Mental Health Flashcards
1
Q
what are the two groups of antipsychotics and their MOA?
A
- Typical or 1st generation antipsychotics
- MOA = D2 receptor Antagonist - Atypical or 2nd generation
- D2 and 5HT receptor antagonists.
- often have alpha adrenergic and histaminergic activity
2
Q
What are examples of typical antipsychotics?
A
- haloperidol
- chlorpromazine
- fluphenazine
3
Q
What are examples of atypical antipsychotics?
A
- Clozapine
- Olanzapine
- risperidone
- quetiapine
- aripiprazole
- paliperidone
4
Q
what are the 6 main side effects of antipsychotics?
A
- EPSEs
- Hyperprolactinaemia
- metabolic effects
- prolonged QT
- anticholinergic effects
- narcoleptic malignant syndrome
5
Q
which class of antipsychotics are EPSEs more common with?
A
- first gen typicals
6
Q
- why do EPSEs occur?
A
Inhibition if the nigrostriatal pathway by dopaminergic antagonists
7
Q
What are the 4 key presentations of EPSEs? (ADAPT)
A
- Acute dystonia
- muscle spasms and stiffness causing torticollis, grimacing, tongue protrusion
- Akathisia
- restlessness, inability to sit still
- Parkinsonism
- cogwhell rigidity, pill rolling tremour, bradykinesia, shuffling gait
- Tardive dyskinesia
- involuntary movements of mouth, tongue, limbs and face associated with chronic antipsychotic use
8
Q
What side effects are more common in First generation APs?
A
- EPSEs
- Hyperprolactinaemia
- Anticholinergic effects
9
Q
what side effects are more common in second generation APs?
A
- metabolic side effects
- weight gain
- hyperglycaemia
- dyslipidaemia
- particularly in clozapine, olanzapine, quetiapine
10
Q
What adverse effects happen in any AP?
A
- Prolonged QT
2. narcoleptic malignancy syndrome
11
Q
What causes elevated prolactin levels
A
due to dopamine blockade in the tuberinfundibular pathway that normally inhibits release
12
Q
- what are they signs and symptoms of elevated prolactin levels?
A
- Males
- gynaecomastia
- galactorrhoea
- erectile dysfunction
- females
- galactorrhoea
- oligomennorhea
- reduced libido
13
Q
what are the three top APs that cause QT prolongation?
A
- haloperidol
- iloperidone
- ziprasidone
14
Q
What are anicholinergic effects of APs?
A
- dry mouth
- constipation
- urinary retention
- tachycardia
- blurred vision
- mydriasis
15
Q
what are the 2 main indications for clozapine?
A
- treatment resistant schizophrenia with persistent symptoms despite optimal therapy with two different APs for at least 6 weeks each
- in patients who develop Tardive dyskinesia
16
Q
what are the 4 components of the workup for clozapine?
A
- Thorough history and exam
- CVD, epilepsy, previous drug induced neutropenia
- bloods
- FBC ( specifically WCC and neutrophils)
- CRP
- UEC
- LFTs
- lipids
- BGL
- Troponin
- ECG and echocardiogram
- biometric data
- Height, weight, temp, BP, HR
17
Q
how often should you be doing bloods once initiating someone on clozapine?
A
- weekly bloods for the first 18 weeks
2. then monthly after that.
18
Q
what are the 3 specific side effects of clozapine that need to be monitored?
A
- Neutropenia and agranulocytosis
- myocarditis
- cardiomyopathy
19
Q
how often and what tests to order to monitor for myocarditis once starting someone on clozapine?
A
- ECG
- crp
- troponins
- weekly for first month
- then whenever patient is febrile
20
Q
when and how do you monitor for cardiomyopathy in a patient on clozapine?
A
- Echocardiogram
- annually
21
Q
what does the choice of antidepressant depend on?
A
- shared decision making process with patient and clinician
- adverse effects in terms of tolerability and comorbidity
- safety to use with other medications
- disease factors
22
Q
What are the four main groups of antidepressants?
A
- SSRIs
- SNRIs
- TCAs
- MAOIs
23
Q
What is the MOA of TCAs?
A
- inhibits serotonin and Noradrenaline reuptake in the synaptic cleft to increase levels of both
- they also block cholinergic, histaminergic, alpha1-adrenergic and serotonergic receptors
24
Q
What is the MOA of MAOIs?
A
- inhibit monoamine oxidase to prevent degredation of NA, serotonin and dopamine
25
Three examples of SSRIs and generic name?
1. Citalopram → celapram
2. escitalopram → lexapro
3. Fluoxetine → prozac, lovan
4. Sertaline → zoloft
5. Paroxetine
26
what are 2 examples of SNRIs and generic name?
1. Venlafaxine → efexor
| 2. Duloxetine
27
what are 3 examples of TCAs and generic name?
1. Amitriptyline → endep
2. doxepin → deptran
3. mirtazapine (tertaCA) → mirtanza
28
what are 2 examples of MAOIs and generic name?
1. Phenelzine
| 2. selegiline → for parkinsons
29
4 side effects of SSRIs?
1. sexual dysfunction
2. anticholinergic effects
3. GI upset
4. sedation
30
5 side effects of SNRIs?
1. sexual dysfunction
2. hypertension
3. anticholinergic effects
4. GI upset
5. Sedation
31
4 side effects of TCAs
1. anticholinergic effects
2. QTc prolongation
3. Weight gain
4. Sedation
32
3 side effects of MAOIs
1. Orthostatic hypotension
2. CNS stimulation → headache, drowziness, fatigue, tremours, hyperreflexia etc
3. Hypertensive crisis
33
What are 4 examples of mood stabilisers ?
1. lithium
2. carbamazepine
3. valproate
4. lamotrigine
34
What is the MOA of valproate?
- originally an antiepileptic
- blocks voltage and use depended Na+ channels
- enhances GABA
- inhibits Glutamate and t-type Ca+ channels
35
MOA of carbamazepine?
prevent repetitive neuronal discharges by blocking voltage dependent and use dependent Na+ channels
36
MOA of lamotrigine?
- for prevention of depressive episodes
- blocks voltage and use dependent Na channels
- inhibits glutamate release
37
what is the therapeutic range of lithium for acute mania?
0.5-1.2mmol/L
38
what is the therapeutic range of lithium for bipolar prophylaxis?
0.4-1.0mmol/L
39
how often should lithium levels be measured?
1. after initiation
2. after dose changes
3. at least 2-4 times per year
40
At what level can lithium become toxic?
above 1.5mmol/L
41
- Overall, what are the clinical features of lithium toxicity? (VANISH LITTHHH)
1. Vertigo
2. Ataxia
3. Nystagmus
4. Intention tremour
5. Stupor
6. Hyperreflexia
7. Leukocytosis
8. Insipidus diabetes
9. T wave inversion
10. (Q) T prolongation
11. hypothyroidism
12. hyperparathyroidism
13. heaviness (weight gain
42
what is the approach to treating lithium toxicity?
1. Discontinuation
2. IV fluid replacement → dehydration and hypotension common → 0.9% NS
3. Haemodialysis for elimination in severe poisioning
4. whole bowel irrigation for ingestions >50g within 4 hours of ingestion time
43
3 classes of drugs for anxiety?
1. Antidepressants → SSRIs
2. Benzodiazepines
3. Beta-blockers → for SNS symptoms
44
What is the MOA of benzodiazepines and what 4 main effects does this have on the body?
1. Sedation
2. hypnosis
3. anxiolysis
4. muscle relaxation and anticonvulsant
45
what are 2 examples of benzos used in the short term to treat anxiety?
1. diazepam
| 2. lorazepam
46
what are 4 examples of antidepressants that can be used to treat GAD?
1. citalopram
2. escitalopram
3. fluoxetine
4. duloxetine
47
what are 6 indications for use of benzos?
1. anxiety
2. sedation or anaesthesia
3. status epilepticus
4. alcohol withdrawal
5. catatonia
6. sleep onset and maintenance
48
what are short term effects of benzos?
1. drowsiness
2. fatigue
3. muscle weakness
4. headache
5. slurred speech
6. nystagmus
7. amnesia
8. ataxia
9. paradoxical euphoria
49
what are long term side effects of benzos?
1. sleep effects
2. emotional blunting
3. menstrual irregularities
50
what other drugs do benzos potentiate the effects of?
opioids and alcohol
51
What are 5 classes of serotinergic drugs and examples for each class?
1. Decrease reuptake
- SSRIs, SNRIs, TCAs,
- Opioids (tramadol or pethidine)
- St john’s wart
2. Decrease metabolism
- MAOIs
3. increase release → illicits
- Opioids
- amphetamines
- MDMA
- Cocaine
4. increase synthesis
- L-tryptophan
5. Receptor agonists
- LSD
- Lithium
52
what is the clinical triad of serotonin syndrome?
1. Neuromuscular excitation
- hyperreflexia, clonus, myoclonus, shivering, tremor, hypertonis, rigidity
2. autonomic dysfunction
- hyperthermia, sweating, flushing, mydriasis, tachycardia
3. CNS effects
- agitation, anxiety, confusion, altered consciousness
53
describe the Hunter serotonin Toxicity Criteria
1. Spontaneous Clonus
2. inducible clonus + agitation/sweating
3. tremor and hyperreflexia
4. hypertonia + temperature > 38 + inducible clonus
54
What is the management for SS?
1. immediate cessation of serotonergic drugs
2. supportive care
3. moderate cases require sedation with benzos
4. severe cases need:
1. sedation
2. rapid cooling techniques → cool IV fluids
3. Fluid resus
4. intubation/ventilation
55
What is the classic tetrad of neuroleptic malignancy syndrome?
1. EPSE
- lead pipe ridigity, bradykinesisa, dystonia, dysphagia, abnormal posture, tremour
2. Temperature dysregulation leading to hyperthermia >39
3. autonomic effects
- tachycardia, labile BP, sweating, tachypnoea
4. CNS effects
- confusion, coma
56
what are the major criteria for NMS?
*Must have all three*
1. exposure to dopamine antagonist drug
2. severe muscle rigidity
3. hyperthermia
57
What are Minor criteria for NMS? – at least two must be present
1. tachycardia, hypertension, labile BP, sweating
2. raised serum CK, leukocytosis
3. dysphagia, tremour
4. altered consciousness, mutism, incontinence
58
what is the definition of MDD?
at least 5 symptoms from the DSM for at least 2 weeks
59
what is subthreshold depression?
patient with only 3-4 symptoms for a period of at least 2 weeks
60
persistent depressive disorder
- aka dysthymia
| - at least 2 years of major depressive syndrome or subthreshold depression
61
What are 4 other subtypes of depression?
- depression with psychotic features – associated with delusions, hallucinations
- seasonal affective disorder – symptoms of MDD associated with particular times of year that fully remits otherwise
- premenstrual dysphoric disorder – severe affective symptoms present up to 7 days prior to onset of menstruation for majority of cycles in a year
- postpartum depression – MDD occurring in the peripartum period (4 weeks after delivery)
62
which population groups is the prevalence of depression higher?
- common in patients that have another medical illness that they are managing
- 3x greater prevalence than in people who do not have general medical disorders
- worldwide 12-month prevalence of unipolar depression is 5%
- lifetime prevalence is 18%
- age of onset ~30 years
63
What are non-modifiable risk factors for depression?
- Age
- young adult common
- Medical
- being in a primary care facility
- having a greater burden of medical illness
- having a history of previous depressive episode
- personality vulnerabilities
- race/ethnicity
- in USA highest in indigenous population
- lowest in pacific islander and asian community
- gender
- greater 2x in females than males
- Family history of depression
64
What are modifiable risk factors for MDD?
- Income
- greater in lower socioeconomic groups
- substance use
- recent stress or bereavement
- medication use → corticosteroids, OCP, interferon, propranolol
65
what are the 4 current hypothesis for development of depression?
1. Monoamine hypothesis
- abnormalities of neurotransmitter symptoms → particularly dopamine, serotonin and noradrenaline
2. Dysregulation of the HPA axis
- long term exposure to cortisol alters brain structure including hippocampal atrophy
3. second messenger system dysfunction
4. abnormal expression of genes involved in neuron regeneration
66
What is the diagnostic criteria for depression?
(D+ SIGECAPS)
1. Depression + 4 or more other symptoms for at least 2 weeks
2. Sleep disturbance
3. Interest Lost (anhedonia)
4. Guilt or worthlessness
5. Energy Loss
6. Concentration
7. Appetite change
8. Psychomotor agitation or retardation
9. suicidal ideation
67
Describe the levels of severity of MDD
1. **Mild**
- symptoms cause distress and person has difficulty with usual activities
2. **Moderate**
- several symptoms present to marked degree and person has considerable difficulty carrying out usual activities
3. **Severe**
- symptoms cause considerable distress and person is unable to continue usual activities beyond a minimal extent
68
what depression screening tools are available?
1. Edingburgh depression Score → PND
2. DASS21
3. Geriatric Depression scale
69
what are some examples of alternative types of depression?
- sadness
- also called dysphoria
- burnout
- adjustment disorder with depressed mood
- occurs in response to identifiable psychosocial stressor
- ADHD
- Bipolar disorder
- mania or hypomanic episodes
- Borderline personality disorder
- mood states that fluctuate throughout the day
- complicated grief
- Delirium
- marked by decreased level of alertness and consciousness
- significant impairment of other neurocognitive functions
- marked fluctuations of symptoms
- Schizophrenia and schizoaffective disorder
70
What are medical DDx for depressive disorders?
- Onset of mood disturbance generally occurs during the first month of medical illness
- Examples:
- adrenal insufficiency
- Huntingtons disease
- hypercortisolism
- hypothyroidism
- mononucleosis
- multiple sclerosis
- obstructive sleep apnea
- Parkinson disease
- stroke
- systemic lupus erythematosus
- traumatic brain injury
- vitamin B12 insufficiency
- Depressive symptoms can be indicative of a prodrome or early manifestation of other medical conditions
71
What things can you look out for on presentation that differentiate between MDD and a medical cause of depressive symptoms?
- Severe new-onset depression, including melancholia and psychotic depression
- New-onset depression in an older adult, or in a younger adult with significant chronic or acute medical conditions
- New-onset or recurrent depression that is not readily understood in the context of the patient's psychosocial stressors and circumstances
- Depression that has not responded to treatment attempts
- Depression with significant coexisting anxiety or neurocognitive impairment
72
investigations to rule out medical causes of depression
- LFTs
- TFTs
- FBC
- UEC and UDS
- BSLs
- CT Brain
73
what is the best strategy for management of mental health disorders?
- SET A PACE
1. Safety
2. Education
3. Therapeutic relationship
4. Assessment
- 4 C’s
- Characterise
- Calibrate
- corroborate
- consider
5. Psychological therapy
6. Antidepressant treatment
7. Combination
8. ECT
74
What are the components of ‘SET’ category in MDD management?
1. Safety
- comprehensive risk assessment:
- for self harm and suicide
- neglect to self or others
- parental responsibilities
2. Educate
- affected individual and family/carer about:
- illness
- treatment options
- possible consequences
- recommend lifestyle changes
- sleep hygiene
- regular exercise
- reduction in alcohol, smoking and illicit drugs
3. Therapeutic relationship
- important to maintain a good therapeutic relationship as this improves outcomes.
75
What are the components in ‘A’ category of MDD management?
- Assessment → 4C (foresee) future outcomes of treatment
1. Characterise
- clinical symptom profile and subtypes
2. calibrate
- severity and chronicity
3. Corroborate
- get a collateral history
- get all info re Past medical history and social context
4. Consider
- Protective factors of the patient
- living/ social circumstance of pts, → Ot or social worker involvement
76
What are the components in ‘PACE’ category of MDD management?
1. Psychosocial interventions
- CBT
- interpersonal psychotherapy
- dialectical behavioural therapy
2. Antidepressants
- choice based on patient preference or in moderate to severe major depression
3. Combination of psychological and antidepressant interventions
4. Electroconvulsive therapy
- indicated for refractory major depression
- in cases of extreme suicidal ideation
77
What are the 1st, 2nd and 3rd line antidepressants used in Aus? - examples
1. First line
- SSRIs → citalopram, escitalopram, fluoxentine, sertraline, paroxetine
- TCAs → mertazipine
2. 2nd line
- SNRIs → venlafaxine, Duloxetine
3. 3rd line
- MAOI → moclobemide
78
What is the definition of bipolar affective disorder?
BPAD is a chronic mental illness characterised by alternating periods of abnormal mood elevation and depression associated with impairment in normal functioning
79
What is the classic triad of manic symptoms of BPAD?
1. abnormally elevated, liable and irritable mood
2. persistently increased energy and activity levels (and lack of sleep requirements)
3. exaggerated sense of well-being and self confidence
80
Bipolar Type I. Describe the criteria for this subtype and the time course.
- At least one lifetime episode of mania and usually and episode of depression as well, however, is not a requirement of the DSM.
- if left untreated, the patient can experience ~10 episodes of mania and depression per lifetime if untreated
81
Bipolar type II. Describe the criteria for this subtype and the time course.
- Different from type 1 in that there are no episodes of mania → only hypomania
- Bipolar II is characterised by episodes of major depression with at least one lifetime episode of hypomania.
82
What are 3 other subtypes of bipolar disorder?
1. cyclothymia → persistent (>2 years) episodes of hypomania and depressed mood that are not severe enough to diagnose BPAD
2. rapid cycling bipolar → 4 x episodes of mania or depression in one year
3. Drug induced bipolar → features of BPAD developing soon after exposure of withdrawal from medication
- eg alcohol, amphetamine, benzos
83
what are some risk factors for developing bipolar disorder?
1. substance misuse
2. Fhx
3. stressful life events
4. personal history of depression or anxiety
84
How does bipolar most often present?
most often onset is a depressive episode that looks similar to a unipolar depression, however, it must be followed by a hypomanic or manic episode to be diagnostic of bipolar.
85
what are the 5 categories that bipolar mood symptoms can fall under?
1. Mania
2. Hypomania
3. major depression
4. Mixed features
5. Psychosis
86
What are the symptoms of Mania? (DIGFAST)
1. Distractibility
2. irresponsibility
3. grandiosity
4. flight of ideas
5. activity increase
6. sleep deficit
7. talkativeness
87
what is the diagnostic criteria of a manic episode?
- 3 or more symptoms of mania for 7 consecutive days
| - **WITH** associative significant functional decline, hospitalisation or psychosis
88
What is the diagnostic criteria of a hypomanic episode?
- 3 or more symptoms of mania for 4 consecutive days
| - **Without** hospitalisation, psychosis or significant functional decline
89
what are the 5 pillars of bipolar management?
1. involvement of a multidisciplinary team
2. pharmacotherapy
3. psychosocial interventions
4. identification and treatment of comorbidities
5. support for families and carers
90
How do you treat acute mania? (ABCs)
1. **Acute** symptoms of mania
- treat with **antimanic** agent → lithium, valproate, carbamazepine
2. **behavioural** disturbance
- short-term **benzodiazepine** → midazolam etc
- antipsychotic → apriprazole, paliperidone, quetiapine, risperidone
3. Cognitive disturbance → **psychosis**
- **Antipsychotic** → only if not already been prescribed.
4. ECT if very severe
91
how do you treat depression in BPAD? ( PPPs)
1. psychological
2. pharmacotherapy
- lamotrigine
- lithium
- olanzapine
- quetiapine
3. Physical
- ECT → third line
92
Describe the pathophysiology of schizophrenia
- dysregulation of neurotransmitter systems:
- **increased** dopamine in **mesolimbic** pathway (**positive symptoms**)
- **decreased** dopamine in **mesocortical** pathway (**negative symptoms**)
- involvement of serotonin, glutamate and GABA also implicated
- neuroanatomical changes – increased ventricular volume, reduced volume of amygdala
and hippocampus
93
What is the DSM diagnostic criteria for schizophrenia?
*At least 2 of the following symptoms, with at least one from the top three:*
1. **Delusions**
2. **Hallucinations**
3. **Disorganised speech**
4. disorganised or catatonic behaviour
5. negative symptoms
Must be associated with a decline in social, occupation or personal function and not attributed to another medical condition or a substance
94
how long must these symptoms be present for to give a diagnosis of schizophrenia?
1. continuous signs of disturbance → > 6 months
| 2. presence of symptoms for > 1 month
95
what are the negative symptoms of schizophrenia?
1. anhedonia
2. apathy
3. social withdrawal
4. avolition
5. flattened affect
6. alogia
96
What is catatonia?
- pscyhomotor syndrome characterised by abnormal movements and behaviours
- most frequently involves immobilisation and mutism
- common signs: immobility, mutism, withdrawal, staring, stereotypy, echolalia, echopraxia
97
what are the cognitive symptoms of schizophrenia?
1. inattention
2. memory impairment
3. poor executive function
98
what are medical/organic causes of psychosis?
- drug toxicity – recreational, prescription, OTC
- structural brain disease
- metabolic/endocrine disturbance
- CNS infection
- neurological malignancy
- dementia/delirium
- withdrawal syndromes
99
what are the differential diagnosis for psychosis/schizophrenia?
1. schizophreniform disorder → features of schizophrenia for 1-6 months
2. schizoaffective disorder → >2 weeks of psychosis without manic/depressive symptoms
3. mood disorder with psychotic features → psychotic symptoms appearing exclusively within manic or major depressive episodes
4. brief psychotic disorder → At least one symptom of psychosis occurring for 1-30 days
5. delusional disorder → At least one type of delusion without any other psychotic features
100
what are the goals of schizophrenia treatment?
1. intervene in psychosis early
2. accelerate remission
3. prevent relapse
4. minimise adverse effects of pharmacological treatment
101
what are first line antipsychotics for schizophrenia?
1. atypicals
- aripriprazole
- quetiapine
- risperidone
102
What are predictors of poor outcomes in schizophrenia?
- prominent negative symptoms
- early age of onset
- insidious onset
- low social class or educational achievement
- male sex
103
What are personality disorders characterised by?
- *maladaptive, ingrained/inflexible and pervasive personality traits* that differ significantly from the expected and accepted norms of an individual's culture
- these traits manifest as inflexible and unhelpful responses in a wide range of social and interpersonal circumstances and *must cause impairment in social and or occupational functioning*
104
What are the three personality disorders in cluster A?
Odd/eccentric:
1. paranoid
2. Schizoid
3. Schizotypal
105
What are the 4 Cluster B personality disorders?
Dramatic/emotional
1. Antisocial
2. borderline
3. histrionic
4. narcissistic
106
What are the three personality disorders in cluster C
Anxious and fearful
1. avoidant
2. dependent
3. Obsessive-complusive
107
Describe paranoid personality disorder
Pervasive distrust and suspicion of others with unjustified suspicion of other’s loyalty and belief they are trying to harm you, perceives benign remarks as attacks and reacts disproportionately, suspicious of spousal faithfulness
108
Describe schizoid personality disorder
Lack of interest in social or personal relationships with limited emotional expression and inability to engage in normal activities and understand social cues, appears cold or indifferent and is comfortable with social withdrawal
109
Describe Schizotypal personality disorder
Odd or eccentric behaviour with peculiar physical appearance/dress, bizarre thinking and perceptual experiences including illusions/delusions/hallucinations, accompanied by social anxiety and a lack of close relationships
110
Describe Antisocial personality disorder
Aggression, deceitfulness, manipulation, and a reckless disregard for the safety of themselves and others, lack of remorse or emotional indifference to others
111
Describe Borderline personality disorder
1. Unstable relationships and sense of self, intense fear of being abandoned and
violent mood swings often with self-harm and suicidal behaviour
112
Describe Histrionic personality disorder
Constant attention-seeking behaviour with excessively emotional, dramatic, or provocative actions to gain attention, easily influenced by others while overestimating the degree of intimacy in relationships
113
Describe narcissistic personality disorder
Excessive sense of self-importance and superiority, strong need, and expectation for favourable treatment from others, often lacking empathy and exploiting others
114
Describe avoidant personality disorder
Feelings of inadequacy leading to social withdrawal, avoidance of interpersonal contact and restraint in relationships though the person is not comfortable with social withdrawal
115
Describe dependent personality disorder
Excessive dependence on others and clingy behaviour due to lack of self- confidence and fear of having to self-care, often stuck in abusive relationships
116
Describe obsessive compulsive personality disorder
Perfectionism, rigid routines and obsession with work and productivity, distinct from OCD as intrusive thoughts and repetitive behaviours are not present
117
what is the development of BPD often associated with?
- experiences of childhood trauma and abuse
- particularly sexual abuse
- strong genetic vulnerability as well
118
What areas do people with BPD have dysregulation in?
1. affective control
2. behaviour
3. interpersonal relationships
4. sense of self identify
5. cognitive function
119
What is the diagnostic criteria for BPD?
- pervasive pattern of instability of:
- interpersonal relationships
- self image
- affect
- begins in early childhood and presents in a variety of contexts
- requires at least 5 of the symptoms of BPD
120
what are the symptoms of BPD?
IMPULSIVE
1. Impulsivity
2. mood instability
3. Paranoid ideation
4. Unstable self of self
5. Labile relationships
6. suicidal ideation and self harm
7. inappropriate anger
8. vulnerability to abandoment
9. Emptiness due to lack of sense of self
121
How does BPD typically present and when?
- usually in adolescence or young adulthood with self harm and suicidal behaviour -> 50-80% of people with BPD
122
What form of therapy is best for people with BPD and what are the components of this?
DBT -> teaches DIME skills
1. Distress tolerance -> coping with extreme emotion, self soothing
2. interpersonal effectiveness -> problem solving skills for coping with relationship problems
3. Mindfullness -> ability to accept and tolerate powerful emotions
4. Emotional regulation -> learning to replace intense, unhelpful or destructive emotions
123
What is PTSD?
a chronic psychological condition that can develop following exposure to a stressful event of an exceptionally threatening or catastrophic nature
124
What are risk factors for PTSD?
- lack of social support
- female sex
- family history
- younger age at time of trauma
- psychiatric co morbidities
125
What are pathophysiological mechanisms for PTSD development?
1. stress- induced hippocampal damage or atrophy
2. failure of prefrontal networks to regulate amygdala activity resulting in hyperreactivity to threat.
3. HPA axis dysregulation → decreases in cortisol (opposite in depression)
126
What are diagnostic behaviours/symptoms that people with PTSD adopt due to exposure to traumatic event?
1. intrusive symptoms
- re-experiencing event
- nightmares, flashbacks etc
2. Avoidance of trauma related stimuli
- thoughts, feelings
- external reminders
3. negative alterations in mood and cognition
- detachment
- fear/horror/distress
- negative thoughts
- distorted memories
4. altered reactivity
- irritability
- hypervigilance
- heightened startle reflex
- sleep disturbance
127
what kind of psychosocial interventions are indicated for people with PTSD?
1. trauma-focused CBT
- challenging misattributions associated with the patients traumatic experience and repeating exposure to associated memories to minimise anxiety response
2. eye-movement desensitiation and reprocessing
3. exposure therapy → vivid recounting of trauma to desensitise emotional response
128
describe the pathogenesis of SUD
1. primary factor in development of addiction is neurobiological reinforcement
2. almost all drugs and activities of abuse stimulate the mesolimbic pathway to release dopamine into nucleus accumbens
- generates euphoric properties
- repeated use alters signalling pathways to create patterns of substance use disorder
129
what are withdrawal symptoms of depressants?
- anxiety
- anhedonia
- tremor
- seizures
- insomnia
- psychosis
- delirium
- death
130
what are the withdrawal symptoms of stimulants?
- ‘crash’
- craving
- dysphoria
- suicidality
131
What is the Diagnositic criteria for SUD?
- at least 2 symptoms present within a year for diagnosis
- number of symptoms can be used to stratify severity:
- mild → 2-3
- moderate → 4-5
- severe → 6+
132
What are the 4 domains of SUD symptoms?
1. impaired control
2. physical dependence
3. social impairment
4. risky use
133
What is the stages of change model?
1. pre-contemplation
- no intention of changing behaviour
2. contemplation
- aware a problem exists
- no commitment to action
3. Preparation
- intent upon taking action
4. Action
- active modification of behaviour
5. Maintainence
- sustained change
- new behaviour replaces old
6. Relapse
- fall back into old patterns of behaviour
134
what are the steps in withdrawal management?
1. supportive care and monitoring of the syndrome of withdrawal
2. specific medications may be used to ameliorate symptoms of withdrawal → depends on circumstance and severity
3. planning and co-ordinating post-withdrawal care = integral
4. motivational interviewing to enhance consumer motivation and commitment to change
135
which vitamin is deficient to cause wernicke-korsakoff?
thiamine B1
136
What is the pathogenesis of wernicke-korsakoff?
- chronic heavy alcohol use results in inadequate intake, absorption and hepatic storage of thiamine
- thiamine is essential cofactor for enzymes involved in cerebral glucose and energy metabolism
- deficiency impairs brain function and can progress to permanent damage to limbic structures
- once it has progress to destroying mamillary bodies and anterior thalamic nuclei → termed korsakoff syndrome and is chronic and irreversible
137
what are the key Clinical features of wernicke encephalopathy?
1. Confusion
2. Oculomotor dysfunction → nystagmus, diplopia, conjugate gaze palsy
3. Ataxic gait
4. Autonomic dysfunction, peripheral neuropathy tachycardia, dyspnoea, coma
138
What are the Clinical features of Korsakoff syndrome?
- Anterograde and retrograde amnesia
- confabulation → fills gaps in memory
- personality changes
- disorientation
- hallucinations
139
what are the indications for ECT?
1. MDD
2. Schizoaffective disorder
3. Refractory bipolar depression or mania
4. refractory schizophrenia
140
What are the different types of ECT offerred?
1. unitemporal
- preferred for most patients
- higher dose of electricity
- associated with LESS cognitive impairment
2. Bitemporal
- most effective
- requires lower dose of electricity
- higher degree of cognitive impairment
141
What is the time course for ECT treatments?
1. 10-12 sessions delivery 2-3 times per week
142
What are common adverse effects of ECT?
1. muscle pain
2. headaches
3. transient confusion
4. memory loss -> new memory formation and retrograde memory loss
143
What medications should be ceased prior to ECT therapy?
1. Benzos -> raise seizure threshold
2. antidepressants and lithium -> worsen side effects
3. antiepileptics
144
What is a mental illness according to the mental health act? (5)
Presence of any one or more of the following
1. delusions
2. hallucinations
3. serious disorder of thought form
4. severe disturbance of mood
5. sustained or repeated irrational behaviour indicating presence of any of the above
145
What is a mentally ill person as defined by the MHA?
A person who has both of the following criteria:
1. a mental illness
2. due to that illness, there are reasonable grounds for believing that care, treatment or control of the person is necessary to protect themselves or others from serious harm
146
What is a mentally disordered person under MHA?
- someone's behaviour that is so irrational as to justify a conclusion on reasonable grounds that temporary care, treatment or control of the person is necessary to protect themselves or others from serious harm.
147
What does 'serious harm' mean in accordance with the MHA?
1. physcial emotional or financial harm
2. self-harm or suicide
3. violence or aggression -> abuse, sexual assault, stalking, predatory intent
4. harm to reputation or relationships
5. Neglect to self or others including children
148
What is irrational behaviour under MHA?
- behaviour which a member of the community that person belongs to would find concerning or not understandable
149
what is the criteria for involuntary admission under MHA?
1. the person is mentally ill or mentally disorder
| 2. no other care of a less restrictive nature is appropriate and reasonably available to the person
150
What is the proess for involuntary admission?
1. Schedule 1 certificate issued to recommend involuntary admission by a doctor or mental health worker – allows for a person to be transported to and detained in a mental health facility for further assessment (5 days for mentally ill, 1 day for mentally disordered)
2. Examination by an authorised medical officer (psychiatrist/registrar) within 12 hours
3.Examination by a second authorised medical officer–if they agree they are formally
detained/scheduled, if they disagree a third medical assessment is required
151
What is the process that occurs after a patient has been formally admitted as involuntary? (eg tribunal)
1. tribunal meeting to assess medical team decision
- if tribunal disagrees, patient is discharged
- if tribunal agrees -> discharged with CTO, admitted for 3 months, or decision deferred for 14 days
