Mental Health / Addiction medicine

Question 1

What are symptoms of abrupt cessation of antidepressant medication?

(6)

Answer 1

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).

Question 2

How do you diagnose gender dyshoria?

(5)

Answer 2

Person needs to have 2 of the following present for at least 6 months:

1. a significant difference between their own experienced gender and their secondary sexual characteristics
2. strong desire to be rid of their secondary sexual characteristics or prevent their development
3. wanting secondary sexual characteristics of the opposite gender
4. wanting to be treated as the other gender
5. the strong belief that they have the feelings/reactions of the opposite gender.”

Question 3

What features of the history, in an adult, may make you consider ADHD as a diagnosis?

(3+4)

Answer 3

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

Question 4

What aspects of management do you need to consider in adult ADHD?

(5)

Answer 4

1. Psychiatrist referral for trial of stimulant medication
2. Psychologist referral to help develop strategies to manage symptoms
3. Relationship counsellor to assist with relationship issues
4. Consideration of the patient’s ability to drive safely
5. Improve psychoeducation to help the patient understand their condition better

Question 5

What questions can you ask to screen someone whom you suspect to have an eating disorder?

(5+2)

Answer 5

“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.

1. Are you satisfied with your eating patterns?
2. Do you ever eat in secret?

Question 6

Investigations to order at baseline for an eating disorder …

(numerous answers)

Answer 6

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

Question 7

Why are the following important to correct in an eating disorder?

Zinc deficiency

Vitamin C deficiency

Vitamin D deficiency

Answer 7

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.

Question 8

What is the HEEADSSS screening tool?
What is it used for, and what do the letters stand for?

Answer 8

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

Question 9

Examination features of Anorexia Nervosa?

(7)

Answer 9

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

Question 10

List three drugs that can be used for long term management of alcohol dependence.

Answer 10

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

Question 11

Specific strategies to help to curb alcohol dependence (non pharm)

(7)

Answer 11

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

Question 12

When managing alcohol dependence, who should get thiamine?
And what is the dose?

Answer 12

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.

Question 13

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

Answer 13

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

Question 14

Other than suicidal ideation, depressed mood and loss of interest, what are psychological features of depression?
FIELD

Answer 14

Feelings of helplessness/hopelessness
Irritability
Excessive Guilt
Low self esteem
Diminished concentration

Question 15

What are the 5 main depressive disorders?

Answer 15

Major depressive disorder
Seasonal affective disorder
Perinatal depression
Substance or drug induced depressive disorder
Sub-threshold depressive symptoms

Question 16

What is the diagnosis criteria for major depressive disorder. (DSM 5)

Answer 16

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

Question 17

What are “static” risk factors for suicide?
(What does “static” mean and what are the exact risk factors?)

(6 main categories)

Answer 17

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

Question 18

What are dynamic risk factors for suicide?

(6)

Answer 18

Active suicidal ideation
Guilt
Hopelessness
Current substance use
Psychological stressors
Problem solving deficits

Question 19

Which two aspects of suicidality/suicidal thoughts determine how dangerous it is?

Answer 19

1. The lethality/potency of the planned act or damage caused by the suicide plan
2. 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.

Question 20

What are some risk factors of harm to others?

HAPPy

Answer 20

history of substance abuse (esp alcohol)
antisocial personality disorder
previous violence
poor impulse control

Negative affect (anger, irritability, humiliation)
Social (conflict with others)

Question 21

What are questions to ask when assessing SUICIDE risk. not depression.

(7)

Answer 21

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?

Question 22

What is one useful and one not so useful action you can do in clinic, to help mitigate suicide risk?

Answer 22

1. writing down a safety plan,
   may include involving close family or friends
   can use resources like Lifeline, beyond blue
2. ’ no self harm contracts,’ have mostly been found to be ineffective.

Question 23

What are the two main aspects of personality disorders that make up the dysfunction?

Answer 23

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)

Question 24

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.

Answer 24

a- complex

b-deficits

c-caregiving

d-adverse

e- 10%

f- abrupt

g- emotions

h- behaviour

Question 25

In order to diagnose a personality disorder traits disturbances in cognition, emotions and behaviour have to be: (4)

Answer 25

1. displayed across a range of situations and contexts 2. associated with substantial distress or significant impairment in functional areas (family, occupational, educational, social) 3. relatively stable traits across years i.e not abrupt 4. distinct from periods of another mental state disorder (eg depressive or manic episodes, periods of intoxication).

Question 26

What three sources of information can you utilise to provide a history into PD?

Answer 26

longitudinal history from the patient previous clinician records/notes collateral history from family, carers or significant others

Question 27

How is the classification of PD changing and why?

Answer 27

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

Question 28

In classifying the severity of PD, which factors should be taken into account? (5)

Answer 28

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

Question 29

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.

Answer 29

-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.

Question 30

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)

Answer 30

Verbal de-escalation Psychoeducation Psychological intervention

Question 31

What is the mainstay of long term management of PD?

Answer 31

Psychological interventions Mainly dialectical behaviour therapy also mentalisation based therapy

Question 32

When might you consider pharmacotherapy for personality disorder, and what would you use?

Answer 32

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.

Question 33

What is the classification of nicotine dependence?

Answer 33

any of: 1. Smoking within 30 minutes of waking up 2. Smoking more than 10cigarettes a day 3. Experiencing withdrawal symptoms upon smoking cessation

Question 34

What are signs of nicotine withdrawal? (6)

Answer 34

Anxiety Frustration Craving Restlessness Insomnia Increased appetite

Question 35

What are some strategies to deal with perceived barriers to quitting smoking?

Answer 35

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

Question 36

What are TGA approved items for smoking cessation?

Answer 36

All nicotine Vareniciline Bupropion

Question 37

For someone that smokes within 30 minutes of waking and smokes more than 10 a day, what nicotine replacement options are there?

Answer 37

nicotine patch 21mg/24 hours patch AND 4mg gum Or 4mg Lozenge or 1mg Spray or 15mg inhaler

Question 38

When starting varenicline, what are the specifics around prescribing it?

Answer 38

Patient has to be enrolled in a conselling program Has to be ready to quit at the time Cannot be used for more than 24 weeks in a given year Can only be using this medication ALONE for cessation efforts

Question 39

What is the dosing instruction for varenicline?

Answer 39

varenicline 0.5 mg orally, daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily for the remainder of a 12-week course

Question 40

What is the goal quit date after starting either Zyban or Champix?

Answer 40

2 weeks arrange a follow up at the 2 week mark

Question 41

What are the dosing instructions for Zyban (Bupropion)?

Answer 41

bupropion 150 mg orally, once daily for 3 days, then 150 mg twice daily for the remainder of a 9-week course

Question 42

What are contraindications to using bupropion?

Answer 42

Seizures are the only contraindication Use discretion with eating disorders Also use discretion if using MAOi's

Question 43

What are non pharmacological strategies to deal with smoking cessation?

Answer 43

1. Conselling 2. Cognitive and behavioural techniques deep breathing drink a glass of water do something else QuitBuddy distraction Other online/paper distractsion 3. Written information 4. Quitline referral 5. Arrange follow up

Question 44

What is the preferred way to administer Nicotine replacement therapy?

Answer 44

As a combination e.g. patch + lozenge.

Question 45

When should the first follow up occur after starting on pharmacotherapy for smoking cessation?

Answer 45

2 weeks

Question 46

What conditions do you have to consider when prescribing pharmacotherapy for smoking cessation?

Answer 46

1. Varenciline - psychiatric and cardiovascular (though the incidence is quite low and furthermore the risk of smoking poses a bigger cardiovascular risk than trying to use this medication to stop smoking) 2. Bupropion- seizures. Still very tiny and almost insignificant evidence. 3. NRT- cardiovascular risk. but again risk of smoking is even worse.

Question 47

What is it important to let patients know about diagnosing ADHD ?

Answer 47

That it is time consuming taking up to 2-3 hours. It requires a longitudinal view of that patient’s life including home and school or work, and the exclusion of other health and mental health conditions that can mimic ADHD

Question 48

Children with ADHD either have ___(a)___ – cannot sit still and are always squirming – or ___(b)____ – where they daydream and tune-out – or a mixture of both. Another characteristic is ____(c)____

Answer 48

a. hyperactivity b. inattentiveness c. impulsivity.

Question 49

What is the estimated proportion of children and adults suffering from ADHD?

Answer 49

apparently 10% of children and 5% of adults. about 25% of children with ADHD also have an autism spectrum disorder

Question 50

What are two main aspects of oppositional defiant disorder.

Answer 50

Negative attitude, hostile, aggressive – temper outbursts, bullying Baseline mood appears lower than normal

Question 51

What does a patient need to display specifically, in order to diagnoses ADHD.

Answer 51

ADHD cannot be diagnosed simply in terms of fulfilling a certain number of listed criteria. Though they should display certain symptoms the key to diagnosis is that the symptoms are associated with functional impairment. This should be across two or more settings, usually home and either at work, school or preschool.

Question 52

Over what domains in life does ADHD cause functional impairment. Remembering you need at least 2 different settings that display impairment for diagnosis.

Answer 52

Is considered capable of higher achievement – could/should do better Behaviour presents unreasonable stress or disruption in school/work Behaviour presents unreasonable stress or disruption in the family Behaviour significantly affects peer relationships Person is aware of having difficulties and has low self-esteem

Question 53

It can be hard to diagnose ADHD in preschoolers as some behaviours may be normal. Hence if so, they majority also have ODD (oppositional defiant disorder). The peak age of ADHD diagnosis is between 5-10 years old. Teachers are quite good at recognising those with hyperactive tendencies as displayed by.... (A) Functional impairment at home may manifest as (B)

Answer 53

Part A A child who is unable to concentrate for long may become bored and disruptive. However teachers are not as good at recognising innattention. Part B Functional impairment at home may manifest as disorganisation requiring numerous reminders for getting dressed and ready.

Question 54

Because of under-diagnosis in childhood an adult may end up with untreated ADHD. This can lead to a lifetime of underachievement, disorganisation and impulsive behaviour and associated poor self-esteem. What issues can further arise from there? (3)

Answer 54

May progress to anxiety, depression or substance abuse

Question 55

What key questions can you ask in an initial consult to help begin clarifying a suspected ADHD diagnosis? Remember you won't be-able to diagnose it in a single consult, and will need a psychiatrist to make the diagnosis at this stage. (5)

Answer 55

1. Ask about functioning. at school or work 2. Ask about a life long nature of it, in an adult or adolescent 3. Ask about their concentration. How long they can focus on a task 4. Ask about mood. Which may be better off coming from an observer. Parent or significant other 5. Specific questions (see another slide)

Question 56

What specific disruptions may you ask about when considering ADHD as a diagnosis? (6)

Answer 56

1. Relationship breakdowns 2. Being dismissed from work 3. Dropping out of courses 4. Substance abuse 5. Driving offences/accidents 6. Criminal activity

Question 57

What medication (no dosing required) can GPs prescribe for ADHD treatment?

Answer 57

Firstly GPs can only prescribe ADHD stimulants after a psychiatrist has done the initial assessment and prescription. Options include Methylphenidate (long or short acting) Dexamphetamine Lisdexamphetamine

Question 58

Treating ADHD goes beyond medication alone, requiring a multimodal approach. What else should be implemented? (4)

Answer 58

social and organisational skills training cognitive training parent behaviour training (for children) classroom management measures (eg strategically positioning the child in the classroom, setting rules and expectations, using a daily report card). again for children.

Question 59

Irrespective of severity of depression, which lifestyle factors should you address with the patient? (7)

Answer 59

Sleep hygiene Regular physical activity Healthy diet Minimise alcohol Stress reduction. Recognise stressful events/factors and plan a way to reduce this Social/community interaction. identify social supports and lean in on this. Time in nature Relaxation techniques

Question 60

What are resources to provide patients for basic psychological intervention? (6) Though there could be others

Answer 60

Smiling mind app - mindfulness Blackdog institute - relaxation strategies Sleep- CBTi apps This way up for cognitive training Mindspot - cognitive training Mood gym- skills for dealing with depression and anxiety

Question 61

When might a mental health crisis plan entail? (6)

Answer 61

1. Implement relaxation strategies if stressed 2. Implement minfulness strategies 3. Phone a family member or friend 4. Phone/chat with beyond blue/lifeline 5. Present to GP clinic 6. Present to E.D

Question 62

What is the recommended initial follow up time frame after commencing ANY management for Major Depressive Disorder?

Answer 62

Initially 2-4 weeks

Question 63

First line medical options to treat Major Depressive Disorder? (4)

Answer 63

1. Sertraline 50mg, oral, daily. up to 200mg 2. Citalopram 20mg, orally, daily up to 40mg 3. Mirtazpine, 15mg, orally, daily, max 60 mg. ideally taken at night 4. Paroxetine 20mg, orally, daily up to 50mg

Question 64

When reviewing a patient started on anti-depressants, if they haven't responded what is the next step? (2)

Answer 64

1. Increase the dose if there has been some response and adjust every 2-4 weeks 2. change medication if there has been no response or if, off course the medication caused too many/too severe side effects

Question 65

What is the definition of treatment failure depression? and what does this imply needs to happen next?

Answer 65

1. Trial of two different medications at their maximum dose for at least 4 weeks EACH. 2. Referral to psychiatrist

Question 66

What is the recommended time frames to consider medication cessation in MDD? (2+1)

Answer 66

1. after 12 months, start to taper the medication after an initial episode and treatment for depression 2. after 3 years if there have been recurrent depressive episodes 3. sometimes lifelong therapy is needed If a patient has had 2 or more depressive episodes within 5 years, 3 or more cumulative episodes, psychotic depression or a serious suicide attempt, continue antidepressant therapy for 3 to 5 years—sometimes lifelong therapy is required.

Question 67

What are two complimentary medical options for treating mild-moderate depression? what are things to keep in mind (2 +info)

Answer 67

St Johns Wort, Do not use with warfarin, digoxin or HIV medication Omega 3- useful in the acute treatment of major depression but there is no evidence for prophylactic or long term use

Question 68

What classification of medical health conditions do these fall under? Adjustment disorder PTSD Acute stress disorder

Answer 68

Trauma/Stress related disorders (yes, PTSD is not an anxiety disorder)

Question 69

What is the definition of adjustment disorder? (4)

Answer 69

Onset is within 3 months of acute stressor Disproportionate symptoms to stressor itself Significant social/occupational functional impairment Symptoms resolve within 6 months

Question 70

What are tools/aspects of management for adjustment disorder? (5)

Answer 70

1. problem recognition and solving 2. Relaxation strategies 3. Guidance; financial, accomodation (not really the GP realm to directly be involved in this, but can refer) 4. Short term conselling or CBT or psychodynamic psychotherapy 5. Short term use of benzodiazepines if anxiety is crippling e.g. diazepam 2 to 5 mg orally, as a single dose. If required, repeat once after 2 hours. Use for up to 2 weeks

Question 71

what is the difference between psychodynamic psychotherapy and CBT?

Answer 71

PDPT - longer term. focuses on gaining insight. focus on understanding thoughts and patient's past CBT- shorter term. focused on maladaptive behaviours. change focused

Question 72

What is the definition of acute stress disorder and /vs. PTSD?

Answer 72

acute stress disorder - significant distress or functional impairment after a traumatic event. Symptoms last for more than 2 days but less than 1 month. PTSD characterised by symptoms lasting for more than 1 month.

Question 73

What are symptoms of PTSD? (4)

Answer 73

1. Intrusive thoughts 2. Persistent avoidance of stimuli associated with the event 3. Negative thoughts or feelings about the event 4. Marked alterations in reactivity and arousal: irritability, aggression, difficulty concentrating

Question 74

What are first line therapies for PTSD?

Answer 74

EMDR - eye movement desensitisation and reprocessing Trauma focused CBT Note Medication, whilst can be used, is NOT first line .

Question 75

What are some adjunctive medications that can be used in conjunction with psychotherapies for PTSD?

Answer 75

1. Sertraline 50mg up to200mg, oral, daily. adjust by 25mg each time. 2. Escitalopram 10mg up to 20mg, oral, daily. Adjust by 5mg each time. 3. Paroxetine 20mg up to 50mg, oral daily. adjust by 10mg each time. 4. Citalopram 20mg t0 40mg, oral, daily. Adjust by 10mg. Review and adjust every 2-3 weeks There is little evidence to support mirtazapine and TCAs but can be used if treatment fails for with SSR/SNRIs

Question 76

What are early interventions following trauma exposure? (3) What is not recommended? (2)

Answer 76

Recommended: Encourage use of social supports Encourage coping strategies Provide advice on good sleep practices Not recommended: No need for structured interventions (like psychological debriefing) No role for pharmacotherapy

Question 77

What are questions to ask yourself if there is apparent failure to treat PTDS or even MDD when initiating a first line anti-depressant ? (7)

Answer 77

1. Do you have the correct diagnosis? 2. Are there possible medical causes for the diagnosis 3. Have alcohol or other substance issues been addressed? 4. Have relevant psychosocial factors been addressed? 5. Is the medication at an adequate dose, and treated for an adequate time to have effect 6. Is there a drug reaction reducing the response? 7. Is the patient adherent to therapy? -stigma? -side effects? -forgetfulness/hard to remember?

Question 78

Recurrent nightmares are common in PTSD. What are three types of management that could be used? (if medication no dosing required)

Answer 78

1. imagery rehearsal therapy 2. CBT 3. Prazosin <- yes prazosin. proven to be safe and effective in managing sleep in PTSD

Question 79

What are some anxiety specific disorders? (6)

Answer 79

Agoraphobia Generalised anxiety disorder Panic disorder Separation anxiety disorder Social anxiety disorder Specific phobias

Question 80

What are the three "obsessive compulsive disorders"

Answer 80

Body dysmorphic disorder Hoarding disorder Obsessive compulsive disorder

Question 81

What needs to be included in the diagnosis of GAD? and assume there is already 1. social or occupational impairment and 2. not due to substance misuse

Answer 81

Needs to have 3+ of the following symptoms with at least one present for 6 months: Restlessness Difficulty concentrating Easily fatigued Irritable Muscle tension Sleep disturbance

Question 82

First line treatment for GAD, panic disorder and social anxiety disorder and adult separation anxiety? (2)

Answer 82

1. CBT and psychotherapies including psychoeducation 2. always address lifestyle factors

Question 83

What are the 4 key aspects of providing psychoeducation to patients?

Answer 83

1. education about their disorder 2. education about the mental health care system, including different types of clinicians and relevant health legislation 3. Maintaining physical health 4. Principles of caring for one-self

Question 84

In providing pyschoeducation, as a GP, what should you cover when educating the patient about their disorder? (6)

Answer 84

1. Cause and symptoms 2. Treatment 3. Prognosis 4. alleviating and aggravating factors 5. characteristic early symptoms/signs of relapse 6. Strategies to prevent relapse

Question 85

What is the difference between agoraphobia and social anxiety disorder?

Answer 85

Agoraphobia tends to develop in response to panic attacks. So it is a fear that develops to being in spaces where they fear of losing control or not being able to escape. It doesn't have to be large public places only and is not restricted to social interactions, more so 'places'. Usually you have to treat the panic disorder- short term benzos and longer term CBT. Social anxiety is the fear of being judged or criticised and risk embarrassment in social situations or even basic interactions such as paying for a bus ticket (though this is a poor example, even now you don't need to even interact with anyone at the supermarket).

Question 86

What is the difference between having a panic attack and panic disorder?

Answer 86

A single panic attack usually occurs due to some kind of stimulus/stress/event. Whereas panic disorder is when there are repeated panic attacks without a clear trigger.

Question 87

What are two potential psychological therapies for an acute panic attack whether a single episode or panic disorder?

Answer 87

Breathing techniques eg. Box breathing 4-7-8 breathing Distraction e.g. 3-3-3 rule (3 sounds, 3 things you see, 3 things you can touch by moving)

Question 88

What are second line (medical) treatments for GAD and panic disorder?

Answer 88

SSRI's/SNRI's similar to MDD however with panic disorder the doses are halved. E.g. citalopram 10mg but still up to 40mg, oral, daily. review and adjust 2-4 weekly.

Question 89

What disorder class does body dysmorphic disorder fall into?

Answer 89

Obsessive compulsive disorder NOT an eating disorder

Question 90

What is the definition of body dysmorphic disorder? (DSM-5) (5)

Answer 90

Has to have.. 1. Appearance preoccupation: person preoccupied with non existent or slight flaws (presumed to be at least 1 hour - accumulative - a day) Note; if there is an obvious appearance flaws this is NOT body dysmorphic disorder. but can still be a disorder. 2. repetitive behaviours: usually observable by others, mirror checking, seeking reassurance, excessive grooming, skin picking or clothes changing. Or mental acts: comparing to others 3. Significant social or occupational or other functional impairment 4. Not better explained by an eating disorder e.g. fear of gaining weight or guilt about weight gain. 5. Specifiers - muscle dysmorphia- feeling they are too small. Why specify? because this type is related to worse quality of life and high suicide. -also specify level of insight. i.e. how aware they are that this is true or not. ranges from: good insight, poor insight, no insight. (no insight would not classify as a psychotic disorder however).

Question 91

What is the best therapy option for treating the OCD and body dysmorphic disorder?

Answer 91

A combination of psychological and pharmacotherapy. e.g. CBT with exposure and response training and SSRIs (at MDD dosing)

Question 92

What are symptoms of mania? (6)

Answer 92

Elevated mood and euphoria Increased energy/activity Reduced need for sleep Grandiosity Increased subjective speed of thoughts Enhanced perceptual experiences (more harmonious more vivid)

Question 93

What is it most important to ask or inform, during the first presentation of suspected major depressive disorder, in assessing differentials and why?

Answer 93

Ask or educate about manic symptoms for assessment for bipolar disorder. Why? 1. because bipolar presents as depression first. 2. those with bipolar have a 30x risk of suicide (than general) so you want to catch it 3. treatment for MDD, if started, can exacerbate or cause or manic episode.

Question 94

For an acute management of mania, what 3 medications will be started in combination? No dosing needed.

Answer 94

Mood stabiliser: valproate or lithium + Anti-psychotic: quetiapine or olanzapine + Anxiolytic: benzo like diazepam.