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Emergency paediatrics Chapter 5: Paediatrics 197
https://t.me/med1917
Injuries & trauma
→ major cause of death in those aged 1–14y
ROAD TRAFFIC ACCIDENTS (passenger or pedestrian)
→ Most common cause of death / serious injury in childhood
HEAD INJURIES (most minor but 1 in 800 develop serious problems)
Assessment
• ABCDE (especially consciousness & pupils)
• Monitor for 2° damage
Management
68
Mild: discharge with written advice
Potentially severe: monitor for signs of 2° damage
Severe: resuscitation, CT, neurosurgical referral
Complications
• Hypoxia: airway obstruction / ventilation
• Hypo-/hyperglycaemia
• Cerebral perfusion: ICP, BP from bleed
• Haematoma
• Infection: open wound, CSF leak
BURNS & SCALDS (death usually due to smoke inhalation rather than burn)
Assessing the burn
A: early intubation if airway swelling
B: check for airway burns
▶ soot in nose, coughing black sputum
▶ stridor, hoarseness, cough
▶ breathing/swallowing difficulties
C: check BP & if low ensure no other cause for fluid loss e.g. bleed
D: assess pain with pain score
E: assess severity of burn: surface area, depth, involvement of delicate sites
Management
1. Burns first aid: cold water 20min + clingfilm
2. Analgesia e.g. IV morphine
3. Fluid resuscitation – if shock / >10% surface area
4. Wound care
• Superficial = clean & dress
• Deeper, >5%, sensitive areas = specialist review
face, ears, eyes, perineum
Red flags of head injuries
• LOC >5min
• Seizure
• GCS <15 2h post-injury
• Focal neurological deficit
• Amnesia >5min
• Signs of fracture
• High risk trauma
• ≥3× vomiting
Surface area
Patient’s palm = 1% of body surface area
• Add 0.5% to each leg with every year >1y
of age
• Subtract 2% from head with every year >1y
of age
Specialist review of burn if:
∙ full thickness >5%
∙ partial thickness >10%
∙ sensitive area
∙ chemical/electrical burn
NEAR DROWNING → BATHS (neonates), POOLS/LAKES (toddlers/children)
1. Mouth-to-mouth resuscitation & CPR
2. Cover and keep warm
3. Hospital admission: monitor for respiratory distress, pulmonary oedema,
development of pneumonia
CHOKING/ASPIRATION
→ Unconscious: paediatric BLS
→ Conscious & ineffective cough: 5 back blows, 5 abdo thrusts
(chest thrusts if aged <1y)
68
NICE (2014, updated 2019) Head injury [CG176]
198 Chapter 5: Paediatrics Emergency paediatrics
https://t.me/med1917
Status epilepticus
→ seizure >30min OR successive seizures over 30min with no recovery between
MANAGEMENT
69
1. ABCDE
• Secure airway, high flow O2, secure IV access
• Don’t Ever Forget Glucose (r/o hypoglycaemia)
• Confirm it is an epileptic seizure (Hx, features, etc.)
2. Manage convulsion
At Step 1:
Obtain Hx including
medication given so far
At Step 2:
CALL FOR SENIOR HELP!
At Step 3:
GET AN ANAESTHETIST
At Step 4:
Mechanical ventilation
Transfer to PICU
IV lorazepam
(or buccal midazolam)
IV lorazepam
(or buccal midazolam)
IV phenytoin/levetiracetam/
sodium valproate
ITU & intubation
Repeat 5min later
Fig. 5.53
Diabetic ketoacidosis
→ see Chapter 2: Endocrinology in General Medicine and Surgery, the companion
volume to this book
69
NICE (2022) Epilepsies in children, young people and adults [NG217]
199
https://t.me/med1917
PSYCHIATRY
Mental Health Act (MHA 1983) &legislation ... 200
Alcohol & substance misuse.........................................201
Depression
Anxiety disorders
Reactions to stress and trauma
Health anxiety & somatisation
Personality disorders
Psychosis & schizophrenia
ABBREVIATIONS
AD – Antidepressant
ADHD – Attention deficit hyperactivity disorder
ADLs – Activities of daily living
AMHP – Advanced mental health practitioner
AP – Antipsychotic
ASD – Autism spectrum disorder
BPAD – Bipolar affective disorder
BZD – Benzodiazepine
CAMHS – Child and Adolescent Mental Health Services
CBT – Cognitive behavioural therapy
CK – Creatine kinase
CNS – Central nervous system
CPN – Community psychiatric nurse
CTO – Community treatment order
DA – Dopamine
DBT – Dialectical behaviour therapy
DEXA – Dual-energy X-ray absorptiometry
ECT – Electroconvulsive therapy
EEG – Electroencephalogram
EMDR – Eye movement desensitisation & reprocessing
EPSE – Extra-pyramidal side-effects
EUPD – Emotionally unstable personality disorder
GABA – Gamma-aminobutyric acid
GAD – Generalised anxiety disorder
GGT – Gamma-glutamyl transferase
IAPT – Improving access to psychological therapies
ICD-10 – International Classification of Diseases10th Revision
ID – Intellectual disability
................................................................................204
................................................................206
................................. 208
.................................. 209
........................................................ 210
............................................ 212
06
Mania & bipolar affective disorder
Antipsychotics
Psychiatric emergencies
.......................................................................216
................................................. 217
Child & adolescent psychiatry
Eating disorders
Intellectual disability
Perinatal psychiatry
LDL – Low density lipoproteins
LSD – Lysergic acid diethylamide
MAO(I) – Monoamine oxidase (inhibitor)
MBT – Mentalisation-based therapy
MCA – Mental Capacity Act
MCV – Mean corpuscular volume
MDMA – 3,4-methylenedioxymethamphetamine
MHA – Mental Health Act
MS – Multiple sclerosis
MSE – Mental state exam
MZ twins – Monozygotic twins
NA – Noradrenaline
NaSSA – Noradrenergic and specific serotonergic antidepressants
NMS – Neuroleptic malignant syndrome
OCD – Obsessive–compulsive disorder
OCP – Oral contraceptive pill
PD – Personality disorder
PPD – Postpartum depression
PPP – Postpartum psychosis
PTSD – Post-traumatic stress disorder
SLE – Systemic lupus erythematosus
SNRI – Serotonin-norepinephrine reuptake Inhibitor
SNS – Sympathetic nervous system
SSRI – Selective serotonin reuptake inhibitor
STI – Sexually transmitted infection
TCA – Tricyclic antidepressant
THC – Tetrahydrocannabinol
...................................................................220
........................................................222
...........................................................223
......................... 214
.................................... 219
200 Chapter 6: Psychiatry
https://t.me/med1917
Mental Health Act (MHA 1983)
&legislation
MENTAL HEALTH ACT 1983: legislation that allows people to be detained in hospital for assessment and/or treatment of their
mental illness, providing certain criteria are met.
Only allows treatment of mental illness, not physical conditions. Treating physical illness against a person’s wishes requires
assessment under the Mental Capacity Act in patient’s best interests.
Appropriate treatment
must be available at the
hospital named on the form
yellow highlight = most important to
knowasjunior doctor
See
Chapter 2: Geriatrics
more information on MCA
for
When diagnosis unclear / no treatment plan
• Allows detention for period of assessment (& Tx if needed)
• After 28d must decide on section 3 or informal Tx
doctor
• 1 ‘section 12’ approved
Cannot implement back-to-back Sections
(specific expertise in mental
illness)
• another doctor
plan
Can be renewed after 6m & then after 12m
• AMHP
waiting for a second medical recommendation would involve undesirable delay
• Allows detention and Tx against patient’s will
before)
(who has ideally met patient
Can convert to Section 2/3 after 2nd doctor assessment
can be done
• Allows detention by any registered doctor until formal assessment
• Only inpatients (excludes A&E)
Not F1 as not fully registered
(ideally the responsible clinician
Up to 72h 1 registered medical practitioner
‘Doctor’s
holding power’
• Cannot treat
• Tell an AMHP or psychiatrist that it has been implemented ASAP
Cannot implement back-to-back Sections
OR nominated deputy – usually
most senior team member)
• Allows detention until appropriate doctor can assess
• Patient must be already receiving treatment for mental health as an inpatient
Cannot implement back-to-back Sections
nurse / 1 learning disability nurse
Up to 6h 1 registered mental health
‘Nurse’s
holding power’
Allows police to enter home and remove person to place of safety
If they have a warrant
• Allows police to remove person to a place of safety for formal assessment
(AMHP applies to magistrates’
court)
immediate need of care or control for the safety of themselves or others
e.g. A&E, 136 suite, (police station in exceptional circumstances)
• Applies to someone suffering from a mental disorder, is outside their home & is in
• Allows Tx under MHA while living in community
• Only relates to psychiatric care (not physical health)
Non-compliance can result in recall to hospital / revoking of CTO
AMHP
As needed/
indefinitely
treatment
order (CTO)
2 Assessment Up to 28d 2 doctors + AMHP
Section Type of order Length Staff involved Explanation
3 Treatment Up to 6m When definitive diagnosis with treatment
4 Emergency Up to 72h 1 doctor + AMHP Allows emergency detention if only 1 qualified mental health doctor present &
5(2) Emergency
5(4) Emergency
135 Power of entry Up to 36h Magistrate
136 Place of safety Up to 36h Police officer
17A Community
Alcohol & substance misuse
https://t.me/med1917
Chapter 6: Psychiatry 201
Acute intoxication: transient physical & mental abnormalities shortly after
administration e.g. altered cognition/behaviour
Harmful use: continued use despite evidence of damage to physical/mental
health or social wellbeing but no dependence
cessation e.g. seizures, delirium, psychosis
acting administration route
continued use despite negative consequences, loss of control of consumption,
tend towards single preferred drug, tolerance & withdrawal
↳ Costs NHS
→ In UK 9% men & 4% women are dependent
→ Younger people drink more heavily, older people drink more frequently
→ Alcoholic liver disease is greatest cause of alcohol-related deaths
↳ prevalence is increasing
£3.5 billion
per year
RISK FACTORS:
• Genetics & gender – male > female
• Mental illness – depression, anxiety disorders, schizophrenia
• Stress, low self-esteem, social anxiety / isolation
• Significant life events – bereavement, trauma
• Lower socioeconomic status
• Occupation – bartenders, farmers, healthcare professionals
ICD-10 diagnostic criteria:
Tolerance Tremor (withdrawal Sx)
Control loss Compulsion
Primacy Persistence despite harm
One unit = 10ml ethanol
Guidelines = ≤14 units per week*
Social consequences of alcohol misuse
• Relationship problems / domestic violence
• Risky sexual activity
• Missed work / poor performance
• Suicide/homicide
• Financial & legal problems
(contact with criminal justice system)
5/6 in past year
Medical consequences Psychiatric consequences
CNS: cognitive/memory impairment, reduced brain volume,
cerebellar degeneration, Wernicke–Korsakoff syndrome
PNS: peripheral neuropathy, optic atrophy
Hepatic: fatty liver, hepatitis, cirrhosis*, hepatocellular carcinoma,
hepatosplenomegaly, pancreatitis
Gastric: gastritis/ulcer, carcinoma, oesophageal varices, Barrett’s,
Mallory–Weiss tears
Renal: CKD, hepato-renal syndrome Anxiety & depression
GI: malabsorption, diarrhoea, thiamine deficiency (Wernicke’s) +
niacin deficiency (pellagra), GI cancer
CVS: cardiomyopathy, arrhythmias, HTN, cerebrovascular events Schizophrenia – increases risk of relapse & violence
↳ esp. AF
Reproductive: sexual dysfunction, infertility, fetal alcohol syndrome
Acute Wernicke–Korsakoff syndrome: due to thiamine (vitamin B1) deficiency**
Wernicke’s encephalopathy:
• Acute confusion
• Ophthalmoplegia/nystagmus
• Ataxic gait
Treat promptly to prevent progression & death:
IV Pabrinex (vit B & C) + alcohol withdrawal Tx
*risk in women
progresses in 80%
Korsakoff syndrome:
• Antero-/retrograde amnesia
• Confabulation (false memories)
• Apathy (indifference/ interest)
Alcoholic hallucinosis:
of abstinence (usually visual)
Respond well to antipsychotics & typically resolve in 24–48h
DDx: acute psychotic episode, delirium tremens
Pathological jealousy – primary delusion that partner is unfaithful
→ associated with violence towards partner
ARBD (alcohol-related brain damage): cognitive/memory
impairment & dementia
Suicide (10–15% risk)
hallucinations while sober / after 12–24h
**In alcoholics: poor diet &
absorption/hepatic storage
Wernicke’s prognosis
15% mortality if untreated
20% complete recovery
25% significant recovery
202 Chapter 6: Psychiatry
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Patients often non-compliant
Stages of change model describes how ready
patients are to change behaviours
Pre-
contemplation
Relapse
Fig. 6.1
Maintenance
Contemplation
Preparation
Action
→ often missed (patient denial is a problem)
HISTORY
Lifetime pattern of consumption
• When did they begin to drink
regularly / first feel they had a
problem?
• Reasons for periods of heavy drinking
Current pattern of consumption
• How often, what type of drink,
how much?
• Where and when?
• Description of a typical day / heavy
day of drinking
Signs of dependence
• Withdrawal symptoms in
morning / if not had a drink
• Having to drink more for same
effect (tolerance)
• Episodes of memory loss / blackouts
(amnesia)
Social/occupational problems
• Missed days of work / lost job
• Relationship difficulties
• Financial impact, criminal charges
Previous treatment attempts
• Nature and effectiveness
Physical and mental health (often
comorbid mental health Dx)
• Resulting from or exacerbated by
drinking
INVESTIGATIONS
• MCV – stays raised 3–6m after
abstinence
• GGT – alcohol-related liver
inflammation
• Liver USS – if indicated
PHYSICAL EXAMINATION
• Of major systems (liver stigmata,
cerebellar signs, peripheral
neuropathy) &for symptoms of
withdrawal
Withdrawal effects Timeframe Signs & Sx
Withdrawal symptoms >6h after last drink
Seizures 12–48h after last drink Tonic–clonic seizures
Delirium tremens 48–96h after last drink
Alcoholic hallucinosis 12–24h after last drink
Screening questions to detect misuse: CAGE
Cut down – ever felt you should cut down your
drinking?
Annoyed – ever been annoyed by others
criticising your drinking?
Guilty – ever felt bad/guilty about your
drinking?
Eye opener – ever drunk first thing in the
morning to steady nerves?
Poor prognostic factors
• Ambivalent about change
• Homeless / unstable accommodation
• Unemployed
• Lack family / social support
• Repeated treatment failures
Insomnia, tremor, anxiety, GI upset, headache, sweating, palpitations
Resolve in 24–48h
Hallucinations, disorientation, HR, BP, sweating, fever, agitation
Last 1–5d
Emergency admission for Tx: PO lorazepam, thiamine, hydration
Vivid visual hallucinations (have insight)
Resolve in 24–48h
→
in the community unless severe/high risk delirium tremens / liver failure
PSYCHOSOCIAL
• Drug & alcohol services (e.g. Alcoholics Anonymous)
• Motivational interviewing, CBT, counselling, self-help resources
• Housing, financial, childcare support, avoid other users
RISK ASSESS
BIOLOGICAL
1. Detoxification/withdrawal management: reducing regimen over 7–10d
• Chlordiazepoxide – a BZD to treat withdrawal symptoms
• Thiamine (B1) – to avoid/treat Wernicke–Korsakoff syndrome
2. Maintaining abstinence:
• Disulfiram – irreversible inhibition of acetaldehyde dehydrogenase (ALDH)
causing acetaldehyde build-up
↳ unpleasant symptoms of flushing, headache, nausea deter further
alcohol consumption
• Acamprosate – enhances GABA transmission to reduce alcohol cravings
(contraindicated in renal failure)
• Naltrexone – reduces euphoric effects (can raise liver enzymes)
1
NICE (2011) Alcohol-use disorders [CG115]
Chapter 6: Psychiatry 203
https://t.me/med1917
Complications of IV drug use:
• abscesses/cellulitis/osteomyelitis
• bacterial endocarditis / septicaemia
• transmission of viruses (HIV, Hep B/C)
Effects: euphoria, sedation, strong analgesia
SEs: N & V, constipation, respiratory depression, consciousness, pinpoint pupils
Withdrawal: irritable/anxious, sweating, shaking, restlessness, insomnia, fever/chills, diarrhoea, arthralgia/myalgia,
blown pupils
→ very unpleasant but rarely serious
Effects: suppressed CNS activity, anxiolytic
μ opioid receptor agonist = GABA inhibition =
reduced inhibition of dopamine release
↳ smoked or IV
BZDs
Potentiate GABA at GABAa receptor
SEs: sedation, dizziness, impaired concentration/coordination, depression
Withdrawal from BZDs: agitation, anxiety, insomnia, seizures, delirium, psychosis
→ may be fatal
Effects: euphoria, feelings of extreme wellbeing, increased mental & motor activity, alertness, energy, confidence → risky/aggressive
behaviour
Cocaine
Monoamine reuptake inhibition
HR, arrhythmias, septal necrosis, panic disorder / paranoia, psychosis
SEs cocaine:
(increased DA, NA, serotonin)
SEs MDMA: nausea, blurred vision, dehydration, depression/anxiety
Withdrawal: dysphoria/anxiety, fatigue, muscle aches/tremors, craving
→ unpleasant but rarely serious
Effects: altered sensory/perceptual experiences (delusions/hallucinations), detachment
SEs: dizziness, dilated pupils, HR, HTN, appetite, anxiety/panic attacks
Cannabis
THC = active chemical → binds CB1 receptors
to cause effects
Link between use of cannabis at young age and developing schizophrenia
LSD: 5HT receptor agonist
PSYCHOSOCIAL
• Drug & alcohol services (e.g. Narcotics Anonymous)
• Motivational interviewing, CBT, counselling, self-help resources
• Housing, financial, childcare support
↳
• Harm reduction: promote use of sterile needles / don’t reuse
↳
Long-acting opioid causes constant receptor occupation so taking illicit opioid on top has no effect
↱ α
↳
or share (if not willing to give up completely)
Class of substance Mechanism Effects
OPIATES
• Heroin (diamorphine)
• Morphine
• Methadone
• Pethidine
↳
DEPRESSANTS
• Alcohol
• Cannabis – smoked
• Barbiturates
• BZDs – oral
STIMULANTS
• Cocaine (‘Charlie’) – snorted
• Crack cocaine – smoked
• Amphetamines
• MDMA (Ecstasy) – oral
HALLUCINOGENS
• Cannabis (‘dope’) – smoked
• LSD
• PCP (phenylcyclidine)
• Ketamine
• Psilocybin (magic mushrooms)
New psychoactive substances (legal highs) → now illegal
→ plant-based/synthetic substances mimicking effects of illicit drugs
BIOLOGICAL
1. Detoxification/withdrawal management
Symptom reduction: Lofexidine, loperamide,
metoclopramide, Z-drugs, ibuprofen
2. Maintenance
Substitute medications: Methadone, buprenorphine
(opiate replacement)
204 Chapter 6: Psychiatry
https://t.me/med1917
Depression
ICD-10 criteria: symptoms for ≥2w
• Mild: 2 core + 2 other (total = 4)
• Mod.: 2/3 core + 3/4 other (total = 6)
• Severe: 3 core + 5 other (total = 8)
Somatic syndrome: physical Sx of depression
• appetite & weight loss (>5% in 1m)
• early morning waking
• psychomotor retardation/agitation
• energy & libido
Estimated 5% of global population (large increase since Covid pandemic);
prevalence peaks in older adults >55y (but increasing numbers in younger
population); F>M (including postpartum depression)
2,3
Core symptoms Other symptoms – ‘GAPSSS’
1. Low mood
worse in morning
2. Anhedonia
loss of pleasure in activities
3. Fatigue Self-harm / Suicidal thoughts
Guilt/hopelessness
Appetite changes (weight loss/gain)
Poor memory, Pessimism, Psychosis
Sleep disturbance
= 2nd person, derogatory
→
= persecutory, nihilistic
(e.g. rotting inside)
Self-esteem = low
Prognosis for depression
• 50% recover in 1y (60% relapse)
• 25% = chronic depression (>2y)
• 5–15% die by suicide
Counselling newly diagnosed patients
• Be aware of stigma
• Explain different courses, outcomes,
treatments
• Remain positive & highlight the benefits of
treatment
• Stress importance of treatment adherence
1. Biological interventions
• Antidepressants
• Atypical antipsychotics (if psychosis)
• Augmentation with lithium (Tx-resistant)
• Augmentation with T3 (Tx-resistant)
2. Psychological interventions
• Psychoeducation • Sleep hygiene
• CBT • Self-help e.g. apps
• Mindfulness • IAPT services
3. Social interventions
• Support for education, training,
employment
• Support for housing/benefits
• Carer support: info, support groups,
assessment
• CPN (monitor Sx, mood, mental state)
if severe
MAO theory: noradrenaline, 5-HT, D2, GABA
• Social: life events, isolation, loss, childhood abuse
• Biological: FHx, hormonal changes, chronic/severe illness
• Psychological: negative thoughts, high expressed emotion, criticism,
personality disorder
• Medications: steroids, antipsychotics, substance misuse
• Psychiatric: schizophrenia, anxiety disorder, SAD, BPAD, dysthymia
• Neurological: Parkinson’s, MS, head injury, cerebral tumour, dementia
• Endocrine: hypothyroidism, hyperparathyroidism, Cushing’s, Addison’s
• Infections: HIV/AIDS, glandular fever, STIs
• Systemic: malignancies, SLE, RA, renal failure
All cases need assessment and active monitoring
Mild/moderate depression:
BIOPSYCHOSOCIAL
APPROACH
Primary care
Low intensity psychological interventions (IAPT)
Consider 1st-line medication (SSRI)
NICE guidelines:
not indicated if only
mild/subthreshold
symptoms for <2w &
Moderate/severe or Tx-resistant:
no Hx of depression
Primary care (may consider referral to 2°)
1st-line medication (SSRI) or alternative
High intensity psychological interventions
Inadequate
response to Tx:
Severe depression:
Inpatient or crisis resolution & home treatment
1st-line medication or alternatives/adjuncts (Li2+)
High intensity psychological interventions
Consider dose,
combine or augment
No response to Tx:
switch drug
ECT
2
WHO (2021) Factsheets: Depression
3
NICE CKS (2022) Depression
4
NICE (2009) Depression in adults [CG90]
https://t.me/med1917
Chapter 6: Psychiatry 205
Especially good if sleep
disturbance / lost appetite
St John’s wort: unlicensed herbal remedy for
treating depression
→ evidence of efficacy but difficult to guide
Withdrawal symptoms
↳
on dosing
SJW = a cytochrome P450 inducer causing
• Anxiety
• Sleep disturbance /
tingling
• Dizzy, numb/
• OCP • Warfarin
metabolism and therapy failure of:
strange dreams
• Shaking
• Nausea/vomiting
• Headache
• Digoxin • Phenytoin, carbamazepine
• ‘Shock’ sensations
• Sweating
SEs: nausea, insomnia, fatigue, diarrhoea, dizziness, sexual dysfunction, restlessness
Cautions: long QT, bleeding disorders (especially citalopram) BUT sertraline is indicated if post-MI
CIs: poorly controlled epilepsy
Advise against alcohol with antidepressants,
Paroxetine = teratogenic
as additive sedation effects
↳
SEs: nausea, diarrhoea, constipation, dry mouth, sleep disturbance, postural hypotension, headache
SEs: more prominent sedation & sexual dysfunction & same as above
Cautions: diabetes, uncontrolled HTN, bleeding disorders, epilepsy
SEs: sedation, weight gain, dizziness, HTN, delirium, antimuscarinic*
Cautions: bipolar, diabetes, epilepsy, high suicide risk
CIs: arrhythmias, heart block, post-MI
Cautions: bleeding disorders, diabetes, elderly
Interact with many drugs / tyramine-containing foods (hypertensive crisis) → rarely used
SEs: weight gain & sedation, dizziness, headache
Cautions: diabetes, seizures, urinary retention, elderly
Rule out bipolar before starting antidepressant monotherapy!
↳
Starting treatment
1. Consider SEs, cautions, CIs
2. Start an effective but tolerated dose → trial for 3–4w before deciding if it is working
3. Review regularly
Withdrawal
DO NOT STOP ABRUPTLY: taper dose over 4w
• Withdrawal symptoms particularly noticeable with paroxetine & venlafaxine
• Continue for at least 6m after resolution of symptoms
Types of antidepressant
Inhibit pre-synaptic 5-HT reuptake
Take up to 6w for effect
Fluoxetine
SSRI Sertraline
Class Drug MOA & other notes SEs, cautions & CIs
Symptoms may worsen before improving
Paroxetine
1st line (fewer SEs)
Citalopram
Inhibit 5-HT & NA reuptake
2nd/3rd line
Duloxetine
SNRI Venlafaxine
Inhibit 5-HT & NA reuptake
TCA Amitriptyline
1st line in pregnancy
Imipramine
Lofepramine
Dosulepin
Irreversible MAO A & B inhibition
Tx-resistant/atypical depression
α2 receptor blockage = NA & 5-HT efflux
Isocarboxazid
Moclobemide
MAOI Phenelzine
NaSSA Mirtazapine
Adjunct in Tx-resistant depression
206 Chapter 6: Psychiatry
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Anxiety disorders
Most common psych condition
Symptoms resulting from hyperventilation:
• Dizziness • Tingling • Numbness
Pathological responses to minimal environmental triggers, resulting
in persistent symptoms that impair function &/or cause disabling
Psychological symptoms Physical symptoms
Worrying thoughts Sleep disturbance
Sense of impending doom
Sensitive to noise Muscle tension
Fearful anticipation
Poor concentration Autonomic arousal*
Fig. 6.2
CONSTANT
GAD Phobias PTSD OCD Panic disorder
ICD-10 criteria:
• Generalised & persistent
somatic & psychological symptoms
• Present most days for at least 6m
ANXIETY SYMPTOMS
Insomnia, night terrors
Aches, tremors
EPISODIC
• apprehension / fear of future
• insomnia
• motor tension
• autonomic overactivity & restlessness
• over-cautious behaviour
*Autonomic symptoms
• Dry mouth
• Sweaty
• Hot/cold
• Shortness of breath
• Chest pain, palpitations
• Diarrhoea, urgent micturition
→
the patient
Unlike panic disorder:
Symptoms only occur during or on contemplation
of specific (non-dangerous) situations, leading to
avoidance of such situations.
ICD-10 criteria:
• Recurrent attacks of severe
anxiety (lasting <15min)
• In circumstances of no
→ not restricted to particular
situations so unpredictable
• Anticipatory anxiety between episodes (fear of another attack)
AGORAPHOBIA
• Crowds / public places
• Travelling alone
• Travelling away from home
↱
• sudden onset of threatening body
sensations
e.g. palpitations, choking, dizziness
• loss of touch with reality /
e.g. losing control, going mad, dying
Symptoms experienced with
phobias may progress to
panic attacks
SOCIAL PHOBIA
Marked fear and avoidance of being the focus of attention/scrutiny/humiliation
• Blushing/shaking
• Nausea/vomiting
• Urgency of micturition
SPECIFIC (ISOLATED) PHOBIA
Marked fear and avoidance of a specific object/situation
e.g. animals, birds, insects, heights, thunder, flying, small spaces, blood, injections,
dentists, hospitals
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