Showing posts with label Management and Treatment. Show all posts
Showing posts with label Management and Treatment. Show all posts

Thursday, 24 May 2018

Schizophrenia :Risk Factors, Treatment, and Antipsychotics

May 24, 2018

Schizophrenia: Risk Factors and Treatment



Schizophrenia :Treatment


Potential Psychosocial risk factors for Schizophrenia  include: 

  • Childhood diversity:
    • Emotional abuse
    • Physical abuse
    • Sexual abuse
    • Ignorance
    • Death of parents.

  • Migration, especially becoming a member of a lower socio-economic ethnic minority in an affluent nation.

  • Being born in the urban area.

  • Any life event full of stress 

  • Illicit Substance Use- Drugs which increase Dopamine activity (Cocaine, Amphetamine, Cannabis)  can cause psychotic symptoms similar to Schizophrenia. 

However, a greater proportion of patients with Schizophrenia use illicit drugs compared to the general population. While these drugs can cause psychotic symptoms,  it is unlikely that they actually cause Schizophrenia, but, in vulnerable individuals, they can-

    • Increase the frequency of relapse in a patient with Schizophrenia.

    • Bring forward the age of onset of Schizophrenia.

    • Can also interfere with the effectiveness of antipsychotics.



Treatment of Schizophrenia- General Principles


Antipsychotics (Neuroleptics) are the mainstay of treatment for Schizophrenia. If available, Cognitive Behaviour Therapy (CBT) may be used in addition to antipsychotic for treatment-resistant psychotic symptoms.



In severe, chronic Schizophrenia, the patient would need psychosocial rehabilitation.


Rationale for Anti-Psychotics

Dopamine Hypothesis of Schizophrenia: This states that Schizophrenia is due to an excess of Dopamine in the brain, so by decreasing the activity of Dopamine, Schizophrenia can be treated. 



Classification of Anti-Psychotics is as follows:

 1) Older / First Generation /Typical:
    
       a)    Chlorpromazine

       b)    Haloperidol

2) Newer / Second Generation / Atypical:

         a) Risperidone

         b) Olanzapine

         c) Quetiapine

         d) Clozapine



Clozapine: Clozapine is superior to antipsychotics as compared to other antipsychotics in managing 'Treatment Resistant'. Schizophrenia. ('Treatment Resistant' Schizophrenia: Schizophrenia that has not responded to at least 2 different antipsychotics given at an adequate dosage for an adequate period of time i.e at least 4-6weeks each.).




 About 20% - 30% of patients with Schizophrenia are Treatment Resistant. The most important thing to keep in mind is Clozapine has also an antisuicidal effect.



General Principles Of Using Antipsychotics:

   "Start Low, Go Slow"
  • Start at a low dose 

  • If needed, increase the dose gradually

  • Review mental state regularly

  • Monitor for side-effects

  • Avoid antipsychotics 'polypharmacy'(using more than one at the same time).

General Principles When Using Antipsychotics:


  • It usually takes at least 2 to 3 weeks for the antipsychotic effect to manifest, and a further 2 to 3 weeks for it to maximize.

  • If the patient improves, do continue medication for several months after recovery.

  •  If the patient does not improve, change to another antipsychotic.

Long-Term Maintenance Treatment for Schizophrenia:


Maintenance treatment is given to:
  • Maintenance control over symptoms.

  • Reduce the risk of relapse.

  • Improve the quality of life/functioning.

How long it needs to be given depends on:

  • A number of episodes.

  • The severity of the episodes.

  • Impact of episodes on functioning.


Other treatment options for Schizophrenia:
  • Psychoeducation

  • Cognitive Behaviour Therapy (CBT)

  • Family Therapy 

  • Art Therapy

  • Cognitive Remediation Therapy

  • Social Skills Training.






Wednesday, 9 May 2018

Eating Disorders: Co-morbidity, Assessment, Management And Treatment

May 09, 2018
Eating Disorder: Assessment, Treatment, and Management


A considerable proportion of patients with Eating Disorders have other psychiatric disorders. Most common co-morbid illness is Depression, followed by Anxiety Disorders and Personality Disorders.


However, Psychosis, OCD, and PTSD are more common in Anorexia Nervosa as compared than in other eating disorders.
Secondly, Alcohol and substance misuse are the more common in Bulimia Nervosa than in other Eating Disorder.

comorbidity, treatment, management of AN,BN and BED


 Assessment For Eating Disorder - General Points

According to a medical report the majority of patients with Eating Disorder especially BN and BED do not receive proper treatment (either patient do not seek treatment or the diagnosis is overlooked). 

Here are the few points that could help for the assessment of Eating Disorder.


  • Take a comprehensive Medical History.

  • Measure the BMI (Body Mass Index).

  • Do a general physical examination, looking for the signs and symptoms of Anorexia Nervosa and Bulimia Nervosa.

  • Do routine blood tests before initiating the treatment.

  • Do a baseline ECG.

Management of Eating Disorders - Overview

  • There are a wide variety of treatments used for Eating disorders.

  • Normalization of nutrition and eating habits is a central goal in the treatment of patients.

  • As eating disorders tend to run  a chronic course, it is important to monitor and address, on an ongoing basis:

    • Psychiatric co-morbidities.

    • Physical health complications.

    • Changes in Social circumstances.

Management of Anorexia Nervosa-
  
Depending on the availability or need patient can be treated in a :

    • Routine Psychiatry Outpatients (Adult or Child and Adolescent Services) clinic.

    • General Psychiatry Inpatient Unit.

    • General Medical Inpatient Unit.

    • Specialist Eating Disorders Inpatients/Outpatients Unit.


Pharmacotherapy for AN

Based on the research, Atypical antipsychotics (Olanzapine) and Zinc supplementation could be beneficial.

 Moreover, it is important to identify and treat any co-morbid depression and anxiety accordingly, with antidepressants.



A rationale for using Atypical Antipsychotics in AN-
  • In order to help promote weight gain(Olanzapine could be beneficial).

  • To reduce hyperactivity (used by patients as a weight losing tactic).

  • According to some evidence from neuroendocrine studies that dopamine neurotransmission is increased in AN.

So, that means Antipsychotics that have dopamine antagonist effect might be helpful.

A rationale for using Zinc in AN-

 There is a zinc deficiency in AN and zinc plays an extreme role in neurotransmitter function, it has an appetite stimulant effect also.
 According to one study, it has been found effective and beneficial that a 14 mg of elemental zinc given daily for two months(as a suggested dose).



Treatment of Bulimia Nervosa-


  • Patients are generally treated as Outpatients.

  • CBT is the treatment of choice- either Individual CBT or Group CBT

  • Other CBT Options: web-based / Telemedicine CBT, Guided Self-help, Bibliotherapy(Self-help books).

  • Interpersonal Therapy may be another helpful option.

  • Education about Healthy dieting can be helpful.


Pharmacotherapy for BN-

 SRRIs (particularly high-dose of Fluoxetine) can be helpful in reducing bingeing urges and other obsessional preoccupation with weight.


 Antiepileptic Topiramate may be helpful as it has an appetite reducing the effect.



Management of Binge Eating Disorder

Studies show that it has a high placebo response. Similar treatment approaches as for BN.

  • Psychotherapy options:

    • CBT: Individual / Group/ Online/ Self- Guided Help/ Bibliotherapy.

    • Other psychotherapies: IPT (Inter-Personal Therapy)

  • Medications:

    • SRRIs (esp. Sertraline/ Esciatalopram / Citalopram), Imipramine, Topiramate, (Sibutramine is no longer approved due to risk of MI and stroke).

  • Weight loss treatment programmes / Individual coaching, etc can be helpful with obesity.



Other helpful Treatment Options for Eating Disorders


Exercise programmes (Light resistance training) this might be helpful in changing the patient's attitudes towards exercise and also may increase bone and joint strength.

  • Mindfulness training

  • DBT (Dialectical Behaviour Therapy)

  • EMDR

  • Yoga

  • Body Awareness Therapy

  • Estrogen Supplementation

  • Bright Light Therapy

  • Parenting skills training (parents need to create awareness among their children to reduce the risk of an eating disorder behaviors from an early age.)

Also, read 

          



Tuesday, 1 May 2018

Bipolar And Unipolar Disorder: Co-morbidity, Prognosis, Factors And Treatment

May 01, 2018
The Co-morbidity is common for both Polar and Unipolar disorders. Some common co-morbid psychiatric disorders include Anxiety disorder, alcohol/substance misuse, personality disorders, eating disorders, ADHD. 

Whereas, Physical co-morbidities include: Thyroid dysfunction, migraine, metabolic syndrome (induced by antipsychotics).
Bipolar and unipolar depression :Signs and Symptoms and treatment


Prognosis Of Mood Disorders- Poor Prognostic Factors

  •  Earlier age of onset(childhood-onset Bipolar).

  • Longer duration/increased severity of episodes.

  • Poor initial response to treatment.

  • Suicidal behavior.

  • Alcohol and substance misuse.

  • Low level of social support/ social integration.

Additionally increased frequency of episodes, Psychotic symptoms, mixed episodes, family factors such as high expressed emotions, and the first episode of depression rather than Mania are some poor prognostic factors for the Bipolar disorder.



Treatment of Depression (Bipolar And Unipolar Disorder)-



There are two main treatment approaches for depression, which is  used either on their own or in combination:
  1. Anti-depressants

  1. Psychotherapy (usually CBT-Cognitive Behaviour Therapy)

Rationale For Anti- Depressants-

Monoamine Hypothesis of Depression: This states that depression is due to a deficiency of Monoamines(Serotonin or Noradrenaline) in the brain so, by increasing the levels of one or both of these monoamines, depression can be treated.


Newer Antidepressant :

1) Agomelatine:
  • Agonist at MT1/MT2 melatonin receptors.
  • Melatonin, secreted by the pineal gland (which is important to sleep).
  • MT1 and MT2 receptors are located in the suprachiasmatic nucleus of the hypothalamus(the sleep center).
  • Common side effects include diarrhea, headache, and nausea.


General Principles When using Antidepressants.

  • Start Low, Go Slow

    •          Start at a low dose.

    •          Increase dose gradually(if needed).

    • Review mental state regularly.

    • Monitor for side effects.

    • Avoid 'poly-pharmacy'(using more than one antidepressant, except for treatment-resistant Depression)

NOTE- It usually takes at least 2 to 3 weeks for an anti-depressant effect to manifest. If the patient improves, continue medication for several months after recovery. 


If the patient doesn't improve, gradually change to the other anti-depressant. If repeated relapses, consider long-term maintenance treatment.


COGNITIVE BEHAVIOR THEORY (CBT)

The aim of CBT is to help the patient'to correct the negative cognitions and other unhelpful behaviors that maintain the depression because of negative cognitions and maladaptive behaviors can cause one to feel low in mood and which leads to depression.


Management Of Bipolar Depression-
  • Among atypicals: Quetiapine may be the drug of choice.

  • Among anti-epileptics: Lamotrigine may be the drug of choice.

  • For severe, treatment-resistant depression: ECT may be an option.

General Management Principles

  • Assess suicidal risk during depressive/mixed episodes.

  • Assess safety issues(to the patient and others as well) during manic episodes.

  • Identify and try to address contributory factors such as work stressors, physical health issues, alcohol misuse, etc.

  • Educate the patient about the illness and rationale of treatment.

  • Advice patients about Sleep Hygiene as disturbed sleep is a prominent risk factor for relapse and also for switching from Depression to Mania.

Long-term course of Bipolar Disorder-
    
  • The average duration of a Depressive episode is (months) is more than that of Manic episodes.

  • Women with the Bipolar disorder may experience more Depressive episodes than men with Bipolar disorder.

  • Patients with Bipolar disorder tends to have more and longer Depressive episodes in the course of their lifetime than patients with the Unipolar disorder.

  • On an average, a Bipolar patient will experience about 10 episodes in their lifetime with a roughly equal number of depressive/manic episodes.




Sunday, 29 April 2018

Personality Disorders :Assessment, Management and Treatment

April 29, 2018

        Assessment of Personality Disorders



Personality Disorders :Assessment, Management and Treatment
  • Personality Disorder shares many common features with functional Mental Disorder. The main differentiating feature is that in Personality Disorder, the one set is early and the features have been persistent and stable, while in functional Mental Disorder, the onset is usually later and the symptoms tend to be episodic. However, this distinction is not clear.

  • Knowing the background personality in a patient with a Mental Disorder helps the Clinician be more realistic with respect to the treatment outcome expectations.

  • So, it is very important to access the patient's Personality as a part of the initial assessment(usually with extra information from another source such as Parents, Siblings, Spouse, Family, Physician, etc) who has known the patient for many years.


  •   It is generally not appropriate to make a diagnosis of a Personality Disorder after just one Assessment session. Usually, a  patient would need to be seen at least a few times.

  • Previous Medical/Psychiatric records, if available, should also be studied.

  • while the exception of Borderline Personality Disorder, most other Personality Disorders are diagnosed the only incidentally in routine psychiatric services in patients presenting with other problems like Psychosis, Depression, Anxiety, etc.

  • Patients with a Personality disorder are at higher risk of developing Mental Disorder.


Management Of Personality Disorder


Apart from the Borderline PD, the vast majority of patients with Personality Disorders(with no co-morbid Mental Disorder) do not to the attention of mental health services. Hence, most of the studies of treatment have been on Borderline PD.


The other Personality Disorders are usually incidentally diagnosed in patients presenting with the other disorders like Depression, Anxiety, Psychosis or Addiction.


 Antisocial PD is, as expected, very common in the prison/criminal justice settings. It is usually diagnosed formally only after the person has committed a crime.


Management Of Borderline Personality Disorder:

 The goals of treatment include:

  • Better management of one's emotion.

  • Avoidance of / reduction of self-harm behavior.

  • Having more clarity about one's purpose in life.

  • Building better quality relationships with others.

  • Improvement in functioning.

  • Addressing the co-morbid Psychiatric/substance misuse issues.

Psychotherapy for Borderline PD-

    • Psychodynamic Psychotherapy

    • Dialectical Behaviour Therapy (DBT)

    • Transference-Focused Psychotherapy (TFT)

    • Mentalisation -Based Therapy (MBT)

    • Emotion Regulation Training (ERT)

    • Cognitive Behaviour Therapy (CBT)

    • Schema-Focused Therapy (SFT)

    • Interpersonal Psychotherapy (IPT)

 Pharmacotherapy for Borderline PD


  • Not used as a primary treatment as it is unlikely to alter the natural course of the disorder.

  • Mainly used for symptoms management.

  • Risk of overdose needs to be borne in mind while prescribing psychotropics.

  • Drugs that may have some benefits include:
              a) Antidepressants: usually SSRIs.

              b)Antipsychotics: usually low/dose atypicals.

              c)  Mood stabilizers: e.g. Valproate, Lithium.

                     d) Others e.g. Clonidine, Omega-3 fatty acids.



Management Of Paranoid Personality Disorder-

Patient with Paranoid Personality Disorder is very difficult to treat as they are mistrustful of most people, including Psychiatrists. A patient with Paranoid PD is unlikely to present for treatment unless there are significant immediate problems. 


For examples, a patient may be at risk of losing a job because of complaints from colleagues or a wife is deciding to leave unable to tolerate suspicious nature of the husband.


Low dose Antipsychotics may be helpful.



Treatment for Personality Disorders


If the patient is willing and motivated to change, and depending on the PD, and the availability of services the following treatments may help.


  • Psychotherapies: ranging from Supportive, through CBT, to Exploratory therapies like Psychodynamic Psychotherapy.

  • Self-help: books and online support groups.

  • Treatment of any co-morbid disorders such as Depression, Anxiety, etc with Medication or Psychotherapy to optimize functioning.