Mental Health / Addiction medicine Flashcards
What are symptoms of abrupt cessation of antidepressant medication?
(6)
The symptoms of ‘antidepressant discontinuation syndrome,’ include: “FINISH”
Flu-like symptoms (lethargy, fatigue, headache, achiness, sweating)
Insomnia (with vivid dreams or nightmares)
Nausea (sometimes vomiting),
Imbalance (dizziness, vertigo, light-headedness)
Sensory disturbances (“burning,” “tingling,” “electric-like” or “shock-like” sensations) and
Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness).
How do you diagnose gender dyshoria?
(5)
Person needs to have 2 of the following present for at least 6 months:
- a significant difference between their own experienced gender and their secondary sexual characteristics
- strong desire to be rid of their secondary sexual characteristics or prevent their development
- wanting secondary sexual characteristics of the opposite gender
- wanting to be treated as the other gender
- the strong belief that they have the feelings/reactions of the opposite gender.”
What features of the history, in an adult, may make you consider ADHD as a diagnosis?
(3+4)
Lifelong history of:
>Impulsivity
>Inattention
>Hyperactivity
Specifically in adults:
-Relationship difficulties
-Dropping out of studies- especially if considered to be capable of higher achievement
-Driving accidents or offenses
-Greater addiction habits: drugs, alcohol, smoking or even computer gaming
What aspects of management do you need to consider in adult ADHD?
(5)
- Psychiatrist referral for trial of stimulant medication
- Psychologist referral to help develop strategies to manage symptoms
- Relationship counsellor to assist with relationship issues
- Consideration of the patient’s ability to drive safely
- Improve psychoeducation to help the patient understand their condition better
What questions can you ask to screen someone whom you suspect to have an eating disorder?
(5+2)
“SCOFF”
S (SICK) – Do you make yourself Sick because you feel uncomfortably full?
C (CONTROL) – Do you worry you have lost Control over how much you eat?
O (?) – Have you recently lost more than 6.35 kg in a three-month period?
F (FAT) – Do you believe yourself to be Fat when others say you are too thin?
F (FOOD)– Would you say Food dominates your life?
—> an answer of YES to more than 1 question prompts the need for a more detailed assessment.
A further two questions have been shown to indicate a high sensitivity and specificity for bulimia nervosa.
- Are you satisfied with your eating patterns?
- Do you ever eat in secret?
Investigations to order at baseline for an eating disorder …
(numerous answers)
This can get quite extensive given the nutritional deficiencies and potential dangerous sequelae.
B12/folate level
Calcium, magnesium, phosphate level
Complete blood count/FBC
Creatine kinase
Electrocardiogram
Electrolytes, Urea and Creatinine
Fasting blood sugar level
Iron studies
Liver function test
Vitamin C level
Vitamin D level
Zinc level
Why are the following important to correct in an eating disorder?
Zinc deficiency
Vitamin C deficiency
Vitamin D deficiency
zinc: is actually important for healthy growth.
more specifically– apparently low levels lead to a vicious cycle of more binging or altered eating habits in itself! So treating the deficiency can lead to an improved rate of recovery!
Vitamin C- more basically prevents things like scurvy
Vitamin D - bone loss, even osteoporosis, can occur with eating disorders.
What is the HEEADSSS screening tool?
What is it used for, and what do the letters stand for?
Used to screen adolescent behaviours and risky environments that can contribute to a poor physical or mental health
Home situation
Education/Employment
Eating (..screening for disorders..) +/- body image
Activities (peer group)
Drugs/alcohol
Sex life
Suicide and Depression
Safety from violence and bullying
Examination features of Anorexia Nervosa?
(7)
Muscle and fat wasting
Weakness
Slow tendon reflexes
Fine downy hair
Decreased peripheral circulation: low volume pulse, acral (finger tip like) cyanosis
Decreased blood pressure
Decreased pulse
List three drugs that can be used for long term management of alcohol dependence.
Disulfiram - best if highly motivated and physically fit
Acamprosate - best for protracted withdrawal symptoms (anxiety, insomnia, craving, irritability)
Naltrexone - best for binge or heavy drinkers
Specific strategies to help to curb alcohol dependence (non pharm)
(7)
Drink only with food
Have a glass of water between drinks
Switch to smaller glass sizes
Switch to low alcohol beer, or trial non-alcoholic beers/spirits etc
Avoid going to the pub after work
Avoid spending time with friends or family that drink heavily
When stressed do exercise or take a walk instead of drinking
Explore new interests
Spend time with friends who don’t drink
When managing alcohol dependence, who should get thiamine?
And what is the dose?
All dependent drinkers are prone to thiamine deficiency because of
poor diet and damage to the gastric lining, and impaired thiamine
utilisation. Current consensus is that thiamine should be given to
all dependent drinkers at a dose of at least 300 mg/day.
Loss of interest in previously pleasurable activities or depressed mood are the key features of depressive disorders.
What other somatic symptoms might you ask about?
(4)
PAFS
Somatic symptoms
-Psychomotor disturbance: can be agitated behaviour like tapping fingers/feet or pacing or rapid talking. Or can be the opposite- retardation: slowed speech and movements
-Appepite loss/ increased appetite / change in weight
-Fatigue
-Sleep deprivation/excessive sleep
Other than suicidal ideation, depressed mood and loss of interest, what are psychological features of depression?
FIELD
Feelings of helplessness/hopelessness
Irritability
Excessive Guilt
Low self esteem
Diminished concentration
What are the 5 main depressive disorders?
Major depressive disorder
Seasonal affective disorder
Perinatal depression
Substance or drug induced depressive disorder
Sub-threshold depressive symptoms
What is the diagnosis criteria for major depressive disorder. (DSM 5)
At least 2 weeks of either ..
A. Depressed mood or
B. Anhedonia
PLUS
four other features (somatic or psychological)
AND
These symptoms must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning.
AND
The symptoms must also not be a result of substance abuse or another medical condition
What are “static” risk factors for suicide?
(What does “static” mean and what are the exact risk factors?)
(6 main categories)
Static refers to fixed/historical risk factors
Previous self harm including suicide attempts
Diagnosis of a mental health disorder, especially MDD
Substance abuse- Especially alcohol
Family history of suicide
Recent stressor or loss
Demographics; age, gender, marital status; worse if older age, male, and divorced
What are dynamic risk factors for suicide?
(6)
Active suicidal ideation
Guilt
Hopelessness
Current substance use
Psychological stressors
Problem solving deficits
Which two aspects of suicidality/suicidal thoughts determine how dangerous it is?
- The lethality/potency of the planned act or damage caused by the suicide plan
- Degree of ideation: How far into planning it is, their desire to live or die and if plans have been made specifically to AVOID discovery
Example a person who has an advanced plan to drink Powerade only until they pass out, and has purchased the Powerade and made sure everyone is out of the house is still unlikely to complete suicide.
Whereas someone who hasn’t quite yet acquired a harmful illicit drug and has only made a half-wit plan might actually be higher risk.
What are some risk factors of harm to others?
HAPPy
history of substance abuse (esp alcohol)
antisocial personality disorder
previous violence
poor impulse control
Negative affect (anger, irritability, humiliation)
Social (conflict with others)
What are questions to ask when assessing SUICIDE risk. not depression.
(7)
Do you feel like giving up?
How does the future look to yoU?
Does life feel so bad that it makes you feel like you want to die?
How severe and how frequent are your thoughts?
Have you made any plans?
How close have you come to doing something?
What stops you from doing something?
What is one useful and one not so useful action you can do in clinic, to help mitigate suicide risk?
- writing down a safety plan,
may include involving close family or friends
can use resources like Lifeline, beyond blue - ’ no self harm contracts,’ have mostly been found to be ineffective.
What are the two main aspects of personality disorders that make up the dysfunction?
Problems with functioning views of oneself (self worth, accuracy of view, self direction and identity)
Interpersonal dysfunction (difficulty maintaining close and mutually satisfying relationships, impaired ability to understand other person’s perspective, and difficulty managing conflict in relationships)
The aetiology of a personality disorder (PD) is ___a_____.
There may be __b____ in the ____c_____ environment during infancy that lead to ongoing maladaptive responses.
__d____ life experiences are associated with a personality disorder, but there are some with a PD that have none.
PD affects _e__% of the Australian population.
Personality disorder does not have an ___f____ onset. You will need to distinguish disturbances in cognition, ___g____ and ____h____ that are part of the person’s usual self versus distinct periods of time.
Personality disorder is most evident during the transition from childhood to adulthood, when capacity for self reflection and life narrative is developed.
a- complex
b-deficits
c-caregiving
d-adverse
e- 10%
f- abrupt
g- emotions
h- behaviour
In order to diagnose a personality disorder traits disturbances in cognition, emotions and behaviour have to be:
(4)
- displayed across a range of situations and contexts
- associated with substantial distress or significant impairment in functional areas (family, occupational, educational, social)
- relatively stable traits across years i.e not abrupt
- distinct from periods of another mental state disorder (eg depressive or manic episodes, periods of intoxication).
What three sources of information can you utilise to provide a history into PD?
longitudinal history from the patient
previous clinician records/notes
collateral history from family, carers or significant others
How is the classification of PD changing and why?
It was previously based on categories e.g. anti-social, histrionic, schizotypical etc.
It is now changing to classifying PD on a spectrum of severity.
WHY?
This is because the previous classification has lots of overlap. It also lacked any validity and no clear threshold existed between the types and degrees of PD
In classifying the severity of PD, which factors should be taken into account?
(5)
the number of areas of personality functioning affected (eg personal, familial, social, educational, occupational)
The amount of interpesonal relationships affected
Person’s ability to perform social and occupational roles
Likelihood of inflicting harm on themselves or others
The level of distress or impairment experienced in areas of functioning
The therapeutic relationship between the patient and clinician is central to personality disorder management and can provide an environment that allows change. However, it can be challenging because, by definition, people with personality disorder have difficulties with interpersonal relationships.
List at least 5 key principles of working with these people. There is a large list.
-Be compassionate.
-Demonstrate empathy.
-Listen to the person’s current experience.
-Validate the person’s current emotional state.
-Take the person’s experience seriously, noting verbal and nonverbal communications.
-Maintain a nonjudgemental approach.
-Stay calm.
-Remain respectful.
-Remain caring.
-Engage in open communication.
-Be human and be prepared to acknowledge both the serious and funny side of life where appropriate.
-Foster trust to allow strong emotions to be freely expressed.
-Be clear, consistent and reliable.
-Remember aspects of challenging behaviours have survival value given past experiences.
-Convey encouragement and hope about their capacity for change while validating their current emotional experience.
Patients with PD usually present in or after an acute crisis. You might be pressured to prescribe pharmacotherapy, but this is not indicated.
What strategies can you use?
(3)
Verbal de-escalation
Psychoeducation
Psychological intervention
What is the mainstay of long term management of PD?
Psychological interventions
Mainly dialectical behaviour therapy
also mentalisation based therapy
When might you consider pharmacotherapy for personality disorder, and what would you use?
If they are acutely distressed and not responding to de-escalation. then
Diazepam 5-10mg, orally, twice a day, for up to 2 weeks. reduce dose over 4 weeks
OR lorazepam 0.5-1mg, orally, BD, for up to 2 weeks. reduce dose over 4 weeks.
if they are agitated AND If they are likely to harm themselves or others then:
-Diazepam 10-20mg, oral, immediately, can be repeated in 30 minutes. max 60mg before consulting
-Olanzapine 5-10mg, orally, repeated in 30 minutes if needed to max 30mg before consulting an expert.
-also lorazepam 1-2mg, orally, 30 minutely, max 6mg before consulting
If suffering from insomnia then
temazepam 10-20mg, orally, 30 minutes before needed. not more than 2 weeks, preferably not on consecutive nights
zolpidem IR 5-10mg, orally, at bedtime for the shortest duration, but not more than 2 weeks.
What is the classification of nicotine dependence?
any of:
1. Smoking within 30 minutes of waking up
2. Smoking more than 10cigarettes a day
3. Experiencing withdrawal symptoms upon smoking cessation
What are signs of nicotine withdrawal?
(6)
Anxiety
Frustration
Craving
Restlessness
Insomnia
Increased appetite
What are some strategies to deal with perceived barriers to quitting smoking?
Belief they can quit at any time. Explore previous attempts and what made it successful or more so why it didn’t last
Feel like health isn’t affected -Explain the health benefits of quitting at any stage, and refer to the timeline of when benefits begin to kick in
Weight gain- only 10% of people gain weight and there are plenty of ways to deal with that
Feeling needing help is a sign of weakness- explain the nature of addiction and withdrawal. And that success is vastly improved with support.
Peer pressure- explore environments and how to avoid high risk social situations
What are TGA approved items for smoking cessation?
All nicotine
Vareniciline
Bupropion
For someone that smokes within 30 minutes of waking and smokes more than 10 a day, what nicotine replacement options are there?
nicotine patch 21mg/24 hours patch
AND
4mg gum
Or
4mg Lozenge
or 1mg Spray or 15mg inhaler
