Mental Health Flashcards
Adjustment disorder (criteria, treatment)
Criteria
● Onset of symptoms within 3 months of a psychosocial stressor
● Marked distress out of proportion to the severity or intensity of the stressor
● Significant impairment of social or occupational functioning
● Resolution of symptoms within 6 months of the stressor
Does not represent normal bereavement or the criteria for another identifiable psychiatric disorder.
Treatment
Primary intervention: Pharmacotherapy has a limited role in managing adjustment disorder.
● Addressing the psychosocial stressor (if feasible)
● Psychosocial interventions e.g. psychoeducation, relaxation strategies, problem solving, stress
management, and accommodation and financial guidance.
Anxiety symptoms: Can consider benzodiazepine if there is severe functional impairment.
ETOH dependency (medication, dose, information)
Naltrexone 50mg PO daily
- Works by making drinking alcohol less pleasurable.
LFTs should be performed before and during use.
Contraindication: Those on chronic opioid therapy.
Acamprosate 666mg TDS if >60kg (333mg BD if <60kg)
- Reduces the symptoms of protracted alcohol
withdrawal (e.g. anxiety, irritability, craving)
Should be started following cessation of the acute
phase of alcohol withdrawal
Disulfiram 100mg daily for 1-2 weeks
- Good for highly motivated and physically fit
individuals who are capable of compliance.
Ingestion of alcohol leads to unpleasant effects of
alcohol toxicity (e.g. flushing, sweating, palpitations,
headache).
Anorexia nervosa (criteria, admission criteria, management)
Criteria
A. Restriction of intake with weight lower that expected
B. Fear of gaining weight
C. Disturbance in body image
*Refer to page 49 of GP Study Notes for criteria
Admission criteria
● hypokalaemia <3.0
● HR <50
● postural systolic drop >20
Management
● Aim: restoration of normal weight, identify contributing factors
● Approach: multi-disciplinary, family therapy
Antipsychotics - ADRs and treatment
Akathisia - Abnormal, uncomfortable sensation of restlessness and the urge to move. - Reduce the medication dose Propranolol 10mg BD ** Only small amount respond Parkinsonism - Seen in the early weeks of starting or increasing the dose of an antipsychotic - Stop/reduce dose Switch to a different antipsychotic Benztropine 1-2mg PO OD-BD Tardive dyskinesia - Repetitive involuntary choreiform movements, particularly of the tongue, lips and mouth. Occurs after chronic use of some antipsychotics. - Stop or reduce dose of other dopamine antagonists (e.g. metoclopramide) Reducing antipsychotic dose Switching to another medication if needed Neuroleptic malignant syndrome - EPSE (rigidity, bradykinesia/ akinesia, dystonia, abnormal movement, dysphagia, tremor) Temperature dysregulation Autonomic effects (tachycardia, hypertension, sweating) Central nervous system effects (drowsiness, confusion, coma) Usually within 1-2 weeks of treatment - Immediate transfer to hospital Bromocriptine for adults with severe or prolonged NMS
Attention deficit hyperactivity disorder (definition, types, DSM/diagnosis, treatment)
Definition: disorder affecting attention, hyperactivity and impulse control.
Types:
● Predominantly hyperactive/impulsive
● Predominantly inattentive
● Mixed (most common)
DSM criteria: Symptoms must present before age of 12 and often persist into adulthood
* Refer to page 64 of GP study notes
Diagnosis: Should be made only by appropriately experienced psychologists, paediatricians or child psychiatrists.
Treatment:
1. Behavioural strategies. Individual or family counselling should be considered.
2. Medications
● Stimulants (e.g. Ritalin, Strattera)
○ Issues: specialist prescription only, decreased appetite/poor weight gain, slight growth
stunting.
Autism Spectrum Disorder (common characteristics)
Common characteristics:
● Difficulties with high-level language skills such as verbal reasoning, problem solving, making inferences and
predictions
● Problems with understanding person’s point of view
● Difficulties initiating social interactions and maintaining an interaction
● May not respond in the way that is expected in social interaction
● Preference for routines and schedules - disruption of a routine can result in stress or anxiety
● Specialised fields of interest or hobbies
Case
33M, considers himself a perfectionist at work. Does not maintain eye contact or involve in conversations with others.
Has high grade academic achievements. Does not have close friends. Gets distressed if his routines are disrupted.
Bereavement/grief (definitions, types of grief)
Definitions
● Bereavement - the situation in which someone who is close dies.
● Grief - the natural response to bereavement.
● Mourning - the process of adapting to a loss and integrating grief.
● Complicated grief - a form of acute grief that is unusually prolonged, intense and disabling. Other terms
chronic grief, complex grief, pathological grief.
Types of grief:
Normal
- Characterised by:
● Separation distress
● Intense sadness, tearfulness
● Loss of usual levels of activity
● Withdrawal from others
● Physical symptoms
● Sleep disturbance
● Fleeting images/hallucinations
● Anxiety about the future
- Fluctuates then gradually declines over weeks to
months
- Starts to improve by 6 months following the death
Complicated
- Characterised by:
● Intense yearning
● Feelings of purposelessness and futility
● Numbness, detachment, or absence of
emotional response
● Excessive guilt, remorse
● Sense of life being empty or meaningless
● Excessive irritability, bitterness or anger
- Grief does not ease with time.
Bipolar disorder (key points, DSM 5 criteria)
Key points
● Bipolar I - > 1 manic episodes and > 1 episode of major depression
● Bipolar II - > 1 hypomanic episode and > 1 episode of major depression
● Cyclothymic - diagnosed in patients with periods of hypomanic symptoms or depressive symptoms that fall
short of the criteria
● Differentials - major depression, schizoaffective disorder, schizophrenia, attention deficit hyperactivity
disorder, and borderline personality disorder
DSM-5 Criteria Bipolar major depression A. Five or more of the following symptoms + same 2 week period + one of the symptoms of either depressed mood/loss of interest or pleasure ● Depressed mood ● Loss of interest or pleasure ● >5% weight change in a month ● Sleep disturbance ● Psychomotor agitation or retardation ● Fatigue ● Worthlessness/guilt ● Concentration/decision making affected ● Suicidal ideation B. - C. - Hypomanic episode A. Persistent elevated, expansive or irritable mood with persistently increased activity of energy for at least 4 consecutive days + present for most of the day B. Three or more of the following symptoms ● Inflated self-esteem or grandiosity ● Decreased need for sleep ● More talkative/pressure of speech ● Flight of ideas ● Distractibility ● Increase in goal-directed activity ● Excessive involvement in activities 70 C. - D. - E. Not severe enough to cause marked impairment in social or occupational functioning or necessitate hospitalisation. F. - Manic episode A. Persistent elevated, expansive or irritable mood with persistently increased activity of energy for at least one week + present for most of the day or any duration if hospitalisation needed. B. Three or more of the following symptoms ● Inflated self-esteem or grandiosity ● Decreased need for sleep ● More talkative/pressure of speech ● Flight of ideas ● Distractibility ● Increase in goal-directed activity ● Excessive involvement in activities
Bipolar depression (key points, monotherapy, combination therapy)
Key point
● Can be more difficult to treat
● Combine antidepressant with mood stabiliser
● SSRIs are least likely to induce a manic episode or provoke a rapid cycling pattern
Monotherapy options:
● Lamotrigine 25 mg PO nocte
● Lithium carbonate IR 500-750 mg PO daily
● Lurasidone 25 mg PO daily
● Olanzapine 5 mg PO daily
● Quetiapine IR 50 mg PO nocte, increase by 50 mg as tolerated
● Quetiapine MR 50 mg PO nocte, increase by 50 mg as tolerated
Combination therapy: Involved short-term use of antidepressant combined with lithium, lurasidone, olanzapine,
quetiapine or sodium valproate.
Borderline personality disorder (characteristics)
Characteristics
● Unstable and intense interpersonal relationships characterised by alternating between extremes of
idealisation and devaluation
● Impulsivity in the areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless
driving, binge eating)
● Recurrent suicidal behaviour, gestures, threats or self-harm
● Affective instability (e.g. intense episodic dysphoria, irritability, or anxiety)
● Inappropriate, intense anger or difficulty controlling anger
Case
24F, asking for assistance with supportive housing. Has been in and out of several accommodations. Tends to have
arguments with neighbours, Several broken relationships in the past. Generally irritable and now angry with the
Housing trust. Wants you to write a letter to fast track her application. When you refuse she gets angry.
Conduct disorder (age, characterisation, significance)
Age: Childhood or adolescence
Characterisation: repetitive and persistent pattern of behaviour in which the basic rights of others or major
age-appropriate norms are violated.
Significance: Precursor to antisocial personality disorder (diagnosed at 18 years)
Conversion disorder (definition, trigger, RF)
Definition: Mental condition in which a person has blindness, paralysis, or other neurological symptoms that cannot
be explained by medical evaluation.
Trigger: Often stressful experience.
Risk factors: Concurrent medical condition, dissociative disorder, personality disorder.
Depression - criteria
DSM-5 Criteria for Major Depressive Disorder
A. Five or more of the following symptoms present during the same 2 week period and represent; at least one
of the symptoms is either (1) depressed mood or (2) loss of interest of pleasure
● Depressed mood
● Diminished interest or pleasure
● Weight loss/weight gain (change of >5% of body weight in a month)
● Insomnia or hypersomnia
● Psychomotor agitation or retardation
● Fatigue
● Worthlessness or guilt
● Inability to concentrate
● Suicidal ideation
B. The symptoms cause clinically significant distress or impairment in areas of functioning
C. The episode is not attributable to organic cause
Depression - management
Key point
● Mild major depression - psychological therapies are preferred
● Moderate major depression - either psychological therapies or antidepressants can be used
● Severe major depression - start with antidepressant +/- concurrent psychological therapy. Consider ECT for
melancholic depression.
● Psychotic depression - referral for urgent treatment by psychiatrist, specialist centre or mental health team.
● Catatonic features - Psychiatrist input.
Depression - ceasing medications
Key points
● Reduce the antidepressant dose by 25-50% every 1 to 4 weeks until the daily dose is half the lowest unit
strength available. Continue at the lower dose for 2 weeks then stop.
● Plan a slower weaning course for paroxetine, venlafaxine, desvenlafaxine or duloxetine.
● Gradual dose reduction is not usually required for fluoxetine.
** Continue for 12 months before considering weaning and ceasing
