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AMC Flashcards > Mental Health by Dr Cyntia > Flashcards

Mental Health by Dr Cyntia Flashcards

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1
Q

List of mood and affective disorders

A
  1. Depressive Disorders
  2. Bipolar and Related Disorders
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2
Q

List of depressive disorders

A

a) Major Depressive Disorder

b) Persistent Depressive Disorder
(Dysthymia)

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3
Q

List of anxiety disorders

A
  • GAD (most common)
  • OCD
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4
Q

List of Bipolar and related disorders

A

a) Bipolar I Disorder

b) Bipolar II Disorder

c) Cyclothymic Disorder

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5
Q

Antidepressants classification

A
  • First line: SSRIs Depression, anxiety
  • Second line:

-Atypical Antidepressants (Depression, anxiety)

-SNRIs: 75% Depression & 25% anxiety, chronic pain

-TCA’s: Depression, anxiety disorder, chronic pain, migraine

  • MAOIs: Atypical Depression
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6
Q

List of 1st line antidepressants

A
  • Fluoxetine (safe in pregnancy)
  • Sertraline (safe in pregnancy)
  • Paroxetine (avoid in pregnancy)
  • Citalopram (Prolongs Q-T - safe in pregnancy)
  • Escitaprolam (safe in pregnancy)
  • Fluvoxamine
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7
Q

List of 2nd line antidepressants

A

Atypical Antidepressants:

  • Bupropion (less sexual side effects)
  • Mirtazapine
  • Trazodone (sedation & priapism)
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8
Q

List of SNRI’s

A
  • Venlafaxine
  • Desvenlafaxine
  • Duloxetine
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9
Q

SNRI indications

A

For treating depression AS WELL AS anxiety (75% depression 25% anxiety)

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10
Q

Venlafaxine contraindication

A
  • Diastolic Hypertension
  • Breast feeding
  • Epilepsy (Decreases seizure threshold)
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11
Q

List of TCA’s

A
  • Nortriptyline
  • Amitriptyline
  • Imipramine
  • Desipramine
  • Dothiepin
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12
Q

List of MAOI’s

A
  • Phenelzine
  • Selegiline
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13
Q

List of mood stabilisers

A
  • Lithium
  • Sodium Valproate
  • Lamotrigine
  • Carbamazepine
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14
Q

List of Typical Antipsychotics (1st Generation)

A
  • Haloperidol (causes arrhythmias)
  • Droperidol
  • Fluphenazine
  • Thioridazine
  • Chlorpromazine
  • Prochlorperazine
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15
Q

Typical Antipsychotics (1st Generation) use and side effects

A

Treatment of POSITIVE symptoms.

  • Haloperidol: Arrithmyas.
  • Chlorpromazine and Thioridazine: More epileptogenic, orthostatic hypotension, and anticholinergic effects (dry mouth, constipation, and urinary retention)
  • Chlorpromazine causes sedation
  • Thioridazine causes retinal pigmentation
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16
Q

Typical Antipsychotics: Mechanism of Action

A
  • Mainly dopaminergic neurotransmission inhibition.
  • Also noradrenergic, cholinergic, and histaminergic inhibition.
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17
Q

Typical Antipsychotics: General Side Effects

A
  • Extrapyramidal Symptoms: Acute dyskinesias, tardive dyskinesia, Parkinsonism, akinesia, akathisia.
  • Agitation
  • Lower seizure threshold
  • Prolonged QT interval
  • Hyperprolactinemia (> 2000): Galactorrhea, amenorrhea, impotence, and anorgasmia
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18
Q

Extrapyramidal symptoms: days

A

Acute Dystonia (2-3d)
- Torticollis (neck muscles spasm & twists to the side)
- Buccolingual crisis (rotruding or pulling sensation of the tongue)
- Oculogyric crisis (upward deviation of the eyeball)
- Opisthotonus: spastic contraction of the extensor muscles of the neck, trunk, and lower extremities (Banana shape)

*Treatment:
1. Reduce the dose of antipsychotic
2. Change to another with less EPS (ACQ)
3. For symptom relief: Benztropine, diphenhydramine, procyclidine

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19
Q

Extrapyramidal symptoms: (weeks)

A

Akathesia (weeks): Legs restlessness

*Treatment:
1. Reduce doses or change the drug.
2. Propranolol, diazepam, benzatropine

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20
Q

Extrapyrimidal smyptoms: MONTHS

A

Tardive Dyskinesia (3-6m)
- Lip-smacking
- Head nodding
- Tongue protrusion

*Treatment:
1. Reduce the dose of antipsychotic
2. Change to Clozapine.

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21
Q

Extrapyrimidal symptoms (6 months):

A

Neuroleptic-induced parkinsonism (> 6 months):

Classic parkinson symptoms.

Treatment:
1. Reduce the dose of antipsychotic
2. Change to another with less EPS (ACQ).
3. For symptom relief: Benztropine, diphenhydramine, procyclidine

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22
Q

List of Atypical Antipsychotics (2nd Generation)

A

Order from lowest to highest potency

  • aripiprazole
  • quetiapine
  • olanzapine
  • risperidone
  • clozapine
  • ziprasidone
  • lurasidone
  • paliperidone
  • amisulpride
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23
Q

Atypical Antipsychotics (2nd Generation) features

A

Treatment of NEGATIVE symptoms.

  • Decreased risk of extrapyramidal symptoms.
  • Increased risk of stroke in older people.
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24
Q

Atypical Antipsychotics that don’t cause extrapyramidal symptoms

A

ACQ:
Aripiprazole, Clozapine, Quetiapine

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25
Q

Atypical Antipsychotics: Mechanism of Action

A

D2-dopamine & serotonin receptor antagonists

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26
Q

Atypical antipsychotic side effects

A
  • Hyperprolactinemia (>2000ml)
  • significant weight gain
  • metabolic syndrome
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27
Q

Atypical Antipsychotics with minimal weight gain

A

Aripiprazole and Lurasidone

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28
Q

Risperidone features

A
  • Used for Tourettes, ADHD, mania/hypomania, postpartum psychosis,schizophrenia
  • Main cause for drug-induced cause hyperprolactinemia (Switch to aripiprazole).
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29
Q

Olanzapine features

A
  • Causes weight gain & HbA1c >7.5% (Change to Aripiprazole)
  • Cause Hypertriglyceridemia (but not cholesterol)

METABOLIC SYNDROME

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30
Q

Clozapine side effects

A
  • Agranulocytosis: Stop when WBC goes < 3000.
  • Myocarditis: Measure troponin ( early)
  • systolic heart failure
  • Tachycardia
  • Hypersalivation
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31
Q

Quetiapine features

A
  • Causes sleeping: Drug of choice for psychosis with insomnia
  • Doesn’t cause hyperprolactinemia
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32
Q

Antidepressants side effects

A
  • GI distress: Most common and temporary. Nausea, Vomiting, Diarrhoea (sertraline)
  • Sexual side effects: Erectile dysfunction, anorgasmia, delayed ejaculation and decreased libido
  • Nervous System: Agitation, insomnia, tremor
  • SSRRs: GI bleeding in combination with AAS or NSAIDs. The best option is TCA’s
  • Serotonin Syndrome
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33
Q

SSRI’s Withdrawal

A

Some adverse effects are likely, but most will go away after 1–2 weeks

[incomplete flash card]

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34
Q

Tardive dyskinesia vs Drug-Induced Parkinsonism

A

Identical symptoms:
- rigidity
- bradykinesia
- postural instability

Differentiating symptoms:
- Tardive: involuntary movements of face and tongue
- Parkinsonism: Stiffness

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35
Q

Drug-induced extra-pyramidal disease features

A
  • Common in the elderly due to diminished brain dopamine stores
  • Caused by neuroleptic drugs
  • Tardive dyskinesia is the primary symptom
  • Treatment is to cease offending neuroleptic
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36
Q

Paroxetine contraindication

A

Avoid in pregnancy:
-causes pulmonary HT in the fetus.

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37
Q

Bupropion Features

A
  • Indicated: smoking cessation
  • Contraindicated: Seizures and eating disorders
  • Decrease seizure threshold
  • Minimal Sexual Side Effects
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38
Q

Mirtazapine Features

A
  • Causes weight gain and sedation
  • Indicated for patients with history ofother drug overdose

MOA: NA and serotoninergic antidepressant.

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39
Q

Venlafaxine contraindication

A
  • Contraindicated in HTA because it causes diastolic HTN
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40
Q

Fluoxetine features

A
  • Long half-life: most likely to cause serotonin symptoms, sleep, and paralysis.
  • Useful for post-stroke depression
  • Indicated in pregnancy and adolescents
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41
Q

Serotonin Synd & NMS Synd SHARE symptoms

A
  • Altered mental status
  • Hyperthermia > 40C
  • Hypersalivation
  • Autonomic Dysregulation: Tachycardia, hypertension, muscle spasms, diaphoresis, erythema
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42
Q

Serotonin Symptoms specific symptoms

A
  • Onset: < 24 h
  • Dose dependant. Increasing doses
  • Severe muscle WEAKNESS, CLONUS, and HYPERreflexia
  • Nausea, vomiting
  • Increased bowel sounds
  • Dilated pupils (Mydriasis)
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43
Q

Serotonin Syndrome causes

A
  1. SSRIs
  2. MAOIs
  3. TCAs
  4. Opioids: Tramadol, Morphine, Meperidine
  5. Illicit drugs
  6. St John’s wort
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44
Q

Serotonin Syndrome step by step management

A
  1. DRABCDE
  2. Stop medications
  3. Cyproheptadine + BZD
  4. Chlorpromazine
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45
Q

NMS specific symptoms

A
  • Onset: Days / Weeks
  • **Not dose dependant. ** Occurs any time
  • Severe muscle RIGIDITY with HYPOreflexia
  • No nausea or vomiting
  • Reduced bowel sounds
  • Normal pupils
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46
Q

NMS causes

A

Dopamine Antagonist (Antipsychotics/Neuroleptics) such as haloperidol

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47
Q

NMS step by step management + medicatons

A
  1. DRABCDE
  2. Stop medications
  3. Benzodiazepines + Bromocriptine
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48
Q

Usually medication is never withdrawn immediately. In what situation is this the exception

A
  1. Serotonin syndrome (SS)
  2. Neuroleptic malignant syndrome (NMS)
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49
Q

TCAs Side Effects

A

3C’s + Anticholinergic symptoms

TCAs DON’T cause impotence!

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50
Q

TCA Mechanism of action

A

Alpha-adrenergic inhibition

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51
Q

TCA 3C’s

Overdose

A
  1. Cardiac arrhythmias (prolong QT, MCC of death)
  2. Convulsions (drowsiness)
  3. Coma (Respiratory depression, hypoxia)
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52
Q

TCA anticholinergic symptoms

A
  • Hyperreflexia
  • Urinary retention
  • Dilated pupils (mydriasis)
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53
Q

TCA Overdose Complications

A
  • Cardiac Arrhythmias
  • Aspiration pneumonia
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54
Q

TCA overdose in suicidal attempt initial investigations

A
  1. ECG
  2. Paracetamol levels (30-40 min after arrival)
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55
Q

TCA Overdose step by step management

A
  • < 1hr: Gastric lavage and ECG for 48hrs
  • > 1hr: Alkalinisation w/ IV sodium bicarbonate (antidote)
  • if severe Hypotension: IV NS + IV glucagon + Mg sulphate (stabilizes the cardiac membrane)
  • if seizures: IV Diazepam
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56
Q

Major Depression Criteria

A

2 core symptoms + 5 other symptoms > 2 weeks

MSIGECAPS

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57
Q

Major depression core symptoms

A
  • Low mood
  • Anhedonia
  • Lethargy
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58
Q

Major depression non-core/other symptoms

A
  • Change in appetite and weight
  • Poor concentration
  • Early morning awakening
  • Suicidal ideations
  • Tiredness
  • Guilt
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59
Q

Major depression MSIGECAPS

A

Mood (low)
Sleep
Interest (low)
Guilt
Energy (low)
Concentration
Appetite (low)
Psychomotor Retardation
Suicidal ideation

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60
Q

Major Depression progression Management

A

Counseling (CBT) + medication

  • Monotherapy preferred
  • 1st episode: Treatment for 6-12m
  • > 1 episode: Treatment for 3-5y
  1. SSRI (Sertraline)
  2. Change to another SSRI
  3. Augmentation therapy by adding Lithium (1st) and atypical antipsychotics (2nd).
  4. Change to an SNRI
  5. ECT (Very severe)
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61
Q

Effect size of most treatments of depression

A

ECT (0.8) > CBT (0.5) > Anti-depressants (0.4)

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62
Q

Moderate Depression Diagnose

A

Criteria: > 2w with 2 core symptom + ≤ 3 other symptoms

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63
Q

Moderate Depression management

A
  1. CBT
  2. SSRI
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64
Q

Mild Depression criteria

A

1 core symptom + ≤ 3 other symptoms > 2w

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65
Q

Mild depression management

A

CBT

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66
Q

Atypical Depression clinical features

A
  1. Weight gain
  2. Hypersomnia
  3. Rejection sensitivity
  4. Reverse diurnal variation
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67
Q

Atypical Depression management

A

MAOI’s

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68
Q

Dysthymia criteria

A

Depression before puberty (usually) + less severe and persisting symptoms > 2y

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69
Q

Dysthymia management

A
  1. CBT
  2. SSRI
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70
Q

Lithium side effects

A
  1. Weight gain
  2. Fine tremors
  3. Stomach pain
  4. Hypothyroidism
  5. Hyperparathyroidism
  6. Diabetes insipidus
  7. Hair loss
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71
Q

Lithium Contraindications

A
  • Chronic renal failure
  • Hypothyroidism
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72
Q

Lithium intoxication

A

Seizures
Tremors
Fever
Hyperreflexia

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73
Q

Lithium in pregnancy

A

In cases of severe bipolar disorder, the benefits outweigh the risks

  • 1st-trimester low risk of Epstein’s anomaly (0.05%) & midfacial and other defects.
  • displacement of the tricuspid valve
  • US & ECHO at 16-20w (2nd trimestrer) to exclude foetal anomalies, especially cardiac anomalies
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74
Q

Risk of developing Ebstein’s anomaly on patients on lithium?

A

approximately 1 in 1000 to 2000
compared with 1 in 20000 in the general population.

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75
Q

Ebstein’s anomaly definition

A

The tricuspid valve is incorrectly formed and located lower than usual in the heart.

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76
Q

Lithium dosage during 1st trimester

A

1 - 12 weeks

Keep the same dose as before pregnancy

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77
Q

Lithium dosage during 2nd trimester

A

13 - 26 weeks

Continue the same lithium dosage. But heavily monitor the fetus by US at 16-20 weeks.

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78
Q

Lithium dosage during 3rd trimester

A

Since 27 weeks

Decrease lithium dosage by 25% to avoid floppy baby syndrome due to neonatal toxicity.

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79
Q

Post Natal Lithium dosage

A

After delivery immediately increase lithium dosage due to
increased risk of relapse in the postpartum period.

NO BREASTFEEDING!!!!

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80
Q

Causes of Lithium Toxicity Syndrome

A
  • Dehydration (vomiting, gastro)
  • Diuretics (Thiazides)
  • NSAIDs
  • Exercise
  • Renal failure
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81
Q

Lithium Toxicity Syndrome clinical features

A
  • Polyuria
  • Polydipsia
  • Coarse tremors
  • Hypertonia
  • Seizures
  • Arrhythmias
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82
Q

Lithium Toxicity Syndrome Management

A
  • < 1 hour: Gastric lavage
  • > 1hr: Check lithium levels:
    Normal: 0.6-0.8
    2 Hospitalisation
    4 haemodialysis until zero.

Monitor for the next 7d because lithium can rebound

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83
Q

Sodium Valproate dosage in pregnancy

A

1st trimester: decrease dose to prevent neural tube defects + High dose folic acid (5mg)

2nd semester: continue decreased dosage through to 3rd semester

3rd trimester: increase the dosage to prevent seizures

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84
Q

If a patient, who has successfully been stable on prophylactic dose of a particular mood stabilizer, develops acute depression, what is the next best step in management?

A
  • Adding an antidepressant to the prophylactic mood stabilizer: the choices of the drug would be the same as for major depression. SSRls first line.
  • Increasing the dose of prophylactic mood stabilizer: ONLY if the patient’s psychosis is indicated in coming back, otherwise continue the same dose
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85
Q

Mania criteria

A

Symptoms ≥7 days + Functional impairment + Delusions

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86
Q

Mania clinical features

A
  • Grandiosity
  • Decreased sleep
  • Talkative, flight of ideas,
  • Distractibility
  • Psychomotor agitation
  • Excessive involvement in pleasurable activities
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87
Q

Mania General Management

A
  1. Antipsychotics + Mood Stabilisers.

Antipsychotics: Olanzapine first, Risperidone if olanzapine not given

Mood stabilizers: Lithium, Sodium Valproate, Carbamazepine

  1. Combine 2-3 of these drugs
  2. ECT

NOTE: Psychosis requires hospitalization

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88
Q

Mania agitated patient management

A
  1. Verbal de-escalation and psychological intervention
  2. Agitation:
    - If agitation is caused by drug intoxication, then benzodiazepine (Midazolam)
  • If agitation is caused by psychosis atypical antipsychotic is preferred.
  • Zuclopenthixol (according to eTG) or
  • Haloperidol (less preferred I think)
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89
Q

Mania Drug Management in Pregnancy

A

1st trimester: Lithium, quetiapine, olanzapine, risperidone

2nd trimester: Carbamazepine

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90
Q

Hypomania Criteria

A
  • Symptoms ≥4 days + NO Functional impairment + NO Delusions and hallucinations
  • NO Hospitalization
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91
Q

Hypomania Management

A

Olanzapine or Risperidone

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92
Q

Bipolar Depression Clinical Features

A

Bipolar I: 1 manic episode + depression

Bipolar II (True bipolar)
1 hypomania + 1 Depression episode

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93
Q

Bipolar Depression familial risk

A

1 parent: 15-30%
2 parents: 50-70%.
Fraternal twins: 15-25%

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94
Q

Bipolar Depression Management

A
  1. First-line drugs:
    - lamotrigine
    - lithium
    - lurasidone
    - olanzapine
    - quetiapine
  2. If no response: add SSRI (any)

For PROPHYLAXIS: Use lithium

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95
Q

Bipolar Depression Management in Pregnancy

A
  1. Lamotrigine, quetiapine, olanzapine
  2. Lithium

Lurasidone: May cause extrapyramidal or withdrawal symptoms in neonates when exposed in the third trimester.

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96
Q

Difference between BPD and Cyclothymic disorder?

A

BPD:
- impulsivity in at least two areas that are potentially self-damaging

  • unstable and intense interpersonal relationships
  • alternating between extremes of idealization and devaluation

Cyclothymic:
- many periods of depressed mood
- many episodes of hypomanic mood for at least 2 years
- 1 year in children and adolescents
- During the above 2-year period the hypomanic and depressive periods are present for at least half the time and
- the individual has not been without the symptoms for more than 2 months at a time

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97
Q

Cyclothymia criteria

A

Alternating episodes of hypomania and moderate depression for >2y

MX
Mood stabiliser
CBT

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98
Q

Postpartum Blues criteria

A

< 2 weeks of delivery.

-80% of the postpartum women

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99
Q

Postpartum Blues clinical features

A
  • neglects baby BUT no thoughts of hurting it
  • low mood
  • sadness
  • mild depression
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100
Q

Postpartum Blues management

A

Family support, usually resolves in 1m

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101
Q

Postpartum Psychosis criteria

A

Appears within 2-w post delivery.

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102
Q

Postpartum Psychosis Clinical Features

A
  • thoughts of hurting the baby
  • Hallucinations
  • Delusions
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103
Q

Postpartum Psychosis Management

A
  1. If hurting baby: CPS and organize psych review
  2. If the prior history of previous postpartum psychosis: start antipsychotics after delivery
  3. Antipsychotics: Olanzapine, risperidone NO CLOZAPINE
  4. ECT: Initial treatment-resistant
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104
Q

Postpartum Psychosis breastfeeding prophylactic management

A

Breastfeeding:

YES: Sodium Valproate

NO: Lithium

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105
Q

Drugs to suppress lactation (postpartum) or treatment for hyperprolactinemia

A
  • Bromocriptine: Can lead to post partum psychosis!!!
  • Cabergoline
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106
Q

Postpartum Depression criteria

A

Appears 1-3m postdelivery.

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107
Q

Postpartum Depression Clinical Features

A
  • Thoughts about hurting baby
  • Features of depression.
  • Risk in future pregnancies: 20-40%.
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108
Q

Postpartum Depression Management

A
  1. Antidepressants: Sertraline or Paroxetine

Avoid Fluoxetine (Karla: why?)

  1. ECT

NOTE: If mum took SSRI or SNRI during pregnancy, observe the baby for 3 days (observing for what?) in the hospital, then discharge

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109
Q

Postpartum obsession criteria

A
  • Appears 1-3m postdelivery.
  • Obsession of hurting the baby
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110
Q

ECT process

A

1–3 sessions per week for 8–12 sessions total

Prior procedure:
- 8 h Fasting
- 2 h refrain from smoking
- Dentures and jewelry removed
- Ensure hair is clean
During the procedure: EEG monitoring

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111
Q

Initial ECT method

A

Unilateral therapy

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112
Q

Alternative to ECT

A

Transcranial direct current electromagnetic stimulation

  • No anesthetic is required, and less invasive
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113
Q

ECT indications

A
  1. Psychotic depression (e.g. delusions, hallucinations)
  2. Melancholic depression unresponsive to antidepressants
  3. Severe postnatal depression and psychosis
  4. Substantial suicide risk
  5. Ineffective antidepressant treatment and/or previous response to ECT
  6. Severe psychomotor depression (catatonia): refusal to eat or drink, depressive stupor, severe personal neglect
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114
Q

ECT absolute contraindication

A

Raised intracranial pressure

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115
Q

ECT relative contraindications

A
  • Hypertension
  • Myocardial Infarction <3 m
  • Bradyarrhythmia
  • Cardiac Pacemakers
  • Intracranial Pathology
  • Aneurysms
  • Epilepsy
  • Osteoporosis
  • Skull Defect
  • Retinal Detachment
  • Benzodiazepines (lower seizure threshold)
  • Water (amitriptyline)
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116
Q

ECT common adverse effects

A

headache, myalgia, nausea, and drowsiness.
- 10 to 30 mins after: Acute confusion
- Resolves at 2w: Anterograde amnesia
- Appears in weeks to months: Retrograde amnesia

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117
Q

ECT uncommon adverse effects

A
  1. Acute post-ECT delirium:
    - Mild: Impaired comprehension and disorientation. Mx: Supervision
    - Severe: Psychomotor restlessness. Mx: IV Psychotropics
  2. Confusion can be Ongoing ictal activity (non-convulsive status epilepticus)
    Ix: EEG monitoring
    Mx: Midazolam.
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118
Q

ECT Combination with Antidepressants

A
  • Cause seizures. Taper them, washout, and then ECT
  • TCA’s + cardiac disease = life-threatening
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119
Q

ECT Combination with Benzodiazepines

A
  • Advisable to withdraw completely
  • Alternative: Use short-term sedative antipsychotics in low-dose
    (treat both, night sedation and agitation)
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120
Q

ECT Combination with Mood Stabilisers

A

Carbamazepine and sodium valproate: increase seizure threshold. Reducing or ceasing (EXCEPT epilepsy)

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121
Q

ECT Combination with Lithium

A

Can cause post-ECT delirium.

Could be suspended during ECT unless there is a strong reason for its continuation

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122
Q

1st line treat for malignant catatonia?

A

ECT

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123
Q

Mental Health Act

A

Involuntary hospitalization of a patient who is at risk of harming himself or others. Ideally, the mental health team treats and reviews the patient.

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124
Q

Common terms: Perseveration

A

Inability to switch ideas along with the social context

Schizophrenia negative symptom

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125
Q

Common terms: Circumstantiality

A

Inability to answer a question without unnecessary and excessive detail

Schizophrenia negative symptom

126
Q

Common terms: Delusion

A

Fixed false belief

127
Q

Common terms: Overvalued idea

A

Same as delusion but holds stronger, and occupies a person’s mind

128
Q

Common terms: Illusion

A

Misperception of a real external stimulus

129
Q

Common terms: Hallucination

A

Misperception without a real stimulus

130
Q

Common terms: Pareidolia

A

Misperception of a real external stimulus and association with meaning known to the observer. Eg. Moon rabbit, objects in clouds

131
Q

Common terms: Hypnagogic hallucinations

A

Happen as you’re falling asleep

NOTE: It’s normal

132
Q

Common terms: Hypnopompic hallucinations

A

Happen as you’re waking up

NOTE: It’s normal

133
Q

Common terms: Egosyntonic

A

Responsive appropriate to the environment gives the situation

OCPD

134
Q

Common terms: Egodistonic

A

Responses and behaviors that are against a person’s beliefs and will

OCD

135
Q

Common terms: Concrete Thinking

A

Inability to think of abstract terms

Schizophrenia symptom

136
Q

Capgras Syndrome

A

Disorder in which a person believes that a relative or friend has been replaced by an identical impostor.

137
Q

Defence Mechanisms

A
  1. Narcissistic
  2. Immature
  3. Anxiety/Neurotic
  4. Mature
138
Q

Narcissistic Defence Mechanisms

A
  1. Projection (mirror)
  2. Denial (don’t accept)
  3. Splitting (Black or White)
139
Q

Immature Defence Mechanisms

A
  1. Blocking (temporary inability to remember)
  2. Regression
  3. Somatization
  4. Introjection (idea or object)
  5. Identification (people)
140
Q

Anxiety/Neurotic Defence Mechanisms

A
  1. Displacement (emotion shifted to another person)
  2. Repression (Bad feelings or ideas removed from the consciousness)
  3. Isolation of affect (Reality accepted without emotions)
  4. Intellectualization (Use the intellectual process to avoid the emotions)
  5. Acting out (tantrums)
  6. Rationalization (EXCUSES. Rational explanations to justify behaviors)
  7. Reaction Formation (Unacceptable impulse transformed in its opposite) “Pyromaniac to a firefighter”
  8. Undoing (Acting out an unacceptable behavior) “Pyromaniac burning down”
  9. Passive-Aggressive (Unconscious passive hostility)
  10. Dissociation (Separates the experience to the body)
141
Q

Mature Defence Mechanisms

A
  1. Humor #foreveralone
  2. Sublimation (Unacceptable impulse into an acceptable channel) “Pyromaniac working in a special effect company”
  3. Suppression (Conscious forgetting,” choosing not to worry about exam until we need to”)
142
Q

List of Personality Disorders

A

Cluster A: Odd, eccentric behavior or withdrawn personality.

Cluster B: Dramatic, emotional and erratic personality

Cluster C: Anxious and fearful personality

Other

143
Q

Personality disorders: Cluster A

A

Withdrawn Cluster

  1. Paranoid: Suspicious but not delusional, accept explanations for their wrong ideas.
    DDx: In paranoid delusion, they are suspicious about one thing only, and functioning is normal.
  2. Schizoid: Happy loner. Emotionally cold
  3. Schizotypal: Bizarre, magical thinking. Doesn’t fulfill the criteria for schizophrenia “ISOLATED HIPPIE”
144
Q

Personality disorders: Cluster B

A

Antisocial cluster

  1. Antisocial: Breaking the law with no remorse.
    a) Deliberate psychopaths (villains)
    b) Impulsive psychopaths (dumbs)
    - cruel to animals
    - vandalism
  2. Histrionic: Usses seduction to attract attention but sexually frigid. Suggestible. Very dramatic.
  3. Narcissistic: I’m the best. Can’t take criticism. Lack of empathy.
  4. Borderline: Mood instability + impulsive. Self-harm can lead to suicide or parasuicide
    Mx: Dialectal behavioural therapy
145
Q

Personality disorders: Cluster C

A

Dependent cluster

  1. Avoidant: Fears rejection, “Unhappy loner”
  2. Dependent: Avoids responsibility. Seek protection. Difficulty making everyday decisions.
  3. Obsessional OCPD: No insight. Egosyntonic.
146
Q

Other personality disorders

A

Personality Change:
- Labile type
- Masochistic
- Disinhibited type
- Aggressive type
- Passive Aggressive type
- Apathetic type
- Combined type
- Unspecified type

147
Q

List of Anxiety Disorders

A
  1. Generalized Anxiety Disorder
  2. Panic Disorder (≠ Panic Attack)
  3. Acute stress disorder
  4. Social Anxiety Disorder (Social Phobia)
  5. Agoraphobia (afraid to leave environments considered to as safer)
  6. Separation Anxiety Disorder
  7. Specific Phobia
  8. Substance/Medication-Induced Anxiety Disorder
  9. Anxiety Disorder Due to Another Medical Condition
148
Q

Anxiety Causes

A
  • Genetic.
  • Psychological.
  • Environmental.
149
Q

Anxiety Risk Factors

A
  • Females.
  • Social history
  • Family history.
  • Past mental illness.
150
Q

List of Obsessive-Compulsive and Related Disorders

A
  1. Obsessive-Compulsive Disorder
  2. Body Dysmorphic Disorder
  3. Hoarding Disorder
  4. Trichotillomania (Hair-Pulling Disorder)
  5. Excoriation Disorder (Skin-Picking)
151
Q

Trauma- and Stressor-Related Disorders

A
  1. PTSD
  2. Acute Stress Disorder
152
Q

Generalised Anxiety Disorder criteria

A

Excessive anxiety for at least 6 months.

Most common anxiety in general practice

The most common psychiatric disorder is depression, however.

153
Q

Generalised Anxiety Disorder management

A
  1. CBT - SPS (structured problem-solving)
  2. Severe or CBT ineffective after 3M:
    - SSRI: Suspend after symptom-free for 6M
154
Q

Generalised Anxiety Disorder alternative management

A
  • SNRI
  • Benzodiazepine: Short term (2W and tapered over next 2W)
  • Buspirone (Anxiolytic)
  • Beta-blockers: palpitation / tremors.
155
Q

Panic Attack criteria

A
  1. Intense symptoms: palpitations, tachycardia, sweating, shaking, SOB, choking, fear of dying, paraesthesia.
  2. develop abruptly and reaches a peak in 10m. Total 30 min duration
  3. Trigger identified
156
Q

Panic Attack differential diagnosis

A
  • Hyperthyroidism.
  • Hypoglycaemia.
  • Pheochromocytoma.
157
Q

Panic Attack management

A
  1. Perform physical examination and/or initial investigations to exclude medical conditions.
  2. Distraction methods (breathing in and out in a paper bag)
  3. BDZ: Diazepam / Lorazepam
  4. To prevent future attacks: CBT (flooding), stress management, exposure and desensitization, SSRI (Paroxetine)
158
Q

Panic Disorder criteria

A
  1. Recurrent panic attacks.
  2. triggers identified.
  3. At least 1 panic attack within 1 m
159
Q

Panic Disorder management

A
  1. CBT
  2. Behavioural therapy (Graded exposure)
  3. SSRI for 6-12m (Fluoxetine)

NOTE: if there is no trigger, exposure therapy is not indicated

160
Q

Social phobia criteria

A
  • Persistent fear of social performance
  • linked to panic attacks
  • avoidance of social events.
  • Kids: symptoms > 6 m for making a diagnosis
161
Q

Social phobia management

A
  1. CBT
  2. BT (exposure-based)
  3. Training for social skills
  4. B-Blockers (situational)
  5. SSRI/SNRI/MAOI
162
Q

Agoraphobia criteria

A
  1. Anxiety about being in open places where escape might be difficult (theatre, queue, public transport)
  2. Avoidance of situations
163
Q

Agoraphobia greatest risk of developing

A

Depressed mood and feeling of guilt

164
Q

Agoraphobia management

A
  1. CBT
  2. SSRI
165
Q

Separation Anxiety Disorder Management

A

Most common anxiety disorder in
children.

  1. Psychotherapy- CBT.
  2. Family therapy.
  3. Medications if severe.
166
Q

Phobias criteria

A

Excessive fear of stimulus which interferes with lifestyle

167
Q

Phobias management

A
  1. CBT
  2. Behaviour Therapy: Exposure and desensitization therapy
    - Teach relaxation techniques and breathing exercises.
    - Hierarchy of unpleasant stimulus
168
Q

Obsessive-Compulsive Disorder (OCD) clinical features

A
  • Obsessive (not inserted thought) and compulsive (do it with rituals, they know it’s unreasonable and excessive) intentional rituals.
  • Have insight
  • Egodystonic
  • Functioning impaired.
169
Q

OCD types

A
  • Cleanliness - order.
  • Counting
  • Hoarding
  • Safety checking.
  • Sexual issues.
  • Religious / moral issues.

Combinations can happen too.

170
Q

OCD management

A

CBT + SSRI together

  1. CBT: Psychodyniamic Psychotherapy
  2. BT: Exposure and response prevention
  3. SSRI: Fluoxetine, sertraline, paroxetine
171
Q

OCD patients are egosyntonic or egodystonic with how they view their disorder?

A

Egodystonic

172
Q

List of eating disorders

A
  • Anorexia Nervosa
  • Bulimia Nervosa
173
Q

Body Dysmorphic Disorder criteria

A
  • Belief that some part of the body is abnormal or defective (face or secondary sexual character)
  • Significant functional impairment
174
Q

Body Dysmorphic Disorder management

A
  • CBT - BT counseling.
  • Might require SSRI if depression is associated.
175
Q

Eating disorders Risk Factors

A

– Female Adolescent
– Low self-esteem
– Personal or family history of depression
– Family history of obesity
– High personal expectations
– Family history of eating disorders
– Disturbed family interactions
- Social factors
- Childhood sexual abuse
- Perfectionism and obsessionist

176
Q

Common clinical features of Anorexia Nervosa

A
  • < 17.5 BMI
  • Significant electrolyte disturbance (K < 3.0 or Na < 130)
    – Amenorrhoea
    – Constipation.
    – Lanugo.
    – Cold intolerance.
    – Cachexia.
    – Hypothermia.
    – Bradycardia. (< 40bpm)
    – Hypotension (< 90mmHg)
  • Raised liver enzymes and Albumin < 35g/L
177
Q

Complications of Anorexia Nervosa

A
  • Secondary amenorrhoea due to low levels of LH and FSH
  • Low TSH levels (Hypothermia)
  • Depression
  • Obsessive-compulsive disorder
  • Increased risk of fractures in later life due to osteoporosis
178
Q

Posttraumatic Stress Disorder (PTSD) criteria

A

3 symptoms for >1m after a serious stressor (threatened death or serious injury):
- Response with intense fear, horror, and helplessness.
- Flashbacks
- Difficulty falling asleep
- Irritability

179
Q

PTSD types/classification

A
  • Acute <3m
  • Chronic >3m
  • Delayed onset: >6m after traumatic event
180
Q

PTSD management

A
  1. CBT
  2. Behavioural therapy (Graded exposure/eye movement desensitization and reprocessing)
  3. SSRI for 6-12m
181
Q

Acute stress disorder (AST) criteria

A

occurring within 4 weeks of trauma and resolving within 4 weeks

182
Q

Acute stress disorder (AST) management

A
  1. Debriefing and counselling
  2. Stress based psychotherapy
183
Q

Adjustment Disorder with Anxiety criteria

A
  1. Within 3 months of the new stressor (new job, migration, divorce)
  2. Resolves within 6 months

**associated with a very increased risk of suicide **

184
Q

Adjustment Disorder with Anxiety criteria management

A
  1. Listen and empathy (counselling)
  2. CBT
  3. Intermittent BZD x 2w (Diazepam 20 mg max. per day)
  4. SSRI
185
Q

Gambling disorder

A

4 symptoms lasting at least 12 months

  • preoccupation on gambling
  • increasing stakes on gambling
  • unsuccessful attempts to stop
  • gamble to escape reality
  • lie to cover up the problem
  • rely financially on others
  • get into criminal activities
  • loss of job
  • irritable anxious
186
Q

List of Impulsive Control Disorders

A
  1. Intermittent Explosive disorder (anger therapy)
  2. Kleptomania
  3. Pyromania
187
Q

List of Impulsive Control management

A

CBT – BT

188
Q

List of Psychosomatic Disorders

A
  1. Somatic Symptom Disorder: With
    predominant pain (4) / sexual sympoms (1) / neurological (1) / GI (2)
  2. Conversion Disorder (Functional Neurological Symptom Disorder) “la belle indifférence”
  3. Factitious Disorder: purposely getting sick or by self-injury
189
Q

Dissociative disorders

A
  1. Dissociative Identity Disorder
  2. Dissociative Amnesia: With dissociative fugue
  3. Depersonalization/Derealization Disorder
190
Q

Dissociative amnesia

A

Amnesia to escape from distress but they don’t travel away

191
Q

Dissociative Identity Disorders

A

Different personalities at different times

192
Q

Dissociative fugue

A

Amnesia to get away from intolerable situations, sudden travel away from home.

They don’t remember the previous episode

193
Q

Depersonalisation

A

Out-of-body experience.

Changes in body shape or size, cannot be recognized in the mirror, feel like watching characters in a boring movie.

Associated with: Schizophrenia, borderline, temporal lobe epilepsy, and PTSD

194
Q

Derealisation

A

The external world seems unreal.

The feeling of being transported to
place you don’t know and don’t understand

195
Q

Schizophrenia/psychosis Prodrome Symptoms: Early pre-psychotic

A

Recurrent depressive symptoms over the course of 3-5 years

196
Q

Schizophrenia/psychosis Prodrome Symptoms: Late pre-psychotic

A
  • Paranoid ideation
  • Odd beliefs
197
Q

2nd earliest symptoms seen in pre-psychotic prodrome of schizophrenia/psychosis

A

Loss of motivation and social disability developing within 12 to 18 months of first recurrent depressive symptoms

198
Q

Anorexia Nervosa Clinical Features

A

BMI<17.5

Amenorrhoea

Loss of body fat

Increased lanugo

Bradycardia (MC finding)

Feelings of inferiority

199
Q

Anorexia Nervosa Admission criteria

A

BP: Postural drop >10mmHg

Bradichardia <45

Albumin <20

BMI<15

Arrhythmias

Haemonamicly unstable

Severe dehydration

200
Q

Bulimia & Anorexia Management

A

CBT + SSRI’s ???

201
Q

Anorexia Nervosa: Refeeding Syndrome

A

Refeeding Syndrome: high mortality rate

Clinical Features:
- Hypophosphatemia (hallmark) Leads to acute respiratory failure

  • Hypokalemia. Leads to metabolic alkalosis
  • Hypomagnesemia (+ Hypokalemia = torsades de pointes)
  • Thiamine deficit. Leads to Wernicke’s and Korsakoff’s encephalopathy.
202
Q

Bulimia Clinical Features

A

BMI>18

Dry skin

Parotid gland swelling

Erosion of dental enamel

Hair loss

Calluses on dorm of hands (Russell’s sing)

Amenorrhoea

Hypokalemia

203
Q

Psychotic Disorders

A
  • Delusional Disorder: 1 month
  • Schizophreniform disorder: > 1 month and < 6 months
  • Schizophrenia: > 6 months.
  • Schizoaffective/psychogenic
    disorder: Schizophrenia + major
    affective disorder.
  • Folie a Deux
204
Q

Delusional Disorder Criteria

A
  • 1 month of JUST delusions with
    no other psychotic symptoms.
  • The delusions are not bizarre
    and can occur in real life (being followed, having an infection, etc)
205
Q

Delusional Disorder Management

A
  1. Antipsychotics
  2. Psychotherapy
206
Q

Types of Delusions: Persecutory

A

Commonest type. Believes they are being persecuted or harmed.

207
Q

Fregoli syndrome

A

Delusional belief that one or more familiar persons, usually persecutors following the patient, repeatedly change their appearance.

208
Q

Types of Delusions: Delusional mood

A

The patient feels something is going on around them but cannot describe what. It usually becomes clearer and more specific when a delusional idea or perception occurs.

209
Q

Types of Delusions: Delusion of love or Erotomaniac

A

The patient thinks that another is in love with them, even if they have never met them before. Usually of higher status, the version involves a celebrity or famous person (Cleraumbault’s Sx).

It’s a secondary delusion

210
Q

Types of Delusions: Delusional perception

A

Occurs when the delusion forms in response to an ordinary object. For example, the traffic light turns green, and Bert therefore knows he is the King of England.

211
Q

Types of Delusions: Delusional ideas

A

Arise out of nowhere are termed autochthonous delusions. Can rarely occur in people without mental illness.

212
Q

Types of Delusions: Grandiose

A

Believes that has inflated worth or power.

213
Q

Types of Delusions: Somatic

A

Delusions around the body function like parts not functioning, infested with insects, emitting a foul odor.

214
Q

Brief Psychotic Disorder Criteria

A
  • Symptoms between 1d and 1m
  • 1st Depression, then psychosis
    (Brief) with a stressor present
215
Q

Brief Psychotic Disorder
Management

A
  • Only antipsychotic for 1 month.
  • Don’t treat the depressive part.
216
Q

Schizophreniform disorder criteria

A

Symptoms like schizophrenia lasting at least 1 month but less than 6 months duration

217
Q

Schizophreniform disorder Management

A

 Treated as first psychotic episode.

 Then like schizophrenia.

 ECT for drug-resistant cases.

218
Q

Schizophrenia Epidemiology

A

Affects about 1 in 100 people

Men and women equally affected

Usually diagnosed between the ages of 15 and 35.

Age of onset tends to be slightly earlier in men (18-25) and later in women (25-35).

Higher incidence in urban areas and among migrants, and lower socioeconomic classes

219
Q

Clinical Features of Schizophrenia

A

Criteria:
- Symptoms >6m.
- 1 of Positive Symptoms (DHD):
- 2 of Negative Symptoms:

usually have poor insight

  • MCC of death: CV disease.
220
Q

Positive symptoms of Schizophrenia

A
  • delusions
  • hallucinations
  • thought disorder
  • disorganized speech and behaviour
221
Q

Negative symptoms of Schizophrenia

A
  • flat affect
  • poverty of thought
  • lack of motivation
  • social withdrawal
  • reduced speech output
222
Q

Schizophrenia familial risk

A

0 parents: 1% risk
1 parent: 13% risk
2 parents: 45% risk

223
Q

Schizophrenia: Management of 1st Psychosis Episode

A
  1. Treatment of agitation:
    - Admission and control agitation with verbal de-escalation.
    - If pt tolerates oral/Cooperative: Diazepam or Lorazepam.
    - If doesn’t: Haloperidol or midazolam IM
  2. Antipsychotics: All except olanzapine because of metabolic side effects.
    - Symptoms last <6m, keep for 1y
    - Symptoms last >6m, keep for 2y
224
Q

Definitive Management of Schizophrenia

A
  1. Antipsychotics
    - Typical: Positive symptoms (DHD)
    - Atypical: Negative symptoms.

*If using typical and not responding, change to atypical.

*Increase dose if there is no response in 3-4w

*Change to another antipsychotic if
no response in 4-6w doing crossover period

*If 2 different antipsychotics were
tried, and there was no change after 6-12w: ECT

  1. Psychotherapy, family counseling
225
Q

Schizoaffective Disorder Criteria

A

Schizophrenia + major affective disorder

If psychotic symptoms are present despite full treatment of depression (bipolar or unipolar) is schizoaffective

1st Psychosis, then depression.

The best way to make the DD is that this px will need a combination of drugs ALWAYS, not only during an episode

226
Q

Folie a Deux: Shared psychotic disorder

A

Criteria: Delusion in a person in a close relationship with another who already has established delusion.

227
Q

Folie a Deux Management

A
  1. Separate the people
  2. Antipsychotics
228
Q

Opioids Intoxication Clinical Features

A

Pinpoint pupils

Resp depression

Euphoria

Constipation

CNS depression

229
Q

Opioids Intoxication Management

A

Naloxone and naltrexone

230
Q

Opioid Withdrawal Clinical Features

A

Flu-like reaction with rhinorrhoea

Dilated pupils

Piloerection

Cramps

Diarrhea

Yawning

NO FEVER according to Bluebook

231
Q

Opioid Withdrawal Management

A

Buprenorphine or methadone

232
Q

Amphetamine & Cocaine Intoxication Clinical Features

A

Agitation

Tachycardia

Fever

Diaphoresis

Arrhythmias

Seizures

Midriasis

HTN

ALSO COCAINE:
- ECG alterations
- Fever

233
Q

Amphetamine Intoxication Management

A

Haloperidol

234
Q

Amphetamine & Cocaine Withdrawal Clinical Features

A

Crash with:
Anxiety

Lethargy

Headache

Cramps

Fatigue

Nightmares

235
Q

Methamphetamine antidote

A

Wait it out?
Activated charcoal of option is given history of patient ingesting within 2 hours

236
Q

Methamphetamine withdrawal treatment of choice?

A

No proper medication to treat withdrawal. but to treat symptoms that arise such as mood disorders in which case : TCA

237
Q

Methamphetamine overdose can cause what fatal symptoms?

A
  • Stroke
  • seizures
  • hyperthermia
238
Q

how to treat sympathomimetic symptoms?

A

Agitation: benzodiazepines (lorazepam IV if not cooperative, diazepam oral if patient cooperative)
Hypertension: nitrates (nitroprusside), beta blockers (metoprolol 2-5mg IV)
Hyperthermia: evaporative cooling, icepacks and maintenance of intravascular volume and urine flow with IV normal saline solution.
Seizures: Phenothiazines as last resort

239
Q

Cocaine & Amphetamine Withdrawal Management

A

Antidepressants

240
Q

Cocaine Intoxication Management

A

Benzos

241
Q

Sertraline and ecstasy drug interaction

A

They are synergistic
(increase concentration of serotonin in the body) –> Serotonin Syndrome

242
Q

Phencyclidine (PCP) or angel dust intoxication Clinical Features

A

Severe violence

Psychomotor agitation

HTN

Nystagmus

243
Q

Phencyclidine (PCP) or angel dust intoxication Management

A

Benzos or haloperidol

244
Q

Marihuana Intoxication Clinical Features

A

Euphoria

Social withdrawal

Can’t drive

Conjunctival injection

Hallucinations

245
Q

Marijuana Intoxication Management

A

CBT

246
Q

Marijuana Withdrawal Clinical Features

A

Insomnia

Night sweats

Nausea

Depression

Irritability

Anger

247
Q

Benzodiazepine Intoxication Clinical Features

A

Hypotension

Bradycardia

Resp failure (mixed with alcohol)

248
Q

Benzodiazepine Intoxication Management

A
  1. Monitor with IV fluids
  2. Flumazenil
249
Q

Benzodiazepine withdrawal Clinical Features

A

Rebound anxiety

Depression

Seizure

Insomnia

HTN

Tachycardia

Noise sensitivity

250
Q

Insomnia Clinical Features

A
  • In anxiety: Difficulty in initiation
    sleep
  • In depression: Early morning
    awakening
251
Q

Insomnia Management

A
  1. Tx comorbidities causing insomnia
  2. Implementing good sleep hygiene
  3. Sleep restriction and stimuli control programs
  4. Cognitive therapy (Best for chronic >4w)
  5. Drugs:
    Best for acute: Short-acting Benzos – Temazepam, zolpidem, zopiclone, eszopiclone (do not give with alcohol->resp depression).

Chronic >55w (>1 year): Melatonin

252
Q

Diagnosis of chronic insomnia

A
  1. A self-reported complaint of poor sleep quality
  2. Sleep difficulties occur despite adequate sleep opportunity.
    Impaired sleep produces deficits in daytime function.
  3. Sleep difficulty occurs three nights per week and is present for three months
253
Q

Chronic insomnia management

A
  1. Treat the comorbidities causing insomnia
  2. Implementing good sleep hygiene
  3. Sleep restriction and stimulus
    control programs
  4. Cognitive therapy (Best for chronic >4w)
  5. Drugs:
    *Acute: Short-acting Benzos (Temazepam, zolpidem, zopiclone, eszopiclone. DO NOT give with alcohol —-> Resp depression)

Chronic insomnia for >55 weeks (1y): Melatonin

254
Q

Grief Stages

A

1 Denial

2 Grief and despair (until 6m)

3 Acceptance (6m-1y).

*If it continues then treatment

NOTE: It’s normal to have a relapse of symptoms during the anniversary

255
Q

Grief Management

A

Normal grief
1. Short-acting benzos

Abnormal grief: Stage 2 sx for >6m
1. Psychotherapy
2. SSRI-Antipsychotics
3. CBT
4. ECT

256
Q

Suicide

A
  • More common season: Spring
  • More common season in
    schizophrenics: Winter
  • Highest risk:
    1. After discharge from hospital.
  1. After improvement of tx
257
Q

2 questions that MUST be asked to assess suicidal ideation

A
  1. Do you feel hopeless?
  2. Have you felt that you’ve lost interest in your usual activities?
258
Q

Suicide Assessment (SAD PERSONS)

A

S: Male SEX 1
A: AGE < 20 and > 45 1
D: DEPRESSION/depressed mood 2

P: PREVIOUS attempts 1
E: EXCESSIVE alcohol/substances 1
R: RATIONAL thinking Loss 2
S: SEPARATE (no spouse) 1
O: ORGANIZED plan 2
N: NO Support 1
S: Sickness (chronic or fatal) 1

259
Q

Suicide Assessment (SAD PERSONS) RESULTS

A

0–4: Low
Fleeting thoughts of self-harm or suicide but no current plan or means

5–6: Medium
Suicidal thoughts and intent but no current plan or immediate means

7–10: High
Continual/specific suicidal thoughts, intent, plan and means

260
Q

Suicide Assessment Management: Low Risk (0–4)

A
  1. Discuss the availability of support and treatment options.
  2. Arrange a follow-up consultation.
  3. Identify relevant community resources and provide contact details.
261
Q

Suicide Assessment Management: Medium Risk (5–6)

A
  1. Discuss the availability of support and treatment options.
  2. Organize reassessment within 1 week.
  3. Have a contingency plan in place for rapid reassessment if distress or symptoms escalate.
  4. Develop a safety plan (a prioritized written list of coping strategies and sources of support to use when experiencing suicidal thinking).
262
Q

Suicide Assessment Management: Hight Risk (7-10)

A
  1. Ensure that the person is in an appropriately safe and secure environment.
  2. Reassessment within 24 hours and monitoring for this period.
    Follow-up outcome of assessment:

*If there is concern about suicide risk and treatment is supervised outside the hospital, prescribe drugs that are less toxic in overdosage (e.g. mianserin or fluoxetine).

263
Q

Suicide Risk Factors

A
  1. Substance abuse
  2. Chronic health issues, pain, or physical disability
  3. Feelings of isolation or helplessness
  4. Negative life events: Abuse history, significant loss, financial crisis (Adjustment Disorder)
  5. Previous suicide attempts or exposure to suicide behavior in others (family, friends)
  6. Young men in rural areas
  7. Borderline personality disorder
264
Q

Paraphilias

A

Criteria:
Sexual fantasies for >6m with clinical impairment.

Management:
1. Insight-oriented psychotherapy

265
Q

Premature ejaculation

A

The most common sexual disorder in Australians

Management:
- Short term:
*Lignocaine before sex
- Long term:
*SSRI/TCA

266
Q

Sexual impotence CF & Ix

A

MCC: Vascular problem

Investigation:
Detailed Hx including information about libido and morning erections

267
Q

Sexual impotence Management

A
  1. Optimise RFs and comorbidities
  2. Phosph 5 inhibitors: Sildenafil
  3. PgE1 for Erection
268
Q

Narcolepsy Management

A
  1. Daytime: Amphetamines/Modafinil
  2. Nightime: Sodium oxybate
269
Q

Bruxism

A

Seen in stress, heavy alcohol
drinkers.

Management:
Place a hot towel against the side of face, counseling, yoga, relaxation
exercises, meditation

270
Q

Alcohol intoxication Clinical Features

A

Impaired judgment and coordination

Gait instability

Slurred speech

Mood and behavior changes

Nausea and vomiting

Hypothermia

Dysarthria

Amnesia

Diplopia and nystagmus

271
Q

Onset of alcohol withdrawal

A

6 and 24 hours after the last drink

272
Q

Alcoholic hallucinosis Clinical Features

A

Onset within 12-24 hours of
abstinence with normal
consciousness

273
Q

Severe alcohol withdrawal: Delirium Tremens CLINICAL FEATURES

A

Onset after 2-3 days of abstinence

Visual hallucinations

Confusion

Tachycardia

Hypertension

Hyperthermia

Agitation

Diaphoresis

Seizures

274
Q

Delirium Tremens Risk Factors

A

History of Delirium Tremens

Concurrent illness

Advanced age

Hypokalemia

Prior withdrawal symptoms or detoxification

275
Q

Initial Investigation in Delirium Tremens

A

Most reliable investigation to diagnose alcoholism: Carbohydrate
deficient transferrin

NO RELIABLE INFO:

  1. ECG: cardiac arrhythmias
  2. ABG: Lactic acidosis
  3. Electrolytes: hypoglycemia, hypomagnesemia, hyponatremia, and hypophosphatemia
  4. Liver function test; prothrombin time
  5. Brain CT scan to rule out intracranial pathology
276
Q

Delirium Tremens Management

A

Acute:
1. Diazepam or Midazolam IV

  1. Tiamine IV
  2. Glucose IV
  3. Metoclopramide IV

Prophylaxis:
- Disulfiram, Naltrexone, Baclofen, or Acamprosate

NOTE:
*Unresponsive to benzodiazepine: Add phenobarbital or propofol + Mechanical Ventilation

*Rapid correction of HypoNatremia can cause central pontine myelinolysis

*ACUTE NOT USE: Neuroleptic drugs (Antipsychotics)

277
Q

CAGE questionnaire:

A

C- Have you ever felt you should Cut down on your drinking?
A- Have people Annoyed you by criticizing your drinking?
G- Have you ever felt bad or Guilty about your drinking?
E- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (Eye-opener)

278
Q

Treatment of alcohol withdrawal

A

Benzodiazepine (Diazepam)

279
Q

Hypochondriacs come for cause in relation to their…?

A

Diagnosis

280
Q

Criteria for Somatic Symptom Disorder criteria

A

-1 or more somatic symptoms that are distressing or result in significant disruption of daily life

  • Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
  1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
  2. Persistently high level of anxiety about health or symptoms.
  3. Excessive time and energy devoted to these symptoms or health concerns.
  4. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months)
281
Q

Difference between hypochondriasis & Illness anxiety disorder

A

hypochondriasis: already have a diagnosis failure to respond to reassurance is an explicit criterion
illness anxiety disorder: has as its primary focus preoccupation with having or acquiring a serious (and undiagnosed) medical illness (think general overall health)

282
Q

St John’s Wort interactions: Antidepressants

A

Serotonin syndrome

283
Q

St John’s Wort interactions: COCP

A
  • SJW reduces the effectiveness of COCs and increases the risk of unintended pregnancy

-Induce the cytochrome P450 enzymes CYP1A2, CYP2C9, and CYP3A4. Therefore metabolizing COCPs at a faster rate, decreasing its effectiveness.

284
Q

St John’s Wort interactions: Warfarin

A
  • SJW reduces the effectiveness of warfarin and increases the risk of stroke, ischemia, arterial blockage etc.
  • SJW’s extracts have been reported to induce the cytochrome P450 enzymes CYP1A2, CYP2C9, and CYP3A4. Therefore metabolizing COCPs at a faster rate, decreasing its effectiveness.
285
Q

Mental Status Exam DOMAINS

A

Appearance

Attitude

Behavior

Mood

Affect

Speech

Thought process

Thought content

Perception

Cognition

Insight

Judgment

286
Q

MMSE score interpretation

A

Normal: 25 - 30

Mild Dementia: 20 - 25

Moderate Dementia: 10 - 25

Severe Dementia: < 10

Pseudo-dementia/ Depression > 24

287
Q

If the patient has scored just below the normal threshold of MMSE due to sight impairment. What should be done?

A

Correct sight impairment and redo test, or perform other cognitive tests that do not require sight (Six-item Cognitive Impairment Test)

288
Q

After MMSE is done to determine cognitive decline (<25), what investigation is best indicated?

A

CT scan (to see if there’s any degeneration of brain tissue, such as atrophy)

289
Q

Pseudodementia clinical features

A

MMSE >24

Depression with cognitive impairment.

The symptoms are worse in the morning

The patient has insight

Common in elderly

“Give up patient”

290
Q

Dementia Types

A
  1. Alzheimer’s disease
  2. Frontal Lobe Dementia (FLD)
  3. Vascular Dementia (VD)
  4. Lewy body dementia (LBD)
  5. Parkinson’s dementia
  6. Alcohol-related dementia:
    - Korsakoff’s syndrome
    - Wernicke’s encephalopathy
291
Q

Alzheimer’s Disease Clinical Features

A

It is the most common form of dementia.

Short-term memory loss.

Repeatedly saying the same thing

Disability to plan, problem solve, organize, and think logically

Language and comprehension difficulties, such as problems finding the right word

Disorientation in time, place, and person

Changes in behavior, personality, and mood.

292
Q

Alzheimer’s Disease Management

A

Acetylcholinesterase inhibitors: donepezil, galantamine or rivastigmine

Moderate to severe: Add Memantine

Severe agitation:
- Citalopram
- Avoid antipsychotics. If it’s indispensable, review every 4–12 w

293
Q

Acetylcholinesterase inhibitors side effects

A

Overstimulation of the parasympathetic nervous system, such as increased hypermotility, hypersecretion, bradycardia, miosis, diarrhea, and hypotension, may be present.

Cholinergic crisis, also known as SLUDGE syndrome:

S: Salivation
L: Lacrimation
U: Urination
D: Diaphoresis
G: Gastrointestinal upset
E: Emesis

Same in toxicity by organophosphates

294
Q

Acetylcholinesterase inhibitors TOXICITY management

A

Atropine + Pralidoxime (2-PAM) –> Synergistic effect

Seizures = Diazepam

295
Q

Acetylcholinesterase inhibitors Contraindications

A

Gastric ulcer (increased risk of gastrointestinal bleeding)

Urinary retention

Bradycardia or cardiac conduction diseases (sick sinus syndrome).

Antihypertensive medications –> Reduce the dose of antihypertensive, risk of severe hypotension.

NOTE: The two previous conditions can be evidenced by syncopal episodes.

296
Q

Adult ADHD main features

A

-Symptoms are more subtle and are subject to change:

*Hyperactivity may be replaced with restlessness
*Impulsivity may be replaced with the inability to control emotions or social inappropriateness.

  • 60% of the children will continue to exhibit symptoms into adulthood
297
Q

Mechanism of action of ADHD medication

A

Inhibition of dopamine and norepinephrine reuptake

298
Q

Define Diogenes syndrome

A
  • Squalor and decline in personal hygiene
  • Sometimes hoarding useless items
  • Significant frontal lobe impairment
299
Q

Define Charles Bonnet syndrome

A
  • Formed visual hallucinations in blind or partially sighted elderly who are not delirious.
  • Always ocular or occipital disease not psychiatric.
  • The patient has good insight
  • Hallucinations characteristics:
    *Last for seconds or hours at a time
    *Vivid, colorful, and well-organized.
    *Not distressing but may be quite engaging
300
Q

Define Ekbom syndrome

A

Two forms:

  1. ‘restless legs’ syndrome
  2. Delusional infestation with parasites or worms in schizophrenic patients

Treatment: treat the underlying iron deficiency anaemia, and levodopa

301
Q

Define Cotard syndrome

A

The patient believes they have lost important body parts, blood, internal organs, or even their soul

Prevalent in schizophrenia, bipolar disorder, non-dominant temporoparietal lesions, and migraine.

302
Q

Psychiatric Drugs that cause HYPOnatremia

A

Antipsychotics

Carbamazepine

SSRIs

SNRIs

303
Q

Symptoms of HYPOnatremia in psychiatric patients under treatment

A

More common in the elderly

  • Confusion
  • Lethargy
  • Worsening of psychosis or dementia
304
Q

Neurotransmitters abnormalities

A

SADPHAM

Schizophrenia: ↑ dopamine
Alzheimer’s: ↓ acetylcholine
Depression: ↓ serotonin/norepinephrine
Parkinson’s: ↓ dopamine
Huntington’s: ↓ acetylcholine
Anxiety: ↓ GABA
Mania: ↑ serotonin/norepinephrine

305
Q

paracetamol intoxication protocol

A
306
Q

Smoking - medication

A
  • CP450 Inducer (always monitor pat when they change smoking status)
307
Q

Smoking Cessation

A
    1. NRT ( Nicotin replacement therapy)
    1. Bupropion ( not if convulsion level low)
    1. Vareniciline ( Just if NRT failed -close monitoting)
308
Q
A
309
Q

Immature Defense Mechanism

A
  1. Acting out: Expressing unacceptable feelings through actions
  2. Denial: Behaving as if an aspect of reality does not exist
  3. Displacement: Transferring feelings to less threatening object/person Intellectualization: Focusing on nonemotional aspects to avoid distressing feelings
  4. Passive aggression: Avoiding conflict by expressing hostility covertly
  5. Projection: Attributing one’s own feelings to others
  6. Rationalization: Justifying behavior to avoid difficult truths
  7. Reaction formation: Transforming unacceptable feelings/impulses into the opposite
  8. Regression: Reverting to earlier developmental stage ( acting like a child)

9.Splitting: Experiencing a person/situation as either all positive or all negative

310
Q

Mature Defense Mechanism

A

Sublimation: Channeling impulses into socially acceptable behaviors

Suppression: Putting unwanted feelings aside to cope with reality

311
Q

Common terms: Countertransference

A
  • conscious and unconscious reaction toward a patient (eg, attitudes, thoughts, feelings, behaviors) that is based on past personal relationships
  1. positive (eg, physician takes extra time with a patient who resembles a beloved grandmother)
  2. negative (eg, physician avoids a patient who resembles a critical parent).

AMC Flashcards (39 decks)

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