Schizophrenia as a Disorder of Disorganized Focus of Attention ONLY. 

Schizophrenia is THE psychiatric condition with variable manifestations involving all the major areas of a mental state examination, appearance and behaviour, thoughts and speech, cognitions, perceptions, mood, and most commonly, insight or reality-testing. Studies have long proposed schizophrenia being related to impaired regulation of attention; we propose a model explaining the entire range of manifestations as the result of a disorganized focus of attention. 

Explaining delusions

The cognitive model of depression proposes that patients with dysfunctional beliefs maintain these because of their selective attention to evidence that confirms these beliefs and their tendency to ignore the evidence against it. In the most severe cases, these dysfunctional beliefs may progress to delusions in which case they absolutely do not attend to evidence against their delusional beliefs and are preoccupied with the evidence and thoughts that confirm their belief system. In the case of schizophrenia, this regulation of attention is not mood dependent, it is disorganised but persistent.

Autochthonous Ideas

Described as cognitive interference, the intrusive thoughts are often influenced by environmental cues (for example, thinking about alternative hypotheses of schizophrenia when reading a new one) or mood state (as in the case of anxiety or mood disorders where patients are preoccupied with worries or sad memories). The cognitive theory of obsessive-compulsive disorder proposes not the occurrence but the obsessional patient’s inability to control intrusive thoughts, which is the intrusive thoughts are normal in humans, but the inability to shift attention from them is not.  A sudden delusional idea in patients with schizophrenia strongly favours the disorganized focus of attention in these patients. Objectively, ideas do not COME to mind, patients do not DEVELOP them, instead of the mind shifts (the focus of) attention to ideas. 

Explaining the Disorganised Behaviour and Speech

The most obvious evidence for a disorganised focus of attention in patients with schizophrenia is their disorganised speech and thoughts. Patients with the loosening of the association are said to “jump from topic to topic with now link between them.” We propose their disorganised focus of attention causes them to switch topics, much less influenced by environmental cues unlike in patients with mania, who exhibit a flight of ideas influenced by their distractibility and abundance of ideas. Patients exhibiting self-laugh or self-talk are not able to attend to the environment, despite being fully conscious. Patients with loss of self-care or avolition, in general, are not able to attend to their needs.

Explaining Mood

The mood is highly intervened with the focus of attention both influencing each other. A patient with anxiety focuses attention on anxiety-related cues, a patient with infectious joviality focuses attention on cues of pleasure. In patients with schizophrenia, there is often a disconnect between the mood and their attention. A patient with incongruent affect may be describing (attending to) depressing events while smiling. 

Explaining Hallucinations

Affect illusions are mild perceptual abnormalities, for example, a person preoccupied with fears walking in the dark may misperceive a bush for a monster. Their perceptual abnormalities occur along a spectrum of severity. Patients with delirium may exhibit any of these, for example in a state of fear, misinterpreting a stethoscope for a snake or seeing giant scorpions on the wall.  

Interlinking with Biology

Attention, executive control of attention, cognitive interference are higher cognitive functions primarily ascribed to the prefrontal cortex. Dopaminergic medications, as in patients with attention deficit hyperactivity disorder, help sustain their attention. Hyperdopaminergia favours the persistence of attention to the delusional ideas and the hallucinatory voices in patients with schizophrenia unlike in patients with mood disorders in whom the delusions and hallucinations are fleeting. 

1. Fuster JM. Human Neuropsychology. 2015:183-235.

Posner MI, Early TS, Reiman E, Pardo PJ, Dhawan M. Asymmetries in hemispheric control of attention in schizophrenia. Arch Gen Psychiatry. 1988 Sep;45(9):814-21. doi: 10.1001/archpsyc.1988.01800330038004. PMID: 3415424.

FCPS-2 October 2014, College of Physicians and Surgeons Pakistan

Q.4 A student of BSc diagnosed with borderline personality disorder presented in an emergency after attempting self-harm following a quarrel with a boyfriend.

1. What signs and symptoms require urgent medical treatment?
2. What care we should take in managing this patient in the ward
3. What psychosocial support you will activate
4. Give instructions on discharge regarding follow-ups.

Q.5 What are the various points that differentiate between the various anxiety disorders in terms of their prevalence and clinical features?

Q.6 A 39-year-old woman is diagnosed with severe depression years after the death of her husband. She is suicidal and has active suicidal ideations and symptoms of psychosis and is not responding to treatment with antidepressants. The psychiatrist plans ECT on this patient. 

1. What are the other indications to start ECT in severe depressive disorder
2. What are the indications for ECT other than severe depression?
3. Enlist the therapeutic interventions the physician can not advise that according to the Mental Health Act 2001?

7.  A 19-year-old girl had gone to spend her summer vacations at her uncle’s house in the other city. One day, about 15 days back, her uncle's son shows her some porn videos and seduced her to have sexual relations with him. On refusal, she was abused sexually. When she returned home, she had complaints of nightmares, jumping in bed on the opening of the door, persistent dull lower abdominal pain, irrelevant talks, over-familiarity, grandiosity, hyperactivity, distractibility, disinhibition with decreased sleep.  

1. What are the mental health sequelae to sexual abuse at an early age?
2. What are the three most likely differential diagnoses?
3. What non-pharmacological options are there to manage the latter on an individual who has been subjected to sexual abuse and with the aim of these non-pharmacological treatments?

Q.10 Mr. Y is an admitted case in the Jail ward of psychiatry de undergoing treatment as a patient in pursuance of an order authority. Two days back, the parents of the patient met the consultant and requested discharge urgently as he is symptom-free. 

1. What section of the Mental Health Act 2001 is concerned with such a patient?
2. What does that section say? 
3. What are the sections concerned with the admission to and treatment according to the Mental Health Act 2001?

Q.11 A 65 years old retired business manager has been brought in an emergency in a wheelchair with two days history of drowsiness, generalized rigidity of the body marked tremors, and irrelevant talking. He has a history of bipolar mood disorder for 12 years. Because of his increasing agitated behavior, they increased his lithium dose from 800 mg to 1200 mg per day, haloperidol from 7.5 mg to 15 mg per day, and lorazepam from 1 mg to 3 mg per day. He had diarrhea four days ago, which lasted for 2 days. On examination, he was disorientated and dysarthric with pulse 80/min, BP 160/90 mm, Hg, and temperature 100'F. He was confused and drowsy with diminished tendon jerks and equivocal planters. 

1. Discuss the differential diagnosis.
2. What further investigations will you carry out? 
3. Give justification for each.
4. What initial and long-term management would you advise?

Q.12 A 38-year-old lady is brought to the psychiatric outdoor clinic in a state of stupor a) What possibilities will you consider in the differential diagnosis? b) What investigations would you like to ask for? c) How will you manage her?

Q.13 In its 65" assembly, the World Health Organization adopted a resolution of the need for a comprehensive and coordinated response from health and social sectors as the mental health action plan. 

1. What are the objectives of this plan?
2. Highlight 5 specific ways to promote mental health in the community

Q.14 There is serious concern about the long-term use of benzodiazepine among older persons owing to adverse outcomes. However, the prevalence of benzodiazepine use in older people remains high. Considering recent advances: 

1. Enumerate the adverse effects of benzodiazepines in the elderly. 
2. Enumerate the reasons.
3. What are some evidence-based interventions for withdrawal in the elderly population according to recent advances?

Q.15 What points will you keep in mind while delivering a lecture on these topics:

1. Indication for behavior therapy
2. Indications for family therapy.
3. Role of the therapist in psychoanalytic psychotherapy. 
4. Nonspecific factors in psychotherapy. 
5. Complications of psychotherapy.

Q.16 There has been substantial uncertainty regarding the incidence of children and adolescents exposed to trauma. A recent meta-analysis evaluated this issue.  

1. Regarding recent advances, what is the overall rate of children and adolescents exposed to trauma?
2. Enlist the potential moderating factors in the development of children and adolescents.
3. What are other mental health consequences in children and ad exposed to traumatic events?

Q.17 A 22 years old female patient presented to psychiatric e patient presented to psychiatric OPD with complaints of weight loss over 20%, and Body mass index. On her mental state examination, they revealed it she has real fatness, therefore she avoids food and shows a behavior aimed to lose weight by vomiting. purging excessive exercise and the use of appetite suppressants and diuretics. She also complains of the absence of menstruation for the last few months. 

1. Enlist 10 specific questions that you would ask this patient for the assessment of eating disorder?
2. Considering the above scenario, what is your provisional diagnosis?
3. How will you manage this case?

18. A man is brought to a psychiatric emergency. His pulse is 100/min, BP is 170/95 mm Hg, and he is profusely sweating. He is shaky and has difficulty in giving his history. He has had difficulty falling asleep for two nights and sees spiders walking on the walls. He has been a drinker for 10 years but has had no drink for the last 3 days. 

1. What is the most likely diagnosis?
2. Name three psychometric scales that are used for alcohol dependence or withdrawal?
3. Mention ten social hazards that can result from chronic alcohol abuse?

Q.19 What strategies you could employ to treat the sexual side effects in a 30-year-old male receiving treatment with an SSRI.

Q.20 A 34-year-old woman who had been married for some time is pregnant for the first time. 4 weeks after delivery, she appears to be agitated. In this state, she drowned the child in the bath and slashed her wrists. 

1. What is the most likely differential diagnosis? 
2. How would you manage this case?
3. What medico-legal issues are likely to be involved here?

 

Post-Traumatic Stress Disorder: Sample CASC

So, I have been asked by your GP to have a chat with you because you are having some difficulties in judging. So, as far as I know, you have, you were in an accident. A few months ago and since then you've been having some difficulties. But if it's okay, I'll let you explain what led you to come in here already.

Yeah, I just had an accident about six months ago. And ever since then, I just can't get out of my head.

was it was a serious accident?

Yeah, it was it could have been, you know, the car was all messed up in a way you

know to sort of concussion

to split a whiplash room in the car was really hard.

I can see where you're getting a bit anxious even talking about it. If you find questions difficult to answer It's okay, we can move on. And you can take your time, too, if you're feeling anxious. So you had this unfortunate accident you said that, although you will not seriously injure the car was quite badly damaged, and you make the most depending on how long you have to be in the hospital.

Just a couple of days.

Yeah.

And you mentioned the competition, did you suffer any kind of memory loss or any confusion? And so this happened, about six months ago. And when did you experience the problems in your programs?

In the beginning, it was normal, you know,

it was really, really horrible.

But it just keeps going on. It just seems to get worse. Get rid of it. It's just taken over my life now.

Difficult. And so, can you describe what has been happening, what sort of experiences have you been to. Have you been experiencing?

And the newest thing is a sort of the last one, really I just sort of. I'll be at work or be out with your friends or anything, I just start hearing. Like screeching tires or metal.

This off. I can hear it and then it's like it's happening all over again. I just feel completely sort of paralyzed. So you've got a couple of minutes. It just seems like a lifetime.

Sounds really scary and some people, when they experience, have this kind of experience they also sometimes have nightmares of these incidents. And is it quite frequent the nightmares?

Yeah, so most nights really seem to get worse. Okay. But now it's sort of every night and it's just sort of stuck in the same thing I'm just reliving it up to where it happens and it's often what we find is a traumatic incident like that, avoid situations that might lead to a similar thing, avoid doing the things that happen on the day of seeing that happen in your case.

And now I'm going to drive with anybody else in the car.

Right. My friend.

I just keep thinking that I could have killed her.

Are you able to drive with no kind of emotional

Avoid at all costs, but I need to keep working. If I can avoid doing anything more than I have to do. I'm late every morning because it's just such a workout to get myself in the car to go.

And are you doing anything to deal with all these problems? And when you say drinking is more than community drink after the incident. Did you use to drink before?

I sort of had a glass of wine after work, but now it's just so I just have another one and then another one. I'm just so worried about going to sleep. So I just, I just have a couple more drinks and it just helps me. It helps me get to sleep.

How much do you drink?

Probably. Probably, um, maybe a bottle of wine.

So asking this, but you won't be using any other substances, middle class, here. So, your drinking has gone up You said that you were feeling quite anxious and agitated. Do you also find that you have become a bit more snappy, irritable, with people?

He says I'm a different person now. He thinks I'm just angry all the time. I get mortgage irritated, the normal, a film just got shorter views than I did before.

And you also are quite easy to be always vigilant about what's going on around you.

You know, if I have to sit in the car with my boyfriend's driving to somewhere. I'm constantly on edge I'm looking around for other cars and any sort of hazards, constantly jumping or saying oh slow down or things like that. Yes.

I think all of this must be quite draining on you, how do you say your mood has been in the last few weeks.

I just feel so tearful all the time. On the verge of crying because I just seem so frustrated, but it's still, still going on.

Do you have any happy times in between the lives of many you're doing anything specific?

that already enjoy much,

Because you feel constantly alone and not enjoying things as well. What would you say your energy levels are like

guess just because on the edge all the time we're just taking a lot out from this what

Do you find the most interesting things that you used to enjoy? And you mentioned trying to sleep. Because you are afraid of sleeping, you have been drinking the evening. But when you go to sleep. Go to sleep.

Wake up a lot. Having these dreams gets to a point. So it's all happening again with the car, and then it gets to a point and then a shock. Wake up and then go back to sleep and it just happens.

So good focus on being able to look after yourself. Eat. Look after food and diet.

And since you've been feeling stressed, I mean, do you find that you've had any specific negative thoughts towards where you're not wanting to live anymore or felt like harming yourself or something.

Oh yeah, I don't, I don't want to live like this anymore. I don't kill myself, that's

Been asking lots of questions and you've been very patient with me Thank you very much. I need to speak to my team, and especially the psychologists in my team, because from what you're paying, what you're doing. Today, it seems like you are experiencing symptoms of post-traumatic stress disorder, commonly known as PTSD, and your concern appears below. So, I would speak to the Secretary of State and see if what the missed approach would be because we need to have. We go for psychological therapy first or try combination therapy and medication. But we have a discussion with the team and arrange another appointment for you so I can discuss more what the plan will be.

Cognitive treatment for depressive disorder

 

Management

Cognitive treatment for depressive disorder

What is the cognitive treatment for depressive disorder?

Cognitive behavioral therapy

Cognitive treatment for depressive disorder

Who and when was it developed?

Beck et al in the 1960s

Cognitive treatment for depressive disorder

What does it combine?

Cognitive and behavioral aspects

Cognitive treatment for depressive disorder

Is it available on the nhs?

Yes

Cognitive treatment for depressive disorder

What is the individual told to focus on and consider?

Focus on negative thoughts and then consider new ways of thinking

Cognitive treatment for depressive disorder

What are the 2 main focuses on cognitive behavior therapy?

 -change distorted thinking present in those with depressive disorder -train patients to use more adaptive methods

Cognitive treatment for depressive disorder

What are the 3 main aims of the treatment?

Challenge negative thinking and replace with constructive positive thoughts that will lead to healthy behaviour -make cognitive errors conscious and then challenge then, make it look like there is no basis

Cognitive treatment for depressive disorder

When does it usually occur?

Once a week/fortnight for 5 to 20 sessions lasting 50-60 mins

Cognitive treatment for depressive disorder

How does the course normally start?

Education phase, patient taught about relationship between thoughts, emotions and actions, ethical issues

Cognitive treatment for depressive disorder

Why is an agenda set?

So the client can do what they want at their own pace

Cognitive treatment for depressive disorder

How does therapist help break down problem?

 -downward arrow technique -breaks down into parts that can be connected

Cognitive treatment for depressive disorder

What does it mean by solution based?

Doesn't dwell in the past, all about the here and now, how thinking is unrealistic

Cognitive treatment for depressive disorder

Why are homework assignments set?

Ao that patient can practice changes talked about, normally hypothesis testing putting self in situations not normally experience

Cognitive treatment for depressive disorder

What other tools are used for the client outside treatment?

To discover self concept, speaking to friends and family to find out things about themselves

Cognitive treatment for depressive disorder

What can the therapy help change?

How you think and what you do

Cognitive treatment for depressive disorder

What does the therapy challenge?

Negative thoughts

Cognitive treatment for depressive disorder

What does the therapist summarise at the start?

The agenda to check full understanding

Cognitive treatment for depressive disorder

What is a mood diary, what does it enable to patient to do?

Log and monitor their thought processes outside therapy

Cognitive treatment for depressive disorder

Who is the programme backed up by? (s)

Government funding by the uk

Cognitive treatment for depressive disorder

What is a strength of the stud in terms of time etc?

Fairly quick, cheap to provide and less side effects when looking at drugs, why the government backs it up

Cognitive treatment for depressive disorder

What did butler conclude? (s)

That cognitive behavior therapy was effective for treating depressive disorder after reviewing several studies and meta analysis where the treatment was used

Cognitive treatment for depressive disorder

What did nice find? (s)

It was the most effective treatment in treating severe and moderate depressive disorder

Cognitive treatment for depressive disorder

What did williams find? (s)

His study is based on cognitive behavior therapy and is our contemporary study he found that cognitive behavior therapy alone combined with an imagery treatment was successful in treating depressive disorder of a woman named carol

Cognitive treatment for depressive disorder

Why is the study ethical?

It has no side effects, so can be regarded more ethical than the drug treatment

Cognitive treatment for depressive disorder

What belief is cognitive behavior therapy based on and why might this idea cause a relapse?

It is based on the belief that depressive disorder is caused by faulty thinking, which might be a result of depressive disorder not a cause, when depressive disorder is removed so is negative thoughts, shows that removing cause may not remove the cause, resulting in a relapse

Cognitive treatment for depressive disorder

What are some ethical implications for the treatment? (w)

It essentially blames the person for their disorder as it is their thoughts that cause it, ethical implication based on how it makes the patient feel

Cognitive treatment for depressive disorder

What type of data is normally gathered to study the treatment?

Self report

Cognitive treatment for depressive disorder

Why is the data gathered to study this treatment unreliable and in valid?

Self report may try to please the clinician and say treatment is working also may depend on mood which will change day to day social desirability

Cognitive treatment for depressive disorder

What did chan et al find? (w)

That drug therapy could be useful as an addition to cognitive behavior therapy and a combination was more effective than cognitive behavior therapy on its own

Cognitive treatment for depressive disorder

Williams contemporary (icbt and cbm)

What was the aim of the study?

Find out if combined treatment of cognitive biased modification immediately followed by icbt would be effective in treating depressive disorder

Where were participants recruited from?

Applied research unit for anxiety and depressive disorder in Sydney online screenings

How many applied through online screenings?

232

What happened to successful applicants?

They were rang for a diagnostic interview using the mini

What is the mini?

Multi international neuropsychiatric interview

Why were participants excluded?

No internet access, drug abuse and suicidal idealization

How many participants met all inclusion criteria and what disorder did they have?

69 and major depressive disorder

How many were in the intervention group at the start and then the finish?

38 and 20

How many were in the control group at the start and finish?

31 and 22

Who many participants were in the baseline questionnaires in both groups?

I-35 c-28

How long was the treatment?

11 weeks

How long was the cbm?

One week

How long was the icbt?

Ten weeks

What was the criteria for participants?

Had to have major depressive disorder no history of psychotic mental illness

What age did participants have to be between?

18-65

What was depressive disorder severity measured by?

-beck depressive disorder inventory 2nd edition -phq-9

What were the primary outcome measures?

Severity of depressive disorder distress interpretation bias

What is the phq-9?

Nine item depressive disorder scale of patient health questionnaire

A recent survey suggested that patients and attendants in the hospitals face difficulties finding places due to the complexity of the building structure and the hustle adding to their distress. You have opted to conduct a study at your hospital to evaluate whether colored hospital map for healthcare staff to guide patients would help them. What would you measure the reduction in distress with?

The K10 is a self-report inventory used often as a simple measure of treatment-outcome for common health conditions, and to identify need for treatment, or measure psychological distress. It is in the public domain. It has a five-point Likert scale, options include: all, most, some, little, to none of the times, scored 5-to-1, respectively. A score of 10 is the minimum for no distress, ranging up to a largest score of 50 for the most severe distress. For further information on the K10 please refer to www.crufad.org or Andrews, G Slade, T. Interpreting score on the Kessler Psychological Distress Scale (K10). Australia and New Zealand Journal of Public Health: 2001; 25:6: 494-497.

K10

General health questionnaire

Patient health questionnaire

Daily Hassles

State-trait anxiety inventory 

 

 

What is the k10

Measures distress ten item kestrel psychological distress scale

How was interpretation bias measured?

Sst

What is the scrambled sentence test?

scrambled sentence test measures interpretation-bias

What were the secondary outcome measures?

Other factors associated with depressive disorder that may affect treatment such as anxiety

What was anxiety as a second outcome measured by?

Stai-t s

What does the STAI-A help you measure in the evaluation of patients presenting with excessive stress an worry. 

The State-Trait Anxiety Inventory (STAI) is self-report, a 4-point Likert scale with 40 questions used to measure state anxiety, or anxiety about an event, and trait-anxiety, individuals with anxiety-personalities. Higher scores correlate with increased severity of anxiety. Form-Y is Its most recent, available in 40 different languages. State-trait anxiety inventory-A is the trait version. It helps assess trait-anxiety, anxiety prone personalities.

Severity of current anxiety

Whether the individual is prone to anxiety

Stress in general adaptation syndrome

Compares state and trait anxiety

It identifies Type-A individuals

 

 

What is the CBM?

Computerized training program in which the individuals are presented with ambiguous scenarios always resolved in a positive manner.

What was the final measure used?

Researchers used their own adapted version of treatment expectancy and outcomes questionnaire

After intervention group had post scores what happened?

Control group took part

What measure was not carried out in post treatment outcomes?

Interpretation bias

Results: what were there no significant differences in?

Baseline measures pre treatment

What percentage had social phobias in each group? (baseline measure)

I-34% c-25%

What was found in the treatment expectancy out outcomes questionnaire?

There were no differences in patients ratings of treatment expectations

What did intervention group show? (results)

Improvement in scores on all measures

Which group had most improvement?

Intervention group

What were some conclusions?

Combined intervention effective in reducing depressive symptoms icbm can reduce symptoms in just one week useful to intergrate cbmi into icbt as a new form of delivery treatment

Why was the internet recruitment a strength? (s)

Allowed to collect a broad sample from all over australia

Why is it useful? (s)

Cognitive behavior therapy was not widely used due to resources encourages the integration of internet based technologies to treat depressive disorder

Ethics? (s)

All 69 gave informed consent beforewent through a screening process to make sure ppts suitable for treatment right to withdraw

Random assignment? (s)

Reduces any bias of ppts characteristics

Reliability?(s)

Easily replicable standardised procedure questionnaires

Use of interviews and questionnaires? (s)

Didn't just reply on one type of data collection method, increased validity

Self report data? (s)

Quick and easy comparison to be made reduces costs of manpower needed

Who was the study approved by? (s)

Human rights ethics committee of st vin cents hospital in sydney

Self report data? (w)

Social desirability lack validity

Cause and effect? (w)

Results could not establish whether change was due to one programme or both

Generalisability? (w)

Inclusion data 18-65

Validity of withdrawal? (w)

May not have worked on those who withdrew

Long term? (w)

No follow up study so no way to tell may relapse §

What % of people in both groups showed changes?

I - 65% c - 35%

Bio treatment for depressive disorder-drugs

Antidepressants are given to patients on the belief that depressive disorder is caused by what?

An imbalance of neurotransmitters in the brain

Bio treatment for depressive disorder-drugs

What do antidepressants help to increase?

The levels of monoamine nt in the brain

Bio treatment for depressive disorder-drugs

What effect should antidepressants have?

Restoring the balance of nt and therefore reducing the symptoms of depressive disorder

Bio treatment for depressive disorder-drugs

What are antidepressants?

Antagonists

Bio treatment for depressive disorder-drugs

How do antagonists work?

By increasing the level of activity, usually by blocking re up take or by preventing the enzyme that breaks them down in the synapse

Bio treatment for depressive disorder-drugs

Where is the nt available for longer when given drugs?

Synapse

Bio treatment for depressive disorder-drugs

Where does activity increase?

Affected neural pathways

Bio treatment for depressive disorder-drugs

What form do ad take form?

Tablet normally

Bio treatment for depressive disorder-drugs

How long do patients normally take then before feeling an effect?

7 days

Bio treatment for depressive disorder-drugs

When first prescribed what dosage is given?

The lowest possible thought necessary

Bio treatment for depressive disorder-drugs

How does a doctor decide on which drug to prescribe?

Uses trial and error, prescribes on sees if it works if not prescribes another

Bio treatment for depressive disorder-drugs

After four weeks and no effect what might the doctor do?

Increase dosage or try alternative medication

Bio treatment for depressive disorder-drugs

How long does a course of treatment usually last?

6 months

Bio treatment for depressive disorder-drugs

Who is given a two year course?

People with a history of depressive disorder

Bio treatment for depressive disorder-drugs

Who is advised to take them indefinitely?

People with recurrent depressive disorder

Bio treatment for depressive disorder-drugs

What does ssri stand for?

Selective seretonin reuptake inhibitors

Bio treatment for depressive disorder-drugs

How do ssris work and is there any side effects?

Normally start by prescribing these safer cause fewer side effects block reuptake of serotonin less likely serious effects if overdose

Bio treatment for depressive disorder-drugs

What is an example of an ssri?

Fluoxetine

Bio treatment for depressive disorder-drugs

What are moais?

Monomine oxidase inhibitors

Bio treatment for depressive disorder-drugs

How do moais work and is there side effects?

Given as a last resorthave serious side effects stop enzymes breaking down monamines in synapse have to have strict diet as can react with certain foods such as cheese and pickles

Bio treatment for depressive disorder-drugs

What percentage of the effect of drugs is placebo effect? (w)

30-40%

Bio treatment for depressive disorder-drugs

What is the placebo effect a weakness?

Means the drugs don't actually work it is just in the patients mind

Bio treatment for depressive disorder-drugs

One the drug is stopped, what rates are high? (w)

Recurrence and relapse rates

Bio treatment for depressive disorder-drugs

What does palliative mean?

Relieving pain rather than dealing with the cause

Bio treatment for depressive disorder-drugs

Why are drugs palliative and not curative? (w)

They do not directly cure the disease or target the cause but relieve some of the symptoms

Bio treatment for depressive disorder-drugs

Are all drugs used for mental health palliative?

Yes

Bio treatment for depressive disorder-drugs

Why is it a weakness if patients reposing well to antidepressants?

They may have to take them indefinitely in order to stop recurrence

Bio treatment for depressive disorder-drugs

If psychotherapy and other treatments doe not work why is drugs a strength? (s)

They are the only treatment that will work

Bio treatment for depressive disorder-drugs

What is a weakness in terms of ethics? (w)

Cause serious side effects, especially old fashioned ones, ssris have been to linked to suicidal ideation in young people

Bio treatment for depressive disorder-drugs

Why are drugs practical? (s)

They are cheaper and can be provided immediately whereas there is usually a waiting list for other therapies

Bio treatment for depressive disorder-drugs

Why might there be ethical concerns in the patient to doctor relationship?(w)

Doctor is prescribing the meds so patient may feel like they have no power and that therefore drugs is there only option as they are just following what the gp says

Bio treatment for depressive disorder-drugs

What treatment is used when drugs does not work as a last resort?

Electroconvulsive treatment

Bio treatment for depressive disorder-drugs

Which drugs has been linked to suicidal ideation in young people?

Ssri

Bio treatment for depressive disorder-drugs

What did pin quart d find?

Reviewed the effectiveness of drug treatment and psychological treatments and found that psychological treatments were most effective

Bio treatment for depressive disorder-drugs

EMOTION & THE RELATED DISORDERS

What is mood? Is anxiety a type of mood? Do we separate pleasure, from euphoria? What is the exact boundary between normal and abnormal mood? How do we differentiate elation and euphoria? What is dysphoria? What is sadness, and how it compares to depression in mood disorder? Is there a difference between mood and affect? What is flattened affect and how does it differ from apathy? What is inappropriate affect? How does anhedonia differ from apathy? What is congruence and incongruence of mood? What do we mean by a labile mood? What is cyclothymic and hyperthymic mood? What is What is the difference between labile mood and cyclothymic mood. What is alexithymia? What is dysthymia? How de we differentiate dysthymia, dysphoria, and displeasure? Is loss of interest different from anhedonia? How do we differentiate between lability and incontinence of mood? How do we differentiate apathy from blunting? What is reactive mood and its importance? What exactly are mood-incongruent delusions and their significance?

What is stress? What is eustress? How eustress differs from distress? If you are the feeling pressure, are you experiencing stress? How do we compare trauma and stress? 

What is emotion? Is stress an emotion? What is blunting of emotional responses? What is emotional incontinence?

What

In this section we will cover the concepts and mechanisms of emotions including normal stress, sadness, pleasure and happiness, worry, eustress. Then we will describe the abnormal variations like clinical anxiety, depression, elation, euphoria, euthymia, eustress, distress, pleasure, dysphoria, anhedonia,  and

Major Depressive Disorder

Must last at least 2 weeks At least Five or more symptoms have been present in the same 2-week period1. Depressed mood most of the day 2. Markedly diminished in interest of pleasure in all, or almost all activities most of the day3. Significant weight loss4. Insomnia or hypersomnia everyday5. Psychomotor agitation or retardation 6. Fatigue or loss of energy7. Feelings of worthlessness or inappropriate guilt8. Diminished ability to think or concentrate9. Recurrent thoughts of death, suicidal tendencies with or without a plan Must cause clinically significant distress or impairment

Mood Disorders

Bipolar I Disorder

Patients with one lifetime Manic episode and patients with both Manic and Depressive episodes. Patients do not need to have diagnosis of MDD for Bipolar I

Mood Disorders

Bipolar II Disorder

Patients with Hypomanic episodes and Major Depressive episode - but never a Manic episode.

Mood Disorders

Mania

A period of abnormally and persistently elevated, expansive or irritable mood lasting for at least one week or less if a patient must be hospitalized. Associated with Inflated self-esteem Grandiosity Decrease need for sleep Distractibility Great physical and mental activity and over-involvement in pleasurable behavior

Mood Disorders

Hypomania

Hypomanic episode lasts at least 4 days and is like a manic episode except it does not sufficiently severe to cause impairment in social or occupational functioning

Mood Disorders

Dysthymia

Characterized by at least 2 years of depressed mood that is not sufficiently severe to fit the diagnosis of MDD.

Mood Disorders

Cyclothymia

A mild form of Bipolar II disorder. Characterized by at least 2 years of frequently occurring hypomanic symptoms that cannot fit the diagnosis of Manic episode and of depressive symptoms that cannot fit the diagnosis of MDD.

Mood Disorders

Prevalence of Major depressive disorder

5-17% - Has the highest lifetime prevalence of any psychiatric disorder

Mood Disorders

Prevalence of Bipolar illness

Less than 1 percent

Mood Disorders

Mood Disorders (with Psychotic features)

Significant treatment implications, eg., antipsychotic drugs along with antidepressants. Distinguished at mood congruent, or mood incongruent. Mood congruent: in harmony with the disorder, eg., I deserve to be punished because i am so bad) Mood incongruent: not in harmony with the mood disorder. - may have schizophrenia or schizoaffective disorder.

Mood Disorders

Mood disorder with Melancholic Features

Used to describe the dark mood of depressive disorder Severe Anhedonia, early morning wake ups, weight loss, and profound feelings of guilt. Associated with changes in the autonomic nervous system and in endocrine functions. Can be applied to MDD, Bipolar I and II Disorder.

Mood Disorders

Mood Disorders with Atypical features

Patients with atypical depressive disorder symptoms include overeating and oversleeping. Sometimes referred to as, "reversed vegetative symptoms" and the pattern sometimes called "hysteroid dysphoria" Typically have a younger age of onset compared to depressive disorder with typical features,

Mood Disorders

Mood-congruent psychotic symptoms

In harmony with the mood disorder," I deserve to be punished because I am so bad “typically those with mood-congruent psychoses have a psychotic type of mood disorder

Mood Disorders

Mood-incongruent psychotic symptoms

Not in harmony with the disorder Delusions or hallucinations whose content does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. Typically have schizoaffective or schizophrenia

Mood Disorders

Tardive Dyskinesia

Orofacial chorea because of long-term antipsychotic use. 

Lithium

 

Lithium

FAQ 01

What are the indications for lithium?

We use lithium in the prophylaxis and treatment of mania, prophylaxis of bipolar disorder, as an augmentation strategy for patients with treatment-resistant depression.

What are the common signs of lithium toxicity?

Thirst, polyuria, memory problems, tremor, weight gain, tiredness, diarrhea. Cognitive dysfunction is the most common symptom that leads to non-compliance. Side effects are dose-related.

What is the concentration at which toxic effects reliably occur?

Toxic effects reliably occur at 1.5mmol/l but toxic effects can occur at MUCH LOWER LEVELS in many patients, especially in older patients, systemically ill patients, and in use of alcohol or other CNS active meds

What are the two systems lithium causes the most damage to?

Thyroid and kidneys

What are the differences between the brands of lithium?

There are differences in bioavailability, and recommendations are to keep to the patient on the same brand. If it is necessary to change formulations, lithium levels must be monitored closely until a patient reaches a steady state.

What are the distinct forms of lithium found in different formulations?

Tablets have lithium carbonate; liquid has lithium citrate.

How is lithium administered, timing-wise?

We give it as a single daily dose at night. 

When should blood for serum lithium estimation be taken?

12 hours after the last dose. IF you're on liquid then you take the blood before the morning dose.

What can cause increased lithium concentrations?

A low-salt diet, diarrhoea, vomiting, excessive sweating, systemic illness of any origin, renal impairment, NSAIDs, ACE inhibitors, ARBs, diuretics.

Tell me about lithium and surgery?

Lithium is probably safe in minor surgery but is usually discontinued before major procedures and restarted once electrolytes normalize. The following points should be considered if you will take lithium during the period. Lithium prolongs the action of muscle relaxant, electrolyte imbalance can precipitate lithium toxicity, dehydration can too. increased, increased arrhythmia

What is your dose determined by?

Blood levels.

What is the therapeutic range of lithium?

0.4 to 1 mmol/l

What kind of damage does lithium cause to the thyroid?

It can cause both hyper and hypothyroidism.

What is lithium's lag phase?

5–7 days

What are the neurochemical effects of lithium?

It enhances serotonergic activity, reduces cholinergic activity, and inhibits PI and cAMP.

How is lithium transported across the cell membrane?

It is actively transported across membranes using a voltage-sensitive sodium channel and sodium-potassium ATPase.

Tell me about lithium and signal transduction?

It increases inositol monophosphate. It depletes free inositol. Adrenergic, cholinergic, serotonergic, and dopaminergic receptors are coupled to Pi turnover in the CNS. There is possibly a compensatory stabilization of biogenic amine imbalance. cAMP accumulation is inhibited. All of this is mediated by G proteins. Chronically, it may have effects through protein kinase C and expression of neuromodulators and components of secondary messenger systems.

Tell me about lithium's mechanism of action?

It affects serotonin precursor uptake, synthesis, release, storage, catabolism, receptors, and receptor effector interaction primarily presynaptically. It increases DA turnover, decreases DA formation, decreases striatal DA activity. Facilitates the release of NA through presynaptic autoreceptor. Stimulates Ach synthesis and release.

What percentage of people relapse when on lithium? What percentage relapse on a placebo?

34% relapse on lithium while 81% relapse on placebo.

What percentage relapse and after abrupt termination of lithium?

50% relapse within 5 months.

What can reduce the risk of relapse when you stop the lithium?

Tapering slowly

What percentage of bipolar patients will show an inadequate response to lithium alone and will require the addition of ADT or anticonvulsant?

50%

What patterns of bipolar show reduced the efficacy of lithium?

Rapid cyclers or mixed states. Personality disorders and substance abuse are also associated with poorer response.

Is MDI better or DMI better in lithium treatment?

MDI pattern which is preceding depression responds better to lithium while DMI which is when you get severe episodes of depression don’t respond as well.

How long does lithium take to work in bipolar depression?

3–4 weeks

What percentage of bipolar patients respond to lithium as an antidepressant vs how many unipolar patients respond to it as an antidepressant?

79% of bipolar patients and 36% of unipolar patients.

What percentage of treatment-refractory patients respond to lithium augmentation?

50%

What other ailments is lithium used to treat?

Schizoaffective disorders, cluster headache, preliminary use in HIV treated patients with zidovudine.

Give me the side effects of lithium by the system?

Neuromuscular: fine tremor, slowed cognition. GI: Nausea, diarrhea, weight gain. Thyroid: hypothyroid, hyperthyroid, raised TSH. Cardio: ST and T-wave changes, sinus Brady, T-wave depression. Renal: polyuria and polydipsia, diabetes insipidus, interstitial nephritis

Why does lithium cause organic damage?

Because of its accumulation and action of lithium on ion transport, second messenger, and receptor signaling systems.

Tell me all about lithiums damage to the thyroid?

It inhibits hormone synthesis and releases and inhibits the action of TSH. TSH induced hypothyroidism occurs between 5–35%. More common in females, 30% have elevated TFTs.

Give me lithium's important drug interactions?

Diuretics (loops<thiazide) increase lithium levels. Caffeine discontinuation can increase levels of NSAIDs to reduce Li clearance. Neuroleptics plus lithium worsen EPSEs.

What teratogenic effects does lithium have?

It has teratogenic effects on the cardiovascular system in the first trimester. Ebstein's anomaly.

What levels do you want lithium at?

0.6–0.8 in maintenance level 0.8–1.2 in an acute manic state.

How do you introduce lithium?

400–600mg given at night, increased weekly depending on serum monitoring to a maximum of 2g.

Describe the monitoring of lithium?

Check lithium level seven days after starting and seven days after each change of dose. Take blood samples 12 hours post-dose. Once the therapeutic serum level has been reached, continue to check lithium level/eGFR every three months and TFTs every six months. Keep an eye on the weight!

What are the side effects of lithium?

Fine tremor, Sedation impaired coordination  GI disturbances polyuria (more urine) Polydipsia (more thirsty)

 What are Signs of toxicity?

Lack of appetite Diarrhoea and vomiting  Blurred vision Marked tremor Drowsiness and confusion Slurred speech

What are the Interactions?

Diuretics, NSAIDS, HAloperidol, carbamazepine , antidepressants , ACEi,s ARBSs

How to counsel a  Patient?

Carry lithium cards will need regular blood tests. Be way of buying otcs, speak to pharmacist Maintain fluid and sodium intake. Women of childbearing age should use contraception to stay on the same brand should only be initiated in secondary care 

Monitoring?

Having a serum lithium concentration took 12 hours after the first dose. routine serum lithium Concentration took after initiation and after each dose change until stable and then every three months.

What type of medication is lithium? 

Mood stabilizer 

What is lithium used to treat? 

Gold standard preferred treatment for mania. 

What is the normal lithium blood serum level? 

0.6 – 1.2 millimoles per litre (mmol/L).

What are the short term adverse effects of lithium? 

Polyuria and polydipsia weight gain nausea and vomiting fine tremor headache metallic taste lethargy acne. 

What are the long term adverse effects of lithium?

Hyper or hypothyroidism kidney problems mild cognitive impairment and memory problems. 

What are the long term adverse effects of lithium?

Hyper or hypothyroidism kidney problems, mild cognitive impairment and memory problems. 

Why do patients taking lithium need to stay hydrated?

Because lithium interferes with regulating water and sodium dehydration, which worsen thyroid and kidney problems , 

What lithium concentration may show lithium toxicity?

1.5–2.0millimoles per liter (mmol/L). Lithium toxicity can also happen in therapeutic ranges (esp in the elderly) 

What are the symptoms of lithium toxicity?

Blurred vision, Vomiting, and diarrhoea, Coarse tremor, Muscle weakness, Confusion, Sluggishness, Ataxia, Dysarthria.

How/when would you monitor lithium blood serum levels?

If lithium toxicity signs are clear 5 days after starting restarting changing dose weekly during acute treatment then every 3 months once mental state and lithium levels are stable 

What diet would someone with lithium be on?

Regular diet with normal sodium and adequate fluid intake 

What is the side effect of sodium valproate?

Alopecia (hair loss)

Adverse effects of lithium?

Polyuria, Polydipsia, Weight Gain and Edema, Metallic Taste, TREMORS, Orthostatic Hypotension

Lithium has what effect during pregnancy?

Teratogenic

Lithium and NSAIDs cannot be given because?

NSAIDS causes lithium, Toxicity.

Lithium causes GI upset and should be taken with?

Food

They must avoid what type of beverages?

Caffeinated drinks

To which class of medications does lithium belong?

It is a mood stabilizer.

What conditions is lithium used to treat?

Used to treat bipolar disorder. Reduces frequency and severity of mania. It helps relieve depression, but more effective in treating mania. It helps to reduce the risk of suicide. Stabilises mood.

How long does it take to see results?

Takes up two weeks before seeing results.

Why are the Blood tests regularly taken?

because of the effect on kidneys and thyroids.

 What is the mechanism of action of lithium?

Though lithium is an effective way to treat bipolar disorder, it is still not clear how it works exactly. But studies have shown lithium affects the excitatory neurotransmitter, glutamate. Lithium changes inward and outward currents of glutamate receptors to help the body keep a healthy level.

What is the route of administration of lithium?

Oral

Side Effects?

Headaches. Nausea. Diarrhea. Excessive Vomiting. Weakness or Muscle Fatigue Tremor. Ataxia. Muscle twitches. Seizures. Coma.

Acute and Chronic Toxicity Acute?

Intentionally or accidentally taking too much lithium Chronic. Taking Lithium every day for a lengthy period. 

Withdrawal Symptoms?

Studies have shown there are no withdrawal symptoms. There is usually no case of addiction when using lithium.

Schedule of drugs?

Not subjected to the controlled substances act, so not a federally scheduled drug.

What is the therapeutic range for lithium?

0.4 to 1 millimole per litter (mmol/l) is the normal therapeutic range. It is 0.8 to 1 millimoles per litter for acute episodes of mania or patients who have previously relapsed.

Can you enlist four tests for the monitoring of lithium?

Serum lithium concentration, renal function (baseline and every six months), cardiac function (before initiation and every six months, same for thyroid), thyroid function.

Lithium route of elimination?

It has a renal excretion, freely filtered at glomerulus with an eighty percent reabsorption rate. 

Enlist ten warning signs for lithium? 

Increasing Gastrointestinal (GI) disturbances (V&D)  Visual disturbances (e.g. blurred vision). central nervous system (CNS) disturbances (drowsiness, unsteadiness, confusion). Fine tremor (and worse)  incontinence, polyuria serum concentration over two millimoles per liter (mmol/L)  leading to seizures, coma, renal failure, arrhythmias, blood pressure changes, circulatory failure, sudden death, hypothyroidism renal dysfunction (polyuria and polydipsia) and benign intracranial hypertension (e.g. persistent headache and visual disturbance).

Enlist six counseling points for lithium?

See the doctor if any of the warning signs occur. Advise patients of staying on the same brand of lithium carbonate. Maintain constant water and salt intake (especially during hot weather and infection). Advise patients on interactions of lithium with over-the-counter (OTC) medications and to avoid alcohol. Do not stop lithium unless the doctor told you otherwise. 

List ten drugs that have increased risk of toxicity when lithium is comorbid with them?

Mainly any drugs that affect renal output: Angiotensin-converting enzyme (ACE) inhibitors, angiotensin-2 antagonists, loop diuretics, thiazides, Non-steroidal potassium-sparing diuretics, aldosterone antagonists, metronidazole, SSRIs, tricyclics. L.A.S.T. T.A.N. M.A.P.

With which drug, there is an increased risk of ventricular arrhythmias when lithium is given? 

Amiodarone

List five medications with which there is an increased risk of neurotoxicity when given with lithium alongside? 

Methyldopa, phenytoin, carbamazepine, diltiazem, verapamil MPCDV 

Increased risk of extrapyramidal side effects when lithium is given alongside these drugs? 

Clozapine, haloperidol, sulpiride, phenothiazines, risperidone, flupentixol, zuclopenthixol.  Mnemonic: CH(ie)FS  PR(e)Z

Safety of lithium in pregnancy? First, second, third trimester?

First trimester: Avoid due to teratogenicity, including cardiac abnormalities. Second and third trimester: Dose requirements are increased during the second and third trimesters, which return to normal after delivery.

Can mothers breastfeed while on lithium treatment?

lithium is present in breastmilk and can cause toxicity in the infant.

When should lithium concentration be monitored in regards to the last dose?

Twelve hours after the last dose.

How often should we carry out serum lithium tests when starting treatment?

Weekly after initiation and, after each dose change, weekly again.

How often should serum lithium be tested once a patient has achieved maintenance therapy?

Every three months, unless a patient develops the intercurrent disease, or has a significant change in sodium or fluid intake.

How should lithium be stopped?

Reduce gradually over four weeks to three months to lessen the risk of relapse.

What to do if the patient must stop lithium immediately, e.g. due to severe renal failure? 

Change to atypical antipsychotic or valproate.

Date: 02/06/2020

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