CL

Question 1

Mood lability after removal of pituitary tumour (can cause cushings, hyperthyroid, hypothyroid)

Answer 1

Endocrine:
Reduction in secretion of pituitary hormone
Addison’s disease -> mood symptoms
Inadequate supplementation with thyroxine and steroids
Over supplementation - Cushing’s

Chronic headaches - undetected metastases

Depression secondary to steroid medication, steroid induced mood lability and insomnia

Cognitive impairment w secondary depression

Post surgery inflammation e.g. cognitive impairment

Adjustment disorder from loss

Recurrence of tumour

Exacerbation of underlying mood disorder e.g. cyclothymia

Question 2

DDx for somatic symptoms, depressed

Answer 2

MDD
-presents with predominant somatic sx in some cultural groups

Adjustment disorder with depressed mood in the context of stressors

Relationship difficulties - exposure to conflict and criticality leading to low self esteem and low mood

Untreated PND

Chronic fatigue syndrome with somatic sx

Grief reaction in context of losses post migration/job loss

Trauma related mood sx - unrecognised DV or emotional abuse

Abnormal illness behaviour or sick role with secondary gain

Question 3

Risk factors for medically unexplained sx (somatic sx disorder, hypochrondriasis etc)

Answer 3

1. Intergenerational transmission (children of parents with same)
2. Childhood abuse
3. Environmental stressors - can precipitate psychological reactions and somatic syndromes
4. Amplification of body sensations - perception of sensations amplifies concerns -> further increases anxiety -> amplifies sensations
5. Psychodynamic issues - the identified patient - one member of a family takes on the role of being weak and defective
6. Sick role - affords relief from stressful or impossible interpersonal expectations (“primary gain”) and, attention, caring and sometimes even monetary reward (“secondary gain”)
7. Illness beliefs - more negative illness perceptions and poorer health status

Question 4

Mx of Somatisation Disorder

Answer 4

CARE-MD

CBT
Assess - rule out organic causes
Regular visits - short frequent visits with focused exams, discuss recent stressors and healthy coping strategies, patient should agree to stop overutilisation of medical care e.g frequent ED visits
Empathy - more time listening, acknowledge pt’s discomfort
Med-psych interface - help pt discover connection between physical complaints and emotional stressors (mind body connection)
Do no harm - avoid unneccessary diagnostic procedures and consults to other specialties

Treat comorbidities:
commonly have coexisting depression (up to 60 percent), anxiety disorders such as panic or OCD (up to 50 percent), personality disorders (up to 60 percent) or substance abuse disorder

Question 5

Antidepressants interaction with illness

Answer 5

CV disease - avoiding fluvoxamine and citalopram if there is a risk of overdose, which has been linked to cardiotoxicity, lithium can cause ECG changes. SSRI first choice, mirtazapine safe in arrhythymias

Hepatic disease - initial dosing of all antidepressants should be reduced by at least 50% in patients with hepatic insufficiency (liver metabolised), desvenlafaxine does not undergo first pass metabolism, low dose citalopram

Renal disease - TCAS safer than SSRIs

D2M - fluoxetine can cause hypos

Epilepsy - TCAS reduce seizure threshold

Parkinsons - Selegeline is a MAO-B - watch out for SSRIs, clomipramine and MAOs. TCAS good for anticholinergic effects

Question 6

ECT contraindications - relative

Answer 6

Increased intracranial pressure or space occupying lesion
recent intracranial bleed
Recent myocardial infarction,
Decompensated heart failure cerebral or aortic aneurysms, acute respiratory tract infection and patients at risk of complications from a general anaesthetic.

Question 7

Pain management (RANZCP)

Answer 7

ASSESSMENT OF PAIN.
i. Discussion with team re possible organic contributors to pain.
ii. Assessment of pain symptoms. Pain charts, vital signs, medication charts to date.

Psychological factors. Explore and address any psychological contributors to pain such as anxiety, fear

PHARMACOTHERAPY.
i. Regular rather than as required analgesia medication.
ii. Appropriate pharmacotherapy for co-morbid psychiatric conditions.
iii. Do not withhold analgesia on the basis of previous drug misuse.

Nonpharmacological pain management. Occupational therapist input, distraction.

Staff liaison and education eg pain is genuine and needs adequate relief. Address staff issues eg hostile attitude/countertransference.

Involvement of Acute Pain Service and/or Drug and Alcohol Service.

Question 8

Mx of psychosis in Parkinsons

Answer 8

• Exclude organic causes
• If patient has psychotic symptoms such as visual hallucinations that are not distressing
  treatment may not be required
• Reduce or stop anticholinergics and dopamine agonists
• Antipsychotics can worsen movement disorder and dopamine agonists can worsen
  psychosis, therefore an optimal balance is necessary
• Consider atypical antipsychotic such as quetiapine
• Consider a cholinesterase inhibitor particularly if the patient has co-morbid dementia
• Try clozapine in a small dose, up to 25 mg/day
• Consider ECT

Question 9

Capacity Ax

Answer 9

 Assessment (points to not forget)
o Speak to treating team – clarify situation, details
o Treat or determine any psych disorder or physical illness impacting
o Set up setting – calm, quiet
o Test orientation – MMSE etc.
o Therapeutic alliance – with consumer
o Explain your role and role of a capacity assessment to consumer
o Ethical dilemma – autonomy of patient vs duty of care

o Components of capacity assessment
 Understand the purpose and information
 Repeat the information
 Understand the risks and benefits
 Understand alternatives
 Communicate decision
 Free from undue influence
 Decision consistent
o If lacks capacity then consult with guardianship tribunal and treating team
o Don’t forget can provide different mediums – audio visual cues, cultural worker, etc.
o Treat any mental illness or reversible causes that can have impact on capacity

 Family considerations
o Discuss with family the delivery of care given that patient lacks capacity
o Psychoeducation about cognitive impairment
o If the family become significantly distressed, arrange additional support
 Regular discussions
 Extended family support
 Social work
 Counselling

Remember that patient may develop more insight and better judgement, or at least be more prepared to take advice, once effectively treated or time is allowed for treatment to have effect