Sunday 8 October, 2006

Dealing with borderline personality disorder

Posted in Emergency Dept., General Practice, In The Field, May Su, Psychiatry at 21:31 by May Su

Original article: May Su :: Printer friendly

There is the hypothesis that borderline personality disorder may not be a true personality disorders but rather a form of post traumatic stress disorder. Regardless, a person with borderline personality disorder will present with particular characteristic traits which can be difficult to manage.

Borderline personality disorder

Characterized by: instability of mood, poor self-esteem and self-image, and poor impulse control (1). These mood fluctuations may occur over the space of hours or days, as opposed to the mood fluctuations that occur in bipolar affective disorder. There is often a great fear of abandonment, and higher sensitivity to rejection (or perceived rejection). This can manifest as more unstable interpersonal relationships. The term “splitting” refers to these intense by transient relationships, which can suddenly switch from idealization to contempt.

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Tuesday 26 September, 2006

How to manage difficult patients

Posted in Emergency Dept., General Practice, May Su, Psychiatry, Wards at 18:13 by May Su

Original article by: May Su :: Printer friendly

There are many reasons why patient interactions can be frustrating or difficult. Most commonly these can be traced to factors relating to the patient, the physician, or the health care system (1).

The management of a “difficult” patient requires time, good communication and firm limit setting.

“Difficult patients” are common and unavoidable. That being the case, “avoidance” should never be the goal of management. More often than not, these patients have real physical and/or psychological health needs. Try to restrain yourself from the all too easy temptation of categorising “difficult” with “undeserving” or tossing them into the “too hard basket”.

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Wednesday 2 August, 2006

How to change antidepressants

Posted in General Practice, Michael Tam, Psychiatry, Wards at 18:34 by Michael Tam

Original article by: Michael Tam :: Printer friendly

Although starting antidepressants is not outside the realm of common experience (1), the changing of antidepressants is shrouded in the aura of mystic voodoo that many consider to be best left to the psychiatrists. The reality, however, is that there isn’t much to it.

For the first line and most common antidepressants used (SSRIs except fluoxetine, mirtazapine, venlafaxine and the tricyclic antidepressants):

Taper the dose of the first antidepressant by 25% per day (with complete cessation in 4-7 days).

Start the second antidepressant 3 days after the cessation of the first.

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Wednesday 14 June, 2006

Schedule 2 and other forms

Posted in Emergency Dept., General Practice, In The Field, Michael Tam, Psychiatry, Resources, Wards at 10:26 by Michael Tam

Original article by: Michael Tam

These forms are probably the ones most commonly used in acute psychiatry where a patient needs involuntary assessment or treatment. They are specific for New South Wales, Australia, only under the Mental Health Act (1990).

Click here for more information on the NSW mental health legal system.

Resources

Schedule 2
Schedule 2 for the NSW Mental Health Act 1990. Allows for transport of the patient to a gazetted unit for review by a psychiatrist. Part 2 of the schedule must be completed for assistance from police.
Form 1
Form 1 for the NSW Mental Health Act 1990. Must be given to an involuntary patient and it outlines their rights under the Mental Health Act.
Form 2
Form 2 for the NSW Mental Health Act 1990. Must be completed by at least two people, one a psychiatrist to hold a patient involuntarily.

Saturday 10 June, 2006

Beware of serotonin syndrome

Posted in May Su, Medicine, Psychiatry, Surgery, Wards at 10:40 by May Su

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Serotonin syndrome is a medical emergency. It usually occurs when several serotonergic agents are used simultaneously or concurrently and is due to excess serotonin in the central nervous system.

Serotonin syndrome is a clinical diagnosis and a high index of suspicion is required:

Clinical features of serotonin syndrome (1)

Cognitive

  • confusion
  • agitation
  • hypomania
  • hyperactivity
  • restlessness

Autonomic

  • hyperthermia
  • sweating
  • tachycardia
  • hypertension
  • mydriasis
  • flushing
  • shivering

Neuromuscular

  • clonus
  • hyperreflexia
  • hypertonia
  • ataxia
  • tremor

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Wednesday 7 June, 2006

Psychotropic medications in the elderly

Posted in Emergency Dept., General Practice, Medicine, Michael Tam, Psychiatry, Wards at 17:57 by Michael Tam

Original article by: Michael Tam :: Printer friendly

Psychotropics and the elderly don’t mix well. The elderly patient is more likely to have side-effects, is more likely to have a drug interaction, more likely to be affected in some unexpected though inevitably deleterious manner.

Try to avoid psychotropic agents altogether. When that is not possible; start low, go slow, and use the lowest possible efficacious dose.

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Tuesday 6 June, 2006

How to use psychotropics in behavioural emergencies

Posted in Emergency, Emergency Dept., Michael Tam, Psychiatry, Wards at 16:44 by Michael Tam

Original article by: Michael Tam :: Printer friendly

The vernacular use of “psychotic” is quite different from the medical or psychiatric use. It conjures up the image of the raving, agitated person who is in danger of harming themselves and probably those around them as well. This is the group of patients that are being referred to by the term “behavioural emergencies”. They can be brought into the emergency department or perhaps “go crazy” on the ward; often in the psychiatric unit.

The principle under the NSW Mental Health Act is “treatment in the least restrictive environment”.

Where it is safe to do so, aim for the top of the list:

  • verbal de-escalation techniques
  • “show of force” with de-escalation
  • voluntary oral sedative +/- antipsychotic
  • takedown” with involuntary intramuscular sedative +/- antipsychotic

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Monday 5 June, 2006

How to start antipsychotics

Posted in Emergency Dept., May Su, Psychiatry, Wards at 17:38 by May Su

Original article by: May Su :: Printer friendly

Antipsychotics are the most appropriate medication to use when someone is suffering from a psychotic illness. This may be in the form of schizophrenia or a schizophrenia-like illness, or part of a psychotic depression or bipolar affective disorder. Antipsychotics are not particularly difficult to use and though they can have significant side-effects, are fantastic when they work well. The “first line” antipsychotics are any of the “atypical” antipsychotics with the exception of clozapine.

Assumptions:

  1. The patient is settled enough to tolerate regular oral medications (i.e., the patient doesn’t have a “behavioural emergency“);
  2. He or she actually has a psychotic disorder, rather than intoxication (e.g., with drugs and/or alcohol), withdrawal or delirium (e.g., from cerebral hypoxia post-operatively);
  3. The patient is of regular size and weight and does not have any specific comorbidity or contraindication to antipsychotics.
For the acutely psychotic but otherwise physically well adult:

Olanzapine

  • Starting: 5 mg daily
  • Week 2: 10 mg daily
  • Further: see below

Risperidone

  • Starting: 1 mg daily
  • Week 2: 2 mg daily
  • Further: see below

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Tuesday 23 May, 2006

Two minute overview of antipsychotics

Posted in Emergency Dept., General Practice, May Su, Psychiatry, Wards at 0:15 by May Su

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Antipsychotics can be classified as typical or atypical. There are very few reasons now where a typical would be used in preference to an atypical in first line treatment. Atypical antipsychotic medications generally have fewer side effects and are as effective (clozapine is more effective than most of the older antipsychotics).

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Friday 19 May, 2006

How to start antidepressants

Posted in General Practice, May Su, Psychiatry, Wards at 23:12 by May Su

Original article by: May Su :: Printer friendly

The antidepressants that would be used as a first line agent would usually be a selective serotonin re-uptake inhibitor (SSRI), venlafaxine or mirtazapine. The choice would be determined by the symptoms of the patients and the side-effect profile that would be tolerable. At times, a side effect of a medication may be used as an advantage. See the antidepressant matrix for a single page overview. Furthermore see the list of antidepressants available in Australia.

Of “first line” agents, a few generalisations can be made:

SSRIs, venlafaxine and mirtazapine:

  • The base effective dose is equivalent to one tablet daily;
  • “start low, go slow”: start with a half tablet daily for 4-6 days (except fluoxetine which has very long half life and can be started as one tablet daily);
  • then increase to one tablet daily;
  • the dose can be increased to at least 2 tablets daily (though there is no “rule of thumb” of the maximum safe daily dose – each drug is different).

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