JLS Psych Revision Flashcards
What is Scott’s systems review mnemonic? And what specific questions will you ask?
DAMPOSE D Depression Have you been feeling down or sad? A Anxiety Have you been feeling anxious or nervous? M Mania Have you felt full of energy, unable to sleep or so excited that other people thought you were acting strangely? P Psychosis Have you heard any voices or noises that other people couldn’t see? Have you seen any visions that other people couldn’t see? Do you feel like people are out to get you? O Organic Have you had any physical symptoms recently? Headaches? Memory problems? S Sleeping How has your sleep been? E Eating How is your appetite?
What is the mnemonic for risk assessment?
MY REASON Comment on acute AND chronic risks M edication non-adherence/deterioration Y oung people/dependents R eputation E xploitation A bsconding S uicide and self harm O others (risk to) -> Include forensic hx N eglect
What are the options for psych definitive management in order?
PELP ME PsychoEducation Lifestyle: SNAP + social support Psychotherapy - CBT/DBT/Graded exposure/mindfulness Medication ECT
Describe the template for management in a psych OSCE
Basics - consider risks, consider compulsory management under the mental act (ie. assessment order) Place and Person - community versus inpatient. Do they need to see a psychiatrist for an AO, for the MHA? Ix and confirm diagnosis - Gain collateral history, physical exam, investigate for organic causes definitive management - psychoeducation, lifestyle factors (SNAP) + social supports, psychotherapy, pharmacotherapy, ECT follow up and prevention - case manager? etc
What is Scott’s mnemonic for Ddx?
DOOP Drugs-induced Organic Other disorders of the same class Personality disorder
What is the mnemonic for the DSM criteria for depression?
DAWGS MEGA CD (Think: What up Dawg?”) Depressed mood Anhedonia Weight loss or gain Guilt / worthlessness Sleep (increase or decrease) Motor (psychomotor agitation or retardation) Energy Guilt / worthlessness (again) And Concentration difficulty Death (thoughts of suicide)
What substances / drugs can cause depression?
o B Blockers o Steroids o ETOH o Levodopa
Which neurotransmitters are reduced in depression?
NA & 5-HT
What is my way to remember the neuroreceptors + relevant side effects?
HAMS MD S = 5HT1 = Gippsland Medical School Has Some Balls H1 = sedation Alpha-1 = arousal + postural hypotension Muscarinic = anti-SLUD (+raised IOP) 5HT = GI upset, Metabolic Syndrome, Sexual Dysfunction, Hyponatraemia, Serotonin syndrome, bleeding MAO = cheese reaction DA = EPSE, prolactinaemia
What is the first line pharmacological treatment for patients with depression, and some examples?
SSRI (fluoxetine, escitalopram, citalopram, sertaline) SNRI (duloxetone, venlafaxine) NaSSA (mirtazapine)
When starting an anti-depressant, how should one review the patient / assess for appropriateness?
Assess response to antidepressant after 2 to 4 weeks of treatment • If there is no initial response, increase the dose • If there is a partial initial response, increase the dose • If an alternative antidepressant is indicated, the new drug may be from the same or a different class • If there are severe or unacceptable adverse effects, switch to an antidepressant with a lower propensity to cause those adverse effects When changing antidepressants: • An appropriate antidepressant-free interval is recommended when changing from one antidepressant to another to reduce the risk of drug interactions and serotonin toxicity. Read etg Because of the high rates of relapses, patients who have recovered with pharmacotherapy should be encouraged to continue follow up for at least 6 months before considering medication taper
What are some second line pharmacological interventions for depression, and some examples?
TCAs (Amitriptyline) MAOis (Pheneizine & Tranylcypromine)
Which first-line antidepressant might I choose for a young male who is worried about sexual dysfunction?
Mirtazapine (a NaSSA)
Which first-line antidepressant would I choose for a young female who is worried about weight gain?
Escitalopram (an SSRI)
If the patient was an elderly female, which first-line anti depressant would you choose?
Escitalopram (an SSRI) - least risk of orthostatic hypotension. Still monitor for hyponatraemia and bleeding
If the patient had bipolar depression, which medication would I choose?
Quetiapine (an atypical antipsychotic)
what side effect of anti-depressants is potentially permanent?
sexual dysfunction
which anti-depressant is most likely to cause withdrawal symptoms?
paroxetine (severe HA and flu-like illness)
when should most SSRIs be given? and which one is different?
Fluvoxamine is the most sedating SSRI Should be given at night (most other SSRIs in the morning - cause arousal)
which anti-depressant has the longest half life? why might his be useful? why might this pose problems?
Fluoxetine Longer half life – advantage if poor adherence but is difficult to switch to another anti-depressant if need be (longer wash-out period)
which class of anti-depressant has a high risk of fatality with OD?
TCAs
which anti-depressant may be most useful in psychotic depression?
MAOi (think – is targeting the dopamine)
for how long does one have to have had symptoms, to diagnose MDD according to the DSM?
2 weeks
for how long does one have to have had symptoms, to diagnose persistent depressive disorder according to the DSM?
2 years (1 year in children/adolescents)
if someone fits the DSM criteria of a MDD, but have had symptoms for two years - what do they have?
NOT dysthymia, still MDD
should the management of depression change if a woman is pregnant or just given birth?
No (but discuss with O&G? and pads r/v after birth of child) Evidence is controversial The risks of not treating depression are possible greater - increased endogenous steroids in baby - depressed mothers more likely to smoke, neglect baby
what is first line management of anxiety disorders?
Psychoeducation Lifestyle factors Psychotherapy - CBT. If this doesn’t work, then consider medication
what is the first line PHARMACOLOGICAL treatment of anxiety disorders?
escitalopram is on the PBS for GAD. Prescribe it at half the dose
what is the second line PHARMACOLOGICAL treatment of anxiety disorders?
Pregabalin Benzodiazapine TCAs
comment on the use of benzodiazapines in the treatment of GAD
should only be used in the short term
what is the NHMRC’s official ‘cut offs’ in regard to safe ETOH consumption for healthy men and women?
No more than two standard drinks / day No more than four standard drinks / sitting
what is the pharmacology of ETOH?
enhance GABA-A transmission → anxiolytic inhibit NMDA-mediated glutaminergic transmission → amnesic dopamine release in the mesolimbic system → euphoric
what is the pathophysiology of ETOH withdrawal?
Ethanol interacts with GABA receptors, enhancing their activity. GABA receptors mediate inhibitory neurotransmission. Chronic alcohol abuse → decreased GABA activity due to alteration of the receptor function and gene expression affecting types of receptors available. Ethanol withdrawal → functional decrease in GABA → loss of inhibitory control of excitatory neurotransmitters norepinephrine, glutamate and dopamine.
What are some of the signs / symptoms of ETOH withdrawal?
Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 beats per minute) Increased hand tremor Insomnia Nausea or vomiting Transient visual, tactile, or auditory hallucination s or illusions Psychomotor agitation Anxiety Grand mal seizures
what is the basic Rx that may be required for ETOH withdrawal?
fluids anti-emetics analgaesia thiamine
what is the definitive management of ETOH withdrawal?
Diazepam (don’t use if still drinking!)
what is the definitive management of ETOH dependence?
Disulfiram (Antabuse) - interacts with alcohol by blocking its metabolism, giving rise to the aldehyde reaction (ie intense flushing, sweating, palpitations, tachycardia, dyspnoea, hyperventilation and the development of a pounding headache). Chest pains, restlessness and a sense of impending doom may develop. Acamprosate - reduces the neuronal hyperexcitability characteristic of alcohol withdrawal, and therefore reduces the symptoms of protracted alcohol withdrawal and REDUCE CRAVINGS. Naltrexone - blocks the effect of endogenous opioids released following alcohol intake. As a result, the person who drinks alcohol reports less pleasurable effects.
What is delirium tremens?
The most severe manifestation of alcohol withdrawal. It usually commences 72 to 96 hours after cessation of drinking and is characterised by gross tremors and fluctuating levels of agitation, hallucinations (usually tactile), disorientation and impaired attention. Fever, tachycardia and dehydration may be present.
what is the definitive management of delirium tremens?
It is a medical emergency that always requires hospitalisation and, if inadequately treated, has a high mortality rate, mainly from heart failure. diazapam haloperidol if hallucinating
What is the triad of Wernicke Encephalopathy?
opthalmaplegia, confusion, ataxia
what is the aetiology of Wernicke encephalopathy?
Thiamine (vitamin B1) deficiency due to chronic alcohol abuse
what are the different types of dementia? what is the most common and second most common type?
Alzheimer’s (most common) Vascular dementia (second most common) Lewi body dementia Fronto-temporal Parkinson’s-related
differentiate between alzheimer’s disease and vascular dementia in terms of their onset
Alzheimer’s disease has a slow, gradual onset of symptoms. Vascular dementia has a sudden onset.
differentiate between alzheimer’s disease and lewy body dementia in terms of onset
levy body dementia is usually of quicker onset
what are the specific symptoms of Lewy body dementia?
Characterised by a dementia syndrome with any two of the following: - visual hallucinations, - spontaneous motor parkinsonism - fluctuation in the mental state in the absence of a clear cause for delirium.
what disease is lewy body dementia closely related with?
Parkinson’s disease
what is the aetiology of vascular dementia?
atherosclerosis of small-medium arteries in the brain causing lacunar infarcts
what are the symptoms of frontotemporal dementia?
Personality change (apathy, disinhibition, loss of insight) Loss of the ability to recognize the meaning of words and objects and Global cognitive decline.
how might you differentiate between FTD and AD?
FTDs have an earlier onset than AD and, at an early stage, do not cause the memory loss and visuo-spatial disorientation that are so characteristic of AD
what is the other name for frontotemporal dementia?
Pick’s disease
what is the aetiology of front-temporal dementia?
40% is genetic (autosomal dominant)
what is the aetiology of normal pressure hydrocephalus?
always idiopathic
what is the clinical picture of normal pressure hydrocephalus?
‘Wet Wacky and Wobbly” Urinary incontinence Gait disturbance Deterioration in cognition (dementia)
What are the potential revserible causes of dementia?
- Depression - Vit B12 deficiency - Drug side effects - Metabolic disorder (eg hypothyroid) - Infectious disease - Neoplasm - Subdural haematoma - Normal pressure hydrocephalus
List some investigations to help rule out the potential reversible causes of depression
- FBE - UEC/LFT/CMP - ESR - TSH - Vit B12 - Urine Drug screen - Serological testing for syphilis (in at risk patients) - HIV testing - MRI
which type of dementia is characterised by amyloid plaques?
Alzheimers
Which congenital abnormality will predispose you to Alzheimer’s disease and why?
Down Syndrome Because amyloid plaques are caused by abnormal cleavage of a normal protein encoded on chromosome 21
What is the typical clinical picture of Alzheimer’s disease?
- loss of recent memory first - difficulty with executive function (reasoning, abstraction, judgment, performing tasks such as planning activities, organizing events and managing money) - dysphasia (difficulties in word finding and naming) - problems with visuospatial function (clock face)
What is the condition in which memory functions are disproportionately impaired compared to other cognitive functions in an otherwise alert patient
amnestic syndrome
What is panic disorder?
At least 1 panic attack followed by at least 1 mth of the following symptoms: I. Persistent worry about additional attacks or their consequences II. Maladaptive change to avoid attack
What is a panic attack?
an abrupt surge of intense fear or discomfort that reaches a peak within minutes and 4 or more of the following occur: 1. Palpitations, pounding heart or accelerated heart beat 2. Sweating 3. Trembling or shaking 4. Sensations of shortness of breath/ smothering 5. Feelings of choking 6. Chest pain or discomfort 7. Feeling dizzy, unsteady, light-headed, or faint 8. Chills or heat sensations 9. Parasthesias 10. Derealisation or depersonalization 11. Fear of losing control 12. Fear of dying
What are the DSM diagnostic criteria of schizophrenia?
Two or more of the following each present for a significant portion of time during a 1 month period. At least one must be of the first 3: 1.Delusions 2.Hallucinations 3.Disorganized speech 4.Grossly disorganized or catatonic behavior 5.Negative symptoms But they have to have had symptoms for >6 months, that might have been a prodrome characterised only by negative features.
How to you classify the symptoms of schizophrenia, and what are they?
Positive Symptoms - hallucinations - delusions Negative Symptoms - andhedonia - affective flattening or blunting - avolition - alogia (poverty of speech) Cognitive symptoms - disorganised speech - disorganised behaviour
what are the negative symptoms of schizophrenia?
Anhednoia Agolia Avolition Affect blunting or flattening
What is schiziophreniform disorder?
Same symptoms of schizophrenia, but only for between one and six months
What is schizotypal personality disorder?
Essentially a loner because displays magical thinking / perceptual disturbances / is just very odd. Luna Lovejoy
What is schizoid personality disorder?
Essentially a loner – similar to negative symptoms of schizophrenia / catonic behaviour
What are the symptoms / diagnostic criteria of ADHD?
hyperactivity inattention impulsivity pervasiveness
When monitoring clozapine, how often do you require an FBE?
Pre treatment, weekly for 18 weeks and then monthly
When monitoring clozapine, how often do you require troponin?
Pre-treatment, weekly for 18 weeks and then three months later, then annually
what investigations / physical examination findings are required whilst monitoring clozapine?
Weight BMI Smoking status FBC CRP LFT BGL (fasting) Lipid profile ECG Echo B-HCG when required clozapine level when re-titrating or commencing
when monitoring clozapine, how often do you require an ECG and echo?
ECG - baseline, 6/12 after commencing close and every 12 months after that Echo - at baseline and then when clinically indicated
with which anti-depressant is weight gain MOST problematic?
mirtazapine
which anti-depressant does not seem to cause hyponatraemia?
mirtazapine (is instead caused by all SSRIs, SNRIs, TCAs and MAOis)
which has a longer half life, diazepam or midazolam?
diazepam midazolam has a quick onset of action and only lasts 15 minutes - 2 hours)
which drug (both the class and specific example) is most likely to cause acute-dystopias, and in whom?
haloperidol of all the first generation anti-psychotics young males are most commonly affected
which of the two zuclopenthixols is shorter acting, and what is the route?
acetate is shorter acting decanoate is longer acting both are IM
what drug class is fluvoxamine?
SSRI
what drug class is paroxetine?
SSRI
Ange aged 81, is wearing her hearing aid and seems to understand you but keeps looking away. Even little things seem to attract her attention away from the interview. Using the information provided in the vignette, choose the most appropriate mental state phenomenon from the list:
Easily distracted
You have to listen very carefully to follow what Mr Williams is saying. It makes sense and the ideas are connected but if you don’t concentrate for a second you lose track of what he is saying. Using the information provided in the vignette, choose the most appropriate mental state phenomenon from the list.
Flight of ideas why not tangentiality? is tangentiality worse?
Ingrid, aged 59, looks as if she is worried about something. She frowns as she describes her problems to you, remaining tense and preoccupied no matter what she is talking about. Using the information provided in the vignette, choose the most appropriate mental state phenomenon from the list:
anxious affect
In the middle of a conversation with you Ian just stops talking in the middle of a sentence. He says that his head suddenly was empty of ideas, as if they had been sucked out. Using the information provided in the vignette, choose the most appropriate mental state phenomenon from the list.
Thought blocking Why not thought withdrawal? Thought withdrawal is more of a symptom (patient reports experiencing it). Thought blocking is more of a sign - the examiner can SEE it
Steve is convinced that when he watches Greys Anatomy on television and everyone talks about McDreamy that they really mean that he should go to bed earlier. Using the information provided in the vignette, choose the most appropriate mental state phenomenon from the list.
idea of reference
You have been Madges’ GP for some 20 years and you know her as a regular drinker but one who has always functioned relatively independently (and still does). Recently you have become aware that she doesn’t seem to remember changes to her medication. She seems to understand them at the time but at the next visit she is back on the previous regime. You have also asked your receptionist to remind her of appointments by telephone (usually ringing up 30 minutes beforehand and telling her to “come down”). MMSE is 27/30 with 0/3 on short term recall.
Amnestic syndrome Amnestic syndromes are conditions in which memory functions are disproportionately impaired compared to other cognitive functions in an otherwise alert patient
Mavis is 50 and for at least ten years has been reluctant to go out as she gets acutely anxious and can’t breathe; not every time she goes out but often enough that she is afraid to go in case it happens again. Using the information provided in the vignette, choose the most appropriate diagnosis from the list. Options: Agoraphobia, GAS, Panic disorder, panic attacks
Agoraphobia with panic attacks Why not GAD? Because it is one specific phobia. Why not panic disorder? Because this is anxiety about having panic attacks. ie. Panic Disorder = at least 1 panic attack followed by at least 1 mth of the following symptoms: I. Persistent worry about additional attacks or their consequences II. Maladaptive change to avoid attacks What is a panic attack? an abrupt surge of intense fear or discomfort that reaches a peak within minutes and 4 or more of the following occur: 1. Palpitations, pounding heart or accelerated heart beat 2. Sweating 3. Trembling or shaking 4. Sensations of shortness of breath/ smothering 5. Feelings of choking 6. Chest pain or discomfort 7. Feeling dizzy, unsteady, light-headed, or faint 8. Chills or heat sensations 9. Parasthesias 10. Derealisation or depersonalization 11. Fear of losing control 12. Fear of dying
Sam aged 23 has been admitted with a first episode of psychosis. Within 24 hours of starting treatment he develops an acute intense muscle spasm in his jaw.
haloperidol (haloperidol, of all the first generation antipsychotics, is most likely to cause acute destinies. Young males are most affected).
Jane was admitted three days ago complaining that she heard a group of people planning to kill her. She has become calmer with the commencement of treatment but has suddenly become extremely agitated and says that one of the visitors just arrived on the ward is “one of them”. She will not listen to reason and doesn’t respond to the reassurance of staff. She hit away an oral PRN offered by a staff member. zuclopenthixol decanoate diazepam midazolam
midazolam (can be given SC) diazepam is longer acting zuclopenthixol decenoate is long acting
adjustment disorder
What is the difference between BPAD1, BPAD2 and cyclothymia?
For Bipolar 1 disorder all you need is ONE manic episode.
For Bipolar 2 you need hypomania plus a major depressive episode.
The diagnosis of cyclothymic disorder is given to adults who experience at least 2 years (for children, 1 year) of both hypomanic and depressive periods without EVER fulfilling the criteria for an episode of mania, hypomania, or major depression.
How do you diagnose BPAD1?
Mood (1 - for at least a week)
- Elevated
- Expansive
- Irritable
- Increased goal-directed activity
Other Symptoms (3 or 4)
- High self esteem
- No need for sleep
- Talkative
- FOI
- Psychomotor agitation
- Distracted
What is the aetiology of BPAD?
Genetics!!!
Bipolar is the most heritable of all the psychiatric diagnoses. There is an average 10-fold increased risk among adult relatives of individuals with bipolar I and bipolar II disorders.
What is the definitive management of acute mania?
Cease anti-depressants, if patient is on them
Commence olanzapine OR risperidone
Possibly in conjunction with lithium (high dose) if severe
What is the maintenance / prophylactic treatment of BPAD?
Lithium (lower dose)
OR
atypical antipsychotic
OR
antiepileptic
what are the components of the MSE?
Appearance
Behaviour & Rapport
Mood
Affect
Speech
Thought
Perception
Cognition
Insight
Judgement
What are the sub-components of ‘affect’ on the MSE?
Quality
Range
Reactivity & Stability
Appropriatentess & Congruence
What are the components of ‘Speech’ on the MSE?
Volume
Rate
Tone
Fluency
What are the components of ‘Thought’ on MSE?
Stream
Form
Content
Posession
What is the overall definitive management of any psychiatric condition?
Psychoeducation
Lifestyle
Psychotherapy
Medication
ECT
What is the overall management of any psych condition?
Basics
- Risk assessment
- Need for Assessment Order under the MHA?
Place and Person
- Inpatient vs Community
Ix and Confirm Diagnosis
- Collateral history if available
- Physical exam
- Ix for organic cause / drug screen
Definitive management
- Psychoeducation
- Lifestyle
- Psychotherapy
- Pharmacotherapy
- ECT
Follow-Up
- Follow up with case manager / psychiatrist
What is the general process of the MHA?
- Assessment Order (within 24 hours) needs to be made by a doctor / case worker for a psychiatrist to review the patient
- The psychiatrist can then make a Temporary Treatment Order which may last for 28 days
- After 28 days, the Mental Health Tribunal can assign a Community Treatment Order (which can last for 12/12) or Inpatient Treatment Order (which can lasr for up to 6/12) in which time patients are made compulsory.
What are the features of a risk assessment?
MY REASON
Medication Non-Compliance + Motor Vehicle Risk
Young + dependents
Reputation
Exploitation
Alcohol and Drugs + Absconding
Suicide + Self harm
Others
Neglect
What is the DDx of any psych disorder?
DOOP
Drug-induced
Organic (eg. delirium, thyroid)
Other illness of the same class
Personality disorder
What are the symptoms of schizophrenia?
Two or more of the following [at least one of dellusions, hallucinations, diroganised speech]
Positive Symptoms
- Dellusions
- Hallucinations
Negative Symptoms
- Anhedonia
- Avolition
- Alogia
- Affective blunting
Cognitive
- Disorganised speech
- Disorganised behaviour
What are the negative symptoms of schizophrenia?
Anhedonia
Avolition
Affective blunting
Alogia
What is the time period for symptoms of schizophrenia required for diagnosis?
What if it doesn’t last this long?
1 month of symptoms required for criteria
But at least 6 months of a “change” eg. may be only prodromal / negative symptoms
If schizophreniform disorder
What is schizophreniform disorder?
Symptoms of schizophrenia for
What is schizoaffective disorder?
symptoms of a major mood disorder + symptoms of schizophrenia
What is schizotypal personality disorder?
Essentially a loner because displays magical thinking / perceptual disturbances / is just very odd.
What is schizoid personality disorder?
Essentially a loner – similar to negative symptoms of schizophrenia / catonic behaviour
what is the name of the personality disorder given to someone who is a loner displaying the negative symptoms of schizophrenia?
schizoid personality disorder
what does Luna Lovejoy have?
Schizotypal personality disorder
What are the components of the MSE?
Appearance
Behaviour (& Rapport)
Mood
Affect
Speech
Thought
Perception
Cognition
Insight
Judgement
[Risk Ax]
What are the components of affect on the MSE?
Quality
Range
Reactivity & Stability
Appropriateness & Congruence
What are the components of speech on the MSE?
Tone
Rate
Fluencu
Volume
What are the components of thought on the MSE?
Stream
Form
Content
Posession
What is the difference between flight of ideas and loosening of associations?
Flight of Ideas = the connection between topics is more clear (links may be puns or rhymes)
Loosening of Associations = is worse, the connection between topics is tenuous or there is no link at all
What is the DSM criteria for schizophrenia?
Two or more of the following each present for a significant portion of time during a 1 month period. At least one must be of the first 3:
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms
Duration: Continuous signs of the disturbance persist for at least 6 months - at least one month of criterion A, may include prodromal/ residual periods manifested by only negative symptoms
What are the positive symptoms of schizophrenia?
Hallucinations
Delusions
WHat are the negative symptoms of schizophrenia?
Anhedonia
Alogia
Avolition
Affective flattening
What are the cognitive symptoms of schizophrenia?
Disorganised speech
Disorganised behaviour (including catatonic behaviour)
What is the difference between schiophrenia and schizophreniform disorder?
The symptoms of schizophrenia last for >6 months (this can include a prodrome)
The symptoms of schizophreniform disorder last between 1 and 6 months (this can include a prodrome)
The symptoms of brief psychotic disorder come on suddenly (usually without a prodrome) and last from 1 day to 1 month
How do you conceptualise the symptoms of schiozphophrenia?
Positive symptoms
- Delusions
- Hallucination
Negative Symptoms
- Anhedonia
- Alogia
- Affective flattening
- Avolition
Cognitive Symptoms
- Disrogrnaised speech
- Disorganised behaviour
What is the difference between schizoaffective disorder and schizophrenia?
Schioaffective = a major mood disorder + symptoms of schizophrenia
What is the difference between delusional disorder and schizophrenia?
Delusional disorder = delusions of at least one month (but no other criteria for schizophrenia)
What are the PDs relating to schiophrenia?
Schizoid PD - essentially a loner, negative symptoms of schizophrenia
Schizotypal PD - magical thinking
Paranoid PD
What are Capgras delusions?
Who normally gets them?
A delusion that a friend, spouse, parent, or other close family member (or pet) has been replaced by an identical-looking impostor.
Seen in schizophrenia
What is thought disorder?
Who gets thought disorder?
Thought diorder is disorganised thinking as evidenced by disorganised speech.
Formal thouught disorder is one of two types of disordered thinkning, with the other type being delusions. The latter involves “content” while the former involves “form”.
Although the term “thought disorder” can refer to either type, in common parlance it refers most often to a disorder of thought “form” also known as formal thought disorder.
FTD occurs in schizophrenia but can occur in other psychiatric conditions and organic conditions.
“FTD is when a patient is not understadable, but has no insight into their non-understandability”
What is a clang association?
Where would it come in under the MSE?
A mode of speech characterized by association of words based upon sound rather than concepts. For example, this may include compulsive rhyming or alliteration without apparent logical connection between words.
It is a type of formal thought disorder.
What is the difference between derailment, tangentiality and circumstantility?
Circumstantiality is when one deviates fromt the initial topic but then comes back to it.
Tangentiality / Derailment is when one deviates from the original topic.
In general, which anti-psychotics give you EPSE and which give you metabolic syndrome?
1st Generation / Typical - EPSE
2nd Generation / Atypical - metabolic syndrome
Which pathway is responsible for the negative symptoms of schizophrenia?
What type of antipsychotic treats this best?
Mesocortical dopamine pathway
All antipsychotics act on this pathway, but the second generation treats the negative symptoms better.
Which pathway is responsible for the positive symptoms of schizophrenia?
Mesolimbic dopamine pathway
What are the receptors / pathways on which antipsychotics act/block, and what are the corresponding effects/side effects?
- Dopamine
- Mesolimbic - Rx of +ve symptoms
- Mesocortical - Rx of -ve symptoms
- Nigrostriatal - EPSE
- Hypothalamic / Tubero-Infundibular - hyperprolactinaemia
- H1 - sedation
- Alpha adrenoceptors - postural hypotension
- Muscarinic receptors - anti-SLUDD & improvement of EPSE
- 5-HT - weight gain & metabolic syndrome
What are the EPSE and when do they occur?
Which meds cause EPSE?
4 hours: “Muscle” = Acute dystonia
4 days: “Rustle” = Akasthisia
4 weeks: “Hustle” = Akinesia
4 years: IRREVERSIBLE: Tardive dyskinesia
1st gen / typical antipsychotics typically cause EPSE
What is an acute dystonia, when does it occur?
Who normally gets it? And with what drug (class and specific type)
Dystonias are an EPSE.
They are a sustained or brief muscle contraction resulting in twisting movements or abnormal postures.
They typically occur with first generation anti-psychotics especially haloperidol when taken by young men.
What is akasthisia and when does it occur?
An abnormal, uncomfortable sensation of restlessness combined with an urge to move about, tends to occur 4 days after taking antipsychotics (typically first gen).
What is akinesia and when does it occur?
rigidity, bradykinesia, and tremor
Within 4 weeks of taking second gen anti-psychotics
What is tardive dyskinesia and when does it occur?
Chronic movement disorder characterised by repetitive involuntary choreiform movements of the tongue, lips and mouth.
Occurs with long term use of second generation antipsychotics.
Olanzapine
Class?
Notable AE?
Effect of smoking cessation?
2nd Gen / Atypical
Has the highest risk of cardiometabolic adverse effects (along with clozapine, with quetiapine second)
Smoking cessation may increase the plasma concentration of olanzapine (and cloazpine), therefor may need dose reduction.
Smoking cessation may increase the relative plasma concentrations of which drugs?
Clozapine
Olanzapine
Clozapine
Class of drug?
Adverse effects?
But why is it GOOD?
Effect of smoking?
Monitoring?
Atypical / 2nd gen
Adverse effects:
NAMES + the usual side effects
Neutropenia
Agranulocytosis
Myocarditis
Excessive salivation
Seziures
+ anti-SLUDD (except not a dry mouth), sedation, postural hypotension, metabolic syndrome
Why is it good?
BUT it is the LEAST LIKELY to give EPSE because of it’s inhibitory effect on ACh
Smoking
Smoking cessation increases the plasma concentration
Monitoring
blood group at first visit
Neutorpenia & agranulocytosis - FBE
Myocarditis - ECG, echocardiocram, tropnonin, CRP
Metabolic syndrome - UEC, LFT, BGL, HBA1C, BP, BMI
Smoking status
Cloz level
BHCG
What is involved in clozapine moniotring?
blood group at first visit
Neutorpenia & agranulocytosis - FBE
Myocarditis - ECG, echocardiocram, tropnonin, CRP
Metabolic syndrome - UEC, LFT, BGL, HBA1C, BP, BMI
Smoking status
Cloz level
BHCG
What are the adverse effects of cloazpine?
NAMES
Neutropenia
Agranulocytosis
Myocarditis
Excessive salivation
Seizures
plus
Anti-SLUD (except excessive salivation)
Sedation
Metabolic syndrome
Postural hypotension
What is a nihlistic delusion?
he belief that oneself, a part of one’s body, or the real world does not exist or has been destroyed
What are the clinical features of lithium toxicity?
How might lithium toxicity occur?
Lithium TOxicity
-
gastrointestinal effects
- nausea, vomiting and diarrhoea
-
CNS effects
- tremor, hyperreflexia, ataxia and dysarthria in mild to moderate toxicity; confusion, coma and seizures in severe toxicity
-
cardiovascular effects
- QT prolongation, hypotension in severe cases
Lithium is usually excreted by the kidneys, lithium toxicity is caused by pre-renal, renal or post-renal faliure, or ovedose.
What is the triad of symptoms of normal pressure hydrocephalus?
- urinary incontinence
- deterioration in cognition (dementia)
- gait disturbances
These can be remembered with the mnemonic
“Wet, Wacky and Wobbly”.
With which anti-depressant is weight gain most common?
With which anti-depressant is weight gain least common?
Most common = mirtazapine (NASSA)
Least common =
- escitalopram (SSRI)
- agomelatine (non SSRI/SNRI)
- Moclobemide (non SSRI/SNRI)
- Reboxetine (non SSRI/SNRI)
What is the difference between fear and axiety?
Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat.
What is GAD?
What is Panic Disorder?
GAD
Persistent and excessive anxiety and worry about various domains:
- Adults: job, health, family matters.
- Children: school performance
- Plus physical symptoms*: restess, keyed up, palpittaions, muscle tension
- Plus cognitive symptoms*: easily fatigued; difficulty concentrating or mind going blank; irritability; and sleep disturbance
Panic Disorder
Recurrent unexpected panic attacks
The person is therefore persistently concerned or worried about having more panic attacks
The person changes his or her behavior in maladaptive ways because of the panic attacks (e.g., avoidance of exercise or of unfamiliar locations).
What are panic attacks?
How are they different to panic disorder?
Panic Attacks - single sudden episodes of painc manifesting in physical and cognitive symptoms
Panic Disorder - Being persistently concerned about having panic attacks (has had multiple in the past). The person changes his or her behavior in maladaptive ways because of the panic attacks (e.g., avoidance of exercise or of unfamiliar locations).
What is another name / way to conceptualise social anxiiety disorder?
Social phobia
What are the DDx of Anxiety DIsorders?
Drug-Induced
Organic eg. hyperthyroidism
Other diagnoses of the same axis:
- generalised anxiety disorder
- panic disorder
- social anxiety disorder
- agoraphobia
- PTSD
- adjustment disorder
Personality Disorders
- avoidant
- dependent
- OCD
What are the cluster C PDs?
“Sad”
Avoidant:
- social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation
Dependent
- An excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation.
OCD Personailty DIsorder
- Preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency
What are the main Trauma-Related Disorders?
Acute Stress Disorder
Post Traumatic Stress Disorder
Adjustment DIsorder
What is acute stress disorder vs post traumatic stress disorder?
What are the similarities and differences?
Both are in response to a significant event eg. exposure (by direct experience or witness) violence, threatened death, sexual abuse etc.
The difference is in the time line.
Acute stress disorder = 3 days - 1 month after the event
PTSD = >1 month after the event
What is adjustment disorder versus acute stress disorder?
Adjustment disorder is in response to a “stressor” rather than a significant event such as parental divorce, diagnosis of a new medical illness.
It usually starts within three months after the stressor but doesn’t persist past 6 months.
Acute Stress Disorder is in response to an experiences / witnessed significant event (such as death, violence, sexual abuse) and is from 3 days - 1 month post the event
What is the defitive management of anxiety disorders?
Psychoeducation - of particular importance in anxiety disorders
Lifestyle - reduction in caffeine, good sleep hygiene
Psychotherapy - CBT usually, graded exposure if phobia
Medications -
- Escitalopram [Half dose]
- Theoretically can use SNRIs but not approved by TGA for use in anxiety disorder
- Pregabalin
- TCAs
- Benzodiazapine [only for short term]
ECT not needed
What are SNRIs?
Desvenlafaxine
Venlafaxine
Duloxetine
Remember: D&V –> N
[ones with Ds and Vs block NA reuptake]
Dave and Veronica were NOT liked by BR
What are the DSM criteria for depression?
DAWGS MEGA CD
(need at least 5/11)
Depressed mood
Anhedonia
Weight (gain or loss)
Guilt / worthlessness
Sleep (insomnia or hypersomnia)
Motor (psychomotor agitation or retardation)
Energy levels reduced / fatigue
Guilt / worthlessness (again!)
And
Concentration reduced / indecisive
Death – thoughts of, suicidal ideation
Name some SSRIs?
Escitalopram
Citalopram
Fluoxetine
Fluvoxemine
Paroxetine
Sertaline
What is the difference between grief and depression?
Grief
- Feelings of emptiness and loss are the predominant feelings
- Self esteem is usually maintained
- Any suicidal ideation is usually pertaining to joining a loved one
- Can lead to depression
Depression
- Depressed mood and anhedonia are definitely a feature
- DAWGS MEGA CD
- Feelings of worthlessness / guilt - loss of self esteem
- Can have suicidal ideation
What is the difference between persistent depressive disorder and major depressive disorder?
Persistent depressive disorder is like a ‘subacute’ depression, don’t need as many of the criteria but needs to last for at least two years
MDD need 5/11 of the criteria and symptoms have to be present for most of the day, every day, for at least two weeks
How do you start someone on an anti-depressant?
1. Ix and CD
* Rule out organic causes of depression
* Substance abuse (ETOH, drugs)
* Hypothyroidism
* B12 / folate deficiency
* Cancer
* Cushings
* Review Medication (which can cause depression)
* B blockers
* Steroids
* Isotretinoin
* Levodopa 2. Choose anti-depressant based on side effect profile (see another slide) 3. Educate RE adverse Effects (See another slide)
* explain that time to adverse effects (1 day) is often quicker than time to effects (2-4 weeks), encourage to persist 4. Review in 2-4 weeks
* If no side effects --\> increase dose
* if side effects --\> change antidepressant in same or differnt class (refer to eTG) 5. Discuss duration * First episode of depression: 6-12 months
* But 50-85% will have a second episode * Second episode: 2-3 years
* But 80-90% will have a third episode * Third episode: consider life-long treatment 6. Cessation
- Have to taper off, can’t stop immediately
- Get symptoms of withdrawal
What are the adverse effects of anti-depressants?
WHICH SPAGS
Weight gain
Headache
Impotence
Cheese Reaction
Hyponatraemia / H/A
Sleep disturbance (sedation / insomnia) [H1]
Postural hypotension [alpha]
Anti-SLUD [muscarinic]
GI upset / Nausea [5-HT3]
Serotonin syndrome / Suicide
What are the first line anti-depressants?
SSRIs
SNRIs
Mirtazapine (NASSA)
What is the mechanism of action of mirtazapine?
Who is it most often used in?
What is a major side effect?
NA reuptake inhibitor
Selectively acts on the 5-HT 1 pathway (and not 2 or 3)
Most often used in males as doesn’t cause impotence
A major side effect is weight gain
Is very sedative, also given at night! BUT important to note that the degree of sedation is inversely proportional to the dose. If disturbed by sedation - increase the dose.
Which anti-depressant has the longest half life and what is the significance of this?
Fluoxetine
This is an advantage if poor adherence but is difficult to switch to another anti-depressant if need be (longer wash-out period)
Hangs around like the flu
Which antidepressant has the least weight gain as an AE?
ESCITALOPRAM
Which antidepressants has the most weight gain?
mirtazapine
Which antidepressant would you choose for an elderly person?
escitalopram
(the least hypotension)
But still need to watch out for hyponatraemnia!
Which antidepressant can be used in anxiety?
Escitalopram (1/2 the dose) is the only one approved the the TGA for this purpose
Which antidepressant is most likely to casue withdrawal symptoms?
Paroextine
Think of a parot - you have to withdraw your hand away when it bites you
Which antidepresant is most sedating?
fluvoxemine (give it at night)
vox in the box
dr seuss bed time story
Which antidepressants have the higest risk of mortality with overdose?
TCAs
What are the specific AE of SSRIs?
Bleeding risk increased
Also cause hyponatraemia / SIADH
Also may cause palpitations, tachycardia, hypertension (makes sense because increasing [NA])
What are the criteria of mania?
Elevated, expansile, irritable mood
+
DIGFAST
Distractibility
Increased goal directed activity
Grandiosity
FOI
Activity - increased psychomotor activity
Sleep - no need
Talkative
What is the difference between bipolar 1 and bipolar 2 and cyclothyma?
- Bipolar 1 = need one episode of mania (1 week), don’t need an episode of MDD
- Bipolar 2 = hypomania (4 days) + MDD
- Cyclothymic = hypomania + depressive symptoms (2 years in adults and 1 year in chlidren)
What are the cluster A personality disorders?
Schizoid PD
Paranoid PD
Schizotypal PD
What are the cluster B PDs?
borderline PD
histrionic PD
narcissitic PD
antisocial PD
What are the cluster C PDs?
avoidant PD
dependent PD
Obsessive compulsive PD
What is the defitive management of acute mania?
Cease anti-depressant
+
High dose lithium
+
olanzapine OR respiradone
What is the definitive management of mania / BPAD maintenance / prophylaxis?
- Low dose lithium, OR
- atypical antipsychotic, OR
- anti-epileptic
What is the definiitive management of bipolar depression?
Maintenance Rx of BPAD
- Low dose lithium; OR
- Atypical anti-psychotic; OR
- Anti-epileptic
PLUS
- SSRI OR
- Quetiapine
What is the difference between pressure of speech and flight of ideas?
FOI = thoughts are rapid
- Part of thought stream
POS = speech is rapid
- Part of speech rate
What are some examples of formal though disorder?
Words
- neologisms
- echolalia
Sentences
- Flight of ideas
- Loosening of associations
- Word salad
- Derailment
- Tangentiality
- Cicrumstantiality
- Over-inclusiveness
What is avoidant personality disorder?
cluster C
A pervasive pattern of social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation, and avoidance of social interaction despite a strong desire to be close to others.
What is stereotypy?
repetitive purposeless movements such as rocking or head banging
What are mannerisms?
quasi-purposeful abnormal movements such as a gesture or abnormal gait
What is a tic versus mannerism?
a tic is an involuntary but quasi-purposeful movement or vocalizations.
a mannerism is a voluntary repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait.
What does “idea of reference” mean and what is a synonym?
Referential delusion
A phenomenon of an individual’s experiencing innocuous events or mere coincidences and believing they have strong personal significance
What is the differnece between a metanym and a neologism?
Neologism: “I don’t like Suzy, she is shammy”
Metanym: “I don’t like Suzy, she is lampshade”
What is an autochthonus delusion
a delusion arising without apparent cause
Scott was a 4th year medical student and was progressing well in his course. One day in the middle of a study group Scott mentioned to his friend Julia that his other friend Helen was a spy for the secret service and so she should be wary of her. He then resumed quizzing Julia on the risk factors for neonatal sepsis.
What is the difference betweem thought withdrawal and thought blocking?
Thought withdrawal is used where the patient reports the removal of thoughts rather than the interviewer being able to observe that it is happening i.e. is subjective
Thought blocking is when a person’s speech is suddenly interrupted by silences that may last a few seconds to a minute or longer i.e. is objective
What is the most common type of dementia?
Alzheimer’s Disease
What are the types of dementia?
FLAPEV
Frontotemporal
Lewy Body Dementia
Alzheimer’s Disease
Parkinson’s Related
ETOH Related (Wernicke’s Encephalopathy or Korsakoff’s Syndrome)
Vascular Dementia
What are the side effects of anti-depressants
WHICH** **SPAGS
Weight gain
Headache
Impotence
Cheese Reaction
Hyponatraemia / H/A
Sleep disturbance (sedation / insomnia) [H1]
Postural hypotension [alpha]
Anti-SLUD [muscarinic]
GI upset / Nausea [5-HT3]
Serotonin syndrome / Suicide
How does alzheimer’s disease present?
Insidious onset & gradual progession of memory loss and learning difficulties (often with a family history of Alzheimer’s disease).
What is the buzz-word pathophyiosology of alzheimer’s disease?
Beta amyloid plaques
Neurofibrillary tangles (made of Tau proteins)
What examination and investigations are required to diagnose someone with Alzheimer’s Disease?
Examaination
- MSE
- MMSE
Investigations
- FBE
- UEC / CMP
- LFT
- TSH
- Vit B12
- Serological testing for syphilis (in at risk patients)
- HIV testing
- CTB / MRI brain
- Geriatric Depression Scale
- Genetic testing if early onset or family history
Referral
- Perhaps to CDAMS [Cognitive, Dementia and Memory Service] for neurocognitive testing
What are the differential diagnoses of confusion?
5Ds
Delirium
Dementia (FLAPEV)
Depression
Diseases: Parkinson’s & Huntington’s
Disguises (reverisble causes of cognitive decline)
- sub dural haemorrhage
- normal pressure hydrocephalus
- brain tumor
How does vascular dementia present?
Usually starts suddenly and will be accompanied by focal neurological signs with imaging evidence of cerebrovascular disease.
Many patients with vascular dementia have evidence of atherosclerotic disease elsewhere.
What are the features of Lewy Body Dementia / How does it present?
2/3 of
- visual hallucinations,
- spontaneous motor parkinsonism
- fluctuation in the mental state in the absence of a clear cause for delirium
How does frontotemporal dementia present?
- Personality change and alteration in behaviour are the earliest manifestations of the condition.
- Social disinhibition and insightlessness may be a problem.
- Sometimes present with word finding difficulty, which progresses to a profound nonfluent dysphasia (semantic dementia).
What are the alcohol related dementias, and what are their feautures?
Wernicke’s Encephalopathy
-
Acute onset, 4 symptoms
- nystagmus
- ataxia
- disorientation, confusion or mild memory loss.
- “Witch Eyes, Wacky and Wobbly”*
- THIS IS AN EMERGENCY, REQUIRES PARENTERAL THIAMINE*
Korsakoff Syndrome
Wernicke’s Encephalopathy progresses to this.
This is the most common cause of amnestic syndrome.
They are unable to form new memories and therefore are prone to confabulation (they make up stuff and they don’t realise they are making it up).
Inability to form new memories.
What is another name for Fronto Temporal Dementia (the aphasic type)?
Pick’s Disease
What tool can be used to diagnose the likelihood of vascular dementia?
Hachinski Ischaemic Score
What is the management of dementia?
Explain that you can’t cure dementia but you can perhaps slow cognitive decline with medication and ensure that the patient continues to live safely, healthily and as independently as possible with a multi-disciplinary approach
Lifestyle
- Reduce ETOH consumption
Pharmacological [note these only slow cognitive decline]
- Anti-cholinesterase inhibitors
- NMDA receptor antagonists
Referral
- Cognitive, Dementia and Memory Service for further testing and treatment advice
- Aged Care Assessment Service for multidisciplnary assessment of patient in his/her home environment
- Alzhimer’s Australia for support groups and information
- Dementia Behaviour Management Advisory Service (DBMAS), which has a 24-hour helpline with trained staff who can advise on strategies to manage challenging behaviours in people with dementia.
When should you be careful in treating behaviorual and mood disturbances in dementia?
Never use first-generation antipsychotics if dementia with Lewy bodies is suspected, or for patients with Parkinson’s disease.
What might you use to treat behavioural or mood disturbances in dementia?
Try non-pharmacological options first eg. call the Dementia Behaviour Management Advisory Service (DBMAS)
Otherwise try:
- risperadone (for hallucinations, delusions or seriously disturbed behaviour)
- olanzapine (for hallucinations, delusions or seriously disturbed behaviour)
- a benzodiazepine (for severe anxiety / agitation)
What is the time frame for acute stress disorder?
what is the time frame for PTSD?
3 days - 1 month
>1 month
What are the features of a delusional disorder?
delusions have to be non-bizarre (i.e. could be happening)
> 1month
What is reactive attachment disorder versus separation ancxiety?
RAD = the strange situation
Separation anxiety = what you think it is
i.e. they are almost the opposite
What is schizoaffective disorder versus major depression with psychotic symptoms?
Schizoaffective disorder =
- Period of time of schizohprenia [Fits criterion A of schizophrenia (2/5 symptoms)]
- a major mood epside [manic or depressed]
Depression with Psychotic Symptoms
- Fits the criteria for MDD
- with hallucinations or delusions
Name one typical and one atypical antipsychotic which is available in both oral and depot form?
How often are you required to take the depot?
Haloperidol
(depot is required every month)
Respiradone
(depot is required every fortnight)
What are your options if someone is non-adherent to medication?
Change to depot (preferably the same drug, but will need to continue the oral meds whilst the depot takes time to have an effect)
Admission to hospital
Which antidepressant causes hyponatraemia, especially in little old women on a hot day, causing them to become confused / delerious (or even coma / death)?
Escitalopram
What is the acute and chronic treatment of ETOH withdrawal?
Acute
Thiamine (B1) (thiamine 300 mg IM or IV, daily for 3 to 5 days then thiamine 300 mg orally, daily for several weeks)
Analgaesia
Diazepam
Anti-emetic
Haloperidol (if psychotic)
Chronic
Disulfiram
Acamprosate
Naltrexone
What is the management of delirium?
Who you are – identify yourself each time you see the patient and orientate them to person, time and place
Haloperidol (oral or IM)
Olanzapine (oral or IM)
Risperidone (oral only)
Environment – quiet, calm, under observation, night light
What is the most common medication which causes an acute dystonia in young men, and how should we treat it?
Haloperidol
Benztropine
What is the stepwise management of acute behavioural disturbances?
Remember ‘BOF’
- Benzos are first line, olanzapine & first generation anti-psychotics are second
- Orals are first line, IM injections are second
Oral:
- Benzos (Diazepam, Lorazepam)
- Olanzapine
- First Generation Anti-Psychotics (Haloperidol, chlorpromazine)
IM:
- Benzos (Midaz)
- Olanzapine
- First Generation Anti-Pyschotics (Haloperidol)
Zuclopenthixol acetate lasts for 2-3 days. Use if you think that behavioural disturbance will be ongoing. Can combine with IM midazolam for short term coverage.
What second gen antipshotic is the most sedationg?
Which ones are the second most sedation?
Clozapine is the most sedating
Quetiapine and Risperidone are the second most sedationg.
What are the causes of nephrogenic diabetes insipidus?
Li+ toxicity
Hypercalcaemia
Hypokalaemia
How does serotonin syndrome present?
The classic triad
- Mental status changes (anxiety, restlessness, delirium, easy to startle)
- Autonomic hyperactivity (hyperthermia, hypertension, tachycardia, diaphoresis, vomiting, diarrhea)
- Neuromuscular abnormalities (hyperreflexia, myoclonus, tremor, muscle rigidity, and bilateral Babinski sign) – more pronounced in lower extremities
Name a cholinesterase inhibitor?
Donepizil
What two antipsychotics have the least EPSE?
Clozapine and Olanzapine
What is the depot form of respiradone?
Respiradone consta
Name a short acting benzo?
Intermediate acting?
Long acting?
Short = midaz
Intermediatate = loraz
Long = diaz
What is the second line treatment for bipolar prophylaxis, after lithium?
Olanzapine
THEN
Respiradone
What are the symptoms of Mania?
Elevated, Expansile, Irritable affect
Distractibility
Increased goal directed activity
Grandiosity
FOI
Activity – increased
Sleep – no need
Talkative
How do you remember the components of the MMSE?
ORArL 2,3, RWD
Think of a toothpaste / car commercial
10 components = 30 points
O: Orientation to Place & Time (5 & 5)
R: Recognition (ball car man. Out of 3. Judge first attempt only but can repeat 5 times)
A: Attention (Serial 7s counting backward from 100 or spelling WORLD backwards - out of 5)
r: recall (ask them to recall the three objects - out of 3)
L: Language (no ifs and or buts - 1 )
2: Identify the names of Two objects (pen and glasses/watch - out of 2)
3: Follow a Three Step command (take this paper in your right hand, fold it in half and place it on the floor - out of 3)
R: Reading (Read this statement and do exactly what it says: “Close your eyes” - out of 1)
W: Writing (Write a sentence - out of 1)
D: Drawing (Copy a figure of two intersecting pentagons - out of 1)
What are the adverse effects of long term Li+ treatment?
GIT AEs : N&V, diarrheoa
Metallic taste in the mouth
Hypothyroidism : responds to thyroxine
Resistance to ADH causing polyuria and polydipsia (SIADH)
Tremor, muscular weakness
Headache/fatigue
Metabolic – weight gain
What is the therapeutic range of lithium fr acute mania and prophylaxis?
At what level is there toxicity?
Therapeutic range
- Acute mania: 0.5–1.2 mmol/L.
- Prophylaxis: 0.4–1 mmol/L.
Note the narrow therapeutic window because toxicity occurs >1.5mmol/L.
What is Russel’s sign?
calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time.
What are the criteria for an assessment order?
- the person appears to have mental illness
- because the person appears to have mental illness, the person appears to need immediate treatment to prevent:
- serious deterioration in the person’s mental or physical health
- serious harm to the person or to another person
- if the person is made subject to an assessment order, the person can be assessed
- there is no less restrictive means reasonably available to enable the person to be assessed.
What are the criteria for a treatment order?
The person has a mental illness
Because the person has a mental illness, the person needs immediate treatment to prevent:
- Serious deterioration in the person’s mental or physical health,
- Or serious harm to the person or to another person
The immediate treatment will be provided to the person if the person is subject to a temporary treatment order (or treatment order – where considered by the Mental Health Tribunal)
There is no less restrictive means reasonably available to enable the person to receive the immediate treatment.
Who can form an Asssessment Order?
A mental health practitioner (MHP) or a registered health practitioner (RHP)
In what time period after making an AO must a client be assessed, and by whom?
Who can’t assess them?
In 24 hours
By an authorised psychiatrist (but not the same one who made the AO)
In what situation may a client receive Rx whilst on an assessment order?
If they consent
If it is necessary to treat them to prevent harm to themselves or somone else
How long can a TTO last?
What happens when the TTO ends?
28 days
The tribunal either evokes it within 28 days or makes it a TO
How long can a CTO last?
How long can a IPTO last?
12/12
6/12
What is Thiamine?
Vitamin B1
What are examples of cholinesterase inhibitors?
donepezil, rivastigmine, and galantamine
What is the difference between stereotypy and a tic?
Both
- patterned and periodic, and are made worse by fatigue, stress, and anxiety.
Stereotypy
- Unlike tics, stereotypies usually begin before the age of three
- involve more of the body
- more rhythmic and less random
- associated more with engrossment in another activity rather than premonitory urges
- eg. arm flapping
- can remain constant for years
- In contrast, children rarely consciously attempt to control a stereotypy, although they can be distracted from one
Tics
- Examples of early tics are things like blinking and throat clearin
- ever-changing, waxing and waning nature
- Tics are usually suppressible for brief periods
What are the cut-offs of the MSE according to IP?
Severe
Moderate 10-20
Mild 20-24
Varied depending on profession
what is reactive attachment disoder, and how is it different to disinhibited social engagement disorder?
What could each be confused with, to help you remember?
RAD has NEGATIVE SYMPTOMS, just don’t interact or seem to love their parents.
(could be confused with autism)
DSED has POSITIVE SYMPTOMS, they are overfamiliar with strangers.
(could be confused with ADHD)
