1. Past Papers Flashcards
what is the main overview to your approach to management of a violent patient?
examine first and then take a history
ABC of management
restraint and tranuilisation
continuously monitor the patient
refer
differentials
Main: what is your approach to the management of a violent patient?
-
examine first and then take a history
- observe and examine the situation
- de-escalate the situation
- take collateral
- examine patient when patient is retrained -
ABC of management
- Assessment: look for signs of the cause (this stage is completed once the patient is sedated)
- Back up: staff/ resources to ensure no harm to people or property
- Containment: pharm or non-pharm.
(5 C’s of containment = be calm, take control, confidently manage staff, contain the patient with reassurances, constraint if needed in the situation) -
restraint and tranuilisation
- 4 point immobilisation = 4 preassigned staff - each take a hip and shoulder of the patient and then the doctor or nurse in charge sedates the patient immediately
- administration of drugs: PO takes longer to work; IM needs monitoring; IV works rapidly but requires back up/ resus
- drug options:
benzodiazepines (Lorazepam 2-4mg SL/PO/IM or in severe cases, Diazepam)
Antipsychotic agents: haloperidol 5-10mg PO/IM/IV +- Lorazepam or Risperidone 1-2mg PO or olanzepine 10mg PO/IM/IV
For 4 point immobilisation: Inject 2-4mg Lorazepam and 5-10mg Haloperidol IM which can be repeated twice in 30-60min interval
- continuously monitor the patient
- look for EPSEs
- treat the underlying cause -
refer
- if unable to establish cause
- hospitalisation is required
- initial strategies to manage persistence violence fails -
differentials
- criminal behavior
- antisocial personality disorder
- substance use disorders
- acute psychotic episode
- mania
- depression
- dementia
- anxiety
- delirium
- epilepsy
- cerebral infarctions/ bleeds/ TB
In managing a violent patient, what are the 5 C’s of containment?
5 C’s of containment =
be calm
take control
confidently manage staff
contain the patient with reassurances
constraint if needed in the situation
In managing a violent patient, what happens in the 3rd step of restraint and tranuilisation
-
restraint and tranuilisation
- 4 point immobilisation = 4 preassigned staff - each take a hip and shoulder of the patient and then the doctor or nurse in charge sedates the patient immediately
- administration of drugs: PO takes longer to work; IM needs monitoring; IV works rapidly but requires back up/ resus
-
drug options:
benzodiazepines (Lorazepam 2-4mg SL/PO/IM or in severe cases, Diazepam)
Antipsychotic agents: haloperidol 5-10mg PO/IM/IV +- Lorazepam or Risperidone 1-2mg PO or olanzepine 10mg PO/IM/IV
For 4 point immobilisation: Inject 2-4mg Lorazepam and 5-10mg Haloperidol IM which can be repeated twice in 30-60min interval
In managing a violent patient, what are your drug options?
- drug options:
benzodiazepines (Lorazepam 2-4mg SL/PO/IM or in severe cases, Diazepam)
Antipsychotic agents: haloperidol 5-10mg PO/IM/IV +- Lorazepam or Risperidone 1-2mg PO or olanzepine 10mg PO/IM/IV
For 4 point immobilisation: Inject 2-4mg Lorazepam and 5-10mg Haloperidol IM which can be repeated twice in 30-60min interval
In managing a violent patient, what happens in the 2nd step of the ABCs of management
- ABC of management
- Assessment: look for signs of the cause (this stage is completed once the patient is sedated)
- Back up: staff/ resources to ensure no harm to people or property
- Containment: pharm or non-pharm.
(5 C’s of containment = be calm, take control, confidently manage staff, contain the patient with reassurances, constraint if needed in the situation)
In managing a violent patient, what are the differentials
what could be wrong with this patient?
- differentials
- criminal behavior
- antisocial personality disorder
- substance use disorders
- acute psychotic episode
- mania
- depression
- dementia
- **delirium **
- anxiety
- epilepsy
- cerebral infarctions/ bleeds/ TB
In managing a violent patient, what medication do you use to sedate the patient?
For 4 point immobilisation: Inject 2-4mg Lorazepam and 5-10mg Haloperidol IM which can be repeated twice in 30-60min interval
Discuss the mood stabiliser lithium in terms of monitoring and therapeutic levels
Monitoring: Measure trough levels after 5 days, then monthly, then 3 monthly once stabilised therapeutic serum level
Narrow therapeutic index: 0.6-1mmol/l [0.4-0.7 for geriatric patients]
If it is required, the dose can be increased in increments and trough levels can be
repeated after 5 days
Discuss the mood stabiliser lithium in terms of the clinical presentation of toxicity
Mild toxicity reached at = 1.5-2.5mmol/l
moderate = 2.5-3.5mmol/l
severe > 3.5mmol/l
o Seen a lot in **chronic treatment ** or if there is decreased excretion due to drug
interactions, dehydration or renal impairment
o Features: nausea and vomiting, dehydration
renal dysfunction, electrolyte imbalance,
restlessness, tremor/fasciculations,
confusion/apathy, dysarthria, ataxia,
hyperreflexia, muscle weakness,
flat or inverted T waves, arrhythmias,
hypotension, convulsions and coma
o Management: gastric lavage within 1-2hrs; monitor fluids and electrolytes/serum
lithium level/cardiac functions, haemodialysis for moderate-severe toxicity
Discuss the mood stabiliser lithium in terms of the use in women of child bearing age
o Increase risk of Ebstein’s anomaly due to T1 exposure and T2 and T3 problems Ā
polyhydramnios, PTL, thyroid abnormalities, floppy baby syndrome
So if mother has:
o Mild stable bipolar disorder: taper down and stop lithium pre-pregnancy
o Moderate risk of relapse: taper and discontinue during T1
o Severe BPD: maintain lithium during pregnancy Ā informed consent, counsel,
detailed USS and echo at 16-18 weeks
Discuss the mood stabiliser lithium in terms of definition
Lithium is mood stabiliser, gold standard for treating bipolar mood disorder
Discuss the mood stabiliser lithium in terms of the indications
- acute manic episodes
- prophylaxis for manic episodes
- augmentation of antidepressants in resistant/recurrent depression
- aggressive or self-mutilating behavior
Discuss the mood stabiliser lithium in terms of the contraindications
- cardiac disease
- renal impairment
- T1 pregnancy
- epilepsy
Discuss the mood stabiliser lithium in terms of what investigations you would do before you start the mood stabiliser
- ECG
- renal function
- pregnancy test
- TSH
- Ca
Discuss the mood stabiliser lithium in terms of the starting dose
- 400-600mg at night
- increased weekly depending on serum levels** to 2g**
Discuss the mood stabiliser lithium in terms of the side effects
Head and neck
2. dry mouth,
4. alopecia, folliculitis, rash, leukocytosis
3. goitre,
4.Hypothyroidism,
GIT
6. Upset GI: N&V, diarrhoea
7. Increased weight,
Limbs
3. tremors and teratogen,
Other
1. Leucocytosis,
2. Insipidus diabetes,
7. Miscellaneous (ECG changes, acne)
what is the management of lithium toxicity?
- gastric lavage within 1-2hrs
-
monitor:
fluids and electrolytes
serum lithium level
cardiac functions - haemodialysis for moderate-severe toxicity
what are the features of lithium toxicity?
Brain
- confusion/apathy, dysarthria, ataxia
- convulsions and coma
Muscles
- hyperreflexia, muscle weakness
- restlessness
- tremor/fasciculations,
Heart muscle and blood
- flat or inverted T waves, arrhythmias,
- hypotension
GIT
- nausea and vomiting,
- dehydration
- renal dysfunction
- electrolyte imbalance,
what are the toxicity levels of lithium toxicity?
Mild toxicity = 1.5-2.5mmol/l
moderate = 2.5-3.5mmol/l
severe > 3.5mmol/l
what is the teratogenicity for lithium toxicity?
o Increase risk of **Ebstein’s anomaly **due to T1 exposure and T2 and T3 problems Ā
polyhydramnios, PTL, thyroid abnormalities, floppy baby syndrome
So if the patient has:
o Mild stable bipolar disorder: taper down and stop lithium pre-pregnancy
o Moderate risk of relapse: taper and discontinue during T1
o Severe BPD: maintain lithium during pregnancy Ā informed consent, counsel,
detailed USS and echo at 16-18 weeks
Main: Discuss the mood stabiliser lithium in terms of:
monitoring and therapeutic level
side effects
clinical presentation of toxicity
the use in women of child-bearing age
Lithium is mood stabiliser, gold standard for treating bipolar mood disorder
Indications:
- acute manic episodes
- prophylaxis for manic episodes
- augmentation of antidepressants in resistant/recurrent depression
- aggressive or self-mutilating behavior
**Contraindications:
**
- cardiac disease
- renal impairment
- epilepsy
- T1 pregnancy
**Before initiation:
**
- pregnancy test
- renal function
- TSH
- Ca
- ECG
**Starting dose:
**
- 400-600mg at night,
- increased weekly depending on serum levels to 2g
**Side effects:
**Leucocytosis, Insipidus diabetes, tremors and teratogen, Hypothyroidism,
Increased weight, Upset GI, Miscellaneous (ECG changes, acne)
weight gain, nausea and vomiting, diarrhoea, anorexia, dry mouth, goitre, hypothyroidism,
diabetes insipidus, alopecia, folliculitis, rash, leukocytosis
Monitoring and therapeutic level:
Not much difference between toxic and therapeutic levels
Narrow therapeutic index: 0.6-1mmol/l [0.4-0.7 for geriatric patients]
Measure trough levels after 5 days, then monthly, then 3 monthly once stabilised
therapeutic serum level
If it is required, the dose can be increased in increments and trough levels can be
repeated after 5 days
**Toxicity:
**o Mild = 1.5-2.5mmol/l, moderate = 2.5-3.5mmol/l, severe > 3.5mmol/l
o Occurs in chronic treatment or if there is decreased excretion due to drug
interactions, dehydration or renal impairment
o Features - nausea and vomiting, dehydration, renal dysfunction, electrolyte
imbalance, restlessness, tremor/fasciculations, confusion/apathy, dysarthria, ataxia,
hyperreflexia, muscle weakness, flat or inverted T waves, arrhythmias, hypotension, convulsions and coma
o Management - gastric lavage within 1-2hrs; monitor fluids and electrolytes/serum
lithium level/cardiac functions, haemodialysis for moderate-severe toxicity
**Teratogenicity:
** o Increase risk of Ebstein’s anomaly due to T1 exposure and T2 and T3 problems Ā
polyhydramnios, PTL, thyroid abnormalities, floppy baby syndrome
o Mild stable bipolar disorder: taper down and stop lithium pre-pregnancy
o Moderate risk of relapse: taper and discontinue during T1
o Severe BPD: maintain lithium during pregnancy Ā informed consent, counsel,
detailed USS and echo at 16-18 weeks
Main: what is the side effect profile of 1st generation anti-psychotics
- Typicals/First gen: Chlorpromazine [phenothiazine], Haloperidol [Butyrophenone]
- Atypicals/Second gen: Clozapine, Olanzapine, Risperidone
EPSEs
- acute dystonia typically in sternocleidomastoid and tongue but can be widespread
- akathisia [feeling of inner restlessness],
- parkinsonism
- NMS - neuroleptic malignant syndrome [rigidity/fluctuating consciousness/pyrexia]
- late TDS - tardive dyskinesia [continuous slow writhing movements] more common with typicals, caused by D2-R blockade in corpus striatum
- orphenadrine co-administration reduces EPSEs
**Anticholinergic side effects:
**
- dry mouth
- blurred vision
- glaucoma
- dysuria
- urinary retention
- constipation
- ileus
Anti-adrenergic: postural hypotension, sexual dysfunction
Anti-histamininc: sedation and weight gain
Other side effects: raised prolactin and cardiac conduction abnormalities from prolonged QT syndrome
In the side effect profile of 1st generation anti-psychotics, what are the EPSEs?
EPSEs
- acute dystonia typically in sternocleidomastoid and tongue but can be widespread
- akathisia [feeling of inner restlessness],
- parkinsonism
- NMS - neuroleptic malignant syndrome [rigidity/fluctuating consciousness/pyrexia]
- late TDS - tardive dyskinesia [continuous slow writhing movements] more common with typicals, caused by D2-R blockade in corpus striatum
- orphenadrine co-administration reduces EPSEs
In the side effect profile of 1st generation anti-psychotics, what are the anticholinergic side effects?
Anticholinergic side effects:
- dry mouth
- blurred vision
- glaucoma
- dysuria
- urinary retention
- constipation
- ileus
In the side effect profile of 1st generation anti-psychotics, what are the anti-adrenergic side effects?
postural hypotension, sexual dysfunction
In the side effect profile of 1st generation anti-psychotics, what are the anti-histaminic side effects?
Anti-histamininc: sedation and weight gain
In the side effect profile of 1st generation anti-psychotics, what are the categories of side effects?
EPSEs
Anticholinergic
Antiadrenergic
Antihistaminic
Other side effects
Main: How do you assess a depressed patient who you suspect might be suicidal in casualty?
- Determine whether they’re high or low risk by looking at the risk factors:
Look at risk factors: SADPERSONS
5-6: medium risk, 7 or more: high risk
● S: Male sex
● A: Age (<19 or >45 years)
● D: Depression
● P: Previous attempt
● E: Excess alcohol or substance use
● R: Rational thinking loss
● S: Social supports lacking
● O: Organized plan
● N: No spouse
● S: Sickness (GMC)
+ general risk factors (family history, non-compliance, feelings of hopelessness, unemployment)
- Then determine ideation, intention, plan
- ideation: content and duration of thoughts
- intention: self-harm vs suicide
- plan: detail, lethality, concealment and preparation - Then examine and assess them
● Assessment steps:
o Ensure physical condition is stabilised
o Physical examination for medical illness/drug intoxication
o Collateral interviews from family, colleagues, friends
o Psych exam: Hx, MSE
o Current presentation of suicidality: lethality of method, level of intent, steps
enacted, feelings of hopelessness
o Psychiatric illness and history thereof
o History of previous suicide attempts
o Psychosocial situation
o Individual strength and vulnerabilities – coping mechanisms, personality traits, past response to stressors - Then do a post assessment
● Post-assessment: Likely risk of further self-harm, is there a treatable mental illness,
psychosocial problems that need to be addressed, intervention and support required to reduce risk - Look out for the **warning signs **of suicide =
o Talk: self-criticism, talking about killing themselves, joke about suicide, having no
reason to live, being a burden to others, feeling trapped
o Behaviour: increased substance use, looking for a way to kill themselves, reckless, change in personality, withdrawal from activities, loss of interest in appearance, sleeping too much/too little, calling people to say bye, preparing for death by giving away possessions
o Mood: depression,* loss of interest*, rage, irritability, humiliation, anxiety, excessive
feelings of guilt
In the assessment fo a depressed/ suicidal patient, what are the warning signs of suicide?
- Look out for the warning signs of suicide =
o TALK: self-criticism, talking about killing themselves, joke about suicide, having no
reason to live, being a burden to others, feeling trapped
o BEHAVIOUR: increased substance use, looking for a way to kill themselves, reckless, change in personality, withdrawal from activities, loss of interest in appearance, sleeping too much/too little, calling people to say bye, preparing for death by giving away possessions
o MOOD: depression, loss of interest, rage, irritability, humiliation, anxiety, excessive feelings of guilt
In the assessment of a depressed/ suicidal patient, what are the main risk factors and how do you score them?
- Determine whether they’re high or low risk by looking at the risk factors:
Look at risk factors: SADPERSONS 5-6: medium risk, 7 or more: high risk
● S: Male sex
● A: Age (<19 or >45 years)
● D: Depression
● P: Previous attempt
● E: Excess alcohol or substance use
● R: Rational thinking loss
● S: Social supports lacking
● O: Organized plan
● N: No spouse
● S: Sickness (GMC)
+ general risk factors (family history, non-compliance, feelings of hopelessness, unemployment)
In the assessment fo a depressed/ suicidal patient, in step 2, what do you need to determine? (IIP)
Ideation
Intention
Plan
- ideation: content and duration of thoughts
- intention: self-harm vs suicide
- plan: detail, lethality, concealment and preparation
In the assessment of a depressed/ suicidal patient, how do you assess and examine the patient?
- ● Assessment steps:
o Ensure physical condition is stabilised
o Physical examination for medical illness/drug intoxication
o Collateral interviews from family, colleagues, friends
o Psych exam: Hx, MSE
o Current presentation of suicidality: lethality of method, level of intent, steps
enacted, feelings of hopelessness
o Psychiatric illness and history thereof
o History of previous suicide attempts
o Psychosocial situation
o Individual strength and vulnerabilities – coping mechanisms, personality traits, past
response to stressors
In the assessment of a depressed/ suicidal patient, what do you do post-assessment?
Post-assessment: Likely risk of further self-harm, is there a treatable mental illness,
psychosocial problems that need to be addressed, intervention and support required to reduce risk
Main: what is the clinical presentation of PTSD?
● Presence of Severe psychological disturbance following a traumatic event characterised by involuntary re-experiencing of elements of the event with symptoms of hyperarousal, avoidance and emotional numbing
● Symptoms and signs:
o Within 6 MONTHS of traumatic event, present for at least **1 month **with clinically significant distress or impairment in social, occupational or other important areas of functioning
o EXPOSURE: directly experiencing, witnessing, events happening to close person,
repeated/extreme exposure to details of traumatic events
o ONE OR MORE: recurrent/intrusive memories of event, recurrent dreams, dissociative reactions where it feels like events are recurring, intense/prolonged distress to cues that symbolise/resemble event
o AVOIDANCE OF STIMULI associated with event – efforts to avoid distressing memories or external reminders of those distressing memories
o NEGATIVE ALTERATIONS in cognition and mood – inability to remember aspects, negative beliefs about oneself, distorted cognition about cause and consequence of event, negative emotional state, diminished interest in activities, detachment/estrangement from others, inability to experience positive emotions
o INCREASED PHYSIOLOGICAL SENSITIVITY and arousal: sleep disturbance, irritability or outbursts of anger, difficulty concentrating, hypervigilance, exaggerated startle response, reckless/self-destructive
Someone comes in w PTSD, how are they presenting?
● Symptoms and signs:
o Within 6 MONTHS of traumatic event, present for at least 1 month with clinically significant distress or impairment in social, occupational or other important areas of functioning
o EXPOSURE: directly experiencing, witnessing, events happening to close person,
repeated/extreme exposure to details of traumatic events
o ONE OR MORE: recurrent/intrusive memories of event, recurrent dreams, dissociative reactions where it feels like events are recurring, intense/prolonged distress to cues that symbolise/resemble event
o AVOIDANCE OF STIMULI associated with event – efforts to avoid distressing memories **or **external reminders of those distressing memories
o NEGATIVE ALTERATIONS in cognition and mood – inability to remember aspects, negative beliefs about oneself, distorted cognition about cause and consequence of
event, negative emotional state, diminished interest in activities, detachment/estrangement from others, inability to experience positive emotions
o INCREASED PHYSIOLOGICAL SENSITIVITY and arousal: sleep disturbance, irritability or outbursts of anger, difficulty concentrating, hypervigilance, exaggerated startle
response, reckless/self-destructive
Your friend asks, so what is PTSD?
Severe psychological disturbance
following a traumatic event
characterised by involuntary re-experiencing of elements of the event
with symptoms of hyperarousal, avoidance and emotional numbing
Main: what is the clinical presentation of borderline personality disorder?
● Mnemonic –** AM SUICIDE**
need 5:
- abandonment
- mood instability [unpredictable affect/labile]
- unstable and intense relationships
- suicidal behaviour/self-harm
- impulsivity
- control of anger is poor
- identity disturbance [unclear identity]
- dissociative symptoms
- emptiness
someone comes in with borderline personality disorder, how are they presenting?
● Mnemonic –** AM SUICIDE**
need 5:
- abandonment
- mood instability [unpredictable affect/labile]
- unstable and intense relationships
- suicidal behaviour/self-harm
- impulsivity
- control of anger is poor
- identity disturbance [unclear identity]
- dissociative symptoms
- emptiness
Main: what are the differences between delirium and dementia?
Delirium/ Dementia
- Onset: Acute [hours to days] Gradual // step-wise decline
- Duration: Days to weeks // Months to years
- Course: Fluctuating // Progressive
- Level OC: *Clouded, fluctuating *// Alert
- Orientation: Impaired // Initially intact, impaired later
- Attention: Decreased // Not initially affected
- Sleep: Reversal of sleep wake cycle // Occasional night-time confusion
- Restlessness: Worse at night // Worse in the day
- Psychomotor activity: Agitated or slowed // Initially unchanged, impaired later
- Mood and affect: *Anxious, irritable, fluctuating *// Labile but not anxious
- Perceptions: *Visual hallucinations *//Variable
- Reversibility: Reversible // Irreversible
how do you know it’s delirium and not dementia?
Delirium/ Dementia
- Onset: Acute [hours to days] Gradual // step-wise decline
- Duration: Days to weeks // Months to years
- Course: Fluctuating // Progressive
- Level OC: *Clouded, fluctuating *// Alert
- Orientation: Impaired // Initially intact, impaired later
- Attention: Decreased // Not initially affected
- Sleep: Reversal of sleep wake cycle // Occasional night-time confusion
- Restlessness: Worse at night // Worse in the day
- Psychomotor activity: Agitated or slowed // Initially unchanged, impaired later
- Mood and affect: *Anxious, irritable, fluctuating *// Labile but not anxious
- Perceptions: *Visual hallucinations *//Variable
- Reversibility: Reversible // Irreversible
In delirium and dementia, what are the categories that are used to compare the 2?
Delirium/ Dementia
- Onset:
- Duration:
- Course:
- Level OC:
- Orientation:
- Attention:
- Sleep:
- Restlessness:
- Psychomotor activity:
- Mood and affect:
- Perceptions:
- Reversibility:
DOC LOA SRP MRP
Primary, assess, educate, organic, urotherapy, techniues, infro, biofeed
Main: what is your approach to the management of an 8 year old presenting with eneuresis (bed wetting)?
● Majority can be managed in primary care or by specialist enuresis clinics, referral to psychiatry only when there is wider disturbance of emotions and behaviour
● Careful assessment – includes thorough medical history and examination with investigations
● Psychoeducation of child and parents on diagnosis and treatment options
● Treat organic causes: structural abnormalities or infection of the Genito-urinary tract
● Urotherapy: increase bladder capacity, decrease night-time urine output, sensitise to unconsciousness awareness of bladder filling
o Techniques: daily increase in fluid intake, reduced nightly intake, regular bladder emptying, pre-bedtime voiding, daily bowel action, avoid caffeine and high sugar containing drinks
o Information, instruction, life-style advice, registration of symptoms and voiding
habits, support with the caregiver
o Biofeedback: pelvic floor muscle retraining
o Alarm therapy: device that gives acoustic signal after episode of incontinence. Bell and Pad method
o Reward systems [star-charts]
● Medication: desmopressin, imipramine, oxybutynin
So a child comes in with eneuresis, what techniques can you use under urotherapy?
o Techniques: daily increase in fluid intake, reduced nightly intake, regular bladder emptying, pre-bedtime voiding, daily bowel action, avoid caffeine and high sugar containing drinks
o Information, instruction, life-style advice, registration of symptoms and voiding
habits, support with the caregiver
o Biofeedback: pelvic floor muscle retraining
o Alarm therapy: device that gives acoustic signal after episode of incontinence. Bell
and Pad method
o Reward systems [star-charts]
So a child comes in with eneuresis, if urotherapy fails, what medication can you give them?
Medication: desmopressin, imipramine, oxybutynin
So a child comes in with eneuresis, how would you explain to the mum the goals of urotherapy?
Urotherapy: increase bladder capacity,
decrease night-time urine output,
sensitise to unconsciousness awareness of bladder filling
Main: what is the clinical presentation and management of neuroleptic malignant syndrome?
Definition: A rare, life-threatening reaction to anti-psychotic and other medication characterised by fever, muscular rigidity, altered mental status and autonomic dysfunction
Symptoms/ signs: hyperthermia >38, muscular rigidity, confusion/agitation/altered LOC, tachycardia, tachypnoea, hyper/hypotension, diaphoresis, tremor,
incontinence/retention/obstruction, creatinine kinase/urinary myoglobin, leukocytosis, metabolic acidosis
Management:
o Benzos for acute behavioural disturbance [restraint and IM may alter CK levels]
o Stop any possible causative agents [anti-psychotics] and restart anti-Parkinsonian symptoms
o Supportive: oxygen, correct hypotension with fluids, reduce temp with cooling
blankets/anti-pyretics/cooled IVI fluids/ice packs/ice-water enema
o Rhabdomyolysis: vigorous hydration and alkalinisation of urine using IVI sodium
bicarbonate to prevent renal failure
o Pharmacotherapy to reduce rigidity: Dantrolene 0.8-2.5mg/kg IV qds, up to 500mg Lorazepam, 2nd line bromocriptine or amantadine, 3rd line Nifedipine, consider ECT
o Follow up: monitor closely, once settled allow 2+ weeks before restarting
medication [use low dose/low- potency/atypicals] and consider prophylactic bromocriptine
People are out here talking about neuroleptic malignant syndrome, what is it?
A rare, life-threatening reaction to anti-psychotic and other medication characterised by fever, muscular rigidity, altered mental status and autonomic dysfunction
Someone comes in with neuroleptic malignant syndrome, how are they presenting?
- hyperthermia >38
~ - muscular rigidity
~ - confusion/agitation/altered LOC
~ - tachycardia
- tachypnoea
- hyper/hypotension
- diaphoresis, tremor, incontinence/retention/obstruction
~ - creatinine kinase/urinary myoglobin
- leukocytosis
- metabolic acidosis
Someone comes in with neuroleptic malignant syndrome, how are you going to manage them?
o Benzos for acute behavioural disturbance [restraint and IM may alter CK levels]
o Stop any possible causative agents [anti-psychotics] and restart anti-Parkinsonian symptoms
o Supportive: oxygen, correct hypotension with fluids, reduce temp with cooling
blankets/anti-pyretics/cooled IVI fluids/ice packs/ice-water enema
o Rhabdomyolysis: vigorous hydration and alkalinisation of urine using IVI sodium bicarbonate to prevent renal failure
o Pharmacotherapy to reduce rigidity: Dantrolene 0.8-2.5mg/kg IV qds, up to 500mg Lorazepam, 2nd line bromocriptine or amantadine, 3rd line Nifedipine, consider ECT
o Follow up: monitor closely, once settled allow 2+ weeks before restarting
medication [use low dose/low- potency/atypicals] and consider prophylactic bromocriptine
Someone comes in with neuroleptic malignant syndrome, what is the medical management to reduce the rigidity?
o Pharmacotherapy to reduce rigidity:
- Dantrolene 0.8-2.5mg/kg IV qds
- up to 500mg Lorazepam
- 2nd line bromocriptine or amantadine,
- 3rd line Nifedipine
- consider ECT
Main: what is the role of the mental health review board?
● Independent, partially JUDICIAL BODIES that derive authority from the Mental Healthcare Act
● Functions:
- considering appeals against decisions of head of health establishment,
- making decisions with regards to assisted and involuntary care, treatment and rehab services,
- considering reviews and making decisions on transfer of patient to max security facilities
- periodic reports of the mental health status of mentally ill prisoners
● Ensure **STEPS FOLLOWED **according to MHCA
● Provide LEGAL ASSISTANCE to patient if requested
● CHECKS FORMS completed correctly: ensure legitimacy of process and accuracy of forms (they have to fill in a form 13 to say that the hospital does have grounds to do the 72 hour assessment and hold the patient during this time)
● Ensure no one is DETAINED ERRONEOUSLY
● ENSURE PROCEDURES are followed
● REVIEWS CASE if patient sends form 15 (for an appeal); MHCB needs to give notice of receiving application within 7 days and see patient within 30 days
Members:
o Mental healthcare practitioner: medical practitioner, psychiatrist, psych nurse, psychologist, OT, social worker
o Legal: magistrate, attorney or advocate
o Community member: good understanding of mental health and referral systems in SA
With the MHR board, who are the peops behind the mental health review board?
Members:
o Mental healthcare practitioner: medical practitioner, psychiatrist, psych nurse, psychologist, OT, social worker
o Legal: magistrate, attorney or advocate
o Community member: good understanding of mental health and referral systems in SA
Main: what are the side effects of SSRIs?
Head and neck
- headache,
- dry mouth
- excessive sweating [diaphoresis]
GIT
- Nausea and GI upset [diarrhoea],
Vibes
- restlessness/agitation/nervousness,
- insomnia,
- rash,
- anxiety,
- weight gain,
- sexual dysfunction
Main: Compare the side effect profile of first generation antipsychotics vs. second generation antipsychotics
● First generation:
Eg: Haloperidol [high potency] and Chlorpromazine [low potency]
-
EPSEs: dystonia, parkinsonism, akathisia [unpleasant inner restlessness and strong
compulsion to move], tardive dyskinesia - Postural hypotension - alpha-adrenergic blockade
- Sedation and weight gain - histamine blockade
- Dry mouth, blurred vision, constipation, urinary retention, glaucoma, ileus - anticholinergic effect
- Hyperprolactinemia, skin photosensitivity, arrhythmias, sexual dysfunction, NMS
● 2nd generation:
Eg: Clozapine, Olanzapine, Risperidone, Amisulpride, Quetiapine,
- QT prolongation, arrhythmia, Torsade, impaired glucose tolerance, diabetes, weight gain, dyslipidaemia [metabolic syndrome] and sexual dysfunction
~
- Clozapine: For treatment-resistant schizophrenia, intolerable EPSE, negative psychotic features
- Side effects: agranulocytosis, myocarditis, toxic megacolon, seizures, sedation, weight gain, hypersalivation
- Neutrophils < 1.5x109 – Stop Clozapine
- Monitoring: WCC – prior to starting treatment
then weekly for 18 weeks
then every 2 weeks for 6 months
then monthly
With 1st gen antipsychotics, You give a patient a 1st gen antipsychotic, what side effects might they experience?
● First generation:
Eg: Haloperidol [high potency] and Chlorpromazine [low potency]
-
EPSEs: dystonia, parkinsonism, akathisia [unpleasant inner restlessness and strong
compulsion to move], tardive dyskinesia - Postural hypotension - alpha-adrenergic blockade
- Sedation and weight gain - histamine blockade
- Dry mouth, blurred vision, constipation, urinary retention, glaucoma, ileus - anticholinergic effect
- Hyperprolactinemia, skin photosensitivity, arrhythmias, sexual dysfunction, NMS
With 2nd gen antipsychotics, You give a patient a 2nd gen antipsychotic, what side effects might they experience?
● 2nd generation:
o Clozapine, Olanzapine, Risperidone, Amisulpride, Quetiapine,
- QT prolongation
- arrhythmia
- Torsade,
- impaired glucose tolerance,
- diabetes,
- weight gain,
- dyslipidaemia [metabolic syndrome] and sexual dysfunction
With 2nd gen antipsychotics, clozapine, what do you choose to give clozapine?
For treatment-resistant schizophrenia, intolerable EPSE, negative psychotic features
With 2nd gen antipsychotics, you give a patient clozapine, what are the side effects you’re expecting?
▪ Side effects:
- agranulocytosis,
- myocarditis,
- toxic megacolon,
- seizures,
- sedation,
- weight gain,
- hypersalivation
With 2nd gen antipsychotics, you give your patient clozapine, what monitoring do you need to do?
▪ Monitoring: WCC – prior to starting treatment
- then weekly for 18 weeks
- then every 2 weeks for 6 months
- then monthly
With 2nd gen antipsychotics, you give your patient clozapine, when do you decide to stop?
▪ Neutrophils < 1.5x10^9 – Stop Clozapine
Main: Discuss approach to unruly and disruptive child in the classroom [ADHD] and mention the differentials
Aetiology: parent with alcohol dependence, antisocial, ADHD, conduct disorder and schizophrenia OR sibling with disruptive behaviour disorder
● See family and the child, support the parent, screen for high risk families
● Obtain a full history with collateral from school, social worker and legal system
● Assess for comorbidities and make a diagnosis
● Formulate the problems and establish management plan
● Address child protection concerns
● Treat comorbidity
● Medical treatment: antipsychotics to manage acute and chronic aggression, stimulants such as Methylphenidate [Concerta or Ritalin]
● Psychological:
o Parent management training: education programmes – provide with info of normal vs concerning behaviours, emphasise a parenting style that recognises strengths of child/positive reinforcement/non-punitive punishment, importance of their behaviour model [psychoeducational]
o Child interventions: CBT, social skills, problem-solving, anger management, confidence building
o Functional family therapy
o Multi-systemic therapy: family-based, including school and community
● Social: community/school interventions, NGOs
● Differential: ADHD, adjustment disorder, autism spectrum disorder, normal child but
parents/teachers have unrealistic expectations, oppositional defiant disorder, learning disability, PTSD, anxiety disorder, depression, learning difficulty, psychosis, deviance
A child comes in with ADHD, what could have caused it?
- parent with alcohol dependence,
- antisocial,
- ADHD,
- conduct disorder and schizophrenia
- sibling with disruptive behaviour disorder
A child comes in with ADHD, what is the medical management?
antipsychotics to manage acute and chronic aggression, stimulants such as Methylphenidate [Concerta or Ritalin]
Parent, child, family, multisystemic
A child comes in with ADHD, what is the psychological management
o Parent management training:
- education programmes – provide with info of normal vs concerning behaviours,
- emphasise a parenting style that recognises strengths of child/positive reinforcement/non-punitive punishment,
- importance of their behaviour model [psychoeducational]
o Child interventions:
- CBT,
- social skills,
- problem-solving,
- anger management,
- confidence building
o Functional family therapy
o Multi-systemic therapy: family-based, including school and community
A child comes in with ADHD, how can you help them through social management
community/school interventions, NGOs
A child comes in with ADHD, what differentials are you thinking about?
Differential:
- ADHD
- adjustment disorder
- autism spectrum disorder, normal child but parents/teachers have unrealistic expectations,
- oppositional defiant disorder, learning disability,
- PTSD
- anxiety disorder
- depression
- learning difficulty
- psychosis
- deviance
antidepressant, anticholinergic, adrenergic, serotonin antagonism, antih
Main: what are the side effects of TCAs?
● Serotonin/noradrenaline reuptake inhibition: antidepressant effects
● Anticholinergic: dry mouth, blurred vision, constipation, urinary retention, confusion/memory problems, palpitations/tachycardia
● Adrenergic antagonism: postural hypotension, sexual dysfunction
● 5-HT2 (serotonin) antagonism: anxiolytic, reduced sexual function, sedation
● Anti-histamine: drowsiness and weight gain
Main: what is the presentation and management of delirium
● Clinical features:
- impaired ability to direct/sustain and shift attention,
- global impairment of cognition with disorientation and impairment of recent memory and abstract thinking,
- disturbance in sleep-wake cycle with nocturnal worsening,
- psychomotor agitation,
- emotional lability,
- perceptual distortions,
- speech may be rambling or incoherent and thought disordered,
- poorly developed paranoid delusions,
- rapid onset with fluctuations in severity over minutes and hours
● Hyperactive delirium:
**- psychomotor agitation,
**- increased arousal,
- inappropriate behaviour,
- delusions and hallucinations
● Hypoactive delirium:
**- psychomotor retardation,
**- lethargy,
- excess somnolence
● Management:
o Identify and treat precipitating cause/exacerbating factors:
- DIMTOP, (drugs, infrctions, metabolic, trauma, oxygen deficient, psychological)
- optimise condition of patient with attention to hydration,
- nutrition,
- input and output and pain control
~
o Provide environmental and supportive measures:
- education to those who interact with patient,
- make environment safe,
- create environment which optimises stimulation [adequate lighting, reduce noise, mobilise when possible and correct sensory impairment],
- reality orientation techniques [clear communication, same
staff members, clocks and calendars]
~
o Avoid sedation unless severely agitated or needed to minimise unnecessary risk
- use single medication and start at low dose
- Oral haloperidol 0.5-1mg daily,
- oral lorazepam 0.5-1mg daily
- oral risperidone 1-4mg daily.
- Consider antipsychotics first as benzos tend to worsen delirium.
- If caused by alcohol withdrawal, give benzos and thiamine
~
o Regular clinical review and follow up:
- MMSEs useful for monitoring cognitive improvement at follow up
Main: what is the presentation and management of EtOH withdrawal?
Withdrawal Presentation:
- Autonomic hyperreactivity (high BP and Temp)
- Hand tremor
- Insomnia
- N&V
- Transient hallucinations
- Anxiety
- Psychomotor agitation
- GTCS
Management of acute withdrawal:
- Minor symptoms above can be treated supportively
- Can use benzos, phenobarbital or Propofol in status epilepticus
Timelines:
- Hallucinations: at 12-48 hours, usually visual
- Withdrawal seizures are usual GTCS occur 12-48 hours after last drink
- Delirium tremens: hallucination, disorientation, tachycardia, hyperthermia, agitation
- Sweating typically starts 48-96 hours after last drink
Supportive care:
i. Benzos for agitation (IV diazepam best)
ii. IV fluid
iii. Nutritional support
iv. Monitor vitals
v. Quite protective environment
vi. Thiamine and glucose (prevent Wernicke’s)
vii. Multivitamins including folate
● Management:
o Detoxification
- which involves psychological support,
- medication to relieve symptoms,
- nutritional supplementation,
- observation.
- Can be in-patient or in community with support
o Detox:
- decide setting,
- assess need for benzos,
- consider need for other meds,
- verbal and written advice,
- inform GP of plans,
- give patient a contact in case of emergency,
- explicit follow-up
o Outpatient:
- for uncomplicated
- if doubts about compliance see daily and breathalyse
o In-patient:
- history of complicated withdrawals,
- symptoms of delirium,
- comorbid physical/mental illness,
- Wernicke’s,
- severe n+v,
- lack of stable home
o Benzo regimen
▪ Helps with unpleasant withdrawal symptoms and reduces risk of withdrawal seizures
▪ Diazepam for in-patient use: faster acting, allows dose titration, can be given parenterally
▪ Indications: clinical symptoms of withdrawal, consumption > 10units/day over previous 10 days
▪ Not needed if: <10 units, no history of withdrawal, BAC =0 and no symptoms
o Thiamine – prevent Wernicke’s
Main: what are the presenting symptoms and management of panic disorder?
Symptoms:
o Autonomic arousal: tremor, tachycardia, tachypnoea, hypertension, sweating, GI upset.
o Concerns of death from cardiac or resp problems leading to patients repeatedly presenting. Fear of death/losing control.
o Unexplained medical symptoms: chest pain, back pain, GI symptoms, headache, fatigue, multiple symptoms
o Suicidal [or homicidal] ideation, impulsive acts
Symptoms:
Abrupt surge of fear with** at least 4** of these present:
- SOB
- Dizziness
- Hot flushes or chills
- Feeling of choking
- Palpitations
- Nausea/ abdo discomfort
- Sweating
- Shaking
- Derealization
- Paresthesias
- Fear of dying/losing control
At least 1 attack has been followed by a minimum period of persistent worry bout further attacks or significant maladaptive change related to attack
● Pharmacological:
o SSRIs: initially increasing panic symptoms, start with lowest possible dose and
gradually increase, may take up to 12 weeks to have beneficial effect. Citalopram 20-30mg, Sertraline 50-200mg
o Alternative antidepressants: SNRIs [Venlafaxine], TCA
o Benzodiazepines: not really recommended as there is potential for abuse and
dependence. Effective for severe, incapacitating symptoms and can be used for 1-2 weeks in combination with antidepressant until the antidepressant becomes
‘effective’
o If rx successful: **continue for 12-18 months **before trial of discontinuation with gradual tapering of dose over 2-4 months. Do not confuse withdrawal effects with re-emergence of symptoms
Pharm
1ST LINE= SSRI (FLUOXETINE?)
Can combine with CBT
● Psychological:
o CBT: treat phobic avoidance by exposure, use of relaxation and control of hyperventilation, teach about bodily responses associated with anxiety
o Psychodynamic psychotherapy: ‘emotion-focused’ treatment where typical fears are explored
Psychosocial:
CBT has been found to be the best psychotherapy choice for panic disorder. It assists the patient in countering their anxious beliefs, being exposed to fear cues, changing their anxiety-maintaining behaviour.
Does require highly motivated patient. And can be resource intensive.
Psychoeducation is also of use with CBT.
Main: Discuss what is meant by facticious disorder
● When patients intentionally falsify their symptoms and past history and fabricate signs of
physical or mental disorder with the aim of obtaining medical attention and treatment
● Diagnostic features: intentional and conscious production of signs and falsification or
exaggeration of history
● Types:
o Wandering: males who move from hospital to hospital, job to job, producing
dramatic and fantastic stories. May be aggressive personality or dissocial PD
o Non-wandering: female, stable lifestyle and less dramatic, paramedical professions.
Chronic somatisation disorder or borderline PD
o By proxy: mothers/carers/paramedical/nursing, simulate or prolong illness in their
dependents
Main: what are the reasons why a patient remains psychotic after 3 months of treatment?
- Defaulting medication [many reasons for non-adherence],
- drug interactions [inducers],
- incorrect dose/dose not high enough,
- serum concentrations not high enough,
- ongoing substance use,
- treatment resistance,
- emotional stressors,
- incorrect diagnosis,
- medical disease of liver/kidneys impairing metabolism
Main: what is meant by pseudo-dementia?
● A presentation of **severe depression **in the elderly where the combination of psychomotor retardation, apparent cognitive deficits and functional decline cause diagnostic confusion with dementia
● Features:
- previous history of depression,
- depressed mood,
- exaggerated symptoms,
- poor effort on testing,
- responds to antidepressants
Main: Discuss side effects of 3 classes of antidepressant in terms of SE profile and therapeutic uses
**● TCAs indications:
**- possibly moderate/severe depressive disorders
- moderate/severe anxiety states
- nocturnal enuresis in child > 11
- neuropathic pain
- migraine prophylaxis
● SSRIs:
- moderate to severe depression,
- anxiety but risk of agitation,
- bulimia nervosa,
- OCD
- label for panic disorder,
- GAD and some personality disorders
**● SNRIs
**o Venlafaxine – moderate and major depressive and anxiety disorders
o Side effects: Anorexia, nausea, constipation, diarrhoea, hypertension, palpitations, dizziness, insomnia, drowsiness, nervousness, sweating
Main: what are the side effects of sodium valproate?
● Indications: acute bipolar mania, maintenance therapy for BPD, epilepsy, migraine prophylaxis
● Dose-related side effects:
- anorexia,
- nausea,
- dyspepsia,
- vomiting,
- diarrhoea,
- raised LFTs,
- tremor,
- sedation,
- alopecia,
- ataxia
● Unpredictable:
- mild leukopenia and thrombocytopenia
- increased appetite
- weight gain
● Rare:
- irreversible liver failure,
- pancreatitis,
- agranulocytosis,
- PCOS/hyperandrogenism
● Teratogenic: NTD [ensure contraception and folate]
Main: what are the indications for ECT?
● Treatment for depression particularly if there is psychotic symptoms
- failure of drug therapies
- patient preference
- high risk of suicide
- high risk of medical morbidity and mortality
- catatonia associated with SCZ/MDD/BPMD
- treatment resistant mania
- required therapies contraindicated in pregnancy
- post-natal depression/psychosis
- life-threatening nutritional compromise
- NMS - neuroleptic malignant syndrome
Main: what are the good and poor prognostic factors of schizophrenia?
Schizophrenia
● Good:
- female,
- rapid onset of symptoms
- older age of first episode
- predominantly positive symptoms
- presence of mood symptoms
- good pre-illness functioning
● Poor:
- genetic factors
- substance use
- pregnancy and birth complications such as hypoxia and
greater paternal age,
- other prenatal/perinatal issues like stress, infection, malnutrition and maternal diabetes
Main: What are the side effects of carbamazepine
Mood disorder; Medication
● Antidiuretic effects leading to hyponatraemia [can develops many months after initiation],
- decrease in thyroxine levels,
- agranulocytosis,
- aplastic anaemia,
- hepatic failure,
- exfoliative dermatitis [SJS],
- pancreatitis
Main: What is the specific managment of a phobia of mice?
● Behavioural: exposure is the treatment of choice which aims to reduce fear response – Wolpe’s systematic desensitisation
● Cognitive: education/anxiety management, coping skills, cognitive restructuring
● Pharmacological: generally not used unless severe then use benzos to reduce fear/avoidance and allow patient to engage in exposure but this may reduce efficacy of behaviour
● Other techniques: reciprocal inhibition, flooding
Main: Compare Schizophrenia and delusional disorder
Delusional disorder // Schizophrenia
Presence of delusions for at least 1 month, criterion A for schizophrenia **never met **// Criterion A: 2+ of, for significant amount of time during 1 month period: delusions, hallucinations,
disorganised speech, disorganised behaviour
Function not markedly impaired // Level of social functioning in one or more major areas is below level prior to onset
Manic/depressive episodes brief compared to
delusional periods // No major depressive or manic episodes have occurred concurrently with active phase symptoms and if they have occurred, they have been present for a minority of the total duration
Not attributable to physiological effect of
substance/other medical condition // Not attributable to physiological effect of substance/other medical condition
Main: What forms do you fill in for involuntary admissions?
● MHCA form 1 – emergency 24-hour admission
● Form 3 – discharge form
● Form 4 – application for involuntary admission filled in by family
● Form 5 x 2 – assessment by 2 physicians
● Form 6 – 72-hour assessment
● Form 7 – admission, filled in by med manager
● Form 8 – approval of further involuntary care
● Form 11 – transfer approval by med manager
● Form 15 – patient fills in when they want to leave
How to do an involuntary admission.
● Fill in a form 04: an application in the head of the health establishment for the assessment of a user. Specify that it is as an involuntary patient.
- Needs to be** filled out by: Someone who knows patient well/sees daily, An associate, MHC practitioner if no one else (would have to specify why it is them filling it in, what efforts were made to find someone, and why you think they need to be admitted)
- Everyone must be over 18!
● Form 04 then needs to be commissioned
● Once this is filled in, the patient needs to present within 2 days of the form being filled out.
● Next, two separate doctors/MHC practitioners need to do independent assessments of the patient. At least one must be a doctor.
● They both fill out a form 05, which is a continued application to say that they believe the patient needs further 72 hour assessment.
● If their assessments agree, a form 07 is filled in, which is an application to the head of the health establishment to detail the patient **for 72 hours for further care as a designated facility approved for this. When this is signed by the head of establishment, is when the 72 hours start.
- During the 72 hours, patient needs to be **seen daily **by a medical doctor and continuous notes must be made.
● After that time, two form 06s can be filled out (by two independent MHC practitioners, as least one is a doctor).
● After 72 hour assessment, **all forms submitted **to MHC review board who must fill in a form 13 to say that the hospital has grounds to keep the patient in hospital.
● If the head of head establishment believes that the patient needs further inpatient care after 72 hours, (s)he fills in a form 08.
~
● If need to be admitted as emergency patient: form 01.
● If transferring patient: form 11.
Main: What are the symptoms of atypical depression?
● Mood is depressed but remains reactive, hypersomnia, hyperphagia, leaden paralysis
[heaviness in limbs], over-sensitivity to perceived rejection
Main: Define treatment resistant schizophrenia and treatment thereof
● Failure to respond to two or more antipsychotic medications given in therapeutic doses for 6
weeks or more
● Mx:
o Clarify diagnosis: re-inspect to ensure correct diagnosis
o Address comorbidity: substance use is common and worsens outcome
o Non-compliance: psychoeducation, compliance therapy, family therapy
o Pharmacological: Clozapine depot injection
o Clozapine resistance: switching to untried 2nd gen or augmentation with benzamides
and anti-epileptics
o Rehab: maximise function/QoL and support those who remain symptomatic
Main: What is the management of a patient with social phobia?
● Bio: SSRI or SNRI as first line,
- requires 4-6 weeks to work,
- max effect at 12 weeks,
- dose response effect,
- may be prescribed on an as needed basis for performance only SAD
● Psycho: CBT group or individual,
- maintenance sessions,
- gradual desensitisation,
- stress management and relaxation techniques
● Social: family psychoeducation,
- assess how it affects job/relationships/family
Main: What are the Key clinical features needed to diagnose dementia
● Impairment in memory and one or more cognitive deficits,
- cognitive decline from previous performance level,
- interferes with independence of activities,
- not exclusively in delirium setting,
- not better explained by another illness
● Slow,
- insidious onset with progressive course,
- memory impairment,
- normal attention and alertness,
- usually intact orientation
Main: What is somatoform disorders?
● Repeated presentation with medically unexplained symptoms affecting multiple organ systems, first presenting before the age of 40
● Non-specific and atypical symptoms
● Chronic
● Significant physiological distress and functional impairment and are at risk of iatrogenic harm
Main: A child stabbed someone, probable diagnosis and management
● Probable diagnosis: oppositional defiant disorder, conduct disorder
Management:
● Antipsychotics: Risperidone is the best one to use, treats acute and chronic aggression
**● Same management principle as the ADHD question?
