Exam BS Flashcards
1
Q
Pharmacological management of alcohol withdrawal
A
- Benzodiazepines: Diazepam 5-15mg 2-3 times/day for ±5 days. Pregnant patients should have risk assessment done first
- Daily thiamine and vitamin B complex to prevent Wernicke-Korsakoff syndrome
- Disulfiram, if relapse prevention is necessary
2
Q
4 key features of motivational interviewing
A
- Patient centred
- Establish rapport, be empathetic and non-judgemental
- Facilitate patient’s movement towards change and self-sufficiency (positive affirmation)
- Identify readiness to change, and stage of change patient is in (cycle of change)
3
Q
Aims of CBT
A
- Therapy that focuses on substance abuse as a disorder of beliefs, behaviour and core belief systems
- CBT aims to modify these factors
4
Q
Aim of psychotherapy
A
Alleviate patient’s illness by promoting the desire to change and developing the ability to cope with change
5
Q
Psychoeducation goals
A
- Educate patient about alcohol and drug use
- Give input on alternative methods of coping
- Give information on self-help groups and local facilities
6
Q
Focus on individual in psychotherapy
A
- Aim to understand the thoughts and feelings leading to behaviour of substance abuse
- Explore the meaning patient attaches to alcohol abuse and dependence
7
Q
Group therapy
A
- Same group of individuals meet regularly with trained leader
- Provides a public forum
- Patients can share their experience
- Place of support and confrontation
- Patient can see the influence of substances in other people’s lives
8
Q
Family therapy
A
- Address family members that reinforce alcohol abuse/dependence
- Allows family to describe the effects of alcohol abuse on the patient
- Helps change family structure to prevent relapse
- Prevents premature relapse
- Improves outcomes
9
Q
Define detoxification
A
Removal of toxic substances from the body using medication to reduce tolerance and alleviate withdrawal symptoms
10
Q
Define withdrawal
A
Substance-specific syndrome following cessation/reduction in use
11
Q
Symptoms of alcohol withdrawal
A
- Anxiety
- Agitation
- Nausea and vomiting
- Insomnia
- Cravings
- Tremor
- Transient hallucinations
12
Q
Time to onset of withdrawal symptoms in alcohol withdrawal?
A
6-8 hours
13
Q
Potential complications of alcohol withdrawal
A
- Delirium
- Psychosis
- Seizures
- Suicidality
- Hepatic disease
- Failed out-patient detox
14
Q
Symptoms of opioid withdrawal
A
- GIT symptoms
- Pain
- Anxiety
- Insomnia
15
Q
Management of opioid withdrawal/detox
A
If mild: out-patient basis
Moderate to severe: in-patient basis, opioid substitution treatment
16
Q
Symptoms of benzodiazepine withdrawal
A
- Arousal
- Restlessness
- Anxiety
- Perceptual changes
- Autonomic hyperactivity
17
Q
Benzodiazepine detoxification
A
- Replace short-acting with long-acting agents
- Use an equivalent dose
- Decrease the dose every 2 weeks
- Monitor and motivate
18
Q
Management of uncomplicated alcohol withdrawal
A
- Out-patient basis
- Thiamine 100mg daily for 2 weeks
- Taper diazepam over course of 1 week, starting at 5mg 6hrly, doubling time between dose after 3, then 2, then 2 days
19
Q
Management of alcohol withdrawal delirium
A
- Hospitalise
- Monitor vitals regularly
- Monitor for dehydration, electrolyte abnormalities, adequate nutrition
20
Q
Symptoms of alcohol withdrawal delirium
A
- Occurs 2-3 days after cessation of prolonged alcohol use
- Visual hallucinations
- Disorientation
- Agitation
- Tachycardia
- Hypertension
- Low-grade fever
- Possible tonic-clonic seizures 24-48 hours after cessation
21
Q
Pharmacological management of alcohol withdrawal delirium
A
Benzodiazepines:
- Diazepam slow IV OR
- Clonazepam IM (if IV not possible) OR
- Lorazepam IV
Maintain mild sedation with diazepam PO
If severely agitated or restless can add neuroleptic such as haloperidol
22
Q
Distinguish between bipolar type 1 and 2
A
Type 1:
- One or more episodes of mania or mixed affective episode
- Often associated with depressive symptoms
Type 2:
- Hypomania and depression
23
Q
Pre-treatment considerations of lithium
A
- Measure renal and thyroid function –> exclude disease
- ECG in pt. with family history of cardiac disease or arrhythmia
- Exclude pregnancy –> teratogenic
- Not recommended for children < 12 y/o
- CNS disorders (e.g. epilepsy)
24
Q
Dose-related side effects of lithium
A
- Ataxia (may lead to seizures)
- Lethargy
- Weakness
- Drowsiness
- GIT disturbances
- Weight gain
- Coarse tremor
- Fatigue
25
Symptoms of lithium toxicity
- CNS symptoms:
- -> Mental retardation
- -> Hyperreflexia
- -> Tremor (fine)
- -> Convulsions and coma
GIT symptoms:
- -> Anorexia
- -> Nausea and vomiting
- -> Diarrhoea
Increased aldosterone secretion --> oedema, sodium retention
Hypothyroidism
EPSE's
26
Management of acute manic episode
1. Detailed assessment and commitment to care
2. Safe environment for patient and others/containment
3. Withdraw antidepressants
4. Antipsychotic medication: one of haloperidol, chlorpromazine, risperidone depending on needs
5. Mood stabilizers: Valproate: safe and sedates, but teratogenic; Lithium: gold standard - mainstay treatment (7-10 days until therapeutic effects felt)
6. Benzodiazepines: Useful in acute phase for sedation: diazepam or lorazepam
7. Electro-convulsive therapy is last-line
8. Supportive psychotherapy for patient and family
27
Indications for second-line mood stabilisers
- Inadequate response to lithium/intolerable side effects, even in combination with antipsychotic after 4 weeks
- Persistent manic symptoms
- Rapid cycling between states in BPMD
- EEG abnormalities
- Head trauma
28
Another delirium definition
Acute onset of state of fluctuating awareness, impairment of memory and attention, and disorganised thinking
29
Direct effects of HIV on psychiatric illnesses
- Crosses BBB (Trojan horse - infected CD4 cells)
- Directly invades brain parenchyma and causes neuronal damage
- May present variably: psychosis, mania, depression, seizures, memory loss, dementia etc
- Exact mechanism of effect of HIV on brain is unknown
30
Indirect effects of HIV on psychiatric illnesses
- Opportunistic infections
- Effects of ARVs on the brain
- Increased prevalence of substance abuse in HIV patients
- Social stigma
- Initial shock of diagnosis
31
Mechanism of action of first gen vs second gen antipsychotics
First generation: D2 receptor blockade in mesolimbic and mesocortical pathways
Second generation: Serotonin receptor blockade, with lower affinity for D2 receptors
32
Pathophysiology of EPSE's
Antagonistic activity at dopamine receptors in the basal ganglia and other dopamine receptor sites in the CNS
33
Which autonomic nervous system receptors are antagonised by antipsychotic agents?
Alpha-adrenoceptors and muscarinic receptors
34
What is the most common cause of neuroleptic malignant syndrome?
Adverse reaction to antipsychotics
35
Clinical features of neuroleptic malignant syndrome?
- Delirium
- Autonomic instability
- Muscle rigidity
- Elevated creatinine phosphokinase
- Leucocytosis
- Hyperthermia
36
Management of neuroleptic malignant syndrome
- Withdraw antipsychotic
- Administer a benzodiazepine
- Monitor vital functions
- Refer as clinically indicated
37
Indications for prescription of clozapine
- Treatment resistance (failure to respond to 2 classes of antipsychotics at adequate dose for sufficient time)
- Intolerable side effects (especially EPSE's)
- Mood disturbances
- Negative features
- Neurocognitive impairments
38
Major adverse effect of clozapine? How is it monitored?
Agranulocytosis
WBC total and differential count prior to initiating treatment, then weekly WCC total count for 18 weeks, thereafter monthly WCC total count
39
What is the plasma concentration of lithium above which toxicity usually occurs?
1,5 mmol/L
40
Disorders where benzodiazepines are classically therapeutically useful (not just for sedation)?
- Anxiety disorders
- Insomnia
- Alcohol withdrawal
- Seizure disorders
41
Why should benzodiazepines not be prescribed for longer than 2-4 weeks?
High risk of developing dependency syndrome (tolerance and withdrawal)
42
Mechanism of action of benzodiazepines
Potentiates inhibitory action of GABA by binding to benzodiazepine receptor/site on the GABA receptor complex, allosterically modulating the GABA receptor to increase the frequency at which it opens per second to allow chloride to enter the cell
43
4 groups of benzodiazepines
- Ultra-short: < 6 hours
- Short: 6-12 hours
- Intermediate: 12-24 hours
- Long-acting: > 24 hours
44
Symptoms of serotonin syndrome
- Mydriasis (bilateral pupil dilation)
- Diaphoresis (sweating)
- Agitation
- Autonomic instability
- Tachycardia
- Increased bowel sounds, diarrhoea
- Clonus (lower extremities)
- Tremor (lower extremities)
- Hyperreflexia (lower extremities)
45
Which drug is used to treat a benzodiazepine overdose and how does it work?
Flumazenil. It is a competitive inhibitor (higher concentration = more inhibition) for the benzodiazepine binding site on GABA receptors
46
Most common therapeutic causes of hypothyroidism?
1. Amudirol (Ca channel blocker, contains iodide)
| 2. Lithium
47
Mechanism of action of tricyclic antidepressants
Block the re-uptake of norepinephrine and serotonin at presynaptic membrane, enhancing transmission of these two neurotransmitters
48
Risk factors for suicidality
Sex - male
Age - middle-aged/elderly
Depression - or other mood disorders
Prior history/Psychosis - self-harm, suicide attempt
Ethanol or other substance abuse
Rational thinking loss/hopelessness
Social support lacking/Stressors
Organised plan
Negative life events/Neglectful parenting/No job
Suicide history in family/Sick (other medical conditions, pain)
49
4 NB questions to assess suicidal patient
- Likely risk of further self-harm/completed suicide?
- Treatable mental illness?
- What psychosocial problems need to be addressed?
- What interventions are required to reduce their risk?
50
10 questions to ask suicidal patient
1. Did you intend to kill yourself?
2. Why did you want to harm yourself?
3. When did you first have these thoughts?
4. Why at this time?
5. Previous suicidal thoughts?
6. Was act impulsive or planned?
7. What were your expectations of what would happen?
8. What were your thoughts before, during and after the incident?
9. What are your thoughts now? (regret at being alive?)
10. What are your coping strategies and support structures?
51
5 causes of acute violent behaviour in a medical setting
Non-medical - criminal behaviour
Aggressive personality - antisocial PD
Mental illness - psychosis, mania, depression, dementia, anxiety
Substance abuse or dependance - intoxication or withdrawal
Medical conditions - delirium, epilepsy, cerebral infection, intracerebral bleed, traumatic brain injury
52
3 levels of violence when performing a risk assessment, and how each level should be managed
Potentially violent: Prevention and management (time to plan strategy)
Urgent situation: De-escalation via calming interview
Emergent violence: Physical and/or chemical restraint
53
Describe the process of de-escalation by calming interview
- Approach with both hands in sight
- Introduction
- Safe distance
- Voice: calm, clear, slow speech
- Allow pt room to ventilate, clarify issues
- "How can we help?"
- Comply with reasonable demands from patient
- Unreasonable demands: "promote vegetative responses that do not compliment rage"
- Everyday activities e.g. humour, eating in a quiet space
- Compliment on co-operativity
54
What are the 5 C's of containment?
1. Be calm, and keep hands in clear site
2. Take control, or appear to
3. Confidently manage staff according to prearranged plan
4. Contain patient with reassurances, move to quiet, more closed space (NB sit next to door)
5. Control the patient either physically or pharmacologically - depending on situation, and once patient has had opportunity to co-operate
55
Classes of medications used for tranquilisation
Benzodiazepines e.g. lorazepam
| Antipsychotics e.g. haloperidol
56
Stages of the cycle of violence
Tension-building phase:
- Minor incidents of emotional/physical abuse
- Victim feels growing tension
- Avoidance by victim to control situation
- Victim can't control abuser
Explosion phase:
- Incident of violence occurs
Honeymoon phase:
- Abuser is sorry
- Abuser promises abuse will not continue
- Idealised and romanticised period; often disappears with time
57
SAFE acronym of questions to ask a patient who you suspect is a victim of intimate partner violence
```
S:
- Stress in relationship?
- Feel safe in relationship?
- Concern for safety
A:
- Ever felt afraid in relationship?
- Partner ever threatened or abused you or children?
- What happens when you and partner disagree/argue?
F:
- Friends aware you have been hurt?
- Family know about the abuse?
- Family or friends be able to support/help you?
E:
- Place to go in an emergency?
- Do you have an escape plan
```
58
Management of intimate partner violence
1. Safe environment: Confidentiality, no debriefing
2. Diagnose and treat injuries: Check for STIs, injuries, pregnancy
3. Educate and plan
4. Refer as appropriate: Protection order, victim empowerment unit at police station, women's group
5. Follow-up plan: Depression, anxiety disorders, substance abuse
59
Medical causes of panic attacks
- Mitral valve prolapse
- Hyperthyroidism
- Hypoglycaemia
- Stimulant use (amphetamines, cocaine, caffeine)
- Medication withdrawal
60
Psychiatric implications of epilepsy
- Epileptic patients have higher rates of psychosis than general population
- Higher rates of MDE, BPMD, anxiety disorder, suicidality
61
Differential diagnosis of older patient with psychotic symptoms
- Dementia
- Delirium
- Depression
- BPMD
- Schizophrenia
- Delusional disorders
- Substance-induced psychosis
- Psychosis due to GMC
62
Define pseudodementia
Depressive pseudodementia is a syndrome seen in older people in which they exhibit symptoms consistent with dementia but the cause is actually depression.
63
Dementia vs pseudodementia
Dementia vs pseudodementia:
Insidious, chronic vs abrupt, acute onset
Recall incorrectly vs "I don't know"
Poor attention and concentration vs intact attention and concentration
Indifferent, unconcerned vs upset, distressed
64
Alzheimer's dementia
- Cortical
- Extracellular plaques (beta-amyloid) and neurofibrillary tangles (intraneuronal B-amyloid)
- Progressive, chronic onset
- Short-term memory loss
- Word-finding difficulties
- Visuo-spatial difficulties
- Deterioration of reasoning, judgement and insight
- Hippocampus, temporal and parietal lobes atrophy
65
Features of mania
```
Distractability
Indiscretion
Grandiosity
Flight of ideas
Agitation, activity increase
Sleep deficit
Talkativeness
```
66
3 common mood stabilizers and 2 side effects for each
Lithium (ataxia, lethargy, weakness)
Epilim (GIT, fatigue, ataxia)
Lamotrigine (SJS, insomnia, toxic epidermal necrolysis)
67
Medical causes of panic attacks
```
Mitral valve prolapse
Hyperthyroidism
Hypoglycemia
Stimulant use (caffeine)
Medication withdrawal
Anaemia
```
68
Clinical feature of cortical vs subcortical dementia
Aphasia/normal vs slow/normal speech
Amnesic (storage prob) vs forgetful (retrieval prob)
Affect unchanged vs depressed/apathetic
Normal motor vs tremor, rigid, slow
69
Causes of psychosis
```
HIV
Brain tumor
Syphilis
HSV encephalitis
Stroke
Dementia
Epilepsy
Mania
Schizophrenia
Agitated depression
Alcohol
Drugs
Lack of sleep
```
70
What psychiatric disorders have a higher prevalence in people with epilepsy?
```
MDD
Anxiety disorder
Mood disorders
Suicidal ideation
ADHD
Psychosis
```
71
Comment on depression and pregnancy as well as Rx
At risk = previous psych illness, unwanted child, substances, poor support
1 in 10 women
Often during pregnancy
Poorer growth, development and attachment
Rx - refer, destigmatise, social support
SSRIs and TCA ok in pregnancy
No mood stabilizers
Antipsychotics reasonably safe
72
Discuss post partum psychosis
```
Rare <1%
Very serious
Normally affective psychosis
Labile, restless, agitated
Delusional
Homocidal
Recognize and Rx
```
73
Discuss prementrual dystrophic disorder
Mood changes linked to luteal phase
Resolves at menses
Rx hormonally or intermittent SSRIs
74
Rx of anxiety
Start low and slow
Give benzo to initiate Rx
Start with SSRIs
(Propanalol?)
75
Indications for lithium
Prophylaxis of manic episodes
Augment antidepressants
Aggressive or self-mutilating behavior
76
Management of ADHD
```
Social shit
CBT
Diet - FFAs
Stimulant - methylphenidate
Non-stimulant - atomoxetine
```
77
Major clinical differences between Alzheimer's and vascular dementia
Alzheimer's:
- History: Memory loss, spatial disorientation, language failure
- Neurology: Myoclonus, akinesia, rigidity (late)
- Memory: Severe amnesia, high mental effort
- Language: Aphasia
Vascular:
- History: Mental and physical decline
- Neurology: Pyramidal weakness, ataxia, pseudobulbar palsy
- Memory: Variable loss, low mental effort
- Language: Dysarthria
78
Atypical depression
- Some of the typical features e.g. depressed mood
- Improved mood in light of positive events
- Increased weight gain and appetite
- Hypersomnia
- Heavy sensation in the limbs ("leaden paralysis")
- Interpersonal rejection sensitivity (long-standing, not limited to periods of mood disturbance)
- MAOIs are much more effective than TCAs
