD
Moderate LD
Severe LD
Profound LD
IQ
70-‐80
50-‐70
35-‐50
20-‐35
<20
Diagnosis
•
•
•
Diagnosis based on clinical findings including IQ result
Adaptive behaviour dysfunction e
...
social problems
Psychometric Assessment: Most commonly used is the Wechsler Adult Intelligence Scale
(WAIS)
Descriptions
Borderline LD
•
•
IQ 70-‐80
Not a category in DC-‐LD, ICD-‐10 or DSM-‐IV
Mild LD
•
•
•
•
•
•
•
•
IQ 50-‐70
Most common
Delayed speech (able to use everyday speech)
Full independence -‐ self care, practical & domestic skills
Difficulties in reading and writing
Capable of unskilled or semi-‐skilled work
Problems if social or emotional immaturity
Rarely organic aetiology (moderate to profound LD are normally associated with organic
pathology)
Moderate LD
•
IQ 35-‐50
•
•
•
•
•
•
•
•
Slow with comprehension and language
Limited achievements
Delayed self care and motor skills
Simple practical tasks -‐ often with supervision
Usually fully mobile
Discrepant profiles
Majority organic aetiology
Epilepsy and physical disability common
Severe LD
•
•
•
•
IQ 20-‐35
Generally more marked impairment than in moderate LD and achievements more restricted
Epilepsy common
Organic aetiology
Profound LD
•
•
•
•
•
•
•
IQ less than 20 (difficult to measure)
Severe limitation in ability to understand or comply with requests or instructions
Little or no self-‐care
Often severe mobility restriction
Physical disorders common
Organic aetiology
Basic or simple tasks may be acquired
Associated Problems
People with learning disability as a group have higher rates of physical and mental health problems
and consequently higher morbidity and mortality rates
...
g
...
•
•
•
•
•
•
•
•
•
•
Mental Illness e
...
SZ, MDD, BPD, anxiety disorders
Epilepsy: Up to 1/3 have epilepsy, depending on severity LD
...
Treatment resistance and multiple seizure types more
common
...
Substance misuse
Physical disability and mobility problems e
...
Cerebral palsy
GI disorders
Sensory impairments
Autistic Spectrum Disorder
Sexual abuse
Family dysfunction
Poor employment prospects
•
Stigma
Aetiology
IQ levels follow a normal distribution curve for IQ's above 70
...
•
•
Mild LD (IQ 50-‐70): Cause often unidentified, in which case more likely to be in socio-‐
economic groups 4 and 5
...
This
illustrates the interaction between genetics and environment i
...
to what extent you actually
fulfil your potential
Moderate/severe LD: Organic cause often identified
...
g
...
g
...
g
...
g
...
g
...
Bilirubin is a highly
neurotoxic substance that may become elevated in the serum, a condition known as
hyperbilirubinemia
...
Only caused by UC bilirubin which is lipid soluble (lipohillic)
...
g
...
•
Addiction is the continued repetition of a behavior (psychological dependency) despite
adverse consequences
•
Classic hallmarks of addiction include impaired control over substances or behavior,
preoccupation with substance or behavior, continued use despite consequences, and denial
=> psychological dependency
•
Physiological dependence occurs when the body has to adjust to the substance by
incorporating the substance into its 'normal' functioning
...
•
Tolerance is the process by which the body continually adapts to the substance and requires
increasingly larger amounts to achieve the original effects
...
•
Withdrawal refers to physical and psychological symptoms experienced when reducing or
discontinuing a substance that the body has become dependent on
...
•
Addiction = dependency (psychologically and physically) + tolerance + withdrawal
ICD-‐10 criteria of substance dependence
•
•
•
Psychological and physical dependency:
! A strong desire to take the substance
! Difficulties in controlling substance use
! Neglect of alternative pleasures
! Persistence despite evidence of harm
Tolerance
A physiological withdrawal state
CAGE
The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used
method of screening for alcoholism
...
The questionnaire asks the following questions:
•
•
•
•
Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-‐opener) to steady your
nerves or to get rid of a hangover?
Neurobiology of addiction
Several complicated mechanisms involved:
•
•
•
•
The reward pathway – appetitive approach
The action of drugs of abuse on the reward pathway
The role of the Prefrontal cortex (executive functioning e
...
will power and self control and
decision making)
Role of the hippocampus/ HPA axis
The reward system (appetitive/approach system)
• The major neurochemical pathway of the reward system in the brain involves the
mesolimbic and mesocortical pathways
...
• The VTA is the primary release site for the neurotransmitter dopamine
...
•
The VTA is the origin of the dopaminergic cell bodies of the mesocorticolimbic dopamine
system and is widely implicated in the drug and natural reward circuitry of the brain
...
•
The VTA contains neurons that project to numerous areas of the brain, from the prefrontal
cortex (PFC) to the NA to the caudal brainstem and several regions in between
...
Research
has indicated the nucleus accumbens has an important role in pleasure including laughter,
reward, and reinforcement learning, as well as fear, aggression, impulsivity, addiction, and
the placebo effect
...
g
...
•
Drugs have many different effects on the brain; however, they all follow the same path
...
•
After prolonged use, physiological drug tolerance and sensitization arises
...
Dopamine receptors are stimulated while someone is consuming a drug or when
the thought of doing a drug occurs
...
It is important to remember that many other neuronal circuits and NTs play a role in
addiction (dependent on the addictive substance) e
...
serotonin, GABA, glutamate, opioids
and canaboids
...
Neurotransmitters such as these play a major role in the reward systems of the brain
...
The continued use of drugs can cause degeneration of such neurotransmitters causing
personality disorders and prolonged personality changes in an individual
...
g
...
Moreover, the prefrontal cortex, which has bearing on judgement, risk taking, and
impulse control, may be complicit in explaining why adolescents are more prone to drug-‐taking
behavior
...
In an addicted brain we have:
•
•
Increased stimulation of the OFC (from nucleus accumbens) resulting in compulsion to take
drug
Decreased inhibition of the OFC (from prefrontal-‐cortex) resulting in failure to inhibit the
compulsion to take drug
Stress
•
•
•
•
•
•
Acute stress triggers release of dopamine in the neural reward pathway
...
Chronic stress leads to dampening of dopaminergic activity through down regulation of D
receptors
...
g
...
Such drugs
may have very different actions
...
Drugs which overstimulate dopamine receptors leads to a decrease in the number of
receptors, and the remaining receptors become less sensitive to dopamine (desensitization)
Desensitization is better known as tolerance, where exposure to a drug causes less
response than previously caused
Pre frontal cortex puts the brakes on the reward pathway including brakes on OFC (which is
important for motivation to act)
Pre frontal cortex matures late (teenage brain hardwired for addiction?)
Pre frontal cortex is dysfunctional in addicted people (due to dysfunction of dopamine
reward pathways)
Hippocampus/amygdala/HPA axis also implicated in the development of addiction (memory
of drug taking experiences/feelings example)
MEDICAL TREATMENTS FOR HEROIN ADDICTION
Principles of Treatment
Prevention
Harm reduction e
...
education, needle exchange programmes, Hep B immunisation,
overdose prevention (distribution of naloxone to heroin users), heroin replacement therapy
(prescription of “safe” heroin), HIV testing, Hep B/C testing
• Recovery: cessation of substance use
Drug recovery (rehabilitation)
Detoxification
• For some addicts, the beginning of treatment (recovery/rehabillitation) is detoxification
...
By itself,
this is not a solution, because most addicts will eventually resume taking the drug unless
they get further help
• Drug detoxification is used to reduce or relieve withdrawal symptoms while helping the
addicted individual adjust to living without drug use; drug detoxification is not meant to
treat addiction but rather an early step in long-‐term treatment
• The withdrawal symptoms of heroin includes agitation, anxiety, tremors, muscle aches, hot
and cold flashes, sometimes nausea, vomiting, and diarrhoea
...
The intensity of the reaction depends on the dose and
speed of withdrawal
...
• No single approach to detoxification is guaranteed to be best for all addicts
...
! Benzodiazepines: can have a role in detoxification
! Opiate blockade with naloxone (still limited option, only impulsive relapsers)
Opioid replacement therapies (ORT)
•
•
•
•
•
Methadone or buprenorphine: Synthetic opioids which can be used to treat opioid
addiction
Form of harm reduction (but can also be used in detox by gradually decreasing the dose) +
...
How could these be made
specific and verifiable? For example, abstinence from heroin use in methadone
maintenance patients could be verified by urine drug screening
...
Abstinence from heroin use in methadone maintenance patients could be
verified by urine drug screening
Patients receive escalating funds for consecutive clean drug tests which they can spend on
recovery activities
Patients are entered into a prize draw for each Hepatitis B vaccination they receive
The evidence base for CM
•
•
•
•
The most efficacious psychosocial intervention for substance misuse
Effective in typical “treatment failure” populations (e
...
dual diagnosis, cocaine dependence,
opiate dependence)
Approximately 50% patients, across populations and target behaviours respond to CM
Research base majority in US but pilot studies in UK suggest it can be incorporated into
routine NHS treatment
ALCOHOL
Adverse effects of alcohol
•
•
•
•
•
•
•
•
One of three biggest lifestyle factors for death & disability
¼ of deaths in 16-‐24 year olds
One million alcohol related violent crimes
Annual cost £3
...
2 million alcohol Related Admissions (7% of all admissions)
Liver disease
Many cancers
Drink driving
Screening
•
Screen with FAST (fast alcohol screening test)
...
It was developed for busy clinical settings as a two-‐stage initial
screening test that is quick to administer since >50% of patients are identified by using just the first
question
...
•
AUDIT score 0-‐7: Low risk Drinking
•
•
•
AUDIT score 8-‐15: Hazardous Drinking: A pattern of alcohol consumption that increases
someone’s risk of harm
AUDIT score 16-‐19: Harmful Drinking: A pattern of alcohol consumption that is causing
mental or physical damage
AUDIT score 20+ Dependent Drinking
Recommended limit
• Men 3-‐4 units per day (21 units per week max) – with two alcohol free days
•
Women 2-‐3 units per day (14 units per week max) – with two alcohol free days
•
Binge > 8 units men; > 6 units women
Hazardous drinking
•
AUDIT score 8-‐15
•
Management = brief intervention e
...
simple advice
•
There is consistent evidence from a large number of studies that brief intervention in
primary care can reduce total alcohol consumption and episodes of binge drinking in
hazardous drinkers, for periods lasting up to a year
...
Harmful drinking
•
AUDIT score 16-‐19
•
Management = extended brief intervention e
...
simple advice, brief counselling and
continued monitoring
Dependent drinking
•
AUDIT score 20+
•
Management= referral to specialist for diagnostic evaluation and treatment
Alcohol dependence syndrome
Categorised by:
•
Compulsion: strong desire to take alcohol (psychological dependency)
Impaired capacity to control substance taking behaviour in terms of onset, termination or
levels of use (psychological dependency)
• Preoccupation with substance use -‐ neglecting activities & interests (psychological
dependency)
• Persistent substance use despite clear evidence of harmful consequences (psychological
dependency)
• Dependency (all of above suggest dependency)
• Tolerance: need significantly increased amounts of the substance to achieve desired effects,
downregulation of GABA receptors
• Withdrawal state when substance is reduced or ceased, downregulation of GABA => when
alcohol is removed we get surge of glutamate activity => CNS hyper-‐excitability
Pathophysiology
•
The development of alcohol dependence involves numerous changes in brain chemistry (i
...
neurotransmission) that lead to psychological dependency as well as the physiological signs
of tolerance and withdrawal upon abstinence from alcohol
• Signalling systems involved include the neurotransmitters glutamate, γ-‐aminobutyric acid
(GABA), dopamine, and serotonin, as well as on other signalling molecules, including
endogenous opioids and corticotrophin-‐releasing factor (CRF)
• Alcohol's primary effect is the increase in stimulation of the GABA (A) receptor, promoting
central nervous system depression
...
This contributes to the
withdrawal effects
...
• Researchers also are exploring the interaction of alcohol with endogenous cannabinoids
(substances naturally produced in the body that have similar effects to cannabis and related
drugs) and the cannabinoid CB1 receptor
...
Chronic alcohol exposure alters both the synthesis of
endogenous cannabinoids and the characteristics of CB1 receptors
...
Withdrawal syndrome
•
•
•
•
•
Alcohol = depressant as stimulates GABA (major CNS depressant)
Chronic use of alcohol leads to changes in brain chemistry especially in the GABAergic
system
...
During acute alcohol withdrawal (due to tolerance and down regulation) we get decreased
GABA activity (due to the down regulation which has occurred) => increased brain activity
=> seizures can occur (amongst other –ve effects)
Neurochemical changes occurring during alcohol withdrawal can be minimized with drugs
which are used for acute detoxification e
...
chlordiazepoxide (BDZ)
...
With abstinence from alcohol and
cross tolerant drugs these changes in neurochemistry gradually return towards normal
...
Clinical features of withdrawal syndrome
•
Clinical features of withdrawal are time dependent:
6 -‐ 8 hours
•
•
•
•
•
Tremor, sweating, nausea, retching
Increased heart rate and blood pressure (hyper-‐excitabilty)
Mild temperature
Anxiety & agitation (hyper-‐excitabilty)
Subsides after 2 days
0 -‐ 48 hours
Withdrawal seizures (primarily due to decreased GABA activity => increased CNS
stimulation by glutamate)
• Peak time scale for seizures = 48 hours
>12 hours
•
•
Auditory, visual & tactile hallucinations (duration 5-‐6 days) – due to increased CNS
stimulation e
...
Lilluputian hallucinations
48 -‐ 72 hours
•
•
•
•
•
Delirium tremens (very serious form of delirium => Tx immediately with chlordiazepoxide)
Course tremor
Confusion
Delusions and hallucinations
Agitation, fever, increased heart rate
Management of alcohol withdrawal
•
•
•
Chlordiazepoxide (BDZ) is the drug of choice for acute alcohol withdrawal syndrome =>
increases GABA activity
Starting dose depends on SADQ (Severity of Alcohol Dependence Questionnaire)
Monitor using clinical institute withdrawal symptom for alcohol (CIWA-‐Ar)
Co morbidities
Physical
•
•
•
•
•
Neurological: peripheral neuropathy, Wernickes (b1 thiamine deficiency), Korsakoffs (b1
thiamine deficiency)
Liver: Alcoholic hepatitis, fibrosis, cirrhosis, hepatocellular Ca
GI: Pancreatitis, Peptic ulcer
Cancer (many types)
Vitamin deficiency related conditions e
...
Vit B12 (cobalamin) deficiency and thiamine (B1)
deficiency (Wernicke’s encephalopathy and Korsakoff’s syndrome)
...
Mental
•
•
•
85% in alcohol treatment services had comorbid psychiatric condition
Depression & anxiety 81%
DSH
Social
•
•
•
•
•
•
50% of violent crimes
17% of road fatalities
17 million working days lost annually
Domestic violence
60% child protection cases involve alcohol
Homelessness : 50% alcohol dependent
Thiamine (vitamin B1) deficiency
•
•
•
Wernicke’s encephalopathy: staggering gait (ataxia), visual problems e
...
diplopia (due to
ophthalmoplegia) and nystagmus, confusional state (20% mortality)
Korsakoff’s syndrome: short term memory loss (amnesia), resulting in confabulations, clear
consciousness (20% improve with thiamine)
Peripheral neuropathy (up to 70%) numbness, pain, hyperaesthesia, glove and stocking
distributions, weakness (due to toxic effects of alcohol and Vit deficiencies)
Wernicke’s encephalopathy
•
Wernicke's encephalopathy refers to the presence of neurological symptoms caused by
biochemical lesions of the central nervous system after exhaustion of B-‐vitamin reserves, in
particular thiamine (B1)
...
•
Causes of Wernicke’s encephalopathy include: alcoholism, malabsorption disorders (e
...
Crohns and coeliac), excessive vomiting (e
...
hyperemesis gravidarum), and cancer
...
However, only 10% of patients exhibit all three features, and other symptoms may also be
present
...
Ataxia can result in abnormal gait and coordination dysfunction
...
Clinical
features include:
•
•
•
•
•
Reduced consciousness (if brain stem affected)
Confusion (if diffuse cerebral dysfunction)
Ataxia (if vestibular region of medulla or cerebellum affected)
Ophthalmoplegia (diplopia and squint) and nystagmus (if brain stem affected)
Hypothermia and hypotension (if hypothalamus affected)
Management:
•
•
Thiamine oral (if low risk of Wenickes)
Pabrinex (contains multiple B vitamins including thiamine) IV/IM (if higher risk of Wernicke’s
or overt Wernickes symptoms)
Inpatient Criteria
•
•
•
•
•
•
Drinking 30+ units daily (e
...
g
...
•
FAST screening
CLINICAL EXAMPLE TUTORIALS
Alcohol Disorders -‐ Case Example
• 19 y/o med student
• Ankle injury (tripped on club floor) after heavy night drinking alcohol
• X-‐Ray showed NBI (no bone injury)
• Initial management: RICE (rest, ice, compression and elevation) and paracetamol +/-‐ NSAIDs
• Should prompt an opportunity to pry if there is greater problems with alcohol
• FH of alcohol problem indicates a genetic/environmental predisposition
• Personal history: Perfectionist traits + social anxiety => may be more predisposed (as use to
relax in uncomfortable environments)
• PMH: head injury (happened in context of alcohol intoxication)
• Alcohol history: 2x/week, 12-‐14 pint/night (approx
...
60 units per week
•
•
•
•
•
•
•
•
•
•
•
•
•
•
We definitely need to discuss alcohol use with this patient (extended brief intervention)
...
Symptoms of withdrawal may be
fatal => in-‐patient management (chlordiazepoxide)
...
Alcohol has significant association with completed suicide and therefore this should also be
discussed
Alcohol works on GABA and in alcohol abuse the body adjusts by reducing GABA receptors
and oversensitising glutamate => GABA system doesn't work well as down-‐regulated
(sensitised)
On withdrawal of alcohol we get an excess of glutamate activity (due to decreased GABA
activity) results in => anxiety, tremor, N&V, increased HR/BP, pyrexia, seizures,
hallucinations, delirium tremens etc
BDZs (chlordiazepoxide) for detox: act on GABA like alcohol does (could technically do detox
with alcohol with gradual reducing)
...
Gradually reduce benzos over 7-‐10 days
...
Short half life BDZs would result in
fluctuating withdrawal symptoms
...
Also need to hydrate, treat infections, keep orientated
...
Very serious illness, can be fatal
...
Key clinical features are opthalmoplegia (diplopia, squint, nystagmus), ataxic gait,
and confusion
...
Fitness to practice issues
...
Indications for inpatient detox: suicide risk/self harm, history of seizures or delirium tremens
(DTs), lack of social support, other physical co-‐morbidities
Drug Disorders: Case Example
• Patient in hospital for heroin overdose
• Heroin use complications: infections, hepatitis viruses, endocarditis, HIV, TB, anthrax
(contamination), Staph pneumonia, and abscesses
• Medication to prevent withdrawals: methadone or buprenorphine – don’t withhold!
• Monitor withdrawal by withdrawal assessments scoring (score heart rate, resp rate, clammy
skin, vomiting, tremors, agitation/aggression etc)
• If very poorly functioning and families/friends drug users => lots of effort to keep off
substances => likely to be on methadone life-‐long (ORT)
• If previously well functioning, highly motivated, not using long => can probably wean off
methadone (detoxification)
• Possible to overdose on methadone
...
g
...
Naloxone has short half life so frequent administration
required
...
• Involved in muscle action through presence at neuromuscular junctions (specialized type of
nicotinic synapse where neurons connect to muscle cells)
...
•
•
•
•
ACh is the transmitter of the parasympathetic half of the autonomic nervous system (pre
ganglionic and post ganglionic)
Also released by pre-‐ganglionic neurones in sympathetic NS (pre ganglions and ACh
stimulate adrenal glands)
ACH is NT in skeletal muscle
People with Alzheimer's disease are usually found to have a substantially low level of
acetylcholine
...
g
...
This is why acetlycholinesterase inhibtors are
indicated in mild AD (e
...
rivastigmine, donepezil and galantamine)
Dopamine
• Appetitive/approach system
• Active in selected areas of brain
• Dopamine (DA) is involved in a wide variety of behaviours and emotions, including pleasure
...
g
...
In other words, dopamine
regulates the pleasurable emotions
...
• A significantly low level of dopamine in basal ganglia system is associated with Parkinson's
disease
• Patients of schizophrenia are usually found to have excess dopamine in mesolimbic system
(resulting in positive symptoms) and low levels in mesocortical (negative symptoms)
• DA is the precursor (chemical forerunner) that is turned into NA, so is closely related to NA
and often affected by the same drugs
...
DA is an important transmitter in several brain systems:
• Extrapyramidal basal ganglia motor system e
...
nigrostriatal pathways (posture and
movement control)
• Mesolimbic/mesocortical system (midbrain connections to limbic system and cortex
respectively) which is important for emotional and cognitive functions respectively
• Hypothalamus-‐pituitary system (menstrual and other hormone regulation) e
...
dopamine is
a potent inhibitor of prolactin release => anti-‐psychotics (dopamine antagonists) can result
in prolactin hypersecretion (particularly typicals such as haloperidol and chlorpromazine)
Serotonin
• Widely distributed
• Aversive / defensive system – major NT
• Serotonin is an important inhibitory neurotransmitter, which can have a profound effect on
emotion, mood, and anxiety
...
A significantly low level of serotonin is believed to be associated with conditions like
depression, suicidal thoughts, and obsessive compulsive disorder
...
• Serotonin is a chemical cousin of the "catecholamines" discussed above
...
• The action of 5HT at a synapse is brought to an end primarily via reuptake
...
• Raphe nucleus
5HT is best known as a transmitter in several brain areas:
• Sleep regions
• Limbic system mood control regions
• Pain suppression system (stimulates endogenous opioid release)
Gamma-‐aminobutyric acid (GABA)
• GABA is an inhibitory neurotransmitter that is very widely distributed in the neurons of the
cortex
...
• GABA is an inhibitory neurotransmitter that slows down the activities of the neurons, in
order to prevent them from getting over excited
...
GABA can thus help prevent anxiety
...
Drugs like Valium and
other BDZs work by increasing the activity of GABA (mostly GABA-‐A receptors)
• Alcohol and barbiturates can also influence GABA receptors
...
• Some drugs that increase the level of GABA in the brain are used to treat epilepsy and to
calm the trembling of people suffering from Huntington’s disease
...
• Glutamate is mainly associated with functions like learning and memory
...
• An excess of glutamate is however, toxic for the neurons
...
Hence why Memantine (NMDA
blocker which blocks effects of glutamate on NMDA receptors) is used
...
Epinephrine
•
•
Epinephrine (also known as adrenaline) is an excitatory neurotransmitter, that controls
attention, arousal, cognition, and mental focus
...
An increased secretion of norepinephrine raises the heart rate
and blood pressure
...
• Norepinephrine is a neurotransmitter that is important for attentiveness, emotions,
sleeping, dreaming, and learning
...
• Norepinephrine plays a role in mood disorders such as manic depression
...
• NE is the primary transmitter carrying messages from the sympathetic half (postganglionic)
of the autonomic nervous system to body organs and glands (with the exception of the
adrenal gland)
• The action of NE at a synapse is brought to an end primarily via reuptake
...
• Locus coerulus
Endorphins
• Endorphins are the neurotransmitters that resemble opioid compounds, like opium,
morphine, and heroin in structure
...
In fact, the name 'endorphin' is actually the short form for 'endogenous
morphine'
...
• The opioid drugs produce similar effects by attaching themselves to the endorphin receptor
sites
...
It basically controls the sleep-‐wake cycle
...
The production of melatonin is dependent on light
...
Summary
NT
Major functions
Excess is associated with
Deficiency is associated
with
Acetyl choline Muscle
movement, Relative excess of ACh to
(Ach)
attention,
arousal, DA in PD => hence why
memory,
emotion
...
Nucleus use
basalis of Meynert
...
Localised
...
in the mesolimbic system
Mesolimbic
...
Alzheimer’s disease
Endorphins
Parkinsonism (in the
nigrostriatal patheay of
basal ganglia)
Schizophrenia (negative
symptoms)
in
the
Mesocortical system
Serotonin
Sleep,
wakefulness, Serotonin syndrome (e
...
in MDD
(5HT)
appetite,
mood, MAO inhibotors such as
aggression, impulsivity, meclobemide)
sensory
perception,
temperature regulation,
pain
suppression
...
NA
Learning,
memory, Anxiety, HT crisis
MDD
(noradrenaline) dreaming,
awakening,
emotion, stress-‐related
increase in heart rate,
stress-‐related slowing of
digestive
processes
...
GABA
Main
inhibitory Alcohol use
Alcohol withdrawal
neurotransmitter in the BDZ
brain
...
Glutamate
Main
excitatory MS
neurotransmitter in the Alcohol withdrawal
brain
Pain relief, pleasure
SUMMARY OF ADDICTION
•
•
•
•
Addiction is a compulsive seeking, and then obtaining, of a substance while behavior
increasingly becomes out of control
Addiction is caused by a combination of genetics, environment and stress
Many types of neurotransmitters play an important role including dopamine, serotonin, and
noradrenaline
Some sources focused solely on dopamine or a dopamine variants, while others credited the
neurotransmitters gamma-‐aminobutyric acid (GABA), glutamate, and opioids as playing roles
in addiction as well
...
•
•
•
•
•
•
•
•
Stress is a key trigger for most addictions
...
When you experience
something pleasurable, dopamine is released to the reward center (the nucleus accumbus)
of your brain
...
Neurotransmitters are then sent to the memory center (the temporal lobe)
...
Reward highways are built from highly pleasurable one-‐time experiences or less
pleasurable experiences that are repeated
...
The stronger
the reward highway, the more the brain wants to repeat the experience that created the
reward highways
...
Some of the most addictive drugs cause increased dopamine activity (e
...
cocaine) either by
mimicking dopamine or causing increased natural dopamine to accumulate in the synaptic
cleft
...
Down regulation of receptors and desensitisation occurs and triggers the need for more,
resulting in the person using more cocaine e
...
tolerance develops
...
These changes also ultimately result in the withdrawal effects if the
stimulus is removed
...
Less harmful stimulants such as caffeine and sugar are also accepted as dopamine
mimics
...
These drugs
will also help prevent problematic behaviors that could have caused the harmful addiction in
the first place
...
FORMATIVE QUESTIONS 1
1
...
If the patient is intelligent and articulate with good insight, there is no reason to take a
collateral history
B
...
A psychiatric history should be documented using technical terms
D
...
Older patients should not be asked about illicit drug use in case they are offended
2
...
“the patient is dishevelled, wearing dirty clothes” – appearance
B
...
“the patient’s mother thinks he has been responding to auditory hallucinations”
D
...
“she is orientated in time, place and person” – cognition
3
...
People generally take overdoses either as a suicide attempt or as a cry for help
B
...
Asking patients about suicidal thoughts can be dangerous as it may suggest the idea to them
D
...
Doctors are at a low risk of suicide compared to the general population, as they are social
class 1
4
...
Morbid dread of fatness
B
...
Sexual dysfunction in men
D
...
Loss of interest in food
5
...
Electrocardiogram
B
...
CT brain
D
...
Full blood count
6
...
Internal locus of control
B
...
Misdiagnosis of conversion symptoms
D
...
Childhood sexual abuse
7
...
Inhibits reuptake of serotonin and dopamine
B
...
Increases release of serotonin and norepinephrine
D
...
Acts as an agonist at serotonin and norepinephrine receptors
8
...
Decreased thyroid releasing hormone in CSF – TRH raised in MDD
B
...
Decreased excretion of cortisol in the urine – cortisol raised in MDD
D
...
Increased hippocampal volume
9
...
Specific genes have been found to predispose to early-‐onset OCD
B
...
You can have obsessions and compulsions but not have OCD
D
...
Most patient with OCD have no other mental illness as very specific parts of the brain are
affected
10
...
People with no mental illness tend not to have any schemas
B
...
Changing a patient’s schemas is quite straightforward with the right therapy
D
...
The content of someone’s assumptions and automatic thoughts tells us about their schemas
Answers
1
...
C
3
...
E
5
...
E
7
...
B
9
...
E
FORMATIVE QUESTIONS 2
5
...
I’ve been waking up very early in the
morning and can’t get back to sleep, I just lie awake worrying about my situation
...
I’m very
tired and I can’t be bothered doing anything, not even meeting up with my friends or playing
football
...
I don’t really
see the point in anything anymore, maybe it would be better if I wasn’t here
...
Lithium carbonate
B
...
Selective serotonin reuptake inhibitor
D
...
Tricyclic antidepressant
2
...
“Since I had my baby I keep getting thoughts in my head about dropping her or letting go of
her pram on a hill
...
B
...
“I can’t stand the house not being perfectly tidy, I spend hours on the housework”
D
...
My neighbours are putting thoughts into my head about horrible things happening to my
children
...
Which piece of information would you give a patient who is considering ECT?
A
...
ECT can only be given to hospital inpatients
C
...
You will need further treatment after the course of ECT
E
...
What is the best description of this woman’s current mood state?
“I felt great a few weeks ago, couldn’t have been better, I’m still very restless but now
feeling ill-‐at-‐ease
...
I can’t get the thoughts of dying a painful death out of my mind
...
I can’t sit still-‐ the nurses keep telling to stop
fidgeting and pacing about the ward, but I can’t
...
A
...
Mania without psychotic symptoms
C
...
Mixed affective state
E
...
Someone who was attacked at knifepoint three months ago makes the following
statements-‐which would not be explained by post traumatic stress disorder?
A
...
“Sometimes when I can’t sleep at night, I feel like I can hear his voice and smell his
aftershave and I panic”
C
...
“I have bad dreams about the attack”
E
...
Under which legislation would you treat the following patient?
Mrs Y is an 81 year old lady who was brought to the emergency department with a few
hours history of agitation, aggressive behaviour and confusion
...
Her bloods show that she is very dehydrated
...
She does not understand why she is in hospital and repeatedly
attempts to leave the ward in order to go home
...
No psychiatrist is available
...
Mental Health (Care and Treatment) (Scotland) Act 2003-‐ Emergency Detention Certificate –
as she wants to leave and thus needs detention
B
...
Adults with Incapacity (Scotland) Act 2000-‐ Section 47
D
...
Common Law
Answers
1
...
3
...
5
...
C
A
D
D
A
A – as she requires detention
ANATOMY OF THE LIMBIC SYSTEM AND MEMORY
•
The limbic system is believed to have a special role in emotional experience and visceral
(ANS and endocrine) regulation
...
It is now obvious that some components act
primarily in other capacities (e
...
the hippocampus functions mainly in memory)
...
g
...
•
The name comes from its location on the medial rim (limb) of the inferior cerebral
hemispheres (although with time, regions distant from this area, but connected to these
original structures, have been added)
...
The cingulate cortex is a part of the brain situated in the medial aspect of the cerebral
cortex
...
It is an integral part of the limbic system, which is involved with emotion formation
and processing, learning, and memory
...
g
...
This role makes the cingulate cortex highly important in disorders such as depression and
schizophrenia
...
g
...
They also project information onto the hypothalamus which also
has multiple functions in particular regulating autonomic and endocrine functions
...
It may be thought of as a kind of switchboard of
information
...
In particular, every sensory system (with the exception of the
olfactory system) includes a thalamic nucleus (e
...
lateral geniculate nucleus for visual
information) that receives sensory signals and sends them to the associated primary cortical
area
...
•
•
•
•
•
•
In order for new memories to be acquired, the circuit of Papez must be intact in at least one
hemisphere
...
g
...
g
...
For example, damage to Broca’s (frontal lobe) or Wernicke’s areas
(temporal lobe) of the brain, which are specifically linked to speech production and language
information, would probably cause language-‐related memory loss
...
This suggests that the hippocampus is critical not only for the efficient encoding
and hence normal recall of new information but also for the recall of episodic information
acquired before the onset of amnesia
...
•
Important for storing emotionally charged memories (with the help of the hippocampus)
essential for survival
•
Found near the temporal pole, deep to parahippocampul gyrus
Important for activating ANS (via the hypothalamus) in flight or fright situations
Olfactory System
•
•
•
•
•
•
The Olfactory tract terminates in the primary olfactory cortex (several regions)
Olfactory (mitral) cells send their axons to a number of brain areas, including the anterior
olfactory nucleus, piriform cortex, the medial amygdala, and the entorhinal cortex
...
The medial amygdala is involved in social functions such as mating and the recognition of
animals of the same species (therefore it should be obvious why the olfactory system
connects to the amygdala)
The entorhinal cortex is associated with memory e
...
to pair odours with memories
...
Hippocampus
•
•
•
•
The hippocampus is an ancient area of cerebral cortex that has three layers
...
The hippocampus has several parts
...
There is a curved area of cortex called the Cornu Ammonis (CA) that is divided
into four regions called the CA fields
...
These contain
prominent pyramidal cells
...
These are primarily from the neocortex
and cingulate cortex and from the septum and hypothalamus (via the fornix)
There are many outputs (efferents)
The loop starting with the hippocampus projecting to the mamillary bodies, which relay to
the anterior thalamic nucleus, which then relay onto the cingulate gyrus and entorhinal
cortex, which finally relay back to the hippocampus was thought to be an important circuit
...
It helps control corticosteroid production
...
Additionally the hippocampus is critically involved in many declarative (explicit) memory
functions (in particular in the formation of new memories)
Hippocampal neurons have been studied extensively in terms of long-‐term potentiation
...
Long term
potentiation is a major cellular mechanisms that underlies learning and memory
Types of memory
• Explicit (declarative memory) refers to the memory of facts and events
...
Storage of explicit memories depends
on the medial temporal lobe and the relationship between the hippocampus and entorhinal
region of the parahippocampal gyrus (Papez circuit)
...
The hippocampus plays a critical role in conversion of short-‐term memory
to long-‐term memory
...
These lesions are more likely to affect new declarative (explicit) learning resulting
in anterograde amnesia
• Implicit (non-‐declarative memory) is the learning of skills (including motor skills processed
via the basal ganglia and cerebellum) as well as associative learning
...
• It has recently been shown that the hippocampus is not only active in encoding memories
but also in retrieval of them
...
The hypothalamus
•
•
•
•
The hypothalamus is the primary output node for the limbic system, and has many
important connections
...
g
...
In order to perform its essential functions, the hypothalamus requires several types of
inputs
...
•
•
•
•
•
•
•
•
It also receives afferent inputs from the hippocampus (via the fornix), the septum and the
amygdala
...
It also has internal sensors for temperature, osmolarity, glucose and sodium concentration
...
These
include steroid hormones, and other hormones as well as internal signals (such as hormones
involved in appetite control such as leptin)
...
There
are localized areas in the hypothalamus that will activate the sympathetic nervous system
and some that will increase parasympathetic activity
...
There are also projections to the reticular formation that are involved in certain behaviors,
particularly emotional reactions and arousal
...
This nucleus is responsible for entraining circadian rhythms to the day-‐night
cycle
...
They regulate autonomic and endocrine function, particularly in response to emotional
stimuli
...
Additionally, many of these areas are critical to particular types of memory (e
...
emotionally
charged memories) and storage of long term memories
Functions of the limbic system include regulation of: energy and water balance, autonomic
functions, temperature, endocrine functions, sexual behaviour, emotional behaviour,
reward/reinforcement, learning and memory
Some of these regions are closely connected to the olfactory system, since this system is
critical to the survival of many species
...
Cingulate gyrus: Autonomic functions regulating heart rate, blood pressure and cognitive
and attentional processing
...
Orbitofrontal cortex: Required for decision making
Piriform cortex: The function of which relates to the olfactory system
...
The hippocampus consists of two “horns”
that curve back from the amygdalae
...
If the hippocampus is damaged, a person
cannot build new memories and lives instead in a strange world where everything he or she
experiences just fades away, even while older memories from the time before the damage
are untouched (anterograde amnesia)
Amygdala: Involved in signalling the cortex of motivationally significant stimuli such as those
related to reward and fear in addition to social functions such as mating
...
The amygdalae also stimulate the hippocampus to remember many
details surrounding the situation (in particular situations involving extreme emotion e
...
fear)
Fornix: C-‐shape bundle of axons that carries signals from the hippocampus to the
mammillary bodies (part of hypothalamus) and septal nuclei
...
They are involved with the process of recognition memory
...
The septal nuclei play a role in
reward and reinforcement along with the nucleus accumbens
...
Hypothalamus: has many nuclei with many functions e
...
ANS and endocrine regulation
NEUROCHEMISTRY OF MEMORY
•
•
•
•
•
•
Memory is the process in which information is encoded, stored, and retrieved
...
In this first stage we must change the information so that
we may put the memory into the encoding process
...
This entails that we maintain information
over periods of time
...
We must locate
it and return it to our consciousness
...
Remember that other higher brain functions (e
...
concentration) can affect how well tasks
are learned/memories stored
The loss of memory is described as forgetfulness, or as a medical disorder, amnesia
...
It is sometimes called explicit memory, since it
consists of information that is explicitly stored and retrieved
...
These can be memories that happened to the person directly or just memories of
events that happened around them
...
Autobiographical memory is a subset of
episodic memory
! Semantic memory consists of all explicit memory that is not autobiographical
...
• In contrast, procedural memory (or implicit memory) is not based on the conscious recall of
information, but on implicit learning
...
It is categorised by an individual doing better in a given task due only to
repetition (with no new explicit memories being formed)
...
Procedural memory involved in motor
learning depends on the cerebellum and basal ganglia
...
The duration of short-‐term memory
(when rehearsal or active maintenance is prevented) is believed to be in the order of
seconds
...
This has been shown to depend on circuitry involving the frontal and
parietal lobes
...
Encoding involves working with the hippocampus (e
...
circuit of Papez) to organize and
select which information should be stored more permanently (therefore the hippocampus is
essential for storage of new memories)
•
•
In addition to encoding, the cortex can be involved with pulling memories out of storage in a
process called retrieval
...
Key points:
! The frontal lobes (e
...
PFC) are important for short term and working memory
...
Circuit of Papez) is important
for encoding of long-‐term memory
Basal ganglia and cerebellum
• The basal ganglia and cerebellum contribute to procedural (implicit) memory
The limbic system
• Encoding of long-‐term memory occurs in the diencephalon (thalamus, mammillary bodies)
and medial temporal lobe (hippocampus, amygdala) => Circuit of Papez
• Therefore lesions of these regions can produce anterograde amnesia
• It also believed that lesions of these regions can produce variable retrograde amnesia
...
Damage to the hippocampus and surrounding area can cause anterograde
amnesia, the inability to form new memories
...
The amygdalae are associated with both emotional learning and memory, as it
responds strongly to emotional stimuli, especially fear
...
Furthermore, the rest of the brain is involved
with strategies for learning and recall, as well as attention, all of which are critical for
effective learning and memorization
...
Frontal traumatic brain injury may lead to difficulty with working memory, meaning that it is
difficult to keep information in mind long enough for it to be encoded
...
AD
•
•
•
•
•
•
Alzheimer disease (AD) is the most common neurodegenerative disease in adulthood and
the most common disease that affects the episodic memory system
...
g
...
Therefore, patients with AD often initially develop an anterograde amnesic disorder, leaving
them impaired or unable to learn new information (generally impairment of anterograde
episodic memory initially)
...
Thus, it might be expected that some patients with AD will exhibit
similar types of memory distortions that patients with frontotemporal or multi-‐infarct
dementia show
...
Finally, as the pathology of AD begins to affect more widespread areas of the brain, these
patients develop problems with other cognitive abilities and are unable to perform activities
of daily living such as eating, dressing and bathing
...
These patients have a ‘two-‐way’ naming deficit: they are
unable to name an item when it is described and they are also unable to describe the item
when given its name
...
Those who have this disease have problems with both their working memory, spatial
memory and implicit motor memory
...
He or she would also have trouble encoding this visual and spatial
information into long-‐term memory
...
People with Parkinson's disease display working memory impairment during sequence tasks
and tasks involving events in time
...
As PD progresses it can also result in dementia with loss of explicit memory
Summary of memory disorders
Types of amnesia
•
Anterograde amnesia refers to the inability to create new memories due to brain damage,
while long-‐term memories from before the event remain intact
...
The two brain regions related with this condition are medial temporal lobe and medial
diencephalon (e
...
hippocampus and circuit of Papez)
...
One may
be able to encode new memories after the incident
...
Episodic memory
is more likely to be affected than semantic memory
...
•
Dissociative amnesia (non-‐organic amnesia) results from a psychological cause (e
...
PTSD)
as opposed to direct damage to the brain caused by head injury, physical trauma or disease,
which is known as organic amnesia
...
This form of
amnesia is distinct in that abnormalities in the hippocampus can sometimes be visualized
using a special form of magnetic resonance imaging of the brain known as diffusion-‐
weighted imaging (DWI)
...
The cause of this syndrome is not
clear
...
Patients are typically amnestic of events more than a
few minutes in the past, though immediate recall is usually preserved
...
It is caused by
brain damage due to a vitamin B1 deficiency (thiamine) and will be progressive if alcohol
intake and nutrition pattern are not modified
...
It should be noted that the person's short-‐
term memory may appear to be normal, however the person may have a difficult time
attempting to recall a past story, or with unrelated words, as well as complicated patterns
...
Patients may confabulate, with
loved ones may interpret as lies
...
It is one of several
phenomena underlying synaptic plasticity, the ability of chemical synapses to change their
strength in response to particular stimuli
...
Even though the neurons of the hippocampus may seem like just a transit point in the
establishment of long-‐term memory, they actually display a great deal of plasticity
...
The most interesting characteristic of LTP is that it can cause the long-‐term strengthening
of the synapses between two neurons that are activated simultaneously
...
Glutamate, the neurotransmitter released into these synapses, binds to several different
sub-‐types of receptors on the post-‐synaptic neuron
...
The AMPA (non-‐NDMA) receptor is paired with an ion channel (ionotropic) so that when
glutamate binds to this receptor, this channel lets sodium ions enter the post-‐synaptic
neuron
...
The NMDA receptor is also paired with an ion channel (ionotropic), but this channel admits
calcium ions into the post-‐synaptic cell
...
For these magnesium ions to withdraw from the
channel, the dendrite’s membrane potential must be depolarized
...
This increased concentration of calcium in the dendrite sets off several biochemical
reactions that make this synapse more efficient (and stronger) for an extended period
...
The necessity for these two simultaneous
•
•
•
conditions gives this receptor associative properties
...
But if this receptor is blocked with a drug, or if the gene involved in its construction is
disabled, or if the neurones involved are damaged, then LTP cannot occur
...
Why is this so important?
•
•
•
Properties of the NMDA receptor allow it to act as a coincidence detector
This is a mechanism for associating two pieces of information being conveyed by different
sets of afferents to same postsynaptic cell
Important for learning and memory
Modulation by neurotransmitters
•
•
•
•
•
•
Glutamate
GABA
Noradrenaline
Corticosteroids
Dopamine
Acetylcholine
Glutamate receptor modulators
•
•
NMDA receptor antagonists
...
They are used as
anesthesia for animals and for humans; the state of anesthesia they induce is referred to as
dissociative anesthesia
...
Drugs include:
! Ketamine
! Memantine (counter-‐intuitively used in AD)
AMPAkines
GABA receptor modulators
•
•
Benzodiazepines (enhance affects of GABA)
Anaesthetics (enhance affects of GABA)
Stress and memory function
•
•
•
•
•
•
•
The effects of stress on memory include interference with one’s capacity to encode and
ability retrieve information
...
Stress can cause acute and chronic changes in certain brain areas which can cause long-‐term
damages
...
One type of stress hormone responsible for affecting memory negatively is the
glucocorticoids (GCs), also known as cortisol
...
Pseudomentia can occur in Cushings and depression induced psudo-‐Cushings
Remember depression is associated with raised cortisol, failure of dexa to supress, and
raised TRH
PTSD is associated with raised catecholamines, and decreased cortisol (adrenal burn out)
Noradrenaline, memory & LTP
•
•
•
•
•
Extreme emotion and release of NA can enhance a memory representation
This enhancement is called a flashbulb memory: a highly detailed, exceptionally vivid
'snapshot' of the moment and circumstances in which a piece of surprising and
consequential (or emotionally arousing) news was heard
Also an effect in PTSD
Activation of beta-‐adrenergic receptors can promote LTP in the hippocampus
Can be inhibited by beta-‐adrenergic antagonists (beta blockers)
Corticosteroid receptors
•
•
Glucocorticoid receptor (GR)
Mineralocorticoid receptor (MR)
Excess GCs are associated with memory impairment:
•
•
•
Cushing’s syndrome (can cause pseudodementia)
Major depression (can cause pseudodementia)
Alzheimer’s disease
Dopamine, memory & LTP
•
•
•
•
•
•
Working memory is the system that actively holds multiple pieces of transitory information
in the mind, where they can be manipulated
...
g
...
g mephylphenidate is
a dopamine reuptake inhibitor => increases dopamine levels in synaptic cleft)
Acetylcholine and memory
•
Cholinergic neurotransmission at the CNS level is thought to regulate sleep, wakefulness,
and memory
...
g
...
g
...
Targeting the glutamatergic system, specifically NMDA receptors, offers a novel approach to
treatment in view of the limited efficacy of existing drugs targeting the cholinergic system
•
•
•
Memantine = low-‐affinity voltage-‐dependent non-‐competitive antagonist of NMDA
receptors
Licensed to treat moderate to severe Alzheimer’s disease
May preferentially inhibit excessive NMDA receptor activation associated with excitotoxicity
and spare normal function
ASSESSMENT AND LOCALISATION OF COGNITIVE FUNCTION
Memory Problems
Some general rules:
•
•
•
•
•
•
Take collateral history from next of kin => always!
Get some idea of how reported problems interfere with ADL (activities of daily living)
Be aware that mood and anxiety can greatly affect memory
Consider potential medical causes (e
...
non psychiatric cause)
Be aware of patients attending alone!
Perform a dementia screen (examination + routine bloods + specific blood tests e
...
syphilis/HIV screen, endocrine screen, and vitamin assay)
Medical conditions to consider:
•
•
•
•
•
•
•
•
•
•
Dementia (primary and secondary)
Depression (common cause of “pseudodementia”)
B12 deficiency
Other vitamin deficiency e
...
thiamine B1 (Korsakoffs syndrome results in amnesia and is
frequently a result from chronic alcoholism)
Hypothyroidism
Metabolic/toxic/endocrine abnormalities (e
...
Cushings can result in pseudodementia)
Infections
Anoxia e
...
due to sleep apnoea, respiratory problem or cardiac problem
SOL (space occupying lesion) e
...
brain tumour
Consider drug history
Dementia
•
•
•
•
Progressive global cognitive decline – not just memory
Represent a decline from previous levels of functioning and performing
Interferes with the ability to function at work or at usual activities
Not explained by delirium or other psychiatric disorder
•
•
•
•
•
•
The cognitive or behavioural impairment involves a minimum of two of the following
domains: memory (amnesia), reasoning, visual-‐spatial abilities (agnosia), language
(aphasia), motor planning (apraxia) and personality/behaviour
Severe, acquired and must involve more than one brain function (one of which is memory)
Dementia is not only a single disease entity e
...
there are many different syndromes
Dementia is not only a disease of the elderly
Dementia is sometimes reversible
Be aware that common medical and psychiatric conditions may present with “cognitive
problems”
Dementia or not?
•
•
•
•
Simple bedside cognitive assessment may allow evaluation of cognitive function
Large number of assessments
Folstein MMSE (score out of 30)
Addenbrookes Cognitive assessment (score out of 100)
Aetiology
Primary causes
•
•
•
•
•
AD (commonest cause): affects frontal, temporal and parietal lobes
Frontotemporal dementia (FTD) including Picks
Dementia with Lewy bodies (DLB)-‐ second commonest cause
Huntington’s disease (HD)
PD with dementia
Secondary causes
•
•
•
•
•
•
•
Vascular dementia – common cause
Drugs
Metabolic/toxic/endocrine disorders
Infection e
...
HIV, syphilis and CJD
SOL
Post stroke
Traumatic brain injury
Purpose of assessment
1
...
What is the underlying pathological process?
Appreciate that bedside cognitive assessment may be a valuable diagnostic tool and that pattern
recognition may allows a confident clinical diagnosis or differential to be established
Assessment process
•
•
•
•
History including functional status – including collateral
Physical Examination (often less relevant)
Cognitive Assessment (MMSE and ACE-‐R)
Relevant Investigations e
...
MRI, CT, SPECT, CSF, bloods etc
History
•
•
•
Take history from patient and always from next of kin (collateral)
Presenting complaint: consider the functional domain (e
...
amnestic, visuospatial/agnosia,
language/aphasia, behaviour, reasoning, motor planning/apraxia) and associated lesion
location
PMH: Vascular disease including stroke (and vascular risk factors), trauma, cancer, major
mental health issues
•
•
DH: prescribed drugs (care with anti-‐cholinergic in the elderly as these can cause memory
problems), OTC drugs, illicit drugs, alcohol (life-‐long history)
FH
Cognitive domains
Discrete brain regions have selective functions
Dementia may selectively involve certain “cognitive functions” in such a way that one can
provide a clinical diagnosis by recognising pattern
Cognitive functions
•
•
•
•
•
•
•
•
•
Attention/ concentration (frontal lobe)
Executive function (frontal lobe) including behavioural changes
Language (expressive-‐ Brocas area in the dominant frontal lobe; receptive-‐ Wernickes area in
the dominant temporal lobe)
Memory: Frontal (short term and working) and temporal/limbic (long term)
Visuospatial function (agnosia): parietal
Orientation (time, place, person)
Praxias (motor skills) – including basal ganglia, cerebellum and parietal
Executive Function
•
•
•
Impairment often seen in association with behavioural changes
Impaired reasoning and handling of complex tasks, poor judgment
...
Visuospatial
•
Symptoms include: inability to recognize faces or common objects or to find objects in
direct view despite good visual acuity, inability to operate simple implements, or orient
clothing to the body
...
Defects result in dysphasia/aphasia – expressive or receptive
Assessment of cognitive function
•
•
•
•
•
Bedside assessment allows a reasonably quick, easy and reproducible assessment to be
undertaken as a screening tool
During the test consider “where is the lesion”?
There is no substitute for formal input and testing from a trained neuropsychologist
Simple bedside cognitive assessment may allow evaluation of cognitive function
Large number of assessments available
Common cognitive assessment methods
•
•
Folstein MMSE (score out of 30)
Addenbrookes Cognitive assessment (score out of 100)
Testing evaluates both the extent of the problem and also the pattern of impairment
Folstein MMSE (mini mental state examination) assessment
Tests (MLOV):
•
•
•
•
Memory (frontal, temporal, limbic)
Language (frontal, temporal)
Orientation
Visuospatial (parietal)
The MMSE is scored out of 30:
•
MMSE>27 “excludes” dementia (Sensitivity: 0
...
7)
•
MMSE <24 “supports” dementia (Sensitivity: 0
...
86)
This is a crude test and can be normal particularly in the young and at an early stage of dementia
Interpretation must take into account the background history including associated medical and
psychiatric co-‐morbidity
Advantages:
Quick
Reproducible
Available in different languages
Useful screening tool
Disadvantages:
•
•
•
•
•
•
•
Not adjusted for age
Poor examining of executive function and praxias
Poor in severe impairment (“floor effect”)
Addenbrookes cognitive assessment (ACE-‐r)
Examines (MLAVE):
•
•
•
•
•
Memory (frontal, temporal and limbic)
Attention/ Concentration (frontal)
Language (frontal and temporal)
Visuospatial (parietal)
Executive function (frontal)
Purpose:
•
•
Extent impairment
Pattern of impairment
1
...
g
...
After subject repeats, say: “Try to remember them as I am going to ask you them
later”
Localisation
Areas of the brain important for attention, concentration and arousal include:
•
•
•
Prefrontal cortex (frontal lobe)
Reticular activating system (brainstem)
Thalamus
2
...
g
...
g
...
Episodic memory refers to life events that people remember
...
Episodic Memory
•
•
Pathological process affecting episodic memory: early Alzheimer's disease, limbic
encephalitis
...
g
...
g
...
Semantic memory
•
•
•
•
Semantic memory loss is loss of general knowledge about the world including words
Semantic memory loss is often accompanied with a marked reduction in verbal fluency and
impairment of irregular words (dyslexia) e
...
pint
Example of disease: Semantic dementia (variant of Frontotemporal dementia)
Localisation? Anterior temporal lobe atrophy
ACE-‐r assessment of memory
Memory: anterograde memory
•
Give patient an address (repeat up to 3 times) and ask them to repeat later
Memory: retrograde memory
Name of current prime minster
Name of the woman who was prime minister
Name of the USA president
Memory: recall
•
•
•
•
Ask: “which 3 words did I ask you to repeat and remember?”
Language: reading
•
Ask the subject to read the words on the assessment form e
...
sew, pint, soot, dough, height
Language: naming
•
Ask the subject to name objects e
...
“which one is a marsupial?”
3
...
In the over 65 age group, FTLD is probably the fourth most common cause of dementia after
Alzheimer's disease, dementia with Lewy bodies and vascular dementia
...
In some patients the
symptoms of FTLD and Alzheimer's may overlap
...
Language
Variants of frontotemporal dementia may selectively involve language
...
Visuospatial
•
Localisation: non dominant hemisphere (non dominant parietal lobe e
...
usually left
hemisphere)
Example of disease:
•
•
•
•
Stroke (non-‐ dominant occipitoparietal)
PD
Parkinson plus syndromes eg
...
Pentagons, cubes, 3-‐D letters, dots counting
Does this patient have dementia?
•
•
•
•
Overall score=100
>88 “excludes” dementia (88/100 sensitivity: 83% Specificity: 71%)
<83 “supports” dementia (83/100 sensitivity: 82% Specificity: 96%)
But always consider not only score and pattern but any potential confounders
Likely pathological process
Summary
•
•
•
•
•
Bedside cognitive testing may have localising value and pattern recognition may allow a
confident clinical diagnosis to be reached
Always obtain collateral history (and beware of the patient attending alone)
ACE-‐r provides a reliable, reproducible bedside cognitive test
Always consider associated psychiatric and medical co-‐morbidity
Series of ACE-‐r are more valuable than a single result
CLINICAL ASPECTS OF DEMENTIA
What is dementia?
ICD 10 Dementia definition: ‘Syndrome due to disease of the brain, usually chronic or progressive in
nature in which there is disturbance of multiple higher cortical function including memory
(amnesia), thinking, orientation, comprehension (receptive aphasia), verbal expression (expressive
aphasia), calculation (acalculia), learning capacity, language and judgment
Dementia can also result in:
BPSD (behavioural and psychological symptoms of dementia)
Personality changes (particularly in FTD e
...
Picks disease)
Prevalence of dementia rises with age but dementia is not caused by ageing
• 5% of those over 65
•
•
•
•
20% of those over 80
33% of those over 85
Diagnostic Challenge of Dementia:
•
•
•
Differentiate dementia from patients without illness
Diagnosis of sub-‐types of dementia
Vitally important that we diagnose and treat dementia
Differential diagnosis of dementia
•
•
•
•
•
•
Primary or secondary dementia
Depression (pseudodementia)
Other psychiatric condition
Delirium
Amnesia syndromes
Other medical conditions causing pseudodementia e
...
Cushings
Types of dementia
Primary dementias:
•
•
•
Alzheimer’s disease
Mixed dementias
Lewy body dementia
(60%)
(10-‐15%)
(5-‐10%)
Secondary dementias:
• Vascular dementia
• Many medical causes (many of which are reversible) => perform dementia screen e
...
FBC,
TFTs, HIV/syphilis screen, LFTs, U&Es, CRP/PV, biochem, full endocrine screen
• VINDICATE
• Dementia secondary to other neurological condition e
...
PD and HD
Alzheimer’s disease
•
•
•
•
•
Characteristic neuropathological findings of intracellular neurofibrillary tangles (tau protein)
and extracellular beta amyloid plaques
Multiple neurotransmitter abnormalities with profound cholinergic loss (nuclus basalis of
Meynert) => acetylcholinesterases inhibitors are useful
Insidious development over 10 years or more, with prominent impairment of episodic
memory (initially)
Average survival time from diagnosis is 8 years
Pathological increase in glutamate activity => NMDA blocker Memantine is useful
Idiopathic AD risk factors
•
•
•
•
Age
ApoE e4 allele (most prominent genetic risk factor in idiopathic AD)
Vascular disease
Family history
Presentation of Alzheimer’s disease
•
•
•
•
•
•
•
•
•
•
•
Progressive (slow and insidious) deterioration of memory function with earlier memories
becoming more impaired
Disturbance of recent memory (in particular episodic) resulting in anterograde amnesia
Repeating conversations
Loss of ability to carry out key daily tasks
Changes in language function
Impairment of insight, judgement and planning
Orientation problems
Neuropsychiatric symptoms such as hallucinations, irritability, depression, personality
change and psychosis are common but mostly self limiting
BPSD prominent throughout and associated with carer stress and institutionalization
Gradual progression over time
End stage AD presents with incontinence, motor disturbance, extra-‐pyramidal signs,
stereotyped behaviour and primitive reflexes (reflexes seen in babies/infants)
Alzheimer's disease diagnostic criteria
•
•
•
•
•
Progressive deterioration in memory
Deficits in 2 or more areas of cognition (in particular episodic memory)
Onset most often after age 65
Absence of systemic disorders that could account for impairments
No disturbance of consciousness
Vascular Dementia (VaD)
•
•
•
•
•
•
Vascular dementia or "multi-‐infarct dementia" is dementia caused by problems in supply of
blood to the brain, typically by a series of minor strokes
...
Psychomotor slowing and gait disturbance common
Emotional lability (especially if frontal lobes affected)
Dysexecutive syndrome includes items such as:
! Impairment of goal formulation, initiation, planning, organizing, sequencing and
execution
...
Patients with dementia
and vascular disease frequently have mixed pathology (ie, both Alzheimer disease and vascular
dementia; “mixed dementia”)
...
g
...
It is characterized anatomically by the presence of Lewy bodies (clumps of alpha-‐synuclein
and ubiquitin protein in neurons) detectable in post mortem brain histology
...
same time in DLB
Visual hallucinations
Falls
Sensitivity to neuroleptic (anti-‐psychotic) drugs due to Parkinsonism: sensitivity to
neuroleptic (anti-‐psychotic) and antiemetic (dopamine blocker and cholinergic blocker
varieties) medications that affect dopaminergic and cholinergic systems-‐ in the worst cases,
a patient treated with these drugs could become catatonic, lose cognitive function and/or
develop life-‐threatening muscle rigidity (due to decreased dopamine activity)
Other causes of dementia
•
•
•
FTD (frontotemporal dementia)
Neurological: Huntingdons, PD, CJD and MS
Secondary dementias (which may be reversible)
PSYCHIATRIC COMPLICATIONS OF PHYSICAL DISORDERS
Delirium
Delirium, or acute confusional state, is a syndrome that presents as severe confusion and
disorientation, developing with relatively rapid onset and fluctuating in intensity
...
Delirium represents an organically caused decline from a previously attained baseline level of
cognitive function
...
It typically involves other cognitive deficits, changes in arousal
(hyperactive, hypoactive, or mixed), perceptual deficits, altered sleep-‐wake cycle, and psychotic
features such as hallucinations and delusions (psychosis)
Delirium itself is not a disease, but rather a clinical syndrome (a set of symptoms), which result from
an underlying disease, from medications administered during treatment of that disease in a critical
phase, from a new problem with mentation or from varying combinations of two or more of these
factors
...
g
...
g
...
g
...
liver failure, pancreatitis)
GU disorders (e
...
UTI, renal failure)
There may be no identifiable cause however…this DOES NOT exclude the diagnosis
...
g
...
g
...
g
...
Collateral history may be necessary: recent activities, prescriptions, past hx
...
g
...
5mg in elderly) – unless contraindicated e
...
cardiac disease, DLB, Parkinsonian
disorders
Sedating drugs can worsen delirium by increasing confusion and unsteadiness
Alcohol withdrawal requires reducing scale of benzodiazepines: commonly
Chlordiazepoxide or Diazepam
Review:
•
•
•
•
Review patients with delirium frequently
Patients can improve quickly (and no longer need prescribed meds)
Patients can worsen quickly and suffer seizures, injuries and sudden death
Follow Up: Repeat the MMSE to avoid misdiagnosis of dementia
Pharmacological management
•
•
•
•
•
Haloperidol 0
...
g
...
For Parkinson’s, Lewy Body Dementia, and Neuroleptic (antipsychotic) Sensitivity:
Lorazepam (not diazepam) 0
...
THYROID DYSFUNCTION
•
•
•
•
Remember that thyroid dysfunction can result in neurological/psychiatric symptoms
Hyperthyroidism can result in anxiety, tremor and mood liability
Hypothyroidism can result in decreased cognition and reversible dementia (if
prolonged/severe), as well as depression and pseudodementia
TFTs in all pts with anxiety or depression
MEMORY
• Types of memory include: short term memory, working memory and long term memory
• Long term memory can be divided into semantic memory, episodic memory and procedural
memory
• Consciously accessible (explicit) long term memory can be divided into: Semantic (memory
of facts and concepts and language etc) and episodic (specific events)
• Autobiographical memory is a subset of episodic memory
• Semantic memory can be defined as knowledge that is retained irrespective of the
circumstances under which it was acquired
• To test semantic memory: ask questions about general knowledge e
...
what is the capital of
France and who is the current UK prime-‐minister?
• Episodic memory can be defined as memory for the events of your life that you have
experienced e
...
recollection of time, place and associated emotions at the time of the event
• To test episodic memory: ask about specific events which have happened in the individuals
life e
...
what did you have for breakfast or where were you when you heard about the twin
towers?
• Whether semantic and episodic long term memory represents truly separate memory
systems is still unclear
...
This is important for complex
motor functions e
...
riding a bike
...
g
...
g
...
Consciousness
is not clouded
...
”
BPSD (behavioural and psychological symptoms of dementia) often characterise the different sub-‐
types of dementia:
•
•
•
•
•
AD: emotional lability, aggression, illusions and delusions
Vascular dementia (VaD): depression, abrupt onset, stepwise, CV disease, previous
strokes/TIA
Dementia with Lewy bodies (DLB): visual hallucinations, fluctuating course and paranoid
ideas, Parkinsonism < 1 year after onset of dementia
Frontotemporal dementia (FTD):
! Behavioural variant and Picks: personality change
! Semantic dementia: semantic memory loss (preservation of episodic)
! Progress non fluent aphasia: problem with naming objects and verbal fluency
Subcortical dementia (e
...
PD and HD): lack of initiation and other movement dysfunction
and visulospatial dysfunction
Impaired memory is a central feature of dementia
...
The term cognition refers to the human
processing of information, and includes domains such as language, praxis, gnosis, visuospatial ability
and executive function
...
The development of multiple cognitive deficits manifested by both
1) Memory impairment (impaired ability to learn new information or to recall previously learned
information), and
2) One (or more) of the following cognitive disturbances:
Aphasia (language disturbance)
Apraxia (impaired ability to carry out motor activities despite intact motor function)
Agnosia (failure to recognize or identify objects despite intact sensory function)
Disturbance in executive function (e
...
planning, organizing, sequencing, abstracting)
B
...
•
•
•
•
Important points
•
•
Dementia is a syndrome characterised by global cognitive decline (not just memory
problems)
...
These include:
•
•
•
•
•
•
•
•
Hypothyroidism
Vitamin B1 deficiency (thiamine)
Vitamin B12 deficiency (cobalamin)
Normal pressure hydrocephalus (“wet, whacky and wobbly”)
Space occupying lesion (SOL)
Pseudodementia (many causes including depression)
Infective causes e
...
HIV and syphilis
Metabolic causes
Investigations (dementia screen)
•
•
•
•
•
•
•
•
Urea and electrolytes (U+Es)
Thyroid function tests (TFTs)
B12 and folate
FBE (full blood exam)
Syphilis and HIV serology
EEG (usually abnormal in early AD, in contrast to frontotemporal dementia)
CT (not considered essential)
SPECT (where regional dementias are suspected)
...
Many other symptoms can occur such
as behaviour and personality changes, depression, problems with language etc
The brain is lighter (due to atrophy of brain tissue) with more prominent sulci (widened
sulci) and narrowed gyri and enlarged ventricles
...
The regions of gray matter with the most marked cell loss are the basal forebrain,
hippocampus, entorhinal, and temporal cortices
...
It is this region of the brain which is very important for storage
of long term episodic memories
...
It was observed, in the 1970s,
that acetylcholine containing neurons of the basal forebrain (nucleus basalis of Meynert)
are particularly susceptible
...
g
...
While still important, the cholinergic hypothesis is
now regarded as an oversimplification
...
It is proposed they be the
products rather than the cause of a degenerative process
...
Genetics
•
•
•
Genetic variation is an important contributor to the risk for idiopathic AD, underlying an
estimated heritability of about 70%
...
Certain mutations in each of these genes are autosomal dominant and cause AD in anyone
who carries them
...
These mutations have been found in only a few
families around the world, and account for only a small minority of AD
...
Confirmation is awaited with interest
...
•
•
•
The nucleus basalis of Meynert is the main source of acetylcholine for the cortex
...
Cholinesterase inhibitors block the action of acetylcholinesterase, an enzyme that removes
acetylcholine from the synapse; they therefore increase ACh in the synapse and improve
cholinergic transmission
...
Pharmacological management of Alzheimers disease
•
•
Cholinesterase inhibitors
Memantine
Acetylcholinesterase inhibitors (AChE Inhibitors)
The cholinesterase inhibitors in current clinical use are:
Donepezil
Rivastigmine
Galantamine
They do not affect the underlying pathological processes in Alzheimers disease, but do slow
cognitive decline by increasing cholinergic transmission
...
Rivastigmine is also licensed for
use in DLB
...
AChE inhibitors are also used to increase ACh levels in myasthenia
gravis, however if the dose is too high then a cholinergic crisis can occur resulting in paralysis of
skeletal muscles including the diaphragm => respiratory failure can occur
...
It works by
blocking NMDA-‐type glutamate receptors (antagonist of glutamate NMDA receptors)
Glutamate is the main excitatory neurotransmitter in the brain and it is thought that
neurons are damaged by glutamate over-‐activation (excitotoxicity) in Alzheimers as well as
in many other neurodegenerative disorders
...
Vascular dementia
•
•
•
•
•
The diagnosis of vascular dementia (VaD) depends on the cognitive disturbances and the
presence of significant cerebrovascular disease
...
25-‐35 % of patients with dementia have cerebral ischaemic lesions that are a major factor in
the dementing process
...
6% in people above 60 years
Dementia is diagnosed in >30% of people three months after acute stroke
...
Left hemisphere (dominant hemisphere) strokes are more likely to produce dementia
...
The
vascular pathology may include atherosclerosis, arteriosclerosis, lipohyalinosis, amyloid
angiopathy, and senile arteriolar sclerosis
...
The clinical diagnosis of VaD vs AD is based on:
•
•
Sudden onset
Stepwise progression
Focal neurological abnormalities
Fluctuating course with day-‐to-‐day improvement
Occurrence of one or more strokes
Evidence of coronary or other major arterial disease
Labile emotional state
Tendency for retained insight
Vascular risk factors e
...
smoker, hypertension, hyperlipidaemia and DM
The Hachinski Ischameic score (HIS) is a quick and easy test that can help in the clinical
differentiation of Alzheimers disease and vascular dementia
...
The prognosis of VaD is less favourable than AD, with a 5 year mortality of >63% (compared to AD
<32 %)
...
Reduction in the prevalence of vascular dementia will
require reduction in the rate of cerebrovascular disease
...
g
...
On histological examination, all
patients with Parkinson’s disease (PD) and DLB, and 40% of patients with AD have Lewy bodies (LBs)
...
Frederick Lewy first described Lewy bodies (eosinophilic, round, cytoplasmic inclusions) in
the cells of the substantia nigra in patients with PD in 1914
...
A classical
Lewy body is an eosinophilic cytoplasmic inclusion consisting of a dense core surrounded by
a halo of 10-‐nm-‐wide radiating fibrils, the primary structural component of which is alpha-‐
synuclein
...
! Parkinsonian features, such as loss of spontaneous movement (bradykinesia),
rigidity (muscle stiffness), tremor, and shuffling gait, to AD-‐type symptoms including
memory loss, acute confusion, and fluctuating cognition
...
If PD (movement dysfunction only) has been present for 1 year or longer before
cognitive impairment, the disorder is termed PD with dementia, otherwise it is designated
DLB
...
LBs are also found in the cortex of many people with PD and all people
with DLB
...
DLB is a slowly progressive disorder for which there is no cure
...
Anti-‐parkinsonian medication (increase dopamine activity) which may help reduce tremor,
reduce hypertonia (rigidty), and improve movement, however may worsen hallucinations
and delusions (as increased dopamine plays a role in psychosis pathophysiology)
Antipsychotic drugs (decrease dopamine activity) which may reduce psychiatric symptoms,
however may markedly worsen movement symptoms
...
Depression may respond to SSRIs, which do not appear to introduce particular
complications
...
The two conditions are distinguished clinically
by the timing of the symptoms
...
• The first was described by Pick (Pick’s disease) and has characteristic histopathology of
ballooned neurones (Pick’s cells) and argentophilic globes (Pick’s bodies)
...
• The frontal and temporal lobes control personality and speech
...
Subtypes of FTD
Progressive Language Decline (aphasia)
•
•
•
Semantic dementia (SD): SD is characterised by loss of semantic memory in both the verbal
and non-‐verbal domains
...
Progressive nonfluent aphasia (PNFA)
...
People lose their ability to generate words easily, and their speech becomes
halting, "tongue-‐tied" and ungrammatical
...
Progressive Behaviour/Personality Decline
• Behavioural variant FTD (BVFTD): takes its greatest toll on personality and behavior
...
As BVFTD progresses people
often develop disinhibition, a striking loss of restraint in personal relations and social life
...
Memory generally intact
• Picks disease
Progressive Motor Decline
• FTD with amyotrophic lateral sclerosis (FTD-‐ALS -‐ MND)
• FTD with parkinsonism
• Progressive supranuclear palsy (PSP): Parkinson plus syndrome (parkinsonism, bulbar palsy,
supranuclear ophthalmoplegia, dementia)
• Multi-‐system atrophy: Parkinson plus syndrome (parkinsonism, cerebellar involvement,
significant ANS involvement)
Summary of differential features
Alzheimer’s disease (AD)
Dementia with cerebrovascular disease (VaD)
Dementia with Lewy bodies (DLB)
Cognitive impairment:
Anterograde amnesia (inability to learn and
retain new information in particular episodic
memory),
Plus impairment in one of the following:
Reasoning
Visuospatial ability (agnosia)
Orientation
Language
Cognitive impairment as for AD
Plus evidence of cerebrovascular disease
Cognitive impairment as for AD,
Plus two of the following:
Parkinsonism
Frontotemporal dementia (FTD)
Visual hallucinations
Fluctuations in arousal
REM sleep behaviour disorder
...
Decline in regulation of personal or
interpersonal conduct (loss of empathy for
others; socially inappropriate behavior that are
rude or sexually explicit; mental rigidity; decline
in personal hygiene; obsessional behaviors), or
2
...
3
...
Atrophy of the whole brain (and hippocampus in particular) accelerates as the patient
moves from normality to cognitive impairment, and as dementia progresses
...
•
Cognitive decline may develop as a direct result of the vascular injury (eg, multi-‐infarcts or a
single stroke affecting a strategic location) and/or lowering the threshold for the expression
of concomitant pathology, such as AD
...
•
Lacunar infarctions, therefore, occur in the basal ganglia, putamen, internal capsule,
thalamus, corona radiata and centrum and lateral brainstem
...
They are cavitating, round, oval or
slit-‐like, and on CT are hypodense
•
Small-‐vessel disease, or leukoaraiosis, is another player in subcortical vascular dementia
...
Dementia With Lewy Bodies
•
•
•
•
•
This accounts for 10% of dementias
...
An absence of MTA (medial temoral lobe atrophy) strongly suggests dementia with Lewy
bodies rather than AD or vascular dementia
...
Therefore, decreased DAT (dopamine uptake transporter) uptake in the basal ganglia is a
potential biomarker
MANAGEMENT OF DEMENTIA
Medical Management
•
•
•
•
•
MDT
Diagnosis and postdiagnostic involvement: need for explanation of the illness, its symptoms
and progression
...
The use of behavioural and pharmacological approaches to symptoms associated with
dementia
...
•
•
They have also been used clinically in Dementia with Lewy Bodies where patients are particularly
sensitive to neuroleptic medication
...
Degeneration of cholinergic neurones and reduction in levels of ACh in synapse is a key
feature of AD
ACh is metabolised by acetylcholinesterase (AChE)
...
Neurological: epilepsy, Parkinson’s Disease
...
Genitourinary: urinary outflow obstruction, recovering from bladder surgery
...
Safe and well tolerated but vertigo, excitation and insomnia reported
...
Behavioural and Psychological Symptoms of Dementia (BPSD)
Can present at any stage of the illness (90%) and include:
Depression
Delusions
Hallucinations
Aggression
Apathy
Agitation
Effects of BPSD: major source of stress for carers and predicts more rapid decline and admission to
Care Home
•
•
•
•
•
•
Pharmacotherapy for BPSD
Psychotropic medication has limited efficacy (although it increases if specific psychiatric symptoms
are targeted) and potential side effects
...
Prior to their use:
•
Physical causes for change in behaviour should be excluded: delirium, dehydration, pain,
medication side effects, sensory impairment etc
Antipsychotic drugs
•
•
•
•
•
•
Also known as neuroleptics
...
Should only be used if absolutely necessary to treat psychotic symptoms (delusion,
hallucinations) and extreme aggression and the golden rule applies
...
Clinical trials have shown that for most people with dementia neuroleptic withdrawal can be
achieved with no detrimental effect and only a small group of patients with more severe
symptoms might benefit from continuous treatment
...
g
...
g
...
Atypical neuroleptics
•
•
•
•
•
Group of newer drugs with less or no EPSE
...
Increased serotonin effects can result in metabolic syndrome meaning that these drugs are
contraindicated in some patients, and typical anti-‐psychotics may be preferred
Risperidone is now licensed also for short-‐term treatment (6/52) of persistent aggression in
moderate to severe Alzheimer’s dementia
...
g
...
Others (lorazepam, diazepam) can be used short-‐term for extreme anxiety/agitation
...
Other antidepressants such as Venlafaxine (SNRI) and Mirtazapine (NaSSA) are used but
there is less research evidence
...
g
...
g
...
g
...
g
...
g
...
All adults are presumed to have sufficient
capacity to decide on their own medical treatment unless there is significant evidence to suggest
otherwise
...
• The impairment or disturbance means the person is unable to make a decision at the
current time
...
Most other Tx, verbal consent
suffices
...
g
...
• It is not always necessary to detain an adult formally under the 2003 MHA because they are
unable to consent to treatment for a mental disorder
...
• But remember mental illness does NOT imply that they lack capacity!
• The wording in the 2000 Act is that the medical practitioner shall have "authority to do what
is reasonable in the circumstances, in relation to the medical treatment to safeguard or
promote the physical or mental health of the adult" (sec 47(2))
...
However other areas such as the inability
to manage money or to agree to discharge arrangements may be important
Principles of the Adults With Incapacity (Scotland) Act 2000
• Intervention must benefit the adult
• Intervention is for a treatment of a medical condition (including psychiatric)
• Such benefit cannot reasonably be achieved without the intervention
• Take account of past and present wishes
•
•
Consult with other relevant persons
Encourage the adult to use residual capacity
Mental Health (Care and Treatment) (Scotland) Act 2003
• This act allows for treatment of mental disorder or physical consequences of mental
disorders in someone with impaired decision making ability AND who requires detention
! Emergency Detention (section 36)
! Short Term Detention (section 44)
! CTO’s
Criteria for Emergency Detention (section 36)
1) Likely to have a mental disorder
2) Significantly impaired decision-‐making ability regarding treatment, due to mental disorder (note
that this criteria does NOT mean lack of capacity, as they may indeed have a degree of capacity)
3) Detention in hospital is necessary as a matter of urgency to determine what treatment is needed
4) Risk to health, safety or welfare of the person, or safety of others
5) Making arrangements for section 44 would involve undesirable delay
Criteria for Short Term Detention (section 44)
1) Has a mental disorder
2) Significantly impaired decision-‐making ability regarding treatment, due to mental disorder (note
that this criteria does NOT mean lack of capacity, as they may indeed have some capacity)
3) Detention in hospital is necessary for assessment or treatment (but non-‐urgent)
4) Risk to health, safety or welfare of the person, or safety of others
5) Cannot be treated voluntarily
NOTE: IF PT DOES NOT NEED DETAINED, THEN CAN USE AWI (IF THEY LACK CAPACITY)
Age of Legal Capacity (Scotland) Act 1991
• Assume capacity if aged over 16 (unless proven otherwise)
...
g
...
g
...
• Depends on situation and child
...
Emergency Detention Certificates (section 36)
The part of the MHA that you need to know most about is the Emergency Detention Certificate
(EDC), as you may need to use this in clinical practice from FY2 onwards
...
Fill in an Emergency Detention Certificate form (DET1)
...
The MHO (Mental health officer) is a social worker who is
highly trained in the use of the MHA
• Call psychiatrist to discuss case and request that an AMP [1] come to do a Short Term
Detention Certificate
...
Short Term Detention Certificates (section 44)
Criteria:
• Has a mental disorder
• Significantly impaired decision-‐making ability regarding treatment, due to mental disorder
(may or may not have lack of capacity, but will most likely have lack of insight)
• Detention in hospital is necessary for assessment or treatment (not emergency)
• Risk to health, safety or welfare of the person, or safety of others
• Cannot be treated voluntarily
STDCs require an AMP and an MHO
...
Sometimes this can be
difficult if, for instance, you are too unwell to make your own decisions
...
• If you have made a valid advance statement then it must be taken into account when
decisions are taken about your care and treatment by those who are responsible for your
care
...
• In an advance statement you can say which treatments work well for you, and which ones
you would not want
...
It might be helpful if you can include any reasons for your views
...
• Doctors would then see whether there were other treatments which would help you
...
Your advance
statement will be taken into account with all the other aspects of your care
...
• If a decision is made which goes against your advance statement you will be given the
reasons in writing
...
Compulsory Treatment Orders
The main points that you need to know about CTOs are:
• A CTO lasts 6 months and has to be renewed if the patient requires ongoing detention
...
• The MHO applies for the CTO and submits 2 medical reports, one by RMO (psychiatrist
responsible for the patient’s care) and one by the patient’s own GP a or second psychiatrist
not working in the same service
...
• A CTO can be hospital or community based
...
g
...
The Power of Attorney (PoA) document contains the
name of the person(s) whom you want to help you, i
...
the attorney and a list of the
individual powers that you want your attorney to have
...
The
PoA will also include when your attorney is to begin acting for you
...
The PoA provides legal authority
for the attorney to make decisions for you e
...
medical decisions and financial decisions
...
This person is
known as a welfare guardian
...
The court can also overturn a PoA and appoint a guardian if the PoA is abusing their trust
...
There is no question of a third
party “applying” for power of attorney, in respect to someone who lacks, or has already lost
capacity
...
For example, if someone was believed to be abusing their role as POA, the court could
overrule them and appoint a guardianship order
...
• Intervention orders are also applied for to the court
...
g
...
g
...
The MHA says the least possible force must be used as possible
AWI can used to treat physical or mental conditions (and is indeed the preferred method if
detention is not required)
...
It will be important, therefore, for practitioners and others to retain clarity about why
the legislation might be required' (Gordon 2004)
...
12 Two areas of particular relevance to this review are the interface between the Acts in relation
to definitions of capacity regarding treatment decisions for mental disorder and treatment in the
community
...
13 Gordon describes the distinction in relation to a treatment decision as ' one of the more
complex interfaces' between the two Acts
...
5
...
1)
...
MHA, capacity and consent in relation to ECT
• Just because a patient is detained does NOT mean that they lack capacity
...
g
...
Note that these patients will likely lack capacity anyhow
...
g
...
Grooming – evidence of self-‐neglect?
Effort with appearance
Scars – self harm, fights
Physique, build – e
...
underweight
Tattoos, piercings
•
•
Signs of physical ill health – e
...
stick, insulin pump
Evidence of drug/alcohol misuse – track marks, flushing, jaundice, spider naevi, parotid swelling
Behaviour
•
•
•
•
•
•
Gaze / eye contact
Level of activity – hypoactive, hyperactive, neutral
Psychomotor agitation / retardation
Attitude / Rapport: cooperative/ uncooperative, hostile, guarded, suspicious
Unusual / abnormal movements – e
...
tics, myoclonus, catatonic movements
Socially appropriate behaviour
Speech
•
•
•
•
•
•
•
•
•
•
•
•
Quantity
Quality
Rate, rhythm, volume, and tone (character)
Form of speech
Pressure or poverty of speech
Spontaneous speech
Latency
Articulation
Accent
Vocabulary
Abnormalities of articulation – stammer, dysarthria
Dysphasia / aphasia
Mood & Affect
Mood
•
•
•
Mood = ‘Climate’
Predominant emotional state of patient (depressed, anxious, angry)
Objective and subjective description of mood
! Neutral, euthymic (display normal range of emotion), dysphoric, euphoric, anxious,
angry, apathetic, irritable
! Rating of mood on a scale (current mood, and what “normal” mood would be)
Affect
•
•
•
•
•
•
Affect = ‘Weather’
Intensity: normal, blunted, exaggerated, flat, heightened
Extent to which affect changes: restricted, labile, reactive, stable
Consider how the patient makes you feel to judge affect
Mood congruent => when mood & affect are the same
Mood incongruent => when mood & affect are opposite each other
Risk assessment
•
•
•
Suicidality: part of mood & affect assessment
...
Questions will not make
anyone feel suicidal
...
e
...
! Also ask about thoughts of life not worth living & thoughts of wanting to harm self
...
Also important to establish if there is any risk of harm to other individuals
Assess for suicide risk demographic factors in the history: previous DSH, psychiatric
problem, physical problem, alcohol or drug dependency, loneliness, lack of social support,
no job, poor finances
Thought process (thought form)
•
•
•
How the thoughts are formed / verbalised
Ask patient if they have had any strange thoughts? Thoughts racing? Thoughts slowed down?
What sort of stuff do you tend to think about?
Formal thought disorder -‐ disorder of the form (e
...
disorder of the way in which thought are
formed), as opposed to the content, of the thought
...
Specific thought disorders include poverty
of speech, tangentiality, illogicality, neologism, and thought blocking
! Poverty of thought -‐ global reduction in the quantity of thought
...
Seen in depression, dementia
...
Manifests as poverty of speech
...
In schizophrenia, this may link into a delusion e
...
thought interference
...
Usually seen in mania, may also be seen in
schizophrenia & extreme anxiety
...
! Flight of ideas -‐ words are associated together inappropriately because of their
meaning/rhyme => speech loses its aim, patient wanders from original theme
...
Usually seen in mania
! Loosening of Associations -‐ muddled, illogical, difficult to follow and cannot be clarified
...
Mania
! Knight’s Move Thinking -‐ jumps from topic to topic with no connection between them
...
! Tangential Thinking -‐ wandering from the topic on tangents (loosely associated) and
never returning to it or providing the information requested
...
! Circumstantial -‐ inability to answer a question without giving excessive, unnecessary
detail
...
! Word salad -‐ confused or unintelligible mixture of seemingly random words and phrases
...
Often seen in schizophrenia
Thought content
• Assess for unusual beliefs, overvalued ideas, delusions, obsessions
! Do you have any strange thoughts? Anything you worry about? What do you tend to
think about? Do you hear or see things that other people cant?
• Delusion = a false belief, inappropriate to the patient’s socio-‐cultural background, firmly held in the
face of logical argument (not amenable to logic) or evidence to the contrary
...
Themes
usually persecutory, jealous, grandiose, religious, hypochondriacal, health, nihilistic
...
May be an origin, such as an attempt to explain an
anomalous experience, e
...
hallucinations
...
• Phobias
• Obsession = An undesired, unpleasant intrusive thought that cannot be suppressed
• Preoccupation = Not fixed, false or intrusive (not a delusion) but have an undue prominence in the
persons mind
• Overvalued Idea = An unreasonable, sustained belief that is held with less than delusional intensity
e
...
hypochondriasis
• Rumination = Rumination is the compulsively focused attention on the symptoms of one's distress,
and on its possible causes and consequences, as opposed to its solutions
...
Ruminating is like a record that’s stuck and keeps
repeating the same lyrics
...
It’s retracing past
mistakes
...
! Thought broadcasting: The experience that one's thoughts are being transmitted from
one's mind and broadcast to everyone
...
! Thought withdrawal: The experience of thoughts being removed or extracted from one's
mind
...
These may therefore include
'made acts and impulses' where the individual feels they are being made to do something by
another, 'made movements' where their arms or legs feel as if they are moving under another's
control, 'made emotions' where they are experiencing someone else's emotions, and 'made
thoughts' which are categorised elsewhere as thought insertion and withdrawal
Perceptions
Perception: abnormalities in any of the 5 sensory modalities (visual, auditory, gustatory, tactile,
olfactory)
...
•
•
•
Derealisation (world around patient is unreal)
Depersonalisation (patient is unreal)
Déjà vu
•
•
Illusions – external stimulus present but perceived wrongly (pseudo-‐hallucination / misperception)
Hallucinations -‐ Perception in the absence of an external stimulus
...
g
...
Hallucinations may be organic (e
...
delirium or DLB) if
predominantly visual
...
! Auditory hallucinations – internal / external space? Open to conscious manipulation? 2nd
(someone else talking to patient) or 3rd (voices talking about patient) person? Second person
are suggestive of depression with psychosis or mania with psychosis
...
Number of voices? Gender? Content? Running commentary? Thoughts
spoken aloud? Do the voices command the patient? Do they feel compelled to act on them?
! Auditory hallucinations can also take the form of a running commentary: first rank symptom
for SZ
! Auditory hallucinations can also take the form of thought echo: thoughts spoken aloud
Cognition
•
•
•
•
•
•
•
Orientation: time, place, person (e
...
address, DOB) – useful for assessing delirium
Attention, concentration and memory (remote & recent)
! Serial 7s (subtract 7s from 100) – useful for assessing delirium
! Digit span (ask patients to remember and repeat a series of numbers) – useful for
assessing delirium
When appropriate (e
...
dementia, alcohol)
! MSQ
! MMSE (30 Qs)
! Addenbrookes Cognitive Examination (ACE-‐R: 100 points in total covering all aspects of
cognition)
Calculation
Language – naming / repeating objects
Visuo-‐spatial
Executive Functioning: similarities between objects, verbal fluency
...
Does they believe their symptoms are a result of illness? Do they think the illness is
psychiatric?
! Appraisal or analysis of consequences of such symptoms
! Acceptance of treatment Do they think treatment will help? Will they accept medical
advice?
Not a present or absent state
Ask what family think about them
MSE examples
Schizophrenia
•
Appearance
•
Behaviour
! Withdrawal
! Suspicious
! Paranoia
! Lack of eye contact
•
Speech
•
Mood and affect
! Flat affect
! Incongruous
! “Odd”
•
Thought process (thought form)
! Formal thought disorder (disorganized thinking as evidenced by disorganized
speech)
! Poverty of thought (negative symptom): global reduction in quantity of thought
! Thought blocking (mind empties of thoughts): may be linked to delusion
! Word salad: confused or unintelligible mixture of seemingly random words and
phrases
! Neologisms: made up words or phrases
! Knights move thinking: jumps from topic to topic with no connection between
them
...
g
...
g
...
! The classic signs of psychosis are hallucinations and delusions (positive signs)
...
Knightsmove thinking has no apparent connection
•
Thought content
! Delusions (if psychosis) of grandeur, special ability, persecution, religiosity
•
Perceptions
! Hallucinations (if psychosis): auditory (typically second person e
...
God’s voice)
•
Cognition
•
Insight
Analysis examples
•
If a pt appears to be delusional state that “I think there is evidence of possible delusions but
as their beliefs have not been specifically challenged it is impossible to say whether or not
they are amenable to logic”
...
It normally recovers
within 72 hours, is characterised by tearfulness but no loss in sense of reality
...
It is a self limiting condition
...
Peaks at around 3-‐4 weeks post-‐birth
...
This behaviour may include threats to
harm herself, partner or the baby
...
The Edinburgh Postnatal Depression Scale may be used to screen for depression:
10-‐item questionnaire, with a maximum score of 30
Indicates how the mother has felt over the previous week
Score >13 indicates a 'depressive illness of varying severity'
Sensitivity and specificity > 90%
Includes a question about self-‐harm
'Baby-‐blues'
Postnatal depression
Puerperal psychosis
•
•
•
•
•
Seen in around 60-‐
70% of women –
normal!!!
Affects around 10% of women
Affects approximately 0
...
g
...
g
...
This behaviour
may include threats to harm herself,
partner or the baby
...
Review in day or so
and there should be
marked
improvement
...
Certain SSRIs such as
sertraline and paroxetine* may be
used if symptoms are severe** -‐
whilst they are secreted in breast
milk it is not thought to be harmful
to the infant
Admission to hospital is usually required
There is around a 20% risk of
recurrence following future pregnancies
*paroxetine is recommended by SIGN because of the low milk/plasma ratio
**fluoxetine is best avoided due to a long half-‐life
Psychiatry exam advice
•
Know structural brain changes in MDD and BPD
•
Neurobiology:
! Dopamine is closely linked to appetitive/approach (reward) system
! Serotonin and NA is closely linked to aversive/defensive system: MDD is
associated with dysfunctional aversive system primarily
! Know hormonal changes e
...
increased cortisol in MDD (pseudo-‐Cushings; failure
of dexa to supress), increased TRH in MDD, low cortisol and high catecholamines
in PTSD
OSCE exam
Potential OSCE stations:
•
Watch video and perform MSE
•
Take a history including psychiatric history + brief MSE
•
If have a potential suicide patient (e
...
many psychiatric patients) then must ask directly:
“Do you have any thoughts of suicide or harming yourself?” Must explicitly ask about
thoughts of taking ones life – not just about self harm
Title: Psychiatry lecture notes
Description: A detailed and comprehensive set of psychiatry lectures notes. Covers all aspects of mental health. Diagrams included to aid learning. Very useful for medical students.
Description: A detailed and comprehensive set of psychiatry lectures notes. Covers all aspects of mental health. Diagrams included to aid learning. Very useful for medical students.