《 Psychiatry | نفسية 》أطباء بلا حدود

• If still indicated, wait at least 2 weeks before re-starting antipsychotic, with low dose and cautious titration. • Schizophrenia sub-types Paranoid schizophrenia • Commonest type. • Complex delusions and hallucinations, often of persecutory, grandiose, and/or religious nature. Hebephrenic schizophrenia • Inappropriate mood and behaviour including silliness, shallowness, and irresponsible actions. • Fragmented delusions and/or hallucinations. • Poor prognosis. Catatonic schizoprhenia • Psychomotor disturbance including stupor, outbursts, waxy flexibility, automatic obedience, and negativism. Simple schizoprhenia • Negative symptoms dominate. • May just consist of a significant and consistent change in some aspect of behaviour e.g. loss of interest, aimlessness, idleness, social withdrawal.

• Oral: chlorpromazine, haloperidol, trifluoperazine, sulpiride, pimozide, prochlorperazine, levomepromazine. • Depot: haloperidol, fluphenazine, flupentixol, zuclopenthixol. Mechanism • Dopamine D2 receptor blockers. Extra-pyramidal side effects (EPSE) Features: • Parkinsonism • Tardive dyskinesia: lip smacking, rocking, rotating ankles, marching in place, repetitive sounds. Happens with chronic use, hence 'tardive' i.e. late, delayed-onset. Treat with tetrabenazine, a monoamine uptake inhibitor. • Akathisia: an inner state of restlessness. Carries increased risk of suicide. • Acute dystonia: painful, sustained muscle spasm, especially of neck (torticollis), jaw, or eyes. Treat with procyclidine or benztropine. Frequency vs. second generation antipsychotics (SGA): • While first-generation antipsychotics (FGA) were traditionally thought to have greater EPSE than SGA, this was only consistently shown for haloperidol, while lower-potency FGA appear no worse than SGA. • It is also worth noting that prophylactic benztropine mitigates the increased EPSE in haloperidol, and haloperidol causes less weight gain than SGA. Other side effects • ↑Prolactin, as dopamine inhibits its release. • Sedation – especially the anti-histaminergic phenothiazines (chlorpromazine, prochlorperazine) – and apathy. • Metabolic syndrome, ↑weight, and T2DM. Stroke and VTE risk in elderly. • Anticholinergic effects. • Postural ↓BP, especially chlorpromazine. • Photosensitivity with chlorpromazine. • Long QT: especially haloperidol and pimozide. • Sexual dysfunction, especially haloperidol, due to ↓dopamine and ↑PRL. • Neuroleptic malignant syndrome. • Many of these – EPSE, sedation, ↑weight, and anticholinergic effects – are lower with sulpiride. • Second-generation antipsychotics Drugs • Oral: amisulpiride, aripiprazole, clozapine, olanzapine, risperidone, quetiapine. • Depot: olanzapine, risperidone. Mechanism • More selective blockade of certain D2 receptors. • Also block 5-HT receptors. Side effects • Traditionally thought to have fewer extra-pyramidal side effects than first generation antipsychotics, but they can still occur, especially with risperidone. • Sedation and apathy. • Metabolic syndrome, ↑weight, and T2DM, especially clozapine and olanzapine. Stroke and VTE risk in elderly. • ↑Prolactin, especially amisulpiride and risperidone. • Sexual dysfunction, especially risperidone. • ↑QT, especially quetiapine. • Neuroleptic malignant syndrome. • Aripiprazole has a lower risk of many side effects, including sedation and metabolic syndrome. It also lowers PRL, so should be considered if this is raised by another antipsychotic. Clozapine • Most effective but 'dirtiest' antipsychotic, with lots of side effects. • Common side effects: sedation, metabolic syndrome, ↓BP, anti-cholinergic effects. Paradoxically, can also cause hypersalivation, which may need to be treated with an anti-cholinergic such as hyoscine hydrobromide. • Agranulocytosis, especially neutropenia, is a rare but severe side effect. Clozapine therefore requires FBC monitoring. • Constipation is relatively common. In rare cases, it can be a severe and life-threatening paralytic ileus. • Levels may jump suddenly after smoking cessation, so look out for side effects. • Neuroleptic malignant syndrome Severe, rare side-effect of antipsychotics with 10% mortality. Pathophysiology Mechanism unclear, but may relate to hypothalamic dopaminergic blockade causing hyperthemia and dysautonomia. Presentation Usually develops in first 2 weeks of antipsychotic use, but can occur any time. Classic tetrad, HARD: • Hyperthermia • Altered mental status. • Muscle Rigidity, generalized. Associated ↑CK. • Dysautonomia: ↑HR, labile BP, sweating. Management • Discontinue antipsychotic. Symptoms usually continue for 5-10 days. • Bromocriptine (dopamine agonist) and/or dantrolene (muscle relaxant) are sometimes used, but evidence is very limited.

Biological: antipsychotics Drug choice and initiation: • 1st line: oral (ideally) or depot, 1st or 2nd generation antipsychotic. If one fails, switch to another, at least one of which should be 2nd generation. • 2nd line: clozapine is the only one which is more effective than the others, but has more side effects. Offer if 2 different antipsychotics were ineffective, which happens in 20% of patients. • Depot drugs if there is poor adherence. Options are olanzapine, risperidone, haloperidol, fluphenazine, flupentixol, or zuclopenthixol. • Start low and titrate up, then observe effectiveness for 4-6 weeks at optimum dose. • Avoid combination treatment, except perhaps for overlap periods when switching. It can also be considered if patients have not adequately responded to clozapine alone. Basic tests at baseline and annual check up: • Basic bloods: FBC, U&E, LFTs. • Metabolic syndrome and cardiovascular monitoring: fasting glucose, HbA1c, lipids, weight, waist circumference, BP, ECG. • PRL Additional monitoring: • Weight: weekly for first 6 weeks, then at 3 months. • BP, HR, lipids, and glucose at 3 months, and PRL at 6 months. • Continued ECG monitoring for haloperidol and pimozide. • Continued FBC monitoring for clozapine. Weekly for first 18 weeks, and then less frequently. In patients with poor health, treatment should be initiated and titrated in hospital. Psychological Psychological therapy should be offered in combination with antipsychotics: • Individual CBT: 16 sessions, focusing on re-evaluating abnormal thoughts and perceptions, and reducing the distress resulting from symptoms. • Family intervention should also be offered, ideally including the patient and involving at least 10 sessions over 3-12 months. Consists of psychoeducation (e.g. how to respond to patient's delusions), advice on crisis management, and emphasizing the importance of creating low stress environments at home. • Art therapy is another option. It can help with self-expression, and is delivered in groups, thus alleviating social isolation. • These treatments can be started in the acute phase or later. Preventing psychosis in those at risk: • Signs of being at risk: distress and impaired social functioning, plus transient/mild psychosis or a 1st degree relative with psychosis. Do not meet criteria for schizophrenia. • Offer CBT ± family intervention. • Do not offer antipsychotics. • Continue to monitor closely until they improve or develop a clear psychotic illness. Social Basics: • Offer a healthy eating and physical activity programme, especially if on antipsychotics. • Assist in getting mainstream education, work or training, and offer alternative specialist services if this is not possible. • Peer support: given by recovered and stable patients who have had schizophrenia or psychosis. • Refer to day centres to help with social isolation. Encourage smoking cessation: • Offer nicotine replacement, bupropion, or varenicline. • Serum antipsychotic levels often increase after cessation as smoking increases antipsychotic metabolism. Monitor patients carefully during this time, and consider dose reduction if necessary. Support carers: • Offer a formal assessment of their needs by mental health services, and provide support as needed. • Discuss with patient what information-sharing they are happy with. • Complications and prognosis Complications: • Drug use • Risk of criminal victimization, including violence. • Suicide • Early death from medication side effects. Prognosis: • 30% recover. • 50% follow a relapsing-remitting course. • 20% are chronically incapacitated. Bad prognostic factors: • Early or insidious onset. • Continued exposure to precipitants. • Family history of schizophrenia or mood disorder, or family members with high expressed emotion. • Negative symptoms or affective elements. • ↓IQ • First-generation antipsychotics Drugs

Schizophrenia • Pathophysiology and epidemiology Dopamine theory: • Overactive dopamine system, especially in the mesolimbic area, causes the positive symptoms of schizophrenia. Associated brain changes: • Larger lateral ventricles. • Reduced volume of the frontal lobe, parahippocampal gyrus, hippocampus, temporal lobe, and/or amygdala. • None of these changes are especially sensitive or specific. Epidemiology: • 0.5% lifetime risk. • Presentation Signs and symptoms Positive symptoms: • Hallucinations: commonly auditory. Usually in the 3rd person but can be 2nd person. May include thought echo, running commentary, or overheard conversations. • Delusions: persecutory, reference, interference, passivity. • Thought disorder: derailment, poverty, circumstantiality, perseveration, blocking. Negative symptoms: • Apathy • Self-neglect • Paucity of speech. • Social withdrawal. • Emotional blunting. • Anhedonia First-rank symptoms: • A group of symptoms which are common and easy to identify. Individually not very sensitive, but all fairly specific for schizophrenia. • They are: auditory hallucinations, thought interference, delusions of control, and delusional perceptions. Prodrome: • Social withdrawal. • ↓Function e.g. in work or studies. • Eccentricity, including odd speech, perceptions, or ideas. • Poor self care. • Low mood or blunted affect. ICD-10 criteria Symptoms must last >1 month. Any 1 of: • Thought echo. • Thought alienation: insertion, withdrawal, or broadcasting. • Delusions of control, influence, or passivity, with clear effect on actions, sensations, or feelings. • Any other persistent delusion e.g. grandiosity. • Delusional perceptions. • Auditory hallucinations. Or any 2 of: • Any other persistent hallucination or overvalued idea. • Breaks in thought leading to incoherence in speech. • Catatonic behaviour: excitement, waxy flexibility, negativism, mutism, or stupor. • Negative symptoms. • Risk factors • Family history. • Perinatal: in-utero viral infection, hypoxic birth injury. • Economic: urban living, ↓socio-economic status. • Race: immigrants, non-white. • DDx: Psychosis Defined as loss of contact with reality, manifest in delusions, hallucinations, thought disorder, and a lack of insight. Psychiatric causes: • Schizophrenia • Mood disorders: bipolar disorder, severe depression, schizoaffective disorder. • Delusional disorder. • Transient psychosis. Organic causes: • Neurodegenerative: dementia, Parkinson's disease or medication for it. • Structural: space-occupying lesions, temporal lobe epilepsy. • Acute: delirium, encephalitis. • Endocrine: thyrotoxicosis, post-partum psychosis. Medicine: • Steroids • Anti-malarials Recreational drugs: • Alcohol and alcohol withdrawal (delirium tremens). • Cocaine • Cannabis • Amphetamines • Hallucinogens e.g. psilocybin. • Investigations Assessment should be carried out by a psychiatrist or other trained specialist, and include: • Full history and MSE. • Neurological examination. • Collateral history. Investigate differentials if indicated: • Endocrine: TFT, cortisol. • Infectious: syphilis serology, HIV. • Urine drug screen: can detect cannabis for weeks or even months after cessation. Commonly also checks for opioids, cocaine, and amphetamines. • Neurological: CT/MRI brain, LP, EEG. • Management Basics: • Follow a bio-psycho-social approach. • New patients should be offered a full MDT assessment in secondary care, addressing psychiatric, physical, psychological, social, and economic needs. • Ideally, those with a first episode of psychosis or at risk of psychosis should be referred to an early intervention in psychosis (EIP) team, regardless of their age or symptom duration. EIP can offer the full range of treatments. • Write a care plan in collaboration with the patient. • If the patient is stable after 1 year on antipsychotics, they can be looked after in primary care.

♦CONDUCT DISORDER AND OPPOSITIONAL DEFIANT DISORDER _Conduct disorder is defined as a repetitive and persistent pattern of behavior in which the basic rights of others or important age-appropriate societal norms or rules are violated. _Disordered behaviors include aggression toward people or animals, destruction of property, deceitfulness, theft, or serious violations of rules (school truancy, running away) ✦. Conduct disorder is the childhood equivalent of adult antisocial personality disorder. It is the most common disorder seen in outpatient psychiatric clinics and is frequently seen comorbidly with ADHD or learning disorders. Adoption studies show a genetic predisposition, but psychosocial factors play a major role. Parental separation or divorce, parental substance abuse, severely poor or inconsistent parenting, and association with a delinquent peer group have been shown to have some relationship to the development of conduct disorder. ✦Treatment involves individual and family therapy. Some children may need to be removed from the home and placed in foster care. Parents who retain custody of a child with conduct disorder are taught limit setting, consistency, and other behavioral techniques. _. Medications are used only to treat a comorbid ADHD or mood disorder but not for the conduct disorder itself. _The long-term outcome depends on the severity of the disorder and the degree and type of comorbidity. Of children with conduct disorder, 25% to 40% go on to have adult antisocial personality disorder. ✦Oppositional defiant disorder is diagnosed in a child with annoying, difficult, or disruptive behavior when the frequency of the behavior significantly exceeds that of other children his or her mental age (or that is less tolerated in the child's particular culture). It is a relatively new diagnosis that is meant to describe children with behavior problems that do not meet criteria for full-blown conduct disorder. Management emphasizes individual and family counseling. #short_note. #psychiatry

♦Catatonia is the  state  of apparent condition  unrespond to external stimulation with No movement or abnormal movement.  the pt may had _Negtivaism"do the opposite things " _Rigidity _wax flexibility _Echolalia "repeate the words" _Echopraxia "repeate the Movement" _mutism _posture "as psychological pillow" ✦ttt ①Started pharmacotheapry Benzodizpam lorazepam is best, Muscle relaxant "dantrolene" ②If no response, do ECT , بعض الدكاترة يقولوا انه نبدأ بالECT #short_note. #psychiatry

✦ Treatment consists of ① changing antipsychotics, lowering the dosage, or switching to clozapine. Clozapine, which appears to work by a mechanism different from other antipsychotics, may reduce or eliminate the abnormal movements of TD .(diphenhydramine or benztropine) are also used frequently. ✦الدكتور علي الاكوع  يقول. ①Clonzapin, ②muscle relaxant "andron" ③vit E. ♦⑤Neurolptic malignant syndrome _is potentially life_threatening complication most commonly associated with antipsychotic drugs use,  " also may occur spontaneously in response  to any medication that blocks dopamine receptors,, and in response to reductions or changes in dopamine agonist drugs. " ✦_Triad of NMS ①Recent use of antipsychotic drugs ②Fever "progressing to sever hyperthermia" ③muscle rigidity _ "autonomic instability coupled with motor abnormalities is essential to diagnosis of NMS" _autonomic instability " Cardiovascular alterations,  cardiac arrhythmia  , labile BP, _Laboratory finding "increase creatine kinase"2ry to muscle necrosis from sustained muscle rigidity",, Leukocytosis,, liver enzyme may be elevated. ✦TTT:" is Medical Emergency" ①stop the drug ②symptom management including ICU with cardiac monitoring and intubation may necessary. ③given  IV fluid and treat hyperthermia ④muscle relaxant "dantrolene" for muscle rigidity ⑤Dopamine agonist "Bromocriptine" sometimes used to reverse dopamine blocking effects of antipsychotic drugs. #short_note. #psychiatry

💢EPS "extrapyramidal symptoms" _is the side effects of use of Antipsychotic drugs "especially Typical antipsychotic drugs". _the cause due to decrease the Dopamine in Nigrostrial area. _consist of 5 side effects ♦①parkinsonism" in responsed to use antipsychotic drugs " the pt had tremor, mask face, lead pipe rigidity, "rigidity that present continuously throughout the passive range of motion of an extremity" or cogwheel rigidity "rigidity with catch and release character" ✦ttt ①is reducing the dose of antipsychotic drugs "if possible" ②adding anticholonergic drugs. ♦②DYSTONIA Def:- Dystonia is a neuroleptic-induced movement disorder characterized by muscle spasms. - Dystonia commonly involves the musculature of the head and neck but may also include the extremities and trunk. _ Symptoms may range from a mild subjective sensation of increased muscle tension to a life-threatening syndrome of severe muscle tetany and laryngeal dystonia (laryngospasm) with airway compromise. The muscle spasms may lead to abnormal posturing of the head and neck with jaw muscle spasm. Spasm of the tongue leads to macroglossia and dysarthria; pharyngeal dystonia may produce impaired swallowing and drooling. Ocular muscle dystonia may produce oculogyric crisis. _Risk factors include use of high-potency antipsychotics, with young men at increased risk ✦. The condition usually develops early in drug therapy (within days). ✦Treatment of dystonia depends on the severity of the symptoms. ①Most commonly, the muscle spasms are mild and respond to oral doses of anticholinergic medication. ②In more severe cases, intramuscular anticholinergic medication (benztropine or diphenhydramine) can be used. ③ If laryngospasm is present, intravenous anticholinergic medication is used. Some cases may require intubation if respiratory distress is severe. ④ Discontinuation of the precipitating antipsychotic is sometimes necessary; in other cases, ⑤ the addition of anticholinergic medications on a standing basis prevents the recurrence of dystonia. ♦③AKATHISIA Def:- Akathisia consists of a subjective sensation of inner restlessness or a strong desire to move one's body. Individuals with _akathisia may appear anxious or agitated. Most commonly, it is seen shortly after the initiation of an antipsychotic medication, particularly in a young male patient. _ Akathisia can produce severe dysphoria and anxiety in patients and may, if unrecognized, drive them to become assaultive or to attempt suicide. _It is important to diagnose akathisia accurately because if mistaken for agitation or worsening psychosis, antipsychotic dosage may be increased with resultant worsening of the akathisia. _Risk factors for akathisia include a recent increase in medication dosing or the recent onset of medication use. _ Most cases occur within the first month of drug therapy but can occur at any time during treatment. ✦Treatment consists of ①reducing the medication (if possible) or ②using either β-blockers (propanolol is commonly used) or ③benzodiazepines (especially lorazepam) ④. Although there is some debate regarding their efficacy, anticholinergics ♦④TARDIVE DYSKINESIA Def:- Tardive dyskinesia (TD) is a movement disorder that develops with long-term neuroleptic use _ rarely, it occurs spontaneously in elderly individuals who have not taken antipsychotic medications"in our country  Is common in Qat chewing "* . TD consists of constant, involuntary, stereotyped,  choreoathetoid (dance-like) movements most frequently confined to the head and neck musculature. At times, the extremities and respiratory and oropharyngeal musculature are also involved. _Risk factors include long-term treatment with neuroleptics, increasing age, female gender, and the presence of a mood disorder. _ Although TD is reversible in some cases, it tends to be permanent.

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