deck_8091483 Flashcards

Question 1

Q

What is the general approach to dealing with a patient with acute behavioural disturbance

Answer

A

1. Maintain safety and calm situation; easy access to exits, maintain some distance between you and the patient 2. Verbal de-escalation and early negotiation (calm voice, sit with patient, offer food/drink, let them voice their concerns, offer oral medication (diazepam PRN or olanzepine once) 3. Show of force; bring large number of staff 4. Physical restraint by trained team 5. Chemical restraint (IV access preferred, give diazepam/midazolam/droperidol or olanzepine, if need to give IM consideer midazolam, olanzapine)

Question 2

Q

Appearance

Answer

A

Physical state: how old do they appear? Do they appear physically unwell? Are they sweating? Are they too thin or obese? EtcClothes and accessories: Are their clothes clean? Are they wearing the same clothes since when you last saw them? Are clothes appropriate for the weather/circumstance? Is the patient carrying strange objects?Self-care &amp; hygiene: does the patient appear to have been neglecting their appearance or hygiene (eg. Unshaven, malodourous, dishevelled)? Is there any evidence of self-harm (eg cuts to wrists/forearm)?

Question 3

Q

BEHAVIOUR

Answer

A

Abnormal movements: tremors, tics, twitchesHow the patient is acting: Are they relaxed/ suspicious/ aggressive/ fearful/ catatonic?Psychomotor abnormalities: retardation (slow, monotonous speech, slow/absent body movements), agitation (inability to sit still; fidgeting, pacing, hand wringing, rubbing/scratching skin or clothes)Rapport: What is their attitude towards you? Do they make good eye contact? May be described as cooperative, cordial, uninterested, aggressive, defensive, guarded, suspicious, fearful, perplexed, preoccupied, disinhibited, etc

Question 4

Q

Parkinsonism

Answer

A

drug-induced signs are most commonly a reduced arm swing + unusually upright posture while walking. Tremor + rigidity are late signs, in contrast to idiopathic parkinsonism

Question 5

Q

Acute dystonia

Answer

A

involuntary sustained muscular contractions or spasms

Question 6

Q

Akathisia

Answer

A

subjective feeling of inner restlessness and muscular discomfort, unable to sit still

Question 7

Q

Tardive dyskinesia

Answer

A

rhythmic, involuntary movements of the head, limbs and trunk, especially chewing, grimacing of the mouth and protruding, darting movements of the tongue

Question 8

Q

Bradykinesia

Answer

A

slowness of movement

Question 9

Q

SPEECH

Answer

A

Rate: may be regular, may have pressure of speech (seen in mania), long pauses/hesitancy + poverty of speech(seen in depression)Tone: may be regular tonality, monotonousVolume: regular, increased or decreasedAlso comment on dysarthria (articulation difficulties), dysprosody (unusual speech rhythm, melody, intonation or pitch), stuttering, slurring

Question 10

Q

Mood

Answer

A

Refers to a patient’s sustained, subjectively experienced emotional state over a period of timeAssessed by asking the patient how they are feeling- Described objectively (your impression from the interview) and subjectively (their description of how they feel) Dysphoric: an unpleasant mood, eg. Depression, anxiety, irritabilityEuthymic: the mood is within the “normal” range, implying that mood is neither depressed nor elevated Expansive: the mood is more elevated than normal, but does not necessarily imply pathologyEuphoric: an intense feeling of well-being

Question 11

Q

AFFECT

Answer

A

A subjective feeling/emotional experience that is manifested by observable behaviours such as attitude, facial expression, tone of voice, etc.Affect is assessed by observing patient’s posture, facial expression, emotional reactivity(1) Changeability• Restricted – characterised by discernible decrease in range + intensity of expressions• Labile – characterised by rapid &amp; abrupt changes , eg. Friendly + cheerful one minute and thenangry and belligerent the next for no apparent reason(2) Range = Normal/ increased/ decreased(3) Appropriateness = congruent/incongruent (discordance between speech and affect)(4) Intensity • Blunted – associated with marked diminuition in emotional expression• Flat – the normal signs of a broad range of affective expression are absent; voice may bemonotonous, face may be immobile/expressionless

Question 12

Q

THOUGHT FORM - Circumstantial

Answer

A

An inability to answer a question without giving excessive, unnecessary detail – differs from tangential thinking, in that the person does eventually return to the original point

Question 13

Q

THOUGHT FORM - tangential

Answer

A

Wandering from the topic and never returning to it nor providing the information requested

Question 14

Q

THOUGHT FORM - Loosening of association

Answer

A

characterized by discourse consisting of a sequence of unrelated or only remotely related ideas. The frame of reference often changes from one sentence to the next.

Question 15

Q

THOUGHT FORM - Neologisms

Answer

A

Creation of a new word, often consisting of a combination of other words, that is understood only by the speaker

Question 16

Q

THOUGHT FORM - Flight of ideas

Answer

A

A rapid shifting of ideas with only superficial associative connections between them that is expressed as a disconnected rambling from subject to subject and occurs especially in the manic phase of bipolar disorder

Question 17

Q

THOUGHT FORM - Thought blocking

Answer

A

Occurs when a person's speech is suddenly interrupted by silences that may last a few seconds to a minute or longer

Question 18

Q

THOUGHT FORM - preservation

Answer

A

Persistent repetition ofwords or ideas even when another person attempts to change the topic

Question 19

Q

THOUGHT FORM Echolalia

Answer

A

Echoing of another speech

Question 20

Q

THOUGHT FORM - Alogia

Answer

A

Poverty of speech, either in amount of content

Question 21

Q

Thought Content - Preocupations

Answer

A

over-valued or recurrent thoughts

Question 22

Q

THOUGHT CONTENT - obsessions

Answer

A

Distressing recurring unwanted thoughts

Question 23

Q

THOUGHT CONTENT - Delusions

Answer

A

A fixed false belief not accounted for by patient's cultural background

Question 24

Q

THOUGHT CONTENT - PARANOID DELUSIONS

Answer

A

The person/group is being attacked, threatened, harassed, endangered, deceived or persecuted

Question 25

Q

THOUGHT CONTENT - GRANDIOSE DELUSIONS

Answer

A

a delusion in which theperson has an exaggerated view of his/her ownimportance, power, knowledge, or identity

Question 26

Q

THOUGHT CONTENT - DELUSIONS OF REFERENCE

Answer

A

events/objects/otherpeople in the subject’s immediate environmentare seen to have unusual &amp; special significance

Question 27

Q

THOUGHT CONTENT - IDEAS OF REFERENCE

Answer

A

similar to delusions ofreference but the beliefs are more shakeable

Question 28

Q

THOUGHT CONTENT - DELUSIONS OF CONTROL/ PASSIVITY EXPERIENCES

Answer

A

belief that the person’s feelings/ impulses/ thoughts/ actions are not his or her own, but rather are inserted by another

Question 29

Q

THOUGHT CONTENT - SOMATIC DELUSIONS

Answer

A

Relates to functioning of the body e.g being pregnant, rotting brain

Question 30

Q

THOUGHT CONTENT - NIHILISTIC DELUSIONS

Answer

A

false belief that self, part of self, others, or the world is nonexistent or ending

Question 31

Q

PERCEPTION

Answer

A

Determine whether the abnormal perceptions are genuine hallucinations, pseudohallucinations, illusions, or intrusive thoughts • Describe from which sensory modality the hallucinations arise – eg. Auditory, visual, tactile, olfactory, gustatory, somatic • Determine whether auditory hallucinations are elementary or complex • If complex – are they experienced in first person (audible thoughts, thought echo), second person (critical, persecutory, complimentary or command hallucinations) or third person (voices arguing or discussing the patient, or giving a running commentary) • It is also important to note whether the patient is responding to hallucinations during the interview, as evidenced by them laughing as though they are sharing a private joke, suddenly tilting their head as though listening, or quizzically looking at hallucinatory objects around the room

Question 32

Q

COGNITION

Answer

A

• Screened by checking orientation to person, place, time• Usually not formerly assessed unless you have time for an MMSE

Question 33

Q

INSIGHT

Answer

A

• Often described as good, partial, or poor – however usually patients lie somewhere on a spectrum and vary over timeKey questions to answer;- Does the patient believe they are unwell in any way? Do they believe they are mentally unwell?- Do they think they need treatment?- Do they think they need to be in hospital?

Question 34

Q

JUDGEMENT

Answer

A

- Reasoning regarding current important issues- Ideas about decisions or actions to be taken, including about current illness- Evidence from past judgements as clues to current thinking

Question 35

Q

MOA, Examples, positives and negatives of 1st generation/ TYPICAL antipsychotic medications

Answer

A

MOA - Block post synaptic D2 receptors in mesolimbic, mess cortical, nigrostriatal and tuberoinfundibulnar pathways EXAMPLES - Haloperidol (high potency) - Chlorpromazine (low potency) POSITIVES - inexpensive - injectable/ depot form - minimal metabolic side effectsNEGATIVES - Extrapyramidal SE - Not mood stabilising - Reduced DA in mesocortiyal pathway can induce negative side effects - Tardive symptoms in long term use

Question 36

Q

MOA, Examples, positives and negatives of 2nd generation/ ATYPICAL antipsychotic medications

Answer

A

MOA - Block post synaptic D2 receptors (less affinity than 1st gen) - Block 5HT2A on presynaptic dopamine terminals to reverse dopamine blockafe in some pathways EXAMPLES - Risperidone - Olanzapine - Quetiapine - Aripiprazole - Clozapine POSITIVES - Fewer EPS - Low tar dive symptom risk - mood stabilising NEGATIVES - Expensive - Metabolic SE !!! (increase wt, BGL, lipids, MetSy) - Exacerbation/ new onset obsession behaviour

Question 37

Q

Second generation antipsychotics adverse effects NOTE: see notes for specific SE of specific SGAs (table)

Answer

A

Common▪ Insomnia▪ Akathesia (very common!)▪ Headache▪ Sedation (esp Quetiapine and olanzapine)▪ Metabolic syndrome + weight gain▪ Cardiovascular- May increase the QT interval, increasing the risk of arrhythmia - orthostatic hypotension- some ↑ in VTE riskUncommon but Serious▪ Extrapyramidal Side effects - Dystonia- Akathesia- Pseudo-parkinsonism -Tardive Dyskinesia▪ Neuroleptic malignant syndrome (FARM symptoms)▪ Blood dyscrasias- anaemia, thrombocytopenia, neutropenia, agranulocytosis▪ New-onset or worsening obsessive-compulsive symptoms (clozapine)EXTRAPYRAMIDAL SIDE EFFECTS▪ highest with haloperidol, fluphenazine and trifluoperazine▪ lower with chlorpromazine, periciazine▪ Is dose dependant – so Reduce antipsychotic dose to avoid recurrent EPSENOTE: AKATHESIA= inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting

Question 38

Q

Clozapine - Indications, contraindications, receptor profile/MOA, adverse effects, interactions, patient counselling, monitoring (Antipsychotic)

Answer

A

INDICATIONS▪ Schizophrenia in people unresponsive to, or intolerant of, other antipsychotics (ie lack of satisfactory clinical response, despite the use of adequate doses of drugs from at least 2 groups of antipsychotics for a reasonable duration; or development of EPSE, including tardive dyskinesia)CONTRAINDICATIONS▪ Contraindicated in bone marrow disorders, drug-induced (including clozapine-induced) neutropenia or agranulocytosis (Neutropenia seems to be more common in children and adolescents than adults)▪ Severe Renal or Liver impairmentRECEPTOR PROFILE/ MOA▪ BLOCK 5HT2 to 90%▪ BLOCK D2▪ BLOCK M1▪ BLOCK D4(with high affinity related to plasma concentration)▪ BLOCK H1, alpha 1ADVERSE Common - Sedation ++- Hypersalivation ++ - Increase HR ++ - Constipation- Seizures - Pyrexia - Urinary incontinence Infrequent - Hepatitis ++- Myocarditis ++- Neutropenia ++- Angranulocytosis ++ - EPS ++- Eosinophilia - Priapism Rare - Cardiomyopathy ++- HTN- Myoclonic jerks - Interstitial nephritis - Fulminant hepatic necrosis Metabolic ▪ ↑↑ BGL. ↑↑ Lipids, ↑↑ weight▪ ↑↑ Risk of developing T2DM (must assess before + during treatment)▪ Blood Dyscaria▪ ↑↑ Risk of agranulocytosismust monitor for this!INTERACTIONS ▪ Tobacco smoking—increases clearance of clozapine; dose may need to be adjusted if patient starts or stops smoking (the dose may need to be adjusted by 50%).▪ Avoid combinations with drugs that may cause agranulocytosis▪ GI obstruction may be exacerbated by the anticholiergic propertiesPATIENT COUNSELLING ▪ Need regular blood tests and other checks to monitor for serious side effects.▪ Do not stop taking this medicine suddenly unless your doctor tells you to.▪ Dose may need changing if you vary your caffeine intake (eg tea, coffee, coladrinks) or if you start or stop smoking tobacco; tell your doctor if any of these habits change.MONITORING ▪ Start treatment only if white cell count and absolute neutrophil count are normal; blood monitoring is required each week for the first 18 weeks and then each month▪ Medical supervision and resuscitation facilities must be available when treatment starts because of possible profound orthostatic hypotension with respiratory or cardiac failure▪ Monitoring for the development of myocarditis:- Baseline troponin + CRP + ECG + ECHO- Monitor CRP + TnI weekly for first 4 weeks- Enquire of symptoms every alternate day (when in patient)and weekly when out patient- Discontinuation of clozapine and investigation byechocardiography is advised if either troponin is in excess of twice the normal maximum or CRP is more than 100 mg/L. - Clinical – flu like illness, sudden BP drop, chest pain, non-specific ECG changes, basal crepitation’s, S3 heart sound, peripheral oedema, ↑ JVP

Question 39

Q

Factors contributing to antipsychotic medication adherence

Answer

A

PATIENT FACTORS ▪ Insight into their own condition▪ Attitude towards taking themedications▪ Medication beliefs (e.g. delusional beliefs the drug is poison)▪ Ongoing substance abuse▪ Psychotic symptoms (a psychotic person won’t remember to take their meds!)MEDICATION FACTORS▪ Side effects --> weight gain, motor symptoms, sedation, hyper- prolactinemia▪ Daily tablet dosing --> easy to miss or forget▪ Depo --> factors affecting access and adherence for repetitive doses▪ Efficacy▪ Time taken to show effect

Question 40

Q

Explain Antipsychotic medications to parent/ carer

Answer

A

▪ INDICATION + MECHANISM- to alleviate the positive symptoms of schizophrenia / psychosis. These include the hallucinations and delusions.- Work to reduce the effects of the chemicals in the brain that are causing the psychotic symptoms▪ OPTIONS- Consider whether a regular injection may suit you better than takingtablets.- This maybe an option that can’t be started off with but can be usedonce doses etc are titrated.▪ TAKING THE MEDS- It is best to avoid using illicit substances as use of cannabis or amphetamine markedly decreases control of psychotic symptoms and increases risk of relapse.- Taking your antipsychotic medicine regularly is important- Stopping or taking it irregularly is associated with high risk of relapse and suicide▪ SIDE EFFECTS- Extrapyramidal side effects are and what you can do about them- Risk of tardive dyskinesia with long-term antipsychotic treatment.- Sedation / drowsiness (↑ effects of alcohol, cannabis or sleepingtablets) = Do not drive or operate machinery- Metabolic effects + weight gain- You may feel dizzy on standing when taking this medicine. Get upgradually from sitting or lying to minimise this; sit or lie down if you become dizzy.▪ MONITORING + FOLLOW UP- Initially will need to check blood (UEC, LFT, prolactin) and ECG- Need annual / 6 monthly monitoring of metabolic variables and ECG- Prophylaxis is usually continued for 1–2 years after remission of a first psychotic episode (to prevent relapse) and for longer after >2 episodes- After stabilisation, the long half-life usually allows the total daily oral dose to be given at night

Question 41

Q

Lithium Initiation, dose, Patient education, monitoring, interactions, precautions, Adverse effects, what to do in pregnancy (MOOD STABILISER)

Answer

A

BEFORE COMMENCING/ INITIATION CHECK: ▪ UEC + eGFR (+/- urinalysis) ▪ Calcium + PTH levels ▪ Thyroid function (can cause hypothyroidism) ▪ ECG (can cause QTc prolongation) ▪ FBC (can cause leucocytosis) ▪ Weight + BMI (can cause gain) DOSE - 125 to 500 mg orally, BD daily for 2 weeks. Dose should then be adjusted according to the serum concentration determined after 5 to 7 days of steady-dose treatment. - Therapeutic range = 0.6 – 0.8mmol/L

PATIENT EDUCATION - Adherence is very very important! - Regular blood tests are important during treatment. - Take with food. - Do not break, crush or chew, and avoid taking with hot drinks. - Maintain a normal diet with regular salt and fluid intake. - Drink more non-alcoholic fluid during hot weather to avoid toxicity. - Avoid sodium bicarbonate (found in products such as indigestion medicines) as it makes lithium less effective. - Educate about lithium toxicity = Be alert for signs (eg extreme thirst and frequent urination, nausea and vomiting), esp during illness, excessive sweating or low fluid intake = If these occur, stop taking the tablets and seek medical attention immediately. - Abrupt cessation leads to relapse of mania within a few months, thus it should be withdrawn slowly over at least 2 months

MONITORING ▪ Measure serum levels 8 – 12 hours after last dose ▪ Serum [lithium] to be reassessed every 3 – 6 months once stable therapeutic concentration is achieved ▪ UEC+eGFRevery3–6months ▪ Thyroid function every 6 – 12 months ▪ Serum [calcium] annually (if ↑, measure PTH) Note: Monitor lithium concentration more frequently during illness (eg gastroenteritis), manic or depressive phases, changes in diet or temperature, pregnancy and concomitant medication (eg diuretics)

INTERACTIONS ↓ lithium renal clearance = [serum] ▪ Diuretics ▪ NSAIDs ▪ ACEi or ERBs ▪ Dehydration or intercurrent illness PRECAUTIONS ▪ Lithium is renally excreted --> ↓ dose in times of renal impairment ▪ Lower dose used in elderly (as they have worse kidney fn) ▪ Hyponatraemia increases the risk of lithium toxicity. Avoid lithium or use it cautiously where sodium levels may decrease (e.g. vomiting, diarrhoea, use of diuretics, dehydration, Addison’s disease). ▪ Psoriasis may be exacerbated or precipitated by lithium.

ADVERSE EFFECTS L - Leukocytosis I - Insipidus --> polyuria, polydipsia, decreased GFR, ESKD T - Tremors + ataxia H - Hypothyroidism I - Increased weight U - Underactive mind (dullness, fatigue, lethargy) M - Mothers --> teratogenic (esp T1 = Ebstein’s anomaly) GIT = nausea, vomiting, diarrhoea ECG = Long QTc, flat T waves, premature beats, conduction delays PREGNANCY ▪ If possible, avoid use particularly during the first trimester (TERATOGEN) ▪ However, at times keeping Lithium is the best option (as carbamazepine, valproate and lamotrigine are not suitable alternatives in pregnancy) ▪ More regular monitoring (every month) ▪ Monitor hydration ▪ Essentially a specialist’s job to deal with it + sort shiz out

Question 42

Q

Lithium toxicity - features, Acute vs. chronic, risk factors, key investigations, management

Answer

A

FEATURES Early/mild= Nausea, vomiting, Tremor, Agitation, Proximal weakness, Poor memory, Flu-like illness Moderate= Blurred vision, ↑ diarrhoea, N + V ▪ Muscle weakness, Drowsiness + apathy,Ataxia, Hypotension, ECG changes Severe=Hypertonia, Hyperreflexia, Myoclonic jerks, Coarse tremor , Dysarthria, Disorientation, Psychosis, stupor, Seizures, Severe Hypotension, Coma ACUTE TOXICITY= Rapid elimination by the kidneys and slow uptake into the CNS after overdose. Here, serum [ ] DOES NOT correlate to toxicity CHRONIC TOXICITY= In patients taking therapeutic doses where there has been a change in dose, addition of other medications or decreased elimination (↓GFR). Here serum [ ] reflect CNS [ ] and they can be used to guide need for dialysis

RISK FACTORS ▪ Impaired kidney function ▪ Dehydration ▪ > 50 years ▪ Drug interactions or med changes ▪ Nephrogenic diabetes insipidus ▪ Thyroid dysfunction

KEY INVESTIGATIONS ▪ ECG ▪ FBC ▪ Serum lithium [ ] ▪ UEC ▪ eGFR

MANAGEMENT - Acute poisoning require no specific treatment except serial measurement of lithium concentrations to confirm elimination. -Chronic poisoning has an insidious onset and more often requires treatment with intravenous fluids and occasionally dialysis. -Clinical recovery can take days to weeks and is significantly delayed compared with the decrease in serum lithium concentrations. -Some neurological effects may be permanent. (1) Circulation ▪ Sufficient fluid replacement is essential ▪ IV Normal Saline is first line in those with normal renal function ▪ Patient may have DI, this must be taken into consideration when giving IV fluids (ie larger fluid requirements to replace increased urine output)

(2) Decontamination ▪ Decontamination is not indicated for acute ingestions < 50 g ▪ Activated charcoal does not bind lithium ▪ If ingested >50g, whole bowel irrigation can be considered if given within the first 6 hours and the patient is awake and cooperative (3) Enhance elimination ▪ Should be discussed with a clinical toxicologist ▪ Haemodialysis increases the clearance of lithium, but is rarely required in patients with normal kidney function. ▪ Dialysis should be continued until lithium concentrations are below 1 mmol/L and further concentrations should be measured to detect rebound (4) Monitor lithium levels - Every 2 - 4 hours

Question 43

Q

LAMOTRIGINE - MOA, Indication, patient education, monitoring, adverse effects (MOOD STABILISER)

Answer

A

MOA Stabilises presynaptic neuronal membranes by blocking voltage-dependent and use- dependent sodium channels and inhibiting glutamate release.INDICATIONS - Epilepsy, bipolar mood stabilisation PATIENT EDUCATION▪ Tablets may be swallowed whole, chewed or dispersed in water.▪ This medicine may cause drowsiness, dizziness or blurred vision; if affected, do not driveor operate machinery.▪ Lamotrigine may also increase the effects of alcohol.▪ Tell your doctor immediately if you develop a rash, fever or swollen glands.▪ Stop treatment immediately if skin reaction or signs of hypersensitivity occur (with orwithout rash)MONITORING Before starting▪ FBC▪ UEC + eGFR▪ LFTOngoing Monitoring▪ FBC every 3 – 6 monthsADVERSE EFFECTS Common - diplopia, blurred vision- dizziness- ataxia- headache- somnolence- hyperkinesia- maculopapular rashUncommon- Alopecia- Severe skin reaction (TEN, SJS) - Multiorgan hypersensitivity syndrome - Aseptic meningitis - Low NE, low platelets Extra notes- Hepatically excreted --> avoid use in hepatic impairment - Teratogenic = patient must be on contraception

Question 44

Q

SODIUM VALPROATE - MOA, DOSE, INDICATION, PATIENT EDUCATION, MONITORING, ADVERSE EFFECTS (MOOD STABILISERS)

Answer

A

MOA - Multiple mechanisms. Prevents repetitive neuronal discharge by blocking voltage‐ and use-dependent sodium channels. Other actions include enhancement of GABA, inhibition of glutamate and blockade of T-type calcium channels.DOSE - 200 to 400 mg PO, BD. The dose should be ↑ weekly in increments of 200 to 400 mg/day and the serum concentration determined after 3 days of steady-dose treatment. - Most patients require a daily dose of 1500 to 3000 mg (1.5g – 3g)INDICATIONS - epilepsy, bipolar mood stabilisation, resistant migraines PATIENT EDUCATION ▪ Take with food to reduce stomach upset. Do not crush or chew tablets.▪ Valproate may make you feel drowsy; if affected, do not drive or operatemachinery. Valproate may also increase effects of alcohol.▪ Your appetite may increase when taking this medicine and you may need to pay more attention to your diet to avoid weight gain.▪ Tell your doctor immediately if symptoms such as fever, rash, abdominal pain,vomiting, jaundice, bruising or bleeding develop.▪ Do not stop taking this medicine suddenly unless your doctor tells you to.MONITORING Before starting▪ FBC▪ UEC + eGFR▪ LFTOngoing Monitoring▪ FBC every 3 – 6 monthsADVERSE V - VA - Appetite increase = wt gainL - Liver toxicityP - PancreatitisR - Reversible hair loss O - OedemaA - Ataxia, tremorT - Teratogen (NTD, congenital anomalies)E - Encephalopathy (from increased ammonia)NOTE Valproate reduces BMD and may increase fracture risk; consider BMD monitoring during long-term treatment and ensure vitamin D status and calcium intake are adequate

Question 45

Q

Valproate OD - Dose required to overdose, Features and management

Answer

A

Dose require to OD < 400mg/kg=little to no effect >400mg/kg = severe toxicity >1g/kg= life threateningFEATURES GIT = nausea, vomit, abdo painCNS = drowsy, ataxia, cerebral oedema, seizures, comaCV = long QTc, ↓ BP, ↑ HRMET = ↑Na, acidosis, ↑ LDH, ↓ Ca, ↓ BGL, ↑ ammoniaFBC =↓plt, ↓ NeMANAGEMENT Measure = ECG, [valproate], BGL, UEC, FBCAirway = severe may need support Circulation = IV saline resus, if severe give IV adrenaline Decontamination = activated charcoal within 2hHaemodialysis at specialist’s discretion

Question 46

Q

CARBMAZEPINE - MOA, INDICATIONS, PRECAUTIONS, PATIENT EDUCATION, MONITORING, ADVERSE EFFECTS (MOOD STABILISER)

Answer

A

MOA - Prevents repetitive neuronal discharges by blocking voltage-dependent and use- dependent sodium channels.INDICATIONS Epilepsy, Bipolar mood stabilisation, trigeminal neuralgiaPRECAUTIONS - Do not use in BM suppression, with clozapine or hypersensitivity history, hepatic ally excreted avoid use in hepatic impairment, teratogenic all female patients must be on contraception PATIENT EDUCATION ▪ Take with food to help prevent stomach upset. Do not chew or crush tablets▪ May cause drowsiness, dizziness or blurred vision especially at the start of treatment or whenthe dose is increased; if affected, do not drive or operate machinery.▪ May increase the effects of alcohol.▪ Interacts with grapefruit juice and many other drugs; avoid grapefruit juice and tell your doctorand pharmacist that you are taking carbamazepine before starting any new medication▪ Tell your doctor immediately if rash, sore throat, fever, mouth ulcers, bruising or bleeding occur.▪ Do not stop taking this medicine suddenly unless your doctor tells you to.MONITORING Before starting - FBC- UEC + eGFR- LFT Ongoing Monitoring - FBC every 3 - 6 months (BM suppression) - Monitor skin reactions - Consider BMD monitoring and vitamin D and calcium supplements ADVERSE C - ConfusionA -Ataxia R - Rash/ SJS / TEN T - Teratogen (contraception!!) D - DizzyD - Diplopia, blurred visionD - Drowsy H - Hypernatremia H - H reduced WCC H - Hepatotoxic

Question 47

Q

Anticonvulsant Hypersensitivity Syndrome - Onset, symptoms, management

Answer

A

ONSET - 1 – 4 weeks after starting therapySYMPTOMS - fever, rash and systemic organ involvement (lymphadenopathy, hepatitis,myositis, myocarditis, pneumonitis)- skin involvement (rash, SJS, TEN)- may affect the liver, kidneys and lungs and can lead to hepatic or renal failureMANAGEMENT - Stop offending drug, resus, rehydration, analgesia, burnsdressings, corticosteroids, ABx if infection suspected, consider plasma exchange

Question 48

Q

SSRIs - Examples, MOA, clinical pearls, side effects, risks

Answer

A

Examples - fluoxetine, citalopram, Escitalopram, Fluvoxamine Paroxetine SertralineMOA - selectively inhibit the presynaptic serotonin reuptake transporter --> ↑ 5HT in synapse↑ 5HT transmission in the brain- ↑ stimulation of 5HT receptors ↑ BDNF (↑gene transcription) BDNF increases neurogenesis in hippocampus and increases development of dendritic processes --> neuroplasticity too!Clinical Pearls- First Line + effective - Well tolerated in most people - Safe in OD- Can be used in pregnancy and breastfeeding (? Some PTL)- taken in the morning to minimise insomnia- Caution of increased suicidal thoughts and behaviour can occur soon after startingSE/RISKS- COMMON = nausea, diarrhoea, insomnia, drowsy, tremor, dry mouth, dizzy, sexual dysfunction, myalgia, rash- UNCOMMON = EPS, sedation, confusion, palpitations, ↓BP, ↑ bleeding re: ↓ plt function- SERIOUS = hepatitis, ↑ prolactin, akathisia, acute glaucoma- GI bleeding (caution if >80y, past UGI bleed or on NSAIDs) – by blocking 5HT uptake into platelets- Hyponatremia (esp in elderly)- Monotherapy in BPAD can precipitate mania- ↓ Dose in hepatic impairment- Serotonin syndrome (when combined with SNRI or MAOI) + QTc prolongation o Discontinuation syndrome (when stopping SSRI treatment taper over several weeks)

Question 49

Q

SNRI - Examples, MOA, Clinical pearls, SE/ RISKS

Answer

A

EXAMPLES- Duloxetine Venlafaxine DesvenlafaxineMOA- Inhibit serotonin and noradrenaline reuptake.- As they lack major receptor blocking actionsfewer side effects than TCAsClinical Pearls - Check BP before starting treatment, and then check regularly- Do UECs for [Na] at baseline, and then soon after starting treatment- Caution of increased suicidal thoughts and behaviour can occur soon after starting- You must taper dose if stoppingSE/ RISKS - COMMON = nausea, dry mouth, constipation, yawning, sweating, dizziness, increased BP, sexual dysfunction- UNCOMMON = orthostatic hypotension and fainting, palpitations, ↑HR o SERIOUS = seizures, akathisia, ↑ prolactin- GI bleeding (caution if >80y, past UGI bleed or on NSAIDs)- Hyponatremia (esp in elderly)- Monotherapy in BPAD can precipitate mania

Question 50

Q

TCAs - Examples, MOA, Clinical pears, SE/Risks

Answer

A

Examples - Amitriptyline Nortriptyline Imipramine ClomipramineMOA- Inhibit reuptake of NA+ 5HT into presynaptic terminals by binding to the amine transporter↑ NA + 5HT transmission- Unrelated to the therapeutic effects, TCAs also block cholinergic, histaminergic, alpha1-adrenergic and 5HT receptors.Clinical Pearls - Cheap- Effective in treating depression- Second line agents due to side effects and risk in ODMonitoring...- BP, FBC, LFT and ECG prior to starting- Assess suicidal ideation- Review in 2 – 3 weeks for effect + toleratingSE/ RISKS- Anticholinergic effects (hot, dry mouth, dry eyes, urine retention, blurred vision, constipation, confusion) – can’t see, cant pee, can’t spit, can’t shit- Cardiaco Arrhythmiaso Heart blocko Lengthen QTco Hypotension, reflex ↑HR- Sedation- Delirium (elderly)- Sexual (↓ libido, impotence)- Blood dyscarias, hepatitis- Precipitate acute angle glaucoma- Caution in hepatic impairment- DO NOT USE IN: prostatic hypertrophy, acute angle glaucoma, 2nd/3rd degree heart block o TOXIC IN OVERDOSE (suicide risk)

Question 51

Q

MAO-I - examples, MOA, Clinical pearls, SE/ Risks

Answer

A

Examples - Moclobemide Selegiline PhenelzineMOA- Inhibit monoamine oxidase A + B to thus ↓ break down of NA + 5HT + DA --> more NA + 5HT in synapses --> more transmissionClinical Pears - Third line agents in depression o Must avoid foods containing tyramine (aged cheese, salami) SE/ RISKS - COMMON = orthostatic ↓BP, insomnia, headache, drowsiness, agitation, tremors, twitching, hypereflexia, sexual dysfunction- UNCOMMON = itch, rash, sweating, blurred vision, peripheral oedema, hypoglycaemia - SERIOUS = Hypertensive crisis, hepatocellular damage- Contraindicated in = pheochromocytomas, use of sumatriptan, CVAs, Angina and epilepsy- Serotonin syndrome (when combined with SNRI or SSRI) - TOXIC IN OVERDOSE (suicide risk)

Question 52

Q

Mianserin Mirtazapine Trazodone - MOA, Clinical Pearls, SE/ RISKS

Answer

A

MOA - Mono-amine receptor antagonists that block various receptors to provide antidepressant effect.Clinical Pearls - Not used much- Not as effective as SSRIs, SNRIs or TCAsSE/ RISKS- Blocks histamine H1 receptors - > sedation- weight gain- fever + chills- memory problems

Question 53

Q

Benzo - diazepam 2-5mg, MOA, when/how to use, SE

Answer

A

MOA - Bind to y subunit of GABA receptor to potentiate its effect --> increased CL channel opening --> increased threshold --> decreased action potentials --> decreased NT release --> inhibitory effects and disinhibition - mainly in motor and limbic system When/how to use - Short term- Low dose- Regular schedule - Avoid PRN- Best in times of crisis (phobia, panic disorder, anxiety)Duration - 2 weeks - taper + cease by 6 weeks SE- Dependence- Withdrawal- Cognitive impairement - Falls Risk- Paradoxical aggression

Question 54

Q

Second generation antipsychotics adverse effects NOTE: see notes for specific SE of specific SGAs (table)

Answer

A

Common▪ Insomnia▪ Akathesia (very common!)▪ Headache▪ Sedation (esp Quetiapine and olanzapine)▪ Metabolic syndrome + weight gain▪ Cardiovascular- May increase the QT interval, increasing the risk of arrhythmia - orthostatic hypotension- some ↑ in VTE riskUncommon but Serious▪ Extrapyramidal Side effects - Dystonia- Akathesia- Pseudo-parkinsonism -Tardive Dyskinesia▪ Neuroleptic malignant syndrome (FARM symptoms)▪ Blood dyscrasias- anaemia, thrombocytopenia, neutropenia, agranulocytosis▪ New-onset or worsening obsessive-compulsive symptoms (clozapine)EXTRAPYRAMIDAL SIDE EFFECTS▪ highest with haloperidol, fluphenazine and trifluoperazine▪ lower with chlorpromazine, periciazine▪ Is dose dependant – so Reduce antipsychotic dose to avoid recurrent EPSENOTE: AKATHESIA= inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting

Question 55

Q

Clozapine - Indications, contraindications, receptor profile/MOA, adverse effects, interactions, patient counselling, monitoring (Antipsychotic)

Answer

A

INDICATIONS▪ Schizophrenia in people unresponsive to, or intolerant of, other antipsychotics (ie lack of satisfactory clinical response, despite the use of adequate doses of drugs from at least 2 groups of antipsychotics for a reasonable duration; or development of EPSE, including tardive dyskinesia)CONTRAINDICATIONS▪ Contraindicated in bone marrow disorders, drug-induced (including clozapine-induced) neutropenia or agranulocytosis (Neutropenia seems to be more common in children and adolescents than adults)▪ Severe Renal or Liver impairmentRECEPTOR PROFILE/ MOA▪ BLOCK 5HT2 to 90%▪ BLOCK D2▪ BLOCK M1▪ BLOCK D4(with high affinity related to plasma concentration)▪ BLOCK H1, alpha 1ADVERSE Common - Sedation ++- Hypersalivation ++ - Increase HR ++ - Constipation- Seizures - Pyrexia - Urinary incontinence Infrequent - Hepatitis ++- Myocarditis ++- Neutropenia ++- Angranulocytosis ++ - EPS ++- Eosinophilia - Priapism Rare - Cardiomyopathy ++- HTN- Myoclonic jerks - Interstitial nephritis - Fulminant hepatic necrosis Metabolic ▪ ↑↑ BGL. ↑↑ Lipids, ↑↑ weight▪ ↑↑ Risk of developing T2DM (must assess before + during treatment)▪ Blood Dyscaria▪ ↑↑ Risk of agranulocytosismust monitor for this!INTERACTIONS ▪ Tobacco smoking—increases clearance of clozapine; dose may need to be adjusted if patient starts or stops smoking (the dose may need to be adjusted by 50%).▪ Avoid combinations with drugs that may cause agranulocytosis▪ GI obstruction may be exacerbated by the anticholiergic propertiesPATIENT COUNSELLING ▪ Need regular blood tests and other checks to monitor for serious side effects.▪ Do not stop taking this medicine suddenly unless your doctor tells you to.▪ Dose may need changing if you vary your caffeine intake (eg tea, coffee, coladrinks) or if you start or stop smoking tobacco; tell your doctor if any of these habits change.MONITORING ▪ Start treatment only if white cell count and absolute neutrophil count are normal; blood monitoring is required each week for the first 18 weeks and then each month▪ Medical supervision and resuscitation facilities must be available when treatment starts because of possible profound orthostatic hypotension with respiratory or cardiac failure▪ Monitoring for the development of myocarditis:- Baseline troponin + CRP + ECG + ECHO- Monitor CRP + TnI weekly for first 4 weeks- Enquire of symptoms every alternate day (when in patient)and weekly when out patient- Discontinuation of clozapine and investigation byechocardiography is advised if either troponin is in excess of twice the normal maximum or CRP is more than 100 mg/L. - Clinical – flu like illness, sudden BP drop, chest pain, non-specific ECG changes, basal crepitation’s, S3 heart sound, peripheral oedema, ↑ JVP

Question 56

Q

Anticonvulsant Hypersensitivity Syndrome - Onset, symptoms, management

Answer

A

ONSET - 1 – 4 weeks after starting therapy

SYMPTOMS - fever, rash and systemic organ involvement (lymphadenopathy, hepatitis, myositis, myocarditis, pneumonitis) - skin involvement (rash, SJS, TEN) - may affect the liver, kidneys and lungs and can lead to hepatic or renal failure

MANAGEMENT - Stop offending drug, resus, rehydration, analgesia, burns dressings, corticosteroids, ABx if infection suspected, consider plasma exchange

Question 57

Q

SSRIs - Examples, MOA, clinical pearls, side effects, risks

Answer

A

Examples - fluoxetine, citalopram, Escitalopram, Fluvoxamine Paroxetine SertralineMOA - selectively inhibit the presynaptic serotonin reuptake transporter --> ↑ 5HT in synapse↑ 5HT transmission in the brain- ↑ stimulation of 5HT receptors ↑ BDNF (↑gene transcription) BDNF increases neurogenesis in hippocampus and increases development of dendritic processes --> neuroplasticity too!Clinical Pearls- First Line + effective - Well tolerated in most people - Safe in OD- Can be used in pregnancy and breastfeeding (? Some PTL)- taken in the morning to minimise insomnia- Caution of increased suicidal thoughts and behaviour can occur soon after startingSE/RISKS- COMMON = nausea, diarrhoea, insomnia, drowsy, tremor, dry mouth, dizzy, sexual dysfunction, myalgia, rash- UNCOMMON = EPS, sedation, confusion, palpitations, ↓BP, ↑ bleeding re: ↓ plt function- SERIOUS = hepatitis, ↑ prolactin, akathisia, acute glaucoma- GI bleeding (caution if >80y, past UGI bleed or on NSAIDs) – by blocking 5HT uptake into platelets- Hyponatremia (esp in elderly)- Monotherapy in BPAD can precipitate mania- ↓ Dose in hepatic impairment- Serotonin syndrome (when combined with SNRI or MAOI) + QTc prolongation o Discontinuation syndrome (when stopping SSRI treatment taper over several weeks)

Question 58

Q

SNRI - Examples, MOA, Clinical pearls, SE/ RISKS

Answer

A

EXAMPLES- Duloxetine Venlafaxine DesvenlafaxineMOA- Inhibit serotonin and noradrenaline reuptake.- As they lack major receptor blocking actionsfewer side effects than TCAsClinical Pearls - Check BP before starting treatment, and then check regularly- Do UECs for [Na] at baseline, and then soon after starting treatment- Caution of increased suicidal thoughts and behaviour can occur soon after starting- You must taper dose if stoppingSE/ RISKS - COMMON = nausea, dry mouth, constipation, yawning, sweating, dizziness, increased BP, sexual dysfunction- UNCOMMON = orthostatic hypotension and fainting, palpitations, ↑HR o SERIOUS = seizures, akathisia, ↑ prolactin- GI bleeding (caution if >80y, past UGI bleed or on NSAIDs)- Hyponatremia (esp in elderly)- Monotherapy in BPAD can precipitate mania

Question 59

Q

TCAs - Examples, MOA, Clinical pears, SE/Risks

Answer

A

Examples - Amitriptyline Nortriptyline Imipramine ClomipramineMOA- Inhibit reuptake of NA+ 5HT into presynaptic terminals by binding to the amine transporter↑ NA + 5HT transmission- Unrelated to the therapeutic effects, TCAs also block cholinergic, histaminergic, alpha1-adrenergic and 5HT receptors.Clinical Pearls - Cheap- Effective in treating depression- Second line agents due to side effects and risk in ODMonitoring...- BP, FBC, LFT and ECG prior to starting- Assess suicidal ideation- Review in 2 – 3 weeks for effect + toleratingSE/ RISKS- Anticholinergic effects (hot, dry mouth, dry eyes, urine retention, blurred vision, constipation, confusion) – can’t see, cant pee, can’t spit, can’t shit- Cardiaco Arrhythmiaso Heart blocko Lengthen QTco Hypotension, reflex ↑HR- Sedation- Delirium (elderly)- Sexual (↓ libido, impotence)- Blood dyscarias, hepatitis- Precipitate acute angle glaucoma- Caution in hepatic impairment- DO NOT USE IN: prostatic hypertrophy, acute angle glaucoma, 2nd/3rd degree heart block o TOXIC IN OVERDOSE (suicide risk)

Question 60

Q

MAO-I - examples, MOA, Clinical pearls, SE/ Risks

Answer

A

Examples - Moclobemide Selegiline PhenelzineMOA- Inhibit monoamine oxidase A + B to thus ↓ break down of NA + 5HT + DA --> more NA + 5HT in synapses --> more transmissionClinical Pears - Third line agents in depression o Must avoid foods containing tyramine (aged cheese, salami) SE/ RISKS - COMMON = orthostatic ↓BP, insomnia, headache, drowsiness, agitation, tremors, twitching, hypereflexia, sexual dysfunction- UNCOMMON = itch, rash, sweating, blurred vision, peripheral oedema, hypoglycaemia - SERIOUS = Hypertensive crisis, hepatocellular damage- Contraindicated in = pheochromocytomas, use of sumatriptan, CVAs, Angina and epilepsy- Serotonin syndrome (when combined with SNRI or SSRI) - TOXIC IN OVERDOSE (suicide risk)

Question 61

Q

DSM-V Criteria for Schizophrenia

Answer

A

A = ≥2 of the following, present for a significant portion of time during a 1 mo period (less if successfully treated). At least one of these must be (1), (2), or (3)1. Delusions2. Hallucinations3. Disorganized speech (e.g. frequent derailment or incoherence)4. Grossly disorganized or catatonic behaviour5. Negative symptoms(i.e. diminished emotional expression or avolition)B = ↓ level of function: for a significant portion of time since onset.- One or more major areas affected (e.g. work, interpersonal relations, self-care) is markedly decreased- If childhood/adolescent onset, failure to achieve expected levelC = at least 6 mo of continuous signs of the disturbance. Must include at least 1 mo of symptoms that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms(the disturbance may manifest by only negative symptoms or by two or more Criterion A symptoms present in an attenuated form - e.g. odd beliefs, unusual perceptual experiences)D = Exclude schizoaffective disorder and depressive or bipolar disorder with psychotic featuresE = Exclude other causes: GMC, substances (e.g. drug of abuse, medication)F = If history of autism spectrum disorder or communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least 1 mo

Question 62

Q

DSM-V Schizoaffective disorder

Answer

A

A – An uninterrupted period of illness where there is concurrent psychosis (criterion A of schizophrenia) and major mood episode. B - delusions or hallucinations for ≥ 2 weeks in the absence of a major mood episode during the lifetime duration of the illness C - major mood episode symptoms are present for the majority of the total duration of the active and residual periods of the illness D - the disturbance is not attributable to the effects of a substance or another medical condition note: difference between schizophrenia and schizoaffective disorder is that schizoaffective disorder has a prominent MOOD component (manic or depressed) as apposed to schizophrenia where mode symptoms may present but they are NOT prominent

Question 63

Q

DSM-V criteria Brief Psychotic Episode

Answer

A

A psychotic illness that meets criteria A + D + E of schizophrenia BUT with a very short duration of symptoms (1day - <1m total) with eventual resolution to full pre-morbid functioning. If the symptoms extend past 1 month, it become schizophreniform disorder. Managed with secure environment, antipsychotics and anxiolytics. This condition is self-limiting and has a good prognosis. Most return to normal pre-morbid functioning within a month.

Question 64

Q

DSM-V for Schizophreniform disorder

Answer

A

A psychotic illness that meets criteria A + D + E of schizophrenia BUT with a shorter duration of symptoms (1 -6m total). If the symptoms extend past 6 months, it become schizophrenia.Full rapid resolution of symptoms is associated with better prognosis. Can develop into schizophrenia.

Answer 65

A

A = The presence of one (or more) delusions with a duration of 1 mo or longerB = Criterion A for schizophrenia has never been metNote: hallucinations, if present, are not prominent and are related to the delusional themeC = Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behaviour is not obviously bizarre or oddD = If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periodsE = The disturbance is not attributable to the physiological effects of a substance, another medical condition or mental disorder

Answer 66

A

A = ≥ 5 of the following have been present during the same 2 week period and represent a change from previous functioning: (one must be low mood or anhedonia)a. Depressed Mood most of the day, nearly every day as indicated by either subjective report (empty, sad, hopeless) or observationb. Markedly diminished Interest or pleasure in all, or almost all activities most of the day, nearly every dayc. Significant weight loss / gain (e.g., ≥ 5% of body weight in a month) or decrease or increase in Appetite nearly every dayd. Insomnia or hypersomnia nearly every day (Sleep)e. Psychomotor agitation or retardation nearly every dayf. Fatigue or loss of Energy nearly every dayg. Feelings of worthlessness or excessive or inappropriate Guilt nearly every dayh. Diminished ability to think or Concentrate or indecisiveness nearly every dayi. Recurrent thoughts of death (suicidal ideations +/- plan or suicide attempt)B = Symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioningC = Episode is not attributable to physiological effects of a substance or to another medical condition"MSIG E CAPS"

Answer 67

A

For Bipolar, one must meet the following criteria of a manic episode (at least 1 episode in lifetime)A = A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week + present most of the day, nearly every dayB = During the period of mood disturbance and ↑ energy or activity, ≥3 of the following are present to a significant degree and represent a noticeable change from usual behavioura. Inflated self-esteem (Grandiosity)b. Decreased need for sleepc. More talkative than usual or pressure to keeptalkingd. Flight of ideas or subjective experience that thoughts are racinge. Distractibilityf. Increase in goal directed Activity or psychomotor agitationg. Excessive involvement in Activities that have a high potential for Painful consequencesC = The mood disturbance is sufficiently severe to cause marked impairment for social or occupational functioning or to necessitate hospitalisation to prevent harm to self or others, or there are psychotic featuresD = The episode is not attributable to physiological effects of a substance or to another medical condition

Answer 68

A

▪ Same as above but not severe enough to cause marked impairment for social or occupational functioning▪ It is associated with an unequivocal change in functioning that is uncharacteristic of individual when not symptomatic▪ Disturbance in mood and the change in functioning are observable by others

Answer 69

A

▪ 1 or more manic or mixed episodes have occurred▪ Commonly accompanied by at least 1 MDE (but not needed for diagnosis)▪ If the patient needs hospitalisation or has psychotic symptoms it’s BPAD I▪ Disorder may become apparent after a patient is given a course of antidepressantmonotherapy for their depressive symptoms.

Answer 70

A

▪ 1 or more hypomanic episodes (4 or more weeks) AND 1 or more major depressive episodes▪ BPAD II is often under diagnosed + under reported as the MDEs are long and there is poor recognition of hypomanic episodes

Answer 71

A

▪ Alternating between hypomanic and mild/moderate depressive symptoms for at least 2 years (never without symptoms for more than 2 months)▪ These people have never reached criteria for an MDE, manic or hypomanic eps.▪ Patients are higher functioning but the symptoms still cause distress or impairmentin important areas of functioning.▪ Management is the same as BPAD I = mood stabiliser +/- psychotherapy, avoidantidepressant monotherapy, address substance use.

Answer 72

A

▪ Long standing depressed mood but does not fulfil criteria for recurrent depressive disorder. They feel tired + depressed and everything is an effort

Answer 73

A

CRITERIA/ CLINICAL PRESENTATION(A) Development of emotional or behavioural symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(B) These symptoms / behaviours are clinically significant as evidenced by either of the following:• Marked distress that is in excess of what would be expected from exposure to the stressor• Significant impairment to social/occupational/academic functioning (C) The stress-related disturbance does not meet criteria for another mental disorder nor is it an exacerbation of a pre-existing mental condition(D) The symptoms do not represent normal bereavement(E) Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 monthsSPECIFIERSo With depressed mood, with anxiety, with mixed anxiety/depression, with conduct disturbance (e.g. reckless driving,), unspecifiedRISK FACTORS / Stressor types▪ An individual’s personality and vulnerability to stress play an important contributing role▪ SINGLE = termination of relationship, loss of a loved one, loss of job▪ MULTIPLE = marked business difficulties, marital problems▪ RECURRENT = seasonal business crisis▪ CONTINUOUS  living in a dangerous neighbourhood, new stoma, dialysis▪ DEVELOPMENTAL EVENTS = going to school, leaving parental home, getting married, becoming a parent, failing occupational goals, retirementMANAGEMENT PLAN/APPROACHNon-Pharmacological▪ Brief psychotherapy= Individual or group= Group good for those with specific medical conditions▪ Crisis intervention▪ Education + social supports▪ Refer to online + written resources Pharmacological▪ Short course of benzodiazepines for those with significant anxiety symptoms (low- dose, limited duration)

Answer 74

A

CRITERIA(A) Exposure to actual or threatened death, serious injury or sexual violence in oneof the following ways: direct experience, witnessing, learning about events happened to a close friend / family member, repeated/extreme exposure to adverse details of traumatic events (e.g. first responders, police officers)(B) Have ≥9 of the following symptoms of any of these 5 categories:▪ Intrusion symptoms (dreams, flashbacks, distress, memories)▪ Negative Mood▪ Dissociative symptoms (dazed, time slowing, 3rd person, amnesia)▪ Avoidance symptoms (of the memory or of people)▪ Arousal symptoms (insomnia, irritability, hyper-vigilance etc.)(C) Duration is 3days – 1 month after trauma exposure. (symptoms usually begin immediately after trauma and persist for at least 3 days, or up to a month)(D) The disturbance causes clinically significant distress or impairment in social, occupational or academic functioning(E) Condition is not attributable to drugs, other mental health disorder or organic illness.MANAGEMENT PLAN/APPROACH-->Aim = manage distress and prevent PTSD Psychological First Aid▪ Ensuring person’s safety + support (provide medical care if needed)▪ Acknowledge the stress reaction▪ Provide information about event + resolution▪ Offer practical assistance▪ Assess suicide risk, risk to others + dependants▪ One off debriefing is NOT recommended as they can increase symptoms andare not effective in treating ASD or preventing PTSD.Psychology Inputs▪ Psychoeducation to understand ASD and encourage use of inherent strengths, support networks and positive judgement.▪ Understanding of adaptive mechanisms and developing coping mechanisms▪ Cognitive behavioural therapy (good to decrease symptoms and ways to deal withfuture events)▪ Fostering + enhancing the therapeutic alliance Pharmacotherapy in select situations (Senior Doctor Discretion)▪ SSRIs for intrusive thoughts or low mood▪ Benzodiazepines for anxiety + insomnia▪ Anticonvulsants or Beta blockers may be helpful in some symptom clusters but this isat the specialist’s discretion

Answer 75

A

CRITERIA A) EXPOSURE to actual or threatened death, serious injury or sexual violence in one of the following ways: direct experience, witnessing, learning about events happened to a close friend / family member, repeated/extreme exposure to adverse details of traumatic events (e.g. first responders, police officers)(B) Presence of ≥1 of the following INTRUSION SYMPTOMS associated with the traumatic event (has started after the event):o Involuntary / recurrent / intrusive memorieso Involuntary / recurrent / intrusive dreams (event or affect)o Dissociative sx / flashbacks feeling like event is reoccurringo Intense / prolonged psychological distress at internal or external stimulithat resemble the evento Intense / prolonged physiological distress at internal or external stimulithat resemble the event(C) Persistent AVOIDANCE OF STIMULI associated with the event, as evidencedby one or both of the following:o Avoids distressing memories / thoughts / feelings re: the evento Avoids external reminders (people, places, conversations, activities, objectsetc.) that arouse distressing memories / thoughts / feelings re: the event(D) NEGATIVE ALTERATIONS in conitions + mood associated with the event, asevidenced by ≥2 of the following:o Amnesia re: event or parts of the evento Negative beliefs or expectations about oneself, others, or the worldo Distorted cognitions about the cause or consequences of the event that leadthe individual to blame them self or otherso Negative emotional state (e.g. fear, horror, anger, guilt, or shame)o Markedly diminished interest or participation in significant activities o Feelings of detachment or estrangement from otherso Persistent inability to experience positive emotions(E) Marked alterations in AROUSAL + REACTIVITY associated with the event, as evidenced by ≥2 of the following:o Irritable behaviour and angry outbursts - typically verbal or physical aggressiono Reckless or self-destructive behaviour o Hypervigilanceo Exaggerated startle responseo Problems with concentrationo Sleep disturbance (e.g. difficulty falling or staying asleep or restless sleep)(F) DURATION symptoms last > 1 month (occur within 6mo of event)(G) Causes clinically significant distress or impairment(social/occupational/academic)(H) Condition is not attributable to drugs, other mental health disorder or organicillness.Men’s trauma is most commonly combat experience/physical assault; women’s trauma is usually physical or sexual assaultCOMPLICATIONS / ASSOCIATED ISSUES▪ Substance abuse▪ Relationship difficulties▪ Depression▪ Impaired social and occupational functioning▪ Personality disorders (esp. Borderline PD)MANAGEMENT PLAN/APPROACHPSYCHOTHERAPY▪ Ensure safety and stabilize: emotional regulation techniques (e.g. breathing, relaxation)▪ Once coping mechanisms established, can explore/mourn trauma - challenge dysfunctional beliefs, etc.▪ Reconnect and integrate - exposure therapy, etc. PHARMACOLOGICAL▪ SSRIs (e.g. paroxetine, sertraline)▪ Prazosin (for treating disturbing dreams and nightmares)▪ Benzodiazepines (for acute anxiety)▪ Adjunctive atypical antipsychotics (risperidone, olanzapine) EYE MOVEMENT DESENSITISATION + REPROCESSING (EMDR)▪ an experimental method of reprocessing memories of distressing events byrecounting them while using a form of dual attention stimulation such as eyemovements, bilateral sound, or bilateral tactile stimulation▪ Its use is controversial because of limited evidence

Answer 76

A

CRITERIA / PRESENTATION (A) Excessive anxiety + worry (apprehensive expectation), for more days than not for 6 months re: a variety of activities / events (B) Difficult to control the worry (C) Associated with ≥ 3 of the C-FIRST symptoms (D) Clinically significant impairment of function (E) Condition is not attributable to drugs, other mental health disorder or organic illness.

TREATMENT - Similar to panic disorder

EXCLUDE ORGANIC ILLNESS = Thyroid ↑, caffeine, stimulants, alcohol withdrawal = Adjustment disorder with anxious mood = If older person, think depression ot dementia with anxious mood

- LIFESTYLE = ↓ caffeine = Good sleep hygiene = Avoid alcohol and other drugs (must explore this area as many patients self-medicate) - PSYCHOTHERAPY (first line!!) = psychoeducation = CBT = interoceptive exposure (eliciting panic attack symptoms and learning how to tolerate them with coping strategies) = Stress management = scheduling, problem focused counselling = Relaxation techniques -

MEDICATIONS (if therapy alone is not enough) = 1st line – SSRIs / SNRIs (paroxetine, escitalopram, sertraline, duloxetine, venlafaxine) = 2nd line – buspirone (TID), buproprion (caution stimulating SEs) = Don’t need high doses usually = Add Benzodiazepines if needed (short-term, low dose, regular schedule, long half-life, avoid prn usage) = DO NOT USE BETA-BLOCKERS NOTE: C-First Symptoms Concentration Fatigue Irritability Restless Sleep Disturbance Tension (muscle)

Answer 77

A

KEY CRITERIA - Exposure to the stimulus provokes an immediate anxiety response (?even panic attack) - Person recognises fear as excessive / unreasonable - Situations are avoided or endured with great stress/ distress/ anxiety - Significant interference with daily routine,/occupational/social functioning. Patient has marked distress.

Answer 78

A

1. Marked + persistent (>6 months) fear of social or performance situations in which one is exposed to unfamiliar people or possible scrutiny of others. They fear that they will act in a way that may be humiliating or embarrassing

2. The phobic situation(s) is avoided or is endured with intense anxiety or distress. - E.g. public speaking, initiating / maintaining conversation, dating, eating in public

MX;

- Psychological – CBT, social skills training

- Medications – SSRI best (need for ~ 6 – 12 weeks)

- Control of hyperventilation + Deep breathing - Cognitive strategies - Propranolol to manage specific symptoms

Answer 79

A

The fear and avoidance of being in places or situations from which escape might be difficult or embarrassing, or in which help might not be available in the event of suddenly developing a symptom that could be incapacitating or embarrassing. Most people with agoraphobia develop this in response to panic attacks.

CRITERIA

(A) Marked fear / anxiety re: 2/5 --> Using public transport --> Being in open spaces --> Being in closed spaces --> Standing inline or being in a crowd --> Being outside home alone

(B) ear that person fears / avoids situations because of thoughts that escape may be difficult or help will be unavailable should panic symptoms arise

(C) Situations provoke anxiety (D) Situations are actively avoided, need a companion or are endured (E) The fear is out of proportion (F) The fear / anxiety / avoidance causes functional impairment or distress (G) Exclude organic or other MH issue (esp. obsessions, perceived flaws in appearance, PTSD, separation anxiety, paranoia)

Management - Manage panic attacks --> SSRI or venlafaxine

- Behavioural therapy with graduated in vivo exposure to overcome the phobic avoidance

Answer 80

A

DEFINITIONS / CRITERIA PANIC ATTACK = an abrupt surge of intense fear or discomfort that reaches a peak within minutes. During this time one experiences ≥4 of the following symptoms: Mnemonic – STUDENTS FEAR 3CS Sweating Trembling Unsteady/ dizzy Depersonalisation/ derealisation Excess HR/ palpitation Nausea Tingling/parasthesia SOB FEAR- of dying, losing control, of going crazy Chest pain Chills or heat Choking feeling NOTE: A panic attack is NOT a DSM-V disorder as it can occur in the context of other conditions.

Answer 81

A

Definition = have panic attacks that have no apparent trigger + experience ≥ 1 month of anxiety about the panic attacks (persistent concern, anticipation, avoidance or significant maladaptive change). This is a DSM-V disorder.Exclusions - not attributable to medications, substance use, organic illness or other mental health disorder.DDX o Amphetamine, cocaine o Alcohol withdrawalo Opioid withdrawalo Arrythmiao Hypoglycemiao Cushings/ steroids o Hyperthyroidism o PETREATMENT Lifestyle- Explain why panic symptoms arise- Offer support + stress management- Limit caffeine and stimulant drinks- Good sleep hygiene- Advise that 50% - 80% improve with treatment, but most people have a chroniccourse and will need help to deal with psychological stressorsPsychological- Relaxation techniques = Visualisation= Controlled breathing techniques, box breathing(help alleviate ↓PCO2 and the associated symptoms)= Progressive muscle relaxation- CBT = interoceptive exposure (eliciting panic attack symptoms and learning how totolerate them with coping strategies)- Cognitive restructuring = address beliefs re: panic attacksPharmacological- FIRST LINE: (if CBT alone is not sufficient)= SSRIs – Fluoxetine, citalopram, paroxetine, fluvoxamine, sertraline= SNRIs – venlafaxine= May have transient increase in anxiety in first days but this resolves= Key SEs – GIT, flushing, sexual dysfunction, drowsy, dry mouth,= 2nd Line (TCAs, MAOIs and some benzoes)- Rules of thumb= Start low, go slow, aim high= Explain symptoms to expect prior to initiation (prevent non-compliance due to SEs)= Usually need high doses + longer therapy than depression (e.g. 12 wks) to see effect= Keep medicated for 6m - 1 year to avoid relapse (the can try stopping)- If Benzodiazepines needed short-term (1m max), low dose, regular schedule, long half-life, avoid prn usage- Try to avoid bupropion or TCAs - stimulating effects (exacerbate anxious symptoms)

Answer 82

A

CRITERIA / PRESENTATION

(A) Has obsessions / compulsions or both *OBSESSIONS = Recurrent / persistent thoughts, impulses or urges that are intrusive and unwanted. They cause marked anxiety or distress = Person tries to ignore or supress the urge or neutralise them with another action (i.e. the compulsion)

*COMPLULSIONS = Repetitive stereotyped behaviours (e.g. hand washing, door closing) or mental acts (e.g. praying, repeating words) that the person feel driven to perform in response to an obsession or in accordance to rules that must be applied = The acts are aimed at reducing the or preventing anxiety and distress from the situation.

(B) The obsessions / compulsions are time consuming (>1hr / day) or cause clinically significant distress and impairment of functionality (C) Condition is not attributable to drugs, other mental health disorder or organic illness.

MANAGEMENT

PSYCHOTHERAPY - Cognitive Behavioural Therapy = Exposure with response prevention (exposure to fear situations with addition of how to prevent and challenge underlying beliefs)

MEDICATIONS

- SSRIs / SNRIs = need high dose + long duration – 12 – 18 week trials = if the condition improves and becomes stable, the medications can be reduces slowly and then stopped = they are best managed by a psychiatrist

Hx; Obsessions - do you have troubling thoughts that keep bothering you and don't go away?

Compulsions - do you have to do certain things repeatedly even though you don’t want to?

Explore common - do you have do you check things a lot? Do you wash or clean a lot?, Are you concerned about putting things in special order?

Other screen - anxiety, depression

Function - do these activities interfere with your life and function?

Risk assessment

Precipitating & perpetuating

Answer 83

A

o Patients are odd / eccentric / withdrawn

o Familial Association (family Hx) with PSYCHOTIC DISORDERS o Higher risk of developing schizophrenia

o Defence mechanisms = intellectualisation + projection + magical thinking

Answer 84

A

Pervasive distrust and suspiciousness of others; interpret motives as malevolent, beginning by early adulthood and presenting in variety of contexts with ≥4 Sx (SUSPECT)

S- Spousal infedility suspected U- Unforgiving (bears grudges) S- Suspect others of exploiting/decieving them P - Percieves attacks on character (+reacts quickly) E - Enemy or friend? (preoccupied with trustworthiness) C- Confiding in others is feared T - Threats interpreted in benign remarks/events Parenting - Harsh + punitive Defence Mechanism - Projection - Identification with the aggressor - Repression - Denial

Answer 85

A

Pervasive pattern of detachment from social relationships (prefers to be alone + social withdrawal) and restricted range of emotions in interpersonal settings (eccentric + reclusive + restricted affect).

≥4 Sx (DISTANT) D = Detached / flat affect (emotionally cold) I = Indifferent to praise or criticism S = Sexual experiences are of little interest T = Tasks done alone A = Absence of close friend N = Neither desires nor enjoys close relationships T = Takes pleasure in few / no activities Parenting - Cold - Emotionally neglect Defence mechanisms - Splitting - Projection - Denial - Rationalisation

Answer 86

A

Pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive/perceptual distortions and eccentricities of behaviour. ≥5 symptoms (ME PECULIAR) M - Magical thinking (superstitious) E - Experiences unusual perceptions (e.g illusions) P- Paranoid ideation E - Eccentric behaviour/ appearance C - constricted/ inappropriate affect U - unusual thinking or speech L - lacks close friends I - ideas of reference (exclude delusions of reference) A - Anxiety in social situations R - Rule out psychotic or pervasive developmental disorders (not part of the A criteria) Defence Mechanism - Denial - Projection - Acting out - Fantasy

Answer 87

A

- Patients are dramatic, emotional and inconsistent- Familial association with MOOD DISORDERS- Defence mechanisms = denial, “acting out”, projection, idealisation / devaluation, regression (HPD), splitting (BPD)

Answer 88

A

Pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity. Has ≥5 symptoms (IMPULSIVE) I - impulsive (min 2. self damaging ways - sex, drugs, spending, driving) M - mood / affect instability P - paranoia / disassociation under stress U - unstable self image L - labile + intense relationship S - suicidal gestures/ self harm I - inappropriate anger V- vulnerable to feeling abandoned (real or imagine --> frantically) E = Emptiness (feeling of) Parenting - Severe developmental trauma - sexual abuse - significant emotional abuse/ neglect Defence - Dissociation - Splitting - Projection

Answer 89

A

Pervasive pattern of disregard for and violation of rights of others in a person > 18years old. Features occured since 15yo (+had conduct disorder when they were <15yo). ≥5 symptoms: (CORRUPT)C - cannot confirm to law, moral values or societal norm (repeatedly offend) O - obligations ignored (irresponsible, can't honour work behaviour or financial obligations. Ignore/ don't care about their children) R - Reckless disregard for safety R - Remorseless U - Underhanded (deceitful, lie, ise aliases) - lie a lot, thus collateral history for diagnosis P - Planning insufficient (impulsive)T- Temper (irritable and aggressive - poor impulsive control) Parenting - Inconsistent parenting - Ineffectual or harsh discipline - Parental criminality and parental substance abuse Defence mechanism - Repression - Denial - Splitting

Answer 90

A

Pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration and lack of empathy. Has ≥5 symptoms: (GRANDIOSE)G - grandiose (exaggerates achievements + talents, undervalue others) R- Requires constant attention + admirationA- arrogant N - needs to be special (+associate with other specials/high-status people) D - dreams of success, power, beauty and love I- interpersonally exploitive (takes advantage of others for their own gain) O- others - lack empathy, recognising other's needsS- sense of entitlement E- envious (or believes others are envious) Parenting - emotional neglect- empathic failure- inability to form meaningful relationshipsDefence Mechanisms - Denial- Splitting - Projection- Intellectualisation - Rationalisation

Answer 91

A

Pervasive pattern of excessive emotionality and attention seeking. Dramatic, flamboyant, extroverted. Has ≥5 symptoms: (ACTRESSS)A - appearance used to attract others C- centre of attention always T- theatricalR- relationships (perceived more intimate than they are)E- easily influenced S- seductive/ provocative behaviour S- shallow expression of emotion (rapidly shifts)S - speech (impressionistic + vague) Parenting - Perceived rejection by same sex parent and identification with opposite sex parent often apparentDefence mechanism - Projecting- Splitting- Fantasy

Answer 92

A

- People are anxious and fearful Familial association with ANXIETY DISORDERS - Defence mechanisms = isolation, avoidance, hypochondriasisTreatmento Social skills trainingo Self-empowermento Anxiety managemento Group-therapy (safe social situations + build social skills)

Answer 93

A

Pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation. Fear embarrassing themselves in social situations – so isolate themselves. ≥4 symptoms: (CRINGES)C- criticism or rejection preoccupies thoughts in social situations R- Restraint in relationships due to fear of shame I- Inhibited in new relationships (fear of inadequacy) N- Need to be sure they're liked before engaging socially G- gets around occupational activities with need for interpersonal contact (e.g reject promotion as can get criticised in new role)E- Embarrassment prevents new activity/ risk taking S- self viewed as unappealing Parenting - Rejection- Severe life threatening/ disfiguring illnessDefence - Projection- Denial- AvoidanceNote: Fear social interaction but crave for it. Very sensitive to criticism

Answer 94

A

Pervasive and excessive need to be taken care of that leads to submissive and clinging behaviours and fears of separation. Difficulty making everyday decisions. ≥5 symptoms: (RELIANCE)R- Reassurance needed for everyday decisions E- Expressing disagreement difficult L- Lifestyle responsibilities assumed by others I- Initiating projects difficult (lack of confidence) A- Alone (feel helpless/ uncomfortable when alone)N- Nurturance (excessive lengths to obtain it)C- Companionship sought urgently when relationships end E- exaggerated fears of being left to care for self Parenting - Separation and losses (physical illness, chronic illness, parental chronic illness or death) Defence mechanisms - Denial - Repression

Answer 95

A

Pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at expense of flexibility, openness and efficiency. ≥4 symptoms: (SCRIMPER)S- stubbornC- cannot discard worthless objects R- rule/ detail obsessed (point of activity lost) I - inflexible re: mortality, ethics and valuesM- miserly (\$\$ is hoarded for future catastrophes) P- perfectionistic (?interfere with task completion)E- exclude leisure due to devotion to workR - Reluctant to delegates to others Parenting- Authoritarian and moralising, inducing shame and guilt Defence - Denial- Reaction formation- Intellectualisation- Isolation of affect

Answer 96

A

CRISIS/ EMERGENCY - When a BPD patient is at risk of suicide or serious self-harm (1) MANAGE AFFECT STORM o Project calmness and confidence o Engage the patient in a dialogue o Clarify emotions o Identify precursors and triggers o Explore positive and negative solutions

(2) RISK ASSESSMENT o Distinguish chronic risk from acute-on-chronic risk o Assess suicide risk, homicide risk and substance abuse o Dynamic factors: --> recent change in social network --> several recent acute life events --> change in drug/alcohol use --> recent hospital discharge --> high level of hopelessness

(3) MANAGE OWN COUNTER-TRANSFERENCE

(4) SHORT TERM ADMISSION IF NEEDED

Psychotherapy TYPES ON OFFER - Psychodynamic Psychotherapy -Cognitive Behavioural Therapy -->Dialectical behavioural therapy or Schema-focused therapy

PHARMACOTHERAPY - DO NOT USE medicines as main treatment for BPD, because medicines only make small improvements in some symptoms of BPD, - Only consider meds in crisis situations (SSRI - fluoxamine , atypical antipsychotics or mood stabilisers)

CASE MANAGEMENT -long term continuity, realistic goals, addressing secondary problems (substance abuse)

Answer 97

A

DSM (A) RESTRICTION OF ENERGY INTAKE relative to requirements, leading to a significantly low body weight in the context of age, sex, development, and physical health. (B) FEAR OR BEHAVIOUR: intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain. (C) PERCEPTION: disturbance ofbody weight or shape, persistent lack of recognition of the seriousness of the low body weight

Severity - BMI >17 = mild - BMI 16 - Moderate - BMI <16 = severe Type - Restrictive = no binge/purging in last 3 months - Purging = binge/purging in last 3 months

RF; family history, exercise where height/weight are critical, anxiety, depression, OCD, borderline, low self esteem, abuse, substance disorder

Signs; extremely low body weight, obvious bony prominences, proximal muscle wasting,breast atrophy, amenorrhea, abdominal pain/constipation, lanugo, brittle hair/nails, dry skin, low BP/HR/RR/T

Ix; looking for complications--> ECG (long QT, hypokalemia), FBC (normocytic normochromic anaemia, leucopenia), UEC/CMP (refeeding syndrome- hyponatremia/kalemia/phosphatemia/magnesia), TFT (hypothyroidism), hyercholesteorlemia, high LFT (starvation hepatitis), BMD scan, low LH/FSH/, high cortisol

MANAGMENT Usually outpatient therapy. Indications for admission;

-Weight - severely low BMI (<14) OR rapid weight loss despite intervention OR several days of no oral intake

-Cardiac - bradycardia <45, BP < 90/60, ECG abnormal (arrhythmia, prolonged QT)

-Hypothermia <36

-Electrolyte disturbance (e.g. hypokalemia, hypoglycaemia)

-Suicidal ideation

-Failed outpatient therapy

Majority is managed as outpatient; Educate patient and family Involve MDT (GP, pscyh, dietician, school counsellor) Pscyhotherapy; CBT, family therapy, supervised weight gain therapy Pharm; not usually used unless serious comorbidities--> antidepressants, bisphosphonates/vit D/calcium, other supplements (zinc, iron, folate, VB12)

Answer 98

A

CRITERIA

(A) RECURRENT EPISODES OF BINGE EATING characterised by both of the following: a. Eating, in a discrete period of time (e.g., within any 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances b. A sense of lack of control over eating during the episode (B) RECURRENT INAPPROPRIATE COMPENSATORY BEHAVIOURS in order to prevent weight gain, such as self- induced vomiting, misuse of laxatives, diuretics,; or excessive exercise. (C) The binge eating and inappropriate compensatory behaviours both occur, on average, AT LEAST ONCE A MONTH FOR 3 MONTHS (D) Self-evaluation is unduly influenced by body shape and weight. (E) The disturbance does not occur exclusively during episodes of AN.

MANAGEMENT - Cognitive behavioural therapy = Educate re: nutrition, shape + weight + complications = self-monitoring of relevant thoughts and behaviours = identify and challenge problematic thoughts etc. - SSRI (fluoxetine 20mg OD) – may be related to a specific serotonin modulating effect on satiety mechanisms

Complications; sialedenitis, parotid gland enlargement/tenderness, russels sign, enamel erosion,esophagitis, upper GIT and esophageal tears (presents with haematemesis), perforations are extremely rare but life-threatening, Vomiting - hypochloremic metabolic alkalosis (vomiting), hypokalaemia, hyponatremia, Laxatives - normal anion gap metabolic acidosis,palpitations, arrhythmia (electrolyte imbalance)

Mx; - Inpatient management only if: at risk of suicide, medically unwell, serious electrolyte anomalies, in the first trimester of pregnancy (spontaneous abortion risk) -Same as anorexia; CBT and SSRI if indicated Note: Hypokalaemia (and subsequent cardiac dysrhythmia) is an important complication of purging and/or self-induced vomiting; potassium replacement can be lifesaving – SO THINK OF CHECKING + TREATING!

Answer 99

A

CRITERIA

(A) Recurrent episodes of binge eating (as in BN)

(B) The binge eating episodes are associated with three (or more) of the following: a. Eating more rapidly than normal b. Eating until feeling uncomfortably full c. Eating large amounts of food when not feeling physically hungry d. Eating alone because of feeling embarrassed by how much one is eating e. Feeling disgusted with oneself, depressed, or very guilty afterwards C) Marked distress regarding binge eating is present (D) The binge eating occurs, on average, at least once a week for 3 months (E) The binge eating is not associated with the recurrent use of inappropriate compensatory behaviour (i.e. exclude BN) and does not occur exclusively during AN MANAGEMENT - CBT or IPT - Weight loss programs - Dietician advice - SSRIs may be useful as adjunct to psychotherapy

Answer 100

A

DEFINITION - Eating disturbance to the extent of persistent failure to meet appropriate nutritional and/or energy needs, resulting in significant weight loss/growth failure and nutritional deficiencies. - Patients experience disturbances in psychosocial functioning and may become dependent on enteral feeding/ oral nutritional supplementation - NO binges + purges i.e. not BN - No evidence of distress in the way in which one’s body weight or shape is experienced i.e. not AN MANAGEMENT - Watch and wait -Behavioural modification - Psychotherapy

Answer 101

A

-Mesolimbic= emotions and reward--> if there is increase dopamine in this pathway it causes positive symptoms of schizophrenia (hallucinations and delusions) -Mesocortical= cognition and executive function--> if there is decreased dopamine in this pathway it causes negative symptoms of schizophrenia (depression, psychomotor retardation) -Nigrostriatal= movement (as involves the basal ganglia)--> low dopamine causes extrapyramidal side effects -Tuberoinfundibular= prolactin regulation--> low dopamine causes increased prolactin

Answer 102

A

-Massive dopamine blockade causing increased dopamine in the synaptic clefts--> caused by increased drug dosage/medical illness/dehydration/decreased nutrition--> most common in young men -CAN BE FATAL -FALTER symptoms; F= fever A=autonomic symptoms (tachycardia, tachypnea, hypertension, hyperthermia) L=leucocytosis T=transaminases E= elevated enzymes (high CK), high potassium R=rigidity

-can present over months/years

Mx; -cease medication and consult psychiatrist -symptomatic= fluids, cooling blankets, treat hyperkalemia, +/- mechanical ventilation, DVT prophylaxis -can use alternative meds; anticholinergics or benzos for muscle rigidity, oral bromocriptine (DA antagonist), IV dantrolene (muscle relaxant) -cease antipsychotic and

Answer 103

A

-Due to sudden increase in serotonin (either through SSRI/MAO-I combination drugs or increased dose or introduction of antibiotics like linezolid that are similar structure to serotonin) Cognitive; agitation, insominia, hallucinations, restlesness, euphoria, hypomania Autonomic; tachycardia/pnea, hypertension, fevers, diaphoresis, mydriasis, arrhythmias Neuromuscular; tremor, clonus, ataxia, incoordination, seizures, hyperreflexia

-Rapid onset of 6 hours but can take days to wear off

Mx; 1. cease antipsychotic 2. general supportive care; cooling blankets, volume replacement, rehydration, benzodiazepines 3. cyproheptadine as antidote

Answer 104

A

-Psychiatric treatment where you are placed under GA then electricity is used to stimulate a minor controlled seizure --> this has been shown to be very effective for certain psychiatric disorders

-Indicated for; severe depression, bipolar or schizophrenia not responsive to treatment, catatonic depression, severe PND, strong suicidal ideation CI; cardiac disease (CHF, IHD) or neurological disease (stroke, high ICP) Adverse; muscle pain, confusion, short or long term memory loss, headache, N/V -rare; stroke, not responsive to tx, prolonged seizure, MI, death

Before; fast for 6 hours, pre-ECG, cease lithium/benzos/antiepileptics, FBC, UEC, BGL, CXR During; sedated with propofol+ketamine, shock waves delivered under anaesthetic observation -watch for response and tailor level according to post-ictal EEG

Answer 105

A

-Flu-like symptoms, insomnia, nausea, postural imbalance, sensory disturbances, hyperarousal -Medication should be tapered slowly and halfed each week until it is at its lowest dose and then it can be ceased -become effective after 4-6 weeks -side effects normally reduce after 1-2 weeks as tolerance builds

-bleeding, hyponatremia, sedation, dry mouth, constipation, orthostatic hypotension, sexual dysfunction, weight gain

Answer 106

A

-Loss of contact w reality; unable to distinguish between real and false perception -4 signs; hallucinations, delusions, disordered thinking (thought disorders) and disordered behaviours (aggression and agitation) -Psychosis is seen in schizotypal PD, bipolar, drug induced psuchosis, psychotic depression, schizophrenia etc -organic; thyroid disease, adrenal disease, wilsons disease, huntingtons disease, alzheimers disease

Answer 107

A

Schizoaffective disorder; bipolar type -had schizophrenic symptoms first and then developemed manic symptoms after 3 weeks

Answer 108

A

-Brief psychotic disorder= a psychotic illness that meets criteria A +D +E of schizophrenia (will have delusions/hallucinations, not attributed to schizoaffect disorder/MDD with psychosis) and not due to other substances or organic causes--> lasts less than 1 month, often due to stressors/post-partum, will have eventual resolution to pre-morbid functioning- manage with antipsychotics/anxiolytics

-Schizophreniform disorder=a psychotic illness that meets criteria A +D +E of schizophrenia (will have delusions/hallucinations, not attributed to schizoaffect disorder/MDD with psychosis) and not due to other substances or organic causes--> can develop into schizophrenia but good prognosis associted with acute onset/confusion/good pre-morbid condition, abscece of/blunted affect

-Schizophrenia= DSM V criteria lasting longer than 6 months -Schizoid personality= personality type; DISTANT; detached/flat affect, indifferent to criticism/praise, sexual experiences of little interest, tasks done on solidarity, absence of close friends, neither desires or enjoys close relationships, takes pleasure in few activities (difficult to avoidant personality as avoidant wants a relationship but is scared of one)

-Schizotypal personality= ME PERCULIAR; magical thinking, experiences unsual perceptions, paranoid ideation, exxentric behaviour or appearance, constricted or innap affect, unusla thinking/speech, lacks close friends, ideas of reference, anxiety in social situations, rule out psychotic disorders

-Delisional disorder= presence of one or more delusions for a duration of 1 mo or longer, but not all components of criteria A for schizophrenia has been met, functioning is not impaired, only brief manic/depressive episodes have occurred, delusions are not attributed to a substance or another medical condition

Answer 109

A

DDX; Medical- neurological (dementia, delirium, head injury, brain tumour, stroke, CNS infection, intracranial bleed, seizures), endocrine (hypo/hyper thyroidism, parathyroidism, cushings disease, addisons disease), metabolic (electrolyte imbalance (BSL, Ca, Na, O2), organ failure (hepatic encephalopathy), B12/Folate deficiency Intoxication/withdrawal-illicit drugs (cocaine, LSD, meth), prescribed drugs (levodopa, anticholingergics, steroids, thyroxine), alcohol Psychotic disorder-brief psychotic episode, schizophreniform disorder, schizophrenia, schizoaffective disorder Mood disorder-depression with psychotic features, bipolar affective disorder Personality disorder-schizotypal, schizoid, BPD, paranoid PD

HX -hx of recent head trauma -recent seizures or hx of known seizure disorder -signs of intracranial path- focal neurological symptoms, new onset headache, visual/speech changes, abnormal movements, memory loss -fluctuating consciousness- delerium -PMHX; thyroid, adrenal, organ failure (hepatic encephalopathy, uremia), multiple myeloma/other malignancy (brain mets), psychiatric conditions -Medications/substances; alcohol, illicit drugs, prescriptions (opiods, steroids, thyroxine, levodopa), toxins (heavy metals, organophosphates) -Diet- VB12/Folate deficiency -Fam hx; neurological/medical, psychiatric -Complete psych hx; premorbid functioning, developemental hx, collateral hx, risk assessment

Exam; Vitals; infeciton, intoxication, withdrawal Appearance; cachectic, dishevelled, confused GCS/Orientation Neuro exam; meningitis, encephalitis, focal deficits (brain lesions) Thyroid/cushings exam; hyper/hypo features + cushing features (steroid induced psychosis) Features of SLE; joint deformities, rash MSE

Ix; -FBC, UEC, GFR, CMP, TFT, LFT, VB12/Folate, ANA/ESR -Urinalysis/MCS/Drug screen -CXR (infeciton sites) -Others; syphilis, blood cultures, troponins, ECG, coag -Head imaging only indicated if cranial pathology is suspected or focal neural deficits present (head trauma, motor anomaly, hydrocephalus)

Answer 110

A

Behavioural/non-pharm approach; -Calm, quiet environement, remove objects that could be weapons, keep a clear exit, have a non-threatening stance -Consider admission to acute ward -Keep carer/support person around

Medical; -Oral benzo (lorazepam) +/- antipsychotic (olanzapine or haloperidol) -May need to use IM if patient refuses oral -repeat dosing every 45-60min

Answer 111

A

-Phases; premorbid, prodome, active (positive sx), remission (neg sx), relapse -Positive sx; delusions, hallucinations, disorganised thoughts and behaviours -Neg sx; depression, anhedonia, avolition, alogia

Good prognosis if; female, acute onset, good premorbid functioning, short duration of symptoms, no fam hx, no structural brain anomaly, good response to medications, good support system -1/3rd improve, 1/3rd worsen, 1/3rd stay same

Mx; -SGA; risperidone, olanzepine, quitiapine, apiprazole -need to give with a benzodiazepine as SGA take around 2-4wks to work -Review after 2-3 weeks, if symptoms still not controlled trial on a different SGA--> if still not controlled then put on clozapine -Start with minimum dose of all SGAs--> if after first presentation remain on medication for at least one year, if have multiple episodes may need 2-5yr tx but can be lifelong -Can give in depot form if non-compliant (give 2-4wk) -May also need adjunctive mood stabilisers (lithium/sodium valproate) and can require concurrent antidepressants (fluoextine) -can use PRN benzo (lorazepam) in acute cases of agitation -ECT can be indicated for patients with symptoms refractive to mx -Other mx includes; screening for co-existing conditions (anxiety, depression, substance use and addiction, personality disorders), addressing psychosocial impact (housing assistance, social skills training, disability support pension, community based mx), addressing psychological factors (suicide prevention, CBT and psychotherapy, family psychotherapy and support) -address co-morbidities--> metabolic syndrome monitoring, LFT, FBC, cardiac function, depression, anxiety, substance abuse

Answer 112

A

-Poor adherence to therapy -Inadequate drug levels (measure blood) -Substance abuse -Antidepressent use (SSRI can trigger mania) -Stressful life event

Answer 113

A

Inclusion; patient needs to have a condition characterised by clinically significant disturbances of thought, mood, perception or memory -Patient needs tonot have capacity to consent to being treated + the abscence of involuntary tx is likely to result in imminent serious harm to the person or others OR result in the person suffereing serious mental or physical deterioration AND there are no other less restrictive ways to treat the person Exclusion; Doesn't cover people who's odd behaviour/distirbances areattributed to; drugs + alcohol, intellectual disability, antisocial or illegal behaviour, experiencingfamily conflict, influenced by religious/cultural/politicial/philosophical beliefs or displaying immoral/indecent conduct

Answer 114

A

EEO= emergency examination order- can be applied by a police officer or ambulance officer if they think the persons behaviour is at immediate risk of harm to self or others and the risk is secondary to e mental health condition/disability/substance AND the person requires urgent examination and care -leads to involuntary examination (12 hours) RR= Request and recommendation -if the doctor believes the person is unwell they can put in for a request for assessment or a recomendation for assessment (RA)--> a request for assessmentlast 72 hours and means the patient has to be reviewed by a psychiatrist BUT a recommendation for assessment can last 7 days ITO= involuntary treatment order = Treatment authority -can be authorised by the doctor who reviewed the patient after the RA and if they think the patient has fulfilled the criteria for involuntary t -has to be reviewed by the mental health tribunal after 4 weeks and then every 6m if the tx is ongoing

JEO= justice examination order -requested by magistrate or JOP- can last 7 days -involves a doctor/mental health practitioner travelling to the patient and assessing them, can then determine whether they need an RA

Answer 115

A

-Everyone has capacity until proves otherwise 4 components; patients needs to have understanding of all the options available, appreciation of the risks and benefits, reasoning and ability to communicate choice

-For a patient to have capacity to consent they need to have an understanding that they have an illness/symptoms that affect their mental health and wellbeing, need to understand the nature and purpose of the teatment, needs to know the risks and benefits of tx and also te consequences of not recieving tx --> they then need to make a decision about tx and communicate their decision

Answer 116

A

Acute stress disorder - trauma <1 month ago and symptoms last <1month

Adjustment disorder - trauma <3 months ago (and usually not life threatening) and symptoms last <6 months

PTSD - lasts >1 month

Answer 117

A

Body dysmorphia=

-Preoccupation with 1+ defect in appearance not obvious to anyone else

-Repetitive behaviours or mental acts in response to concern (mirror checking, reassurance seeking etc.)

-Significant distress or functional impairment

-Not explained by an eating disorder

Clinical features;

-Defect either minimal or completely imagined with strong beliefs they are unattractive or repulsive -Common complaints; muscle, skin defects (acne, scars, wrinkles), hair (thinning or excessive), nose, eyes, teeth, stomach, breasts

-Associated repetitive behaviours; applying foundation, hats/scarves/lots of clothing, repeatedly touching the area, seeking reassurance -High rates of suicide

Muscle dysmorphia; -Subset occurring mainly in males -Preoccupation that body is insufficiently lean or muscular - usually normal or very muscular -Excessively exercise, diet or use anabolic steroids

Management;

SSRIs

CBT

Answer 118

A

RF; BMI less than 16, pre-existing low levels of K/Mg/PO4, weight loss more than 15% in last 6 months, little to no nutrient intake for past 10 days

Path; starved patient--> loss of electrolytes intracellularly/intracellular space shrinks but extracellular space retains electrolytes--> introduction of glucose means activation of insulin which moves glucose/K/Mg/PO4 across into intracellular space--> causes drop in serum electrolytes

Prevent;

6000kJs/day initially increasing 2000kJ every 3 days

Via continuous NG tube

Supplemental phosphate & thiamine

Mx; -Slowly refeed over weeks -Monitor electrolytes regularly and replace as indicated

Symptoms; loss of deep tendon reflexes, arrhythmias, seizures, resp, distress, anaemia, GI sx, hypotension, weakness, lethargy

Answer 119

A

SCOFF S= have you ever made yourself SICK because you feel uncomfortably full C=do you feel like you have lost CONTROL O=have you lost ONE stone (6.3kg) in the past 3 months F= do you believe you are FAT when others say you are thin F= has FOOD taken over your life -score of 2 or more indicates potential AN/BN and requires investigation

DDX; -hyperthyroidism, addisons disease, malignancy, coeliac disease, IBD, systemic rheum disease

Answer 120

A

GI;

Liver failure - AFLD & cirrhosis

Pancreatitis

HAEM;

Thiamine/B12/folate deficiency*

Macrocytic anemia

Pancytopenia

Hypoglycaemia & ketoacidosis

NEURO;

Withdrawal syndrome

TBI - risk of injury

Wernicke's encephalopathy & Korsakoff's psychosis

Wernicke's - confusion, ophthalmoplegia (diplopia), ataxia, thoughts (memory loss) --> reversible

Korsakoff's - retrograde amnesia, anterograde amnesia, confabulation, apathy --> irreversible

Peripheral neuropathy (alcohol + thiamine deficiency)-->Symmetrical polyneuropathy, Sensory - painful paraesthesias (main Sx), numbness, glove-and-stocking, Motor - cramps, weakness, gait abnormalities

PSYCH;

Depression & anxiety

Suicide

CVS- dilated cardiomyopathy, HTN, AF

RESP- ↑risk of pneumonia

MSK -gout

NEOPLASM- throat, oral, hepatic

Answer 121

A

o Primary survey (assume OD if unconscious)

· D - don PPE, safe to approach

· R - AVPU

· S - ED reg if worried

· A- assess airway, temporary measures if required, intubate if required (not maintaining or aspiration)

· B - assess respiration, SpO2, start O2 15L non-rebreather if hypoxic

· C - assess circulation, P/BP/ECG, IV access and fluids

· D - look for TBI, BGL & treat hypoglycaemia, eye exam (raised ICP, opioids?)

· E - look for trauma or injury

o Rx

· Thiamine 300mg IV

· Commence AWS

· Admit if withdrawal symptoms - diazepam + thiamine + AWS + sedation score

o Supportive care

· Manage behavioural disturbances - de-escalation, chemical & physical restraints

· Fluids

o Monitor

· Airway & vitals

· Observe until BAC = at least 0.2%

· Withdrawal may begin at BAC = 0.1%

o Closing

· Referral - ATODs, child safety, GP for long-term management (below)

Follow-up - GP

Answer 122

A

o Active

·Thiamine--> IM or IV 300mg TDS (poorly absorbed by GIT) for 3-5 days then 300mg PO for weeks (longer if relapse)

o Check glucose is normal before and give before glucose - otherwise may precipitate Wernicke's

Benzodiazepines--> Diazepam

o Benefits - rapid onset + long half-life, symptomatic relief, prevention and treatment of seizures

o Use (dose depends on severity): diazepam 20mg PO every 2 hours until symptoms subside (60mg max)

o Taper down over 2-7 days then cease completely after 7

o Monitor using AWS & sedation score

o If poor liver function use a benzo that bypasses the liver (LOT- lorazepam, oxazepam, temazepam)

o Supportive

· Fluid balance

· IVFs

· Analgesia - paracetamol

· Low stimulus environment

o Ongoing monitoring

· Admit to hospital

· Alcohol withdrawal scales

o Follow-up

· Arrange continued alcohol intervention

Bio-psycho-social

Answer 123

A

-NRT- to soothe the cravings but doesn’t contain any harmful substances that are in cigarettes

-Buprorpion-antidepresssantà inhibits reuptake of NA and dopamine

-Varenicline (Champax)- partial nicotinic receptor agonist (to soothe cravings) and partial competitive nicotinic receptor antagonist (to reduce the response to smoked nicotine)à high risk of suicide, depression, insomnia

Answer 124

A

Psychosocial

· Rehabilitation

· CBT

· Counselling

· Community support groups

Pharmacological long-term therapy for dependence (MAINTENANCE)

· Benefits

o Reduce craving

o Reduce withdrawal symptoms

o Reduces euphoric effects of heroin in relapse

Drugs used; -LA opioid agonists; methadone, buprenorphine, -Can use clonidine (A2 adrenergic agonists= decreased SNS outflow) -If inpatient= give 4-6mg of opioid agonist and reassess in 3 hours -If outpatient= can do 7 day plan of methadone/buprenorphine- can pick up daily from chemist -Manage symptomatically= analgesia, fluids, rest, metoclopramide, diazepam (restlessness)

Time course; -heroin withdrawal takes about 5-10 days, onset 6-12 hours post heroin intake, peaks at 24-48h -long acting opioids like methoadine take 3-6wks to fully detox- begins 36-48h post drug ingestion

Symptoms; -anorexia, N/V, abdo pain, cold and flu symptoms (rhinorrhea, myalgia, arthralgia, cramps, hot and cold flushes), restless legs, diarrhoea, perspiration, dilated pupils, intense cravings Scale; COWS= clinical opiod withdrawal scale OOWS= objective opioid withdrawal scale Subjective opioid withdrawal scale

Answer 125

A

o Resuscitation

· A - intubate

· B - ventilation

o Decontamination

· Not indicated

o Antidote- Naloxone - if reduced GCS

Answer 126

A

Hyperactive sx; euphoria, increased concentration, increased SNS (high HR/BP, sweating, midriasis), pressured speech, restlessness Pscyhotic sx; can look like schizophrenia- agitation, paranoia, delusions Acute; -IV diazepam to control seizures and acute agitation -Haloperidol or zuclopenthixol (antipsychotic) for psychosis -HTN and HR need calcium channel blockers (don't use B-blockers) Withdrawal; -Present with dysphoria, fatigue, restlessness, can cause relapse and suicide 3 Phases; -Crash; day 0-2, fatigue, flat affect, increase sleep and appetitie -Withdrawal; day 2-4 (can last up to 10wks), low mood and energy, either increased or decreased sleep, vivid unpleasant dreams, psychomotor retardation or agitation, poor concentration -Extinction; occurs weeks to months after, the symptoms of the withdrawal slowly subside -Withdrawal is not medically dangerous and no medications have been shown to improve withdrawal - mainstay of management is symptomatic

Answer 127

A

Path= thiamine is stored in the liver but only lasts 18 days--> thiamine def causes decreased activity of thiamine dependent enzymes--> causes neuronal death in neurons w increased metabolic requirements and thiamine turnover (ie. brain)

Wernicke's= COAT (confusion, opthalmoplegia (and nystagmus, non-reactive pupils etc), ataxia (of lower limbs/gait), tremor) --> these are irreversibe

Korsakoff's= RACK (retrograde amnesia, anterograde amnesia, confabulation) --> these are permanent and associated with apathy and decreased response/euphoria to events Mx of acute wernicke's; -Immediate recognition of underlying undernutrition -BGL, FBC, UEC, CMP, LFT, Tox screen -Check for hypo--> give thiamine BEFORE giving glucose -Give IM/IV thiamine 100mg for 3-5 days -Check for other electrolyte abnormalities -Supportive care; rehydration, correction of electrolyte abnormalities, nutritional therapy, ALCOHOL CESSATION

Answer 128

A

-Organic brain conditions (ie.psychosis in dementia and drug induced psychosis)cause visual hallucinations, often have little or no improvement when antipsychotics are used, vague delusions, moderate insight, thought form more organised

-Mental illness; antipsychotics will have some effect, often present with fixed delusions and more auditory hallucinations, less insight, tangential/circumstantial thought form

Answer 129

A

Psychosis; -Neurological (dementia, delerium, head trauma, CNS infection/bleed, tumours), endocrine (hyper/hypothyroidism, cushings, addisons), metabolic (electrolyte disturbance, VB12 def), illicit drug use/withdrawal, schizophrenia/schizoaffective disorder, depression with psychotic features, BPD Delerium; I WATCH DEATH Infection (UTI, pneumonia, meningitis), Withdrawal, Acute metabolic condition (electrolytes, organ failure, acidosis), Toxins/drugs, CNS path (stroke, TIA, seizures), Hypoxia (anaemia, HF, resp failure, hypotension), Deficiencies (B12, folate, thiamine), Endocrine (hyper/hypothyroid, cushings, addisons), Acute vascular (haemorrhage, hypertensive encephalopathy), Trauma (head injury, chronic pain), Heavy metals (lead, mercury), Gastointestinal (constipation),

Answer 130

A

Hx; onset, course, duration, change in medications, dehydration, falls, trauma, infection, bowel/bladder function (constipation, UTI), alcohol/drugs (withdrawal), PMHX, medications (anticoag), social Hx, premorbid status Full body examination looking for evidence of trauma or infection IX; ECG, BSL, MSU, sputum, FBC, UEC, CMP, LFT, lipids, TFT, B12/Folate, blood cultures, ABG, LP +/- CXR, CT brain

Assessing severity; use Confusion Assessment Method (score is 0-7, the higher the score the more severe the delerium) --> looks at inattention, acute onset and fluctuating course, disorganised thinking, altered LOC -can also use delerium index, confusional state examination, confusion rating scale

Mx; -Treat underlying issue and manage the environment -Medications may be required to control anxiety, agitation, aggression, delusions or hallucinations--> oral or IM haloperidol or olanzepine (single dose is usually sufficient) -Can give thiamine if cause is unknown -AVOID BENZO- can worsen confusion and cause resp depression

Answer 131

A

Diagnostic criteria; memory impairment, 1 or more cognitive disturbances on formal testing (aphasia, apraxia, agnosia, disturbed frontal executive functioning (planning, initiation, judgement, adaptability), sufficient to interfere with ADL's, not delerium or another disorder

History; onset/timing (chronic and progressive=dementia), PMHX (look for potentially treatable conditions- MIND WAVES), explore the sx of dementia (psych-hallucinations/paranoia, mood-depressed/anxious/irritable, behavioural- personality change/safety, cognitive-memory/ADLs/judgement), psychosocial aspect (wills+estate, AHD, residence, financial security, alcohol/drug use)fam hx of dementia Risk assessment; suicidal, vulnerable, violence, falls, driving, AWOL Exam; vitals, neuro exam (visual field defects can indicate vasc dementia, upgoing plantars=vasc dementia, focal neurology=SOL, parkinsonism), CVS (RF for vascular dementia), resp/abdo (infective causes- delerium) Ix;MSU dipstick - UTI, Glucose - DM, hypoglycaemia, FBC - anemia, infection, UECs + CMP - electrolyte disturbance, renal function, LFTs - alcohol, liver failure, TFTs - hypothyroid, B12/folate, HIV/syphilis serology (TPPA) - if history suggestive -CXR, CT head - all patients rule out structural causes, MRI head - specific diagnosis (AD), K10 +/- ANA/anti-dsDNA - collagen disease

Screening; MMSE (<24=prob dementia), GPCOG (gp assessment of cognition), FAB (frontal assessment battery- <12 prob dementia), ADAS-cog, kimberley indigenous cognitive assesmment, dementia severity rating scale

Mx;

Answer 132

A

Primary degenerative; alzheimers, vascular dementia, lewy body dementia, parkinsons dementia, frontotemporal dementia (Picks) Treatable/imitators; MINDWAVES Meningioma (or other CNS tumours), infectious (neurosyphilis, HIV, CJD, chronic meningitis), Nephron (uremia, hepatic encephalopathy), Depression/delerium, Wenickes, Alcohol and drugs, Vitamin B12 def, Endocrine (hypothyroidism), Subdural (chronic)

-Dementia occurs in older patients and is associated with a change in cognitive AND behavioural changes

Answer 133

A

-Used to fistinguish fronto-temporal tye dementia from DAT in mildly demented patients (MMSE >24), higher the score the better the performance -score of 12-18 indicates frontal lobe dysfunction -tests conceptualisation, mental flexibility (naming words starting with S), programming (fist-edge-palm), conflicting instructions (tapping), inhibitory control (don't tap) and environmental autonomy (don't grab my hands)

MMSE Addenbrooks; a brief cognitive test that assesses five cognitive domains, namely attention/orientation, memory, verbal fluency, language and visuospatial abilities. Total score is 100, higher scores indicates better cognitive functioning.

Answer 134

A

-Somatic symptom disorder= somatic symptoms are unconciously produced and there are no physical findings--> suspect a somatasising patient if they complain of multiple symptoms in multiple systems over a 3 month period, will have a history of extensive invesigations which are negative, symptoms often cause disruption of functioning

Common PCs; Pain - diffuse, joint, back etc, CVS - atypical chest pain, palpitations, Resp - dyspnoea, hyperventilation, GIT - unexplained abdominal pain, IBS, Neuro - headaches (tension type), ENT - globus syndrome (lump in throat)

Illness anxiety;Hypochondriasis; llness preoccupation becomes part of identity --> common topic of discussion and characteristic response to stress, Extensive history of unsatisfactory medical care with repeated negative diagnostic tests, 2/3 have comorbid depressive or anxiety disorder, high level of anxeity about health, illness preoccupation has been present for at least 6 months -possible role of SSRI due to extreme anxiety

Conversion disorder;abrupt onset neurological symptoms which are incompatible with investigation results,Motor - include: weakness, paralysis, psychogenic seizures, abnormal movements, tremor, abnormal posture, difficult swallowing, unable to speak, incontinence, Sensory - include: altered/reduced/loss of skin sensation, hearing or vision

Factitious disorder; Munchausen syndrome-psychological or physical syptoms that are faked for sympathy or a sick role - patient is not concerned about developing the symptoms or medical condition Malingering; physical or psychological sx are faked for secondary gain (money, medication, leave)

-Illness anxiety disorder -Conversion disorder -Factitious disorder -Malingering

Answer 135

A

Sick role; role taken by a patient and is when a person does not have to fulfil their normal roles (work, chores), should seek medical attention and do as doctors say, must try to get well and is not held accountable for their illness

Illness behaviour; the way a person monitors their bodies, fedines and interprets their symptomas and takes remedial action and utilises soures of help --> arise from biological predispositions and the nature of symptomatology/learned pattern of response -illness behaviour is affected by gender (most likely F to access healthcare), age, ethnicity, culture, education, family structure, finances, insurance -abnorm illness behaviour is a maladaptive manner of experiencing or acting in response to health and illness which is disproportionate to the pathology Primary gain; produces positive internal motivations--> if a dx is present it makes the patient have less psychological distress -falsifying symptoms for primary gain is factitious disorder Secondary gain; falsification of symptoms for secondary gain is malingering -external motivator--> is if a patients disease allows them to miss work/avoid duties/get financial compensation/obtain drugs

Brainscape's Knowledge GenomeTM

deck_8091483 Flashcards

Brainscape's Knowledge Genome^TM