Mental health SDL cases and answers

Question 1

Case 1: Theme Psychosis

Week 1 (Theme Psychosis)
Scenario: A 19 year old man is brought to see his GP by his parents who have become concerned about his behaviour. He has been asking his parents repeatedly whether there is something wrong with him, and then refusing to believe them, saying strange things like, ‘there are imbalances and improbabilities underfoot’. At times it appears as if he is talking to himself. Over the previous week his parents have heard him shifting furniture in his room throughout the night.

1. What questions would you ask to illicit delusions and hallucinations?
2. How would you rule out an organic or substance-use related cause of psychosis?
3. You suspect that this man might need to be assessed under the MHA – describe the process and how you would explain to him and his family.
4. What psychopharmacological treatments could be offered to him and how would you counsel him and his family about the benefits and side effects?

Answer 1

Here are screening questions for hallucinations in each sensory modality:

• Have you been hearing any voices?
• Does it seem that other people are commenting on your behavior?
• Have you been seeing any visions?
• Have you been having any unusual feelings on your body or skin?
• Have you been experiencing any unpleasant smells that others don’t notice?
• Have you been experiencing any unusual bad tastes lately that others don’t notice?

Here are some screening questions for paranoid delusions and delusions of reference:

• Does it seem like people are talking about you?
• Are people paying special attention to you?
• Do you feel that people are out to get you?
• Does it ever seem that the television or radio is talking specifically to you?Tell me about that.

Here are some questions for some other, less common delusions:

• Do you feel that you have any special abilities? What are those?
• Do you feel that you have some special importance? What is that?
• Have you ever felt that you could read people’s minds or that they could read your mind?

Thought disorder can also be a prominent symptom. If hallucinations and delusions are present, but there are not observable symptoms of thought disorder in the client’s speech (tangentiality, disorganized; see Chapter 8), you might ask the following:

• Are you having difficulties getting organized?
• Planning?
• Getting things done?
• What does your home (bedroom) look like?
• Is it messy?
• Are you having any difficulties with feeling confused or having your thoughts feel scattered?

Question 2

How would you rule out an organic or substance-use related cause of psychosis?

What is your differential diagnosis for new-onset psychosis?

Answer 2

The medical workup!!!

• A thorough history and physical examination with emphasis on the neurological and cognitive parts are the cornerstones for the initial approach to psychosis.
• To detect fluctuations in mental status typical for a toxic psychosis, repeated visits with bedside testing of cognition may be necessary.
• The extent of the laboratory workup to complement the history and physical examination is a matter of debate, and there is no agreed-on workup.14
• For test selection, test characteristics (sensitivity and specificity) as well as the prevalence of the disease are key considerations.
• f a disease is unlikely (low prior probability), a positive test result is probably a false positive, which argues against indiscriminate screening.
• Among the tests selected for screening, the most sensitive test needs to be ordered because a negative test result removes the disease from the clinician’s differential diagnosis list.
• For example, the rapid plasma reagin (RPR) is not the most sensitive test for neurosyphilis, and a negative result could be a false negative; if one were to truly want to rule out neurosyphilis, a treponemal-specific test would be needed Further complicating test selection is the unavailability of sensitive and specific tests for many diseases.
• If there is a strong clinical suspicion for a disease, its diagnosis must be actively pursued with repeated tests (eg, serial electroencephalograms [EEGs] for epilepsy). Finally, a positive finding on an examination or a positive laboratory test result alone (eg, a urine drug test positive for cannabis) does not establish causality. This point is perhaps most relevant with regard to incidental findings on a sensitive neuroimaging modality, such as a brain MRI.
• One possible medical workup is outlined in Table The suggested laboratory battery is a compromise between broad-based screening (eg, erythrocyte sedimentation rate for inflammatory conditions) and exclusion of some specific conditions that are treatable if diagnosed (eg, HIV infection, syphilis, thyroid disease, vitamin B12 deficiency). If there is clinical concern for a delirium, EEGs, arterial blood gases, or lumbar punctures become more important.
• Of note, there is no consensus regarding the need for routine brain imaging in first-episode psychosis.
• CT or MRI may be reserved for patients with an atypical clinical presentation, neurological findings, or an unusual/treatment-refractory course. A normal baseline CT or MRI scan, however, is reassuring and can help patients and families accept that medical and neurological causes of illness have been excluded.
• The appropriate role of routine genetic screening in patients with psychosis is an area in flux. Currently, only the Clinical Practice Guidelines for the Treatment of Schizophrenia by the Canadian Psychiatric Association recommends testing for a genetic syndrome, the velocardiofacial syndrome, but only if it is clinically suspected.

Question 3

How will you clinically differentiate primary and secondary (or organic causes of psychosis? What key point in the clinical assessment MUST be covered.

Answer 3

Question 4

What is recommended a part of the Medical work up for an organic cause of psychosis?

Answer 4

Question 5

List important medications that can cause psychosis?

Answer 5

Question 7

Question 3: You suspect that this man might need to be assessed under the MHA – describe the process and how you would explain to him and his family.

Answer 7

Introduction

The Mental Health Act 2016 sets out to:

• improve and maintain the health and wellbeing of people who have a mental illness who do not have the capacity to consent to treatment
• divert people from the criminal justice system if they are of unsound mind at the time of committing an unlawful act or unfit for trial
• protect the community.

The aims of the Act are to be achieved in a way that:

• safeguards the rights of people
• is least restrictive of the rights and liberties of a person who has a mental illness
• promotes the recovery of a person who has a mental illness and their ability to live in the community.
• The Objects and Principles of the Act play a critical role in determining how the Act is to be interpreted and administered.
• A person must have regard to the principles in performing a function under the Act. 7 2.2
• Objects The main objects of the Act are: to improve and maintain the health and wellbeing of persons who have a mental illness who do not have the capacity to consent to be treated
• to enable persons to be diverted from the criminal justice system if found to have been of unsound mind at the time of committing an unlawful act or to be unfit for trial, and
• to protect the community if persons diverted from the criminal justice system may be at risk of harming others.
• The main objects are to be achieved in a way that:
• safeguards the rights of persons
• is the least restrictive of the rights and liberties of a person who has a mental illness (see below)
• , and promotes the recovery of a person who has a mental illness, and the person’s ability to live in the community, without the need for involuntary treatment and care.
• A way is the least restrictive of the rights and liberties of a person who has a mental illness if the way adversely affects the person’s rights and liberties only to the extent required to protect the person’s safety and welfare or the safety of others.
• Principles The following principles apply to the administration of this Act in relation to a person who has, or may have, a mental illness:
• Same human rights the right of all persons to the same basic human rights must be recognised and taken into account a person’s right to respect for his or her human worth and dignity as an individual must be recognised and taken into account
• Matters to be considered in making decisions to the greatest extent practicable, a person is to be encouraged to take part in making decisions affecting the person’s life, especially decisions about treatment and care to the greatest extent practicable, in making a decision about a person, the person’s views, wishes and preferences are to be taken into account
• a person is presumed to have capacity to make decisions about the person’s treatment and care and other matters under this
• Support persons to the greatest extent practicable, family, carers and other support persons of a person who has a mental illness are to be involved in decisions about the person’s treatment and care, subject to the person’s right to privac
• Provision of support and information to the greatest extent practicable, a person is to be provided with necessary support and information to enable the person to exercise rights under this Act, including, for example, providing access to other persons to help the person express the person’s views, wishes and preferences
• Achievement of maximum potential and self-reliance to the greatest extent practicable, a person is to be helped to achieve maximum physical, social, psychological and emotional potential, quality of life and self-reliance Acknowledgement of needs a person’s age-related, gender-related, religious, communication and other special needs must be recognised and taken into account a person’s hearing, visual or speech impairment must be recognised and taken into account
• Aboriginal people and Torres Strait Islanders —–
• the unique cultural, communication and other needs of Aboriginal people and Torres Strait Islanders must be recognised and taken into account Aboriginal people and Torres Strait Islanders should be provided with treatment, care and support in a way that recognises and is consistent with Aboriginal tradition or Island custom, mental health and social and emotional wellbeing, and is culturally appropriate and respectful to the extent practicable and appropriate in the circumstances, communication with Aboriginal people and Torres Strait Islanders is to be assisted by an interpreter
• Persons from culturally and linguistically diverse backgrounds the unique cultural, communication and other needs of persons from culturally and linguistically diverse backgrounds must be recognised and taken into account services provided to persons from culturally and linguistically diverse backgrounds must have regard to the person’s cultural, religious and spiritual beliefs and practices to the extent practicable and appropriate in the circumstances, communication with persons from culturally and linguistically diverse backgrounds is to be assisted by an interpreter
• Minors to the greatest extent practicable, a minor receiving treatment and care must have the minor’s best interests recognised and promoted, including, for example, by receiving treatment and care separately from adults if practicable and by having the minor’s specific needs, wellbeing and safety recognised and protected Maintenance of supportive relationships and community participation to the greatest extent practicable, the importance of a person’s continued participation in community life and maintaining existing supportive relationships are to be taken into account, including, for example, by providing treatment in the community in which the person lives 4
• Importance of recovery-oriented services and reduction of stigma the importance of recovery-oriented services and the reduction of stigma associated with mental illness must be recognised and taken into account Provision of treatment and care treatment and care provided under this Act must be provided to a person who has a mental illness only if it is appropriate for promoting and maintaining the person’s health and wellbeing Privacy and confidentiality a person’s right to privacy and confidentiality of information about the person must be recognised and taken into account. The Act also establishes principles for victims of unlawful acts

Question 8

Continue how to explain this to him and his mother, explaining what is meant by, EEA, Examination authority, Recommendation for assessment, treatment authority,

What is meant by involuntary patient?

Answer 8

Who is an involuntary patient

• An involuntary patient is: a person subject to a treatment authority a person subject to:

1. a forensic order
2. a person subject to a treatment support order
3. a person subject to an examination authority
4. a person subject to a recommendation for assessment
5. a person subject to a judicial order
6. a person detained while a recommendation for assessment is being made for the person, or a person who is absent without permission from another State and is detained in an authorised mental health service.

Emergency examination authorities are made under the Public Health Act, Persons subject to emergency examination authorities are not involuntary patients under the Mental Health Act 2016.

• Treatment authorities are made by authorised doctors.
• They authorise the involuntary treatment and care of a person for a mental illness, and, if necessary, detention in an authorised mental health service.
• Forensic orders are a forensic order (mental health), forensic order (disability) or forensic order (Criminal Code).
• Forensic orders (mental health) and forensic orders (disability) are made by the Mental Health Court to protect the safety of the community.
• A forensic order (mental health) allows the involuntary treatment and care of a person for a mental condition, and if necessary detention in an authorised mental health service.
• A forensic order (disability) allows the involuntary care of a person for an intellectual disability, and, if necessary, detention in the Forensic Disability Service or an authorised mental health service.
• Forensic orders (Criminal Code) are made by the Supreme Court or
• Treatment support orders are made by the Mental Health Court to protect the safety of the community in circumstances where a forensic order is not warranted.

Question 9

What psychopharmacological treatments could be offered to him and how would you counsel him and his family about the benefits and side effects?

First Pharmological treatment:

Answer 9

Atypical antipyshcotics

• Antipsychotic medications work by altering your brain chemistry to reduce psychotic symptoms like hallucinations, delusions and disordered thinking. They also help prevent those symptoms from returning.

Antipsychotic medication facts

• Experiences vary: all antipsychotic drugs are designed to do the same thing — reduce psychotic symptoms and keep them away — but they’re known to affect people in different ways, so your experience of taking them will be unique to you.
• Antipsychotic medications are common: in 2011, nearly 350,000 Australians had at least one prescription filled for antipsychotic medication. That’s 1.6% of the population.

Antipsychotic medication myths

• Myth: ‘You can get addicted to them’
• Reality: Antipsychotic medications aren’t addictive and you won’t need to take more over time to get the same effect.
• Myth: ‘They cure you’
• Reality: Antipsychotics reduce psychotic symptoms and distress, but they’re not a cure for mental illness.
• Myth: ‘They’re happy pills’
• Reality: Antipsychotics don’t make you feel happy no matter what. You’ll still feel normal ups and downs in your emotions.
• Myth: ‘Medication is the only treatment’
• Reality: There are many other forms of help: psychological therapies, support with housing and work, physical and occupational therapy and more.

Kinds of antipsychotic medication

• Modern medications for treating psychosis are known as ‘second-generation’ or ‘atypical’ antipsychotics. Some common atypical antipsychotics include:

1. aripiprazole
2. clozapine
3. olanzapine
4. quetiapine
5. risperidone
6. ziprasidone

These are the names of the drugs themselves, but they’re often sold under different brand names.

• Older, ‘first-generation’ or ‘typical’ antipsychotic medications are generally only prescribed if the second-generation medications aren’t working for you.
• I’m very grateful for the medication as it allowed me to sleep for the first time in five months

— Carlo

How antipsychotic medications work

• Antipsychotics change the levels of chemicals in your brain called neurotransmitters — the chemicals that carry messages around your brain. The neurotransmitter most targeted by antipsychotics is called dopamine.
• Changing the levels of these chemicals reduces, in almost all cases, the hallucinations and delusions of psychosis. In some cases, they also improve your mood and reduce anxiety.

Talking to doctors about medication

• Here’s a list of some useful things you might want to discuss with your doctor.

Tell your doctor about:

• any other medications you’re taking
• any other physical conditions you have
• your allergies.

If your doctor suggests medication, ask:

• how long will it take to start working?
• what side-effects and benefits will it have?
• how long will you need to take it for?
• Ask your doctor what is or isn’t recommended while taking medication. For example:

1. if your medication can make you drowsy, your doctor might suggest you don’t drive
2. you may need to avoid alcohol with some medications. This can be a challenge if alcohol is a big part of your social life.
3. Talk to your doctor about what is a safe amount to drink and whether other treatment options are available.
4. if you’re planning to become pregnant, tell your doctor in case any changes need to be made.

While you’re taking medication, tell your doctor immediately about:

• any side-effects you experience
• difficulty remembering to take your medication
• any changes to your physical health.

How to take antipsychotic medication

• There are two ways to take antipsychotic medication: by mouth or as a depot (sometimes called a ‘long-acting injectable’). The dose you take each time usually starts low. As your symptoms are monitored over time, your doctor might increase it or keep it at the same level.
• Medication by mouth usually means a tablet, once or twice a day. Listen to any instructions you’re given and read the pamphlet that comes with medication to make sure you follow the right method for taking them.
• Medication by depot is when you take your medication as a regular injection. The depot sits under your skin and releases the medication over two or four weeks, so you get a steady dose. It’s the same medication as the tablet.
• Depots are used when there’s a risk you might forget or stop taking your medication, which can lead to a rapid worsening of your symptoms.
• You can choose a depot yourself, but there are circumstances where a doctor can legally require you to take medication by depot, even without your consent. That’s only done rarely, and always with your health and safety in mind.

How long until they work

• It commonly takes up to six weeks from your first dose for medication to start reducing symptoms, and several months before you feel their full effect.
• How long to take antipsychotic medication
• If your psychotic symptoms reduce or go away, it doesn’t mean your medication is unnecessary. It means your medication is working — part of its job is to stop your symptoms coming back.
• When people stop taking their medication too soon or too suddenly, they are at very high risk of having another episode.
• You should have completely recovered from psychosis and had 12 months of good mental health before even starting the discussion about stopping medication.
• To give yourself the best possible chance of recovery and good health, take your doctor’s advice and, where advised, take your medication.

If you feel you need to change your medication, always do this in consultation with your doctor.

Side-effects

• All antipsychotic medications have potential side-effects. They vary from person to person, but can include:

1. drowsiness
2. weight gain
3. unusually dry or watery mouth
4. restlessness
5. trembling, especially in the limbs
6. muscle stiffness
7. dizziness
8. eyesight problems
9. moving more slowly
10. changed interest in sex, problems having sex
11. nausea
12. constipation
13. increased sweating
14. pain or irregularity in menstruation.

If you’re taking antipsychotic medication, it’s very likely you will experience some side effects. Work is being done to improve medications, but at the moment it’s often necessary to live with side-effects to reduce your active psychotic symptoms.

If you start experiencing side-effects, make sure you tell your doctor about them straightaway.

Changing medications

For some people, it can take months to find the right medication — that’s normal.

If the side-effects of the medication you’re taking are too severe, or if your psychotic symptoms don’t subside, it might be possible to try other options.

Talk to your doctor. Changing medicine can take time and will need careful guidance and observation from a health professional.

Within three months of the change in his medication, Jock took over his own life. He didn’t look back

— Jock’s mother Dianne

Safety with medication

• There are a few things you can do to make sure your experience with medication is safe:
• Tell your doctor everything: your allergies, other medication you take, your alcohol, smoking and recreational drug habits, if you’re pregnant or breastfeeding, and anything else they ask. It all helps with finding the right medication plan for you.
• Store your medication carefully: medicine doesn’t like heat or damp, so keep your medication out of bathrooms and cars. Keep it in a container in a cool, dry place. Store it high to make sure children can’t reach it.
• Don’t share medication: your medication is designed for you and no one else. Don’t take anyone else’s medication and don’t let anyone take yours. It can do real harm.
• Take the right dose: taking too little or too much reduces how effective your medicine is, and can do harm. Stick to the instructions on the packet.

Limits of antipsychotic medication

• Some people with psychotic illness find that the usual antipsychotic medications don’t reduce their symptoms over time. If this happens, your doctor may suggest clozapine, a drug which is very effective but comes with a greater risk of side effects.
• Antipsychotic medications are designed to reduce and prevent the return of psychotic symptoms, including hallucinations, delusions and disordered thinking. They may not affect the other symptoms of your illness, so you may need to get other treatments for these symptoms.
• Antipsychotic medication is considered the main treatment for psychosis, but other treatments are available.

Related: Psychosis factsheet

• Other medication you might need to take
• Along with psychosis, you may experience other mental health issues, like depression, mania, anxiety, and the ‘negative’ symptoms of schizophrenia.
• So you may be prescribed anti-anxiety medications, anti-depressants or mood stabilisers along with your antipsychotics. This is relatively common — the medications are often used together

Question 10

What are the key recommendations for FEP (first episode Psychosis RANZCP- Guideline recommendations

Answer 10

Question 11

What are key psychiatric management principles when first giving antipsychotics (THINK WHAT YOU NEED TO MONITOR/SCREEN FOR)

Answer 11

• Discuss risks and benefits of the medication with the patient beforeinitiating treatment, if feasible, and identify target symptoms (e.g.,anxiety, poor sleep, hallucinations, and delusions) and acute sideeffects (e.g., orthostatic hypotension, dizziness, dystonic reactions,insomnia, and sedation)
• .Initiate antipsychotic medication as soon as it is feasible. It may beappropriate to delay pharmacologic treatment for patients whorequire more extensive diagnostic evaluation or who refusemedications or if psychosis is caused by substance use or acute stressreactions.3.
• Use of Antipsychotic Medications in the Acute PhaseAssess baseline levels of signs, symptoms, and laboratory values relevant to monitoring effects of antipsychotic therapy.
• Measure vital signs (pulse, blood pressure,
• temperature).
• Measure weight, height, and body mass index (BMI), which can becalculated with the formula weight in kilograms/(height in meters)2or the formula 703 ×weight in pounds/(height in inches)2or witha BMI ble
• Assess for extrapyramidal signs and abnormal involuntarymovements
• .Screen for diabetes risk factors and measure fasting blood glucose.
• Screen for symptoms of hyperprolactinemia.
• Obtain lipid panel.
• Obtain ECG and serum potassium measurement before treatmentwith thioridazine, mesoridazine, or pimozide; obtain
• ECG beforetreatment with ziprasidone in the presence of cardiac risk factors.•
• Conduct ocular examination, including slit-lamp examination, whenbeginning antipsychotics associated with increased risk ofcataracts.•Screen for changes in vision.
• Consider a pregnancy test for women with childbearing potential.

TREATING SCHIZOPHRENIA •

1. Minimize acute side effects (e.g., dystonia) that can influence willingness to accept and continue pharmacologic treatment.
2. Initiate rapid emergency treatments when an acutely psychotic patient is exhibiting aggressive behaviors toward self or others.
3. Try talking to the patient in an attempt to calm him or her. • Restraining the patient should be done only by a team trained in safe restraint procedures.
4. Use short-acting parenteral formulations of first- or secondgeneration antipsychotic agents with or without parenteral benzodiazepine.
5. Alternatively, use rapidly dissolving oral formulations of secondgeneration agents (e.g., olanzapine, risperidone) or oral concentrate formulations (e.g., risperidone, haloperidol).

Question 12

CASE 2

Week 2 (Theme: Mood Disorders)
Scenario: A 37 year old man with a history of several depressive episodes is brought to ED by his partner. They are concerned because he has been acting unusually for the past few days – sleeping very little, spending large amounts of money, and embarking on risky business ventures. The patient is adamant that there is nothing wrong, saying he has ‘never felt better’. He takes citalopram which was recently increased to 40mg daily.

• What is the most likely diagnosis?
• Discuss the factors you would take into account when considering if this man should be treated in hospital.
• What change would you make to his current medication?
• What alternative medications could be started to treat his condition in the immediate and longer term?
• What is the prognosis for his condition? How would you explain this to him and his partner?

Answer 12

• Hypomania/Mania, with hx of depressive illness - Makes Type 2 bipolar likely. - Switching effect

Question 13

What is the lifetime prevalence of mood disorders (Bipolar/depression) ?

Answer 13

Question 14

Discuss the factors you would take into account when considering if this man should be treated in hospital.

Question 15

What are some screening questions to ask patients with depression to screen their cognition?

Question 16

Outline a general stepwise approach to depression management/treatment?

Answer 16

Question 17

Outline strategies to implement ‘Sleep hygiene’, in depression/mood disorders

Answer 17

Question 18

Outline, Dietary recommendations for depression/mood disorders/any condition really?

Answer 18

Question 19

Outline strategies for implementing ‘Regular excercise” into treatment:?

Answer 19

Question 20

Outline strategies to assist patients with quitting smoking?

Answer 20

Question 21

Outline ways to assist patients with substance and alcohol misuse?

Answer 21

Question 22

Outline statgeis to assist with daily functioning and routine maintenance?

Answer 22

Question 23

Outline strategies for assisting psychoeducation??? List different online resources to assist this?

Answer 23

Question 24

Outline stratgeies for implementing social support?

Answer 24

Question 25

What are the psychological therapies for acute depression, explain briefly (CBT + IPT) few more..

Answer 25

• Interpersonal and social rhythm therapy (IPSRT). The small number of existing trials of IPSRT have generated complex findings (hence its lower recommendation level in international guidelines including the MDcpg2015), with some evidence that it may be more effective for acute depressive symptoms than for maintenance treatment.

Question 26

Discuss the factors you would take into account when considering if this man should be treated in hospital

What choices of medication should be considered and why in ACUTE mania

Answer 26

• Social Support
• Insight judgement
• Previous history of well controlled symtoms in the community
• RISK ASSESSMENT:
• Medication compliance

The management of mania.

Actions:

• Severe and acute mania is a psychiatric emergency.
• The individual may have reduced insight and is subject to impulsive and risky behaviour, and thus pose a risk to themselves and others.
• Therefore, management may require hospitalisation, and acute treatment to counter any behavioural disturbance.
• The risk that mania poses should be assessed carefully († Consider inpatient treatment using mental health act).
• This includes risk to self and others, and an appraisal needs to be made of future risky decision making that may, for example, impact the individual’s reputation. In addition, it is important to assess the individual’s insight and also determine whether they are experiencing acute psychotic symptoms in the context of mania.
• This again will determine whether other Actions are possible and what treatments can be implemented and in which setting this is most appropriate.
• Assuming the individual is accepting of management strategies and amenable to persuasion, it is important to institute measures that reduce arousal, provide structure and routine, limit activity and ensure restoration of normal sleep.
• Medications that may be contributing to manic symptoms, along with alcohol and substance misuse, should be stopped and a suitable assessment should be conducted so as to determine the best setting for management and the degree of supervision required.

Question 27

What change would you make to his current medication?

What alternative medications could be started to treat his condition in the immediate and longer term?

Answer 27

• Immediately cease citalopram- due to probable switching effect.

Choices Once the appropriate

• Actions have been implemented, three elements need to be treated: mania, agitation and psychosis.
• The latter two may not be present but if agitation or psychosis are present then they will need targeted treatment (see Table 14)
• The Choices take into consideration treatment of all three components (mania, agitation, psychosis) whenever possible.
• Monotherapy is preferable as is oral administration where the individual is agreeable.
• All the indicated Choices also serve as antipsychotics, though severe psychosis may require additional medication.
• All of them also serve to quell agitation with the exception of cariprazine, which is untested in this regard.
• Antipsychotics may cause akathisia and exacerbate agitation, so this side effect must be carefully monitored and managed with dose adjustment if necessary.
• If monotherapy is insufficient, second-generation antipsychotics can be combined with a mood-stabilising agent (MSA) such as lithium or valproate and as the symptoms subside a MSA should be considered alongside any SGA already in place in order to transition to maintenance and prophylaxis.
• However, if the symptoms do not subside then Alternatives need to be considered.

Question 28

Outline flow chart in the management and things needed to be addressed and managed in Bipolar, (Think, Biopsychosocial in all management)

Outline a flow chart in choices of medication for bipolar medium to long term

Answer 28

Question 29

Outline the management for bipolar depression

Answer 29

Choices.

• The treatment of bipolar depression often takes weeks and months and so long-term tolerability is an impor-tant consideration, especially given that once the acute depressive episode resolves, management transitions to maintenance and prophylaxis.
• Hence, long-term mood stabi-lisation is the aim, and for this reason mood-stabilising agents are preferable to second-generation antipsychotics, which carry the risk of metabolic syndrome.
• For the acute resolution of symptoms agents from both classes have simi-lar efficacy, however SGAs may be slightly faster (possibly because of easier administration) and within the two classes of agents there is a slight gradient of efficacy from lithium to lamotrigine to valproate and from quetiapine to lurasidone to
• • The management of bipolar depression.This schematic summarises the treatment recommendations for the management of bipolar depression.
• It begins with measures that are necessary and form a foundation for specific treatment strategies.ActionsManagement begins with Actions that need to be undertaken to facilitate functional recovery. T
• hese Actions have been categorised further into those that have to be instituted largely by the patient such as lifestyle changes, those that must be addressed, often jointly with a specialist, such as the cessation of smoking and substance misuse and those that must be implemented such as psychological interventions and psychoeducation – usually necessitating the involvement of a psychologist and other mental health care staff such as case managers and social workers.
• These three groups of Actions are considered essential for the management of major depression.
• Building upon the foundation provided by the Actions, further pharmacological interventions – termed Choices can be considered should they be needed.
• The clinician can choose from the agents listed, which have been ranked giving mood-stabilising agents (MSAs) primacy over second generation antipsychotics (SGAs).
• This preference is based on both efficacy and tolerability. In the pharmacotherapy of bipolar depression, it is critical to bear in mind the long-term management of the disorder, and therefore, potential mood stabilising properties and long-term tolerability are important considerations.
• Within the various monotherapy Choices, mood-stabilising agents are also given preference because their blood levels can be carefully monitored.
• Overall, lithium is the first Choice followed by lamotrigine and valproate and among the SGAs quetiapine is first Choice followed by lurasidone and cariprazine.
• However, it is important to note these differences are subtle and in essence, any one of these Choice agents is suitable.
• Once suitable Choice agents have been trialled, if a satisfactory response has still not been achieved, several management options are available to achieve a suitable response and full recovery.
• These Alternatives include combinations of mood-stabilising agents and SGAs and antidepressants, both as dyads and triads.
• Once again, preference should be given to fewer medications and therefore dyads are regarded as preferable to triads. MSAs are given preference and so combinations initially begin with these agents.

Question 30

What is the prognosis for his condition?

How would you explain this to him and his partner?

Answer 30

What is bipolar disorder?

• Bipolar disorder is a mental illness that affects a person’s mood and energy levels.
• Everyone has highs and lows, but people with bipolar have extreme ups and downs in mood. These mood changes can be distressing for them and other people. They can affect how they live their life, and even put them in risky situations. Between these mood swings, however, they feel and act normally.
• People with bipolar disorder have times when their highs are extreme and they have too much energy. These highs are called ‘mania’ when severe, or ‘hypomania’ when less severe.
• Most people with bipolar disorder also have times when they feel extremely down. They can feel hopeless, helpless or empty. This is called bipolar depression.

In the past, bipolar disorder was called ‘manic depression’.

• Bipolar disorder is a lifelong condition, but with the right treatment the symptoms can be well controlled.

Types of bipolar disorder

• There are two types of bipolar disorder: bipolar I disorder (bipolar one disorder) and bipolar II disorder (bipolar two disorder).
• People with bipolar I disorder have mania, and most also have depression.
• People with bipolar II disorder have hypomania and depression.

Doctors use these categories to help them choose the right treatment.

What causes bipolar disorder?

• There is no single cause of bipolar disorder. It can be caused by different things in different people.
• We know that bipolar disorder changes how the brain works, and this causes symptoms of mental illness.
• Some things that make it more likely that someone will develop bipolar disorder are:

1. having particular genes
2. stress while a child or teenager (e.g. trauma or illness)
3. using drugs.

• There is still a lot about the causes of bipolar disorder that isn’t yet well understood.
• When someone already has bipolar disorder, their symptoms can be brought on by stress.

Who gets bipolar disorder?

• Around 1 in every 100 people will have bipolar disorder (I or II) during their life.
• It is seen in males and females, and in all countries and cultures.
• For people with bipolar I, symptoms usually begin during their late teens, with depression.
• For bipolar II, symptoms tend to start later, when the person is in their late 20s.

Symptoms of bipolar disorder

• People with bipolar disorder have extreme highs (mania or hypomania) and most also have lows (bipolar depression).

Different people have these in different combinations. For example, people can have:

• mostly mania/hypomania
• mostly depression
• depression followed by mania/hypomania
• features of both at the same time (this is called ‘mixed states’).

Between these mood swings, however, they feel and act normally.

• People with bipolar disorder usually have depression for much more of the time than they have mania or hypomania.
• Bipolar is different for everyone, but a common pattern is that someone will have at least one episode of bipolar symptoms every few years, with each episode lasting for a few months.

Some people have ‘rapid cycling’ bipolar, which means they have at least 4 episodes per year.

• Mania and hypomania - symptoms
• Depression - symptoms

Getting help for bipolar disorder

• Early medical care is vital to a good recovery. The sooner you get help, the more chance you have of getting the correct diagnosis and getting effective treatment and help to manage your problems.
• Where to get help – Australia
• Your GP (family doctor) – a GP can refer you to a public mental health service or a private psychiatrist, psychologist or private hospital clinic.
• headspace – Australia’s National Youth Mental Health Foundation.

How is bipolar disorder diagnosed?

• Bipolar disorder is diagnosed based on a person’s symptoms and behaviour.
• The diagnosis is usually made by a psychiatrist. Some GPs and clinical psychologists can also diagnose bipolar disorder.
• To make a diagnosis, a doctor needs to spend time with the person so they can understand them and their symptoms. The doctor may not make a diagnosis right away. Sometimes they might want to see how the person goes over time, before making a diagnosis.
• A medical check-up and tests are needed to make sure the symptoms are not caused by other medical conditions.

How is bipolar disorder treated?

• Treatments for bipolar disorder include:
• medications for mania, hypomania and depression
• medication to stop symptoms returning
• psychological treatments (talking therapies).
• In some circumstances, electroconvulsive therapy (ECT) might be recommended.

You and your health-care team will work together to find the treatment that works best for you.

Recovery from bipolar disorder

• Over time, a person with bipolar disorder can get to know their symptoms better, and learn how to stay well.
• While there is no cure for bipolar disorder, it can be treated effectively with medication and psychological treatment and the symptoms can be well controlled.
• This means many people with bipolar disorder can live full lives.
• Many people with bipolar disorder have responsible jobs and successful careers.

Remember

• People with bipolar disorder have unusual ups and downs in mood and energy, which can be extreme.
• Treatments for bipolar disorder include medications, psychological treatment (talking therapy) and sometimes electroconvulsive therapy (ECT).
• Bipolar disorder is a lifelong condition, but the symptoms can be well controlled. Most people with bipolar disorder live full, normal lives.

Question 31

Outline how you would explain the treatment of bipolar to the patient and his partner? Answer questions likely to be asked as seen in the answer

Answer 31

Treatment of bipolar disorder

• What works?Why should I get treatment?
• Treatments for mania
• Treatments for bipolar depression
• Psychological treatment for bipolar disorder
• Medication for bipolar disorder
• Will I have to go to hospital?
• Can I be forced to have treatment?

Treatment for bipolar disorder has two main aims:

• to deal with symptoms when they occur
• to stop symptoms from coming back.

Treatments include:

• medications for mania, hypomania and depression
• medication to stop symptoms returning
• psychological treatments (talking therapies).
• In some circumstances, electroconvulsive therapy (ECT) might be recommended.

You and your health-care team will work together to find the treatment that works best for you.

• Most people with bipolar disorder will need medication to control symptoms.
• Psychological treatments can help you deal with depression, live well with bipolar disorder, and control stress (which can set off mania).

What works?

• People with bipolar disorder do best if they:
• get the right medications
• get psychological treatment
• get education about their illness (individual psychoeducation)
• have a supportive partner, family member or friend involved in their care
• have access to 24-hour crisis support
• have a mental health professional who takes care of planning and coordinating their individual care
• have support to find a job or continue education
• have somewhere safe and affordable to live
• have a healthy lifestyle (eat well, stay physically active, quit smoking and other drugs, get regular sleep).

Why should I get treatment?

The right treatment can help you:

• control your symptoms, thoughts, feelings and actions
• get back to school, study or work
• keep your friendships and social life
• avoid suicidal thinking or self-harm
• stay healthy.

Treatments for mania

• If you have mania, you need urgent care from a doctor – even if you feel great.
• You will need medication, and you may need to go to hospital. Severe mania is a medical emergency.

Medications for mania include:

• short-term sedatives to calm you down when the symptoms are at their worst.
• antipsychotic medications, such as aripiprazole, asenapine, haloperidol, olanzapine, quetiapine, risperidone and ziprasidone
• mood-stabilising medications such as lithium, sodium valproate and carbamazepine.
• These treatments can also be used to treat hypomania.
• ECT is occasionally used to control some types of severe mania. It is a safe and effective treatment.

Treatments for bipolar depression

• A combination of medication and a psychological treatment (talking therapy) is the best treatment for bipolar depression.

Medications for treating bipolar depression include:

• antipsychotic medications, such as quetiapine
• mood-stabilising medications, such as lithium
• a combination of an antidepressant medication and a mood stabiliser.
• Antidepressants can sometimes set off mania. People with bipolar depression should only have antidepressants in combination with medications that prevent this happening (mood stabilisers).
• ECT is sometimes used for people with severe bipolar depression.

Psychological treatment for bipolar disorder

• Psychological treatment aims to help you learn skills to:
• cope with having bipolar disorder
• have fewer episodes of mania or depression
• recognise the signs of mania or depression early, so you can get treatment
• improve your quality of life.
• Treatments are provided by trained therapists (e.g. psychiatrists, other doctors, or psychologists).

Psychological treatments that are effective for bipolar disorder include:

• cognitive behavioural therapy (CBT) – a type of psychological treatment that asks you to challenge unhelpful thoughts.
• psychoeducation – a program to help you become an expert in managing your own illness
• family-focused therapy – helps whole families learn to communicate and solve problems better, to reduce stress on the person with bipolar disorder
• interpersonal and social rhythm therapy – aims to reduce stress, improve relationships, and set up a pattern of regular sleep.
• For psychological treatment to work, you and your therapist need to work well together. This means being honest, and being able to trust them.

More about psychological treatments

• Medication for bipolar disorder
• Getting the most out of your bipolar disorder medication
• Take every dose of your medication at the time recommended to you by your psychiatrist.
• When starting a medication, give it time to start working properly.
• Don’t change your medication without talking to your psychiatrist.
• If you have symptoms that you think could be a side effect of medications, tell your doctor as soon as possible.

Side effects of medication

• Bipolar disorder medications can sometimes cause side effects, especially when you start a new medication.
• Side effects differ between medications and between people. Ask your doctor or pharmacist to explain the possible side effects of your medication. You can ask for a printed leaflet, or read about the medication at:

If you have side effects that bother you, speak to your doctor about them. They will carefully assess how the medication is working for you as well as the side effects. They might be able to reduce the side effects by changing the dose of the medication, or switching to a different medication. Some side effects can be treated with other medications.

Some medications for bipolar disorder can cause problems such as:

• nausea
• headache
• weight gain
• fluid retention
• drowsiness or sleepiness
• constipation
• sexual problems (e.g. problems getting an erection, not feeling aroused, or problems reaching orgasm)
• increased levels of blood fats (lipids) and glucose
• high blood pressure
• breast problems
• skin problems
• dizziness or light-headedness
• problems with nerves and muscles
• blurred vision
• dry mouth.

Most people will only have one or two side effects.

• How long will I have to keep taking medication?
• Most people need to keep taking medication long-term to stop symptoms returning.
• After recovering from mania or depression, you will normally need to continue your medication for weeks or months. After that, your doctor may adjust your treatment.
• If you take your medication regularly, you have less chance of having mania or depression. Some people will be advised to keep taking medication for many years.

Will I have to go to hospital?

• Your usual treatment will involve regular visits to your GP, hospital outpatient clinic, a psychiatrist, a psychologist or other therapist.
• There may be times when you need to stay in hospital. If you have severe mania or depression, going to hospital will keep you safe, allow for close monitoring of medications and get your symptoms under control.
• Your doctor may also arrange a hospital stay if you are at risk of harming yourself or other people, or if you have not been eating or drinking enough.

About psychiatric hospitals

Can I be forced to have treatment?

• Having mania or hypomania stops you being able to think clearly and avoid risks. At the time, you may not believe you need treatment.
• You can be given treatment without your consent if you are at risk of harming yourself or others. This is called involuntary treatment. If the risks are very severe you may have to spend time in hospital while you receive treatment.
• If this happens, your doctor should give you a booklet that explains your rights. If you don’t get a booklet, ask for it.
• Involuntary treatment can only continue while it is necessary to keep you safe. You, and your family or carers, have the right to have the decision reviewed by an independent authority, such as a court or tribunal

Question 32

Outline the management principles for maintenance therapy for bipolar?

Answer 32

Question 33

Week 3 (Theme: Anxiety Disorders)
Scenario: A 22 year old woman tells her GP that she is becoming increasingly reluctant to socialise due to anxiety. She is not significantly depressed and has no psychotic symptoms. She is not taking any medication and does not drink alcohol or take any substances.

• What anxiety disorders would you include in a wide differential diagnosis?
• What questions would you ask to narrow the differential diagnosis?
• Discuss the treatment options from a biopsychosocial approach for social phobia and agoraphobia.
• What medical conditions might you want to rule out?
• How would you explain anxiety disorders to the patient?

Resources: RANZCP clinical practice guidelines Anxiety disorders https://www.ranzcp.org/files/resources/college_statements/clinician/cpg/anxiety-cpg.aspx

https: //www.yourhealthinmind.org/mental-illnesses-disorders/anxiety-disorders
https: //www.yourhealthinmind.org/mental-illnesses-disorders/anxiety-disorders/treatment-for-anxiety-disorders

Answer 33

What anxiety disorders would you include in a wide differential diagnosis?

• Generalised anxiety disorder
• Phobia
• Panic disorder
• Social anxiety
• OCD
• Avoidant personality disorder (APD)
• Agoraphobia
• Somatoform disorder
• Substance related anxiety disorder (CNS depressant withdrawal, e.g benzos)
• Situational anxiety
• Hyperthyroidism
• IBS?

—> actually social/agoraphobia

Question 34

What questions would you ask to narrow the differential diagnosis?

What is screening tool test used to assess GAD?

Answer 34

The following brief screening questions during the clinical interview can assist in the recognition of social anxiety cues, symptoms, and behaviors:

• Do you feel anxious or uncomfortable being around other people?
• Do social situations make you feel anxious or nervous?
• Are you worried about being embarrassed or criticized by others?
• In what ways has this anxiety interfered with your life? Are you avoiding situations because of your anxiety?
• Do you have to use alcohol or other substances in order to feel comfortable in social situations?

For the Diagnosis of GAD you need the following:

In adults, at least three of the following key symptoms are required to make a diagnosis in addition to a predominant picture of chronic, excessive worry for 6 months that causes distress or impairment (only one item is required in children):[1]

• Muscle tension
• Sleep disturbance
• Fatigue
• Restlessness or sense of feeling ‘on edge
• Irritability
• Poor concentration.

Other symptoms may include muscle aches, sweating, dizziness, shortness of breath, chest pain, nausea, diarrhoea, or other gastrointestinal complaint

the GAD-7 -

Question 35

Outline the initial assessment, treatment/managment a patient presenting with anxiety symptoms.

Answer 35

Question 36

• Discuss the treatment options from a biopsychosocial approach for social phobia and agoraphobia

Describe first principles of management of anxiety disorders (refer to picture)

Answer 36

Question 37

Outline principles of CBT and how CBT and psychotherapies can be delivered in anxiety disorders

Answer 37

• Treatments for anxiety disorders

Psychological interventions. CBT with an experienced therapist has been studied more than other psychological therapies and is supported by numerous meta-analyses (Craske and Stein, 2016).

• Related psychological therapies, such as

1. prob-lem-solving
2. relaxation
3. interpersonal therapy
4. cognitive bias modification
5. mindfulness
6. or psychodynamic approaches,
7. • ALL appear to be of benefit but the evidence base is smaller.
   • CBT is typically staged and involves education about the condition, arousal management, graded exposure, safety response inhibition, surrender of safety signals and cognitive strategies
   • It should be noted, however, that CBT is a broad term encompassing a variety of component strategies.
   • Specific CBT programmes can vary and not all are equally efficacious for a given disorder
   • For about half of the par-ticipants in clinical trials of CBT, symptoms improve to the point that they no longer meet criteria for the disorder.
   • Dis-ability decreases and quality of life improves

Mode of delivery of CBT.

• CBT can be delivered face-to-face (individual or group)
• through digital CBT (dCBT) accessed by computer, tablet or smartphone application, or through self-guided CBT books for patients (self-help books).
• Face-to-face delivery of CBT (particularly individual therapy) has been the most extensively studied with effi-cacy supported by meta-analyses (Craske et al., 2005)
• dCBT is a rapidly growing field and there is now an evi-dence base for dCBT. .

Question 38

Outline how to assess, diagnose, and treat social anxiety disorder/agoraphobia:

• Whats important things to note in these conditions

How can they be differentiated from other mental health conditions

Answer 38

Panic disorder and agoraphobia

Assessment The aims of assessment are as follows:

• To establish a good therapeutic relationship;
• To establish a primary diagnosis of panic disorder (including distinguishing between normal and pathological anxiety) and to determine whether agoraphobia is also present;
• To rule out differential diagnoses;
• To identify comorbid disorders that may affect treatment and outcome;
• To identify predisposing, precipitating and perpetuating biopsychosocial and lifestyle factors.

Comprehensive assessment includes obtaining information about all of the following:

• The nature, severity and duration of symptoms, avoidance behaviours and use of safety behaviours;
• The degree of distress and functional impairment;
• The presence of comorbid anxiety or mood disorders, substance use (including tobacco, illicit substances, prescribed and over-the-counter medications and other substances such as caffeine and ‘energy’ drinks) and medical conditions;
• Personal and family history of mental health disor-ders, and personal history of chronic health prob-lems, domestic violence or sexual abuse;
• Experience of, and response to, past treatments;
• The quality of interpersonal relationships, and socialsupport network, living conditions, social isolation, employment status including work environment, and immigration status;
• Safety, including suicide risk;
• Medical evaluation including system review and appropriate physical examination and blood tests including, at a minimum

1. Thyroid function tests
2. Urea and electrolytes (U&E)
3. Full blood count (FBC)
4. Blood glucose level (BG)
5. Electrocardiography(ECG) if cardiac symptoms or relevant family his-tory (e.g. arrhythmias);

The patient’s goals and expectations of treatment.

People with panic disorder:

• Experience recurrent, unexpected panic attacks;
• Are persistently concerned about having another panic attack or the consequences of a panic attack (e.g. that they are having a heart attack or losing control);
• May change their behaviour in ways which are designed to avoid having further panic attacks (e.g. avoiding situations from which escape may be difficult or where help might not be available in case of a panic attack).
• A panic attack is an abrupt surge of intense fear or discomfort that reaches a peak within minutes (Table 6).
• The person often feels that they have to do something urgently (e.g. escape to a safer place).
• The requirement that panic attacks need to be recurrent for a diagnosis of panic disorder is to ensure a high threshold for diagnosis, because non-recurrent panic attacks are relatively common in the population
• The surge of anxiety that occurs in the context of exposure to a dangerous situation is not conceptualised as a panic attack, despite it having similar physical symptoms, as the ‘catastrophising’ cognitive symptoms do not occur.

Question 39

What are common conditions associated with panic attacks or panic-like symptoms?

Answer 39

Question 40

What are scoring systems associated with panic disorders?

Answer 40

Question 41

Outline Recommendations for the treatment of panic disorder:

part 1

Answer 41

Question 42

Outline Recommendations for the treatment of panic disorder:

part 2 (TREATMENT panic social anxiety similair)

Answer 42

Question 43

What is GAD

Answer 43

Generalised anxiety disorder

Diagnosis

All people worry about things that have a possibility of going wrong, but can temporarily dismiss their worries so that they can get on with the task in hand.

People with GAD

• Worry excessively over a succession of everyday things – some within their control and some not (e.g. relationships, family, finances, work, study, illness, community and world affairs), and worry excessively about things within their control going wrong in catastrophic and improbable ways.
• Are troubled by persistent restlessness, a feeling of being on edge or muscle tension.

Question 44

Outline an assessment for GAD,

How do we differentiate GAD from non-pathological worry?

Answer 44

Assessment The aims of assessment are as follows: •

• To establish a good therapeutic relationship;
• To establish a primary diagnosis of GAD;
• To rule out differential diagnoses;
• To identify comorbid disorders that may affect treatment and outcome;
• To provide a foundation for treatment planning.

Comprehensive assessment includes obtaining information about all of the following:

• The severity and duration of worry;
• The degree of distress and functional impairment;
• Substance use disorders and medical conditions;
• Comorbid depressive or anxiety disorders;
• Personal and family history of mental disorders;
• Experience of, and response to, past treatments;
• The quality of interpersonal relationships, living conditions and employment;
• The patient’s goals and expectations of treatmen

Differential diagnosis

Distinguishing GAD from non-pathological worry.

Several features of the worries distinguish GAD:

• The amount of worry is more frequent, more extreme and out of keeping with the threat posed by the adverse event, should it occur.
• People with GAD report spending much more time per day worrying than non-clinical populations
• And, although many people worry when there is a problem, people with GAD worry about the future even when things are going well (e.g. worrying about the health of children even when they are not sick).
• The worry is highly pervasive, pronounced, difficult to control and frequently occurs without precipitant (e.g. patients’ report that the worry is intrusive, hard to stop, comes into their minds when they want to concentrate on other things).
• The history of excessive worry has a long duration (years rather than hours or days).
• The worrying impacts on the patient’s quality of life; it is distressing or disabling (e.g. it is associated with muscle tension, impaired sleep, relationship difficulties and reduced work productivity).

Question 45

What are two screening/self reporting tools for GAD?

Answer 45

Question 46

What are the treatment recommendations for GAD?

Answer 46

Question 47

Discussing anxiety disorders to patients:

Answer 47

Types of anxiety disorders

• Generalised anxiety disorder
• Social anxiety disorder
• Panic disorder
• Agoraphobia
• Specific phobia

These are the most common types of anxiety disorders.

Generalised anxiety disorder

• People with generalised anxiety disorder worry much of the time about all sorts of everyday things – to do with work, finances, health or family for example. They worry something terrible might happen, even if there’s no real reason to think so.
• They can’t stop feeling anxious, even though it’s affecting their life.
• For example, they might not want to drive a car because they’re worried about having an accident.
• They often ask for reassurance that the terrible things they fear won’t happen.
• People with generalised anxiety disorder don’t sleep well, and often complain of headaches and muscle tension in their necks and shoulders.

Social anxiety disorder

• Someone with social anxiety disorder worries about other people noticing their anxiety and thinking less of them because of it.
• Being the centre of attention is a problem for them.

For example, they might feel anxious about:

• meeting new people
• speaking or performing in front of other people
• going to meetings or parties
• catching public transport
• being watched while eating or drinking.
• They worry that they might do something embarrassing, or that other people might notice that they’re anxious.
• They will avoid situations where other people could notice their anxiety.

Normal shyness isn’t social anxiety disorder.

Anxiety creeps in over a long period of time. I think I lived with anxiety for years and years before I knew what it was.

Panic disorder

• Someone with a panic disorder has repeated panic attacks, which seem to happen for no particular reason, and then they worry a lot about having more panic attacks.
• A panic attack is a sudden surge of fear or anxiety in situations where others would not be afraid.

Agoraphobia

• Agoraphobia is when someone is very fearful about certain situations, because they’re afraid that they might have a panic attack, or something awful might happen to them. They then go out of their way to avoid these situations.
• Someone with agoraphobia would be very anxious about:
• using buses, trains, trams, or planes
• being in open spaces (car parks, bridges, parks)
• being in enclosed places (shopping centres, cinemas)
• being in a crowd.

Specific phobia

• If someone is very fearful of one particular thing or situation, they might have a specific phobia.
• People can have phobias about things such as:
• animals – for example spiders or dogs
• flying in aeroplanes
• heights
• getting an injection.

The fear is usually out of proportion to the actual danger, and can cause problems with people’s day-to-day lives. For example, someone might refuse to go for a walk in the park because they’re worried about dogs.

Problems that are related to anxiety disorders are PTSD and OCD.

Question 48

How would you explain treatment of anxiety disorders to patients?

Answer 48

Treatment for anxiety disorders

• Psychological treatment
• Online CBT
• Face-to-face
• CBT
• Exposure therapy
• Medication

The recommended treatment for anxiety disorders is psychological treatment (usually cognitive behavioural therapy).

If this hasn’t worked, or if you have very severe anxiety, your doctor might recommend medication as well.

It’s best to try psychological treatments first. They can work just as well as medication. Discuss the options with your doctor.

Psychological treatment

• The best type of psychological treatment for anxiety disorders is cognitive behavioural therapy (CBT).
• When you do CBT you will start by learning about healthy anxiety and the way our brains handle anxiety. Then you will learn how to challenge your unhelpful thoughts and control your anxious thoughts and behaviours.
• If the treatment is working you should see an improvement in 4–8 weeks.

Online CBT

• You can get self-guided CBT online. It can be low cost or even free, and you can do it where and when suits you. Online CBT from these websites has been shown to work well for anxiety:

1. This Way Up(Australia; free and paid)
2. MindSpot Australia; free)
3. Mental Health Online

• Face-to-face CBT
• You can do CBT face-to-face with a qualified therapist – usually a psychologist or psychiatrist. Around 8–12 sessions are recommended.

More about psychological treatments

Exposure therapy

• Exposure therapy is sometimes part of CBT. It’s where you gradually confront a situation that makes you anxious.
• First, you make a list of all the things you’d like to do, but currently can’t. Then you start by doing the easiest thing, and gradually work your way up to the hardest.
• For example, if you are anxious about train travel, your list might look like this:

1. Spend some time on the train platform
2. Travel one stop with a friend
3. Travel one stop alone.
4. Travel to the city alone at a quiet time.
5. Travel to the city alone at a busy time.

Medication

• In general, you should only be treated with medication if psychological treatments haven’t worked.
• However, if you have a severe anxiety disorder or severe depression, your doctor will probably recommend both medication and psychological treatment from the start.

Types of medications used for anxiety

• The best medications for anxiety disorders are antidepressants. Antidepressants work well for anxiety as well as depression.
• The antidepressants most often used to treat anxiety are the selective serotonin reuptake inhibitors (SSRIs). Examples are fluoxetine and citalopram.
• SSRIs aren’t suitable for some people, so your doctor might recommend a different type of antidepressant instead – a serotonin and noradrenaline reuptake inhibitor (SNRI). Examples are venlafaxine and duloxetine. In some cases, your doctor might recommend other antidepressants.
• Benzodiazepines (also called sleeping pills) are sometimes used to treat anxiety, but they are no longer recommended as an initial treatment. This is because they’re addictive, and their effects don’t last long.

Question 49

Week 4 (Theme: Eating Disorders)

Scenario: As a GP you are asked to see an 18-year-old woman who was brought to the surgery by her mother. The mother says that she is very concerned because her daughter is eating next to nothing and is exercising excessively. The young woman is clearly upset but says nothing. In an attempt to get her to talk more freely, you ask to speak to her alone, The young woman looks very thin.

• What questions would you want to ask her to clarify the extent of her eating problems?
• You discover that the woman regularly vomits after episodes of binge eating. Her BMI is 16. What medical complications, related to starvation and vomiting should you be concerned about?
• What is re-feeding syndrome and how is it managed?
• What is the longer term treatment for anorexia nervosa and bulimia nervosa? How can you distinguish between these two diagnoses?

Answer 49

Two subtypes of anorexia nervosa are specified:

• restrictive type (with or without compulsive exercise);
• and binge eating/purging type, with binge eating (uncontrolled overeating) and purging (vomiting, laxative or diuretic misuse).

Severity is specified according to BMI (kg/m2) status.

What is bullimia?

Bulimia nervosa and binge eating disorder are both defined in the DSM-5 by having regular and sustained binge eating episodes. People with bulimia nervosa also compensate for binge eating with regular extreme weight control behaviours (such as purging). As they do not engage in such compensation regularly, people with binge eating disorder are likely to be overweight or obese. People with bulimia nervosa also have a self-view that is unduly influenced by weight and shape overvaluation.

What is the aeitology of eating disorders?

• strongest risk factor being female
• First world ideals
• genetic heritability- a fmaily history of ‘leaness’, may be associated with eating disorders
• early menarche -controlling body weight
• epigenetics
• psycholgical factors: mostly LOW self esteem which is prevalent in all eating disorders
• high levels of clinical perfectionism
• emotional abuse/sexual abuse - lead to maladaptive coping mechanisms

Question 50

What important factors from history need to be asked?

Think how you can phrase questions about diganosis/and signs and symptoms related to the condition:

Answer 50

Question 51

Outline comphrehensive assessment of eating disorder

Part 1

Answer 51

Question 52

OUtline comphrensive assessment: Part 2

Answer 52

Question 53

What are the recommendations for the management of Anorexia nervosa

Answer 53

Question 54

You discover that the woman regularly vomits after episodes of binge eating. Her BMI is 16. What medical complications, related to starvation and vomiting should you be concerned about?

What investigations need to be ordered?

Answer 54

Investigating any medical complications and the current level of medical risk.

This is essential and should include a brief physical examination including measurement of:

• Weight, height, calculation of BMI, seated and standing pulse rate to detect resting
• Bradycardia and/or tachycardia on minimal exertion due to cardiac deconditioning,
• Blood pressure (seated and standing) and temperature. These findings are needed to determine if immediate hospital admission is required =

Investigations

• should include serum biochemistry to detect hypokalaemia, metabolic alkalosis or acidosis, hypoglycaemia, hypophosphataemia, and hypomagnesaemia,
• serum liver function tests
• serum prealbumin levels
• Full blood examination looking for evidence of starvation-induced bone marrow suppression such as neutropaenia
• Electrocardiogram (ECG). A bone mineral density scan should be performed routinely

If the person has been underweight for six months or longer with or without amenorrhea and there after every two years whilst still struggling with an eating disorder . The assessment should also include any history of fainting, lightheadedness, palpitations, chest pain, shortness of breath, ankle swelling, weakness, tiredness and amenorrhoea or irregular menses

Answer: Refeeding syndrome

Refeeding syndrome. Refeeding syndrome is a serious and potentially fatal medical complication of aggressive refeeding of an individual who has been malnourished for a lengthy period.

• Refeeding syndrome is understood to be due to the switch from fasting gluconeogenesis to carbohydrate-induced insulin release triggering rapid intracellular uptake of potassium, phosphate and magnesium into cells to metabolise carbohydrates
• This, on top of already low body stores of such electrolytes due to starvation, can lead to rapid onset of hypophosphataemia, hypomagnesia and hypokalaemia.
• In addition, insulin-triggered rebound hypoglycaemia can occur, exacerbated by the fact that such patients have depleted glycogen stores.
• The risk factors for refeeding syndrome include

1. The degree of malnutrition and adaptation to this state
2. The levels of serum minerals and electrolytes such as phosphate and potassium and the rate of provision of carbohydrate in relation to other nutrients

There is a wide range of opinion as to ideal starting doses of nutrition for adults with anorexia nervosa, with often little evidence to support the varied opinions

Traditionally, it has been thought that the risk of refeeding syndrome can be reduced by ‘starting low’ and ‘going slow’ with nutrition, and monitoring
serum phosphate, potassium and magnesium daily for the first 1–2 weeks of refeeding, and replacing these electrolytes immediately if they fall below normal range

• All authors agree on the importance of regularly monitoring and replacing phosphate, potassium and magnesium.
• However, traditional recommendations for refeeding designed to prevent refeeding syndrome are now seen by many to be too conservative, and unnecessarily put the severely malnourished person at risk of ‘underfeeding syndrome’ and further medical deterioration.
• Findings from case series studies range from those reporting large numbers of adolescents being fed on relatively high initial rates of up to 8400kJ of low carbohydrate continuous nasogastric feeds with supplemental phosphate without causing refeeding syndrome
• To those of severely malnourished adults reporting that 45% of participants developed significant refeedinginduced hypophosphataemia with much lower mean initial refeeding doses of 4000kJ/day
• Thus, refeeding syndrome has been observed even with very low initial feeding doses, and initial dose has not been shown to be a predictor of refeeding hypophosphataemia or refeeding syndrome

In light of the conflicting and inadequate literature, the CPG group recommend taking a
‘middle path’ with adults, commencing refeeding at 6000kJ/day.

• This should be increased by 2000kJ/day every 2–3 days until an adequate intake to meet the person’s needs for weight restoration is reached.
• This diet should be supplemented by phosphate at 500mg twice daily and thiamine at least 100mg daily for the first week, and thereafter as clinically indicated for people at high risk of refeeding syndrome (e.g. BMI <13).
• For people at high risk of refeeding syndrome, commencing with continuous nasogastric feeding with low-carbohydrate preparations (i.e. 40–50% of energy from carbohydrates) seems prudent to avoid triggering postprandial rebound hypoglycaemia due to insulin secretion in people with inadequate glycogen stores.
• The most important aspects of preventing refeeding syndrome are a heightened physician awareness of the syndrome, and regular monitoring of the person’s clinical status, including physical observations and biochemical monitoring, especially to guide phosphate prophylaxis or supplementation.
• Refeeding protocols should, however, be individualised where necessary to minimise bot
• the risk of refeeding syndrome and complications due to underfeeding, and involve the input of a dietician experienced in the treatment of eating disorders.
• Methods of nutritional provision include supervised meals, high energy high protein oral liquid supplements and nasogastric feeding.
• On very rare occasions where the above methods are unable to be utilised, parenteral nutrition may be indicated.
• The least intrusive and most normal method of nutrition that can be reliably provided should be used.

Question 55

What is the longer term treatment for anorexia nervosa and bulimia nervosa?

How can you distinguish between these two diagnoses?

Answer 55

Assessment for Bullimia

Question 56

Outline recommendations for assessment and treatment of Bullimia

Answer 56

Question 57

What are the major differences in criteria between the DSM criteria for diagnosis of the various eating disorders?

Answer 57

Question 58

What is your differential diagnosis for anorexia nervosa like symptoms? (eating disorder)

Answer 58

Question 59

What are clinical indicators for medical, vs psychiatric admission?

Answer 59

Question 60

What are various Physical and biochemical findings and their associated management?

List in according to system: e.g Cardiac: Bradycardia, Qt prolongation

Answer 60

Question 61

Outline Physical and laboratory findings and their management. (continued)

E.g skin, GI, Haem, dental

Answer 61

Question 62

Week 5 (Theme: Substance Use Disorders)
Scenario: A 41 year old woman is with a 10-year history of severe alcohol use disorder presents requesting support to cease using alcohol.

• How would you approach taking a history of substance use? What questions would you ask?
• What are the major risks of alcohol detoxification?
• What are the contraindications to outpatient detoxification?
• How do you identify and treat Wernicke’s encephalopathy?
• What pharmacological and psychological treatments can be offered for alcohol use disorder after detoxification to prevent relapse?

Answer 62

Screening tools

• There are two major brief screening tools used in practice to identify signs of hazardous drinking and dependence:

1. CAGE questionnaire: a brief, easy to use screening test consisting of only four questions.
2. AUDIT-C: a shortened version of the AUDIT screening tool, consisting of three questions.

CAGE

• The CAGE questionnaire is often used in general history taking to briefly screen for problematic alcohol issues.
• The CAGE questions should not be preceded by any questions about alcohol intake as its sensitivity is dramatically enhanced by an open-ended introduction.

CAGE introduction

• “I’m going to ask some general questions about your alcohol use and how it affects you.”

CAGE questions

1. Have you ever felt that you should Cut down on your drinking?
2. Have people Annoyed you by criticising your drinking?
3. Have you ever felt bad or Guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (known as an Eye-opener)?

Interpretation

• The patient should be given 1 point for each question they answer yes to.
• A score of over 2 suggests problematic drinking.

AUDIT-C

AUDIT-C introduction

• “Now I am going to ask you some questions about your use of alcoholic drinks during this past year.”
• AUDIT-C questions

How often do you have a drink containing alcohol?

• Never – 0 points
• Monthly or less – 1 point
• 2 to 4 times a month – 2 points
• 2 to 3 times a week – 3 points
• 4 or more times a week – 4 points

How many units of alcohol do you drink on a typical day when you are drinking?

• 1 or 2 drinks – 0 points
• 3 or 4 drinks – 1 point
• 5 or 6 drinks – 2 points
• 7 to 9 drinks – 3 points
• 10 or more drinks – 4 points

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

• Never – 0 points
• Less than monthly – 1 point
• Monthly – 2 points
• Weekly – 3 points
• Daily or almost daily – 4 points

Interpretation

If a patient scores 3 or more out of 12, the full AUDIT questionnaire should be asked.

Origin of the drinking problem

• Ask the patient when they first noticed an increase in their alcohol intake and try to identify any factors that played a role in this:
• “When did you first notice an increase in the amount of alcohol you were drinking?”
• “Was there anything going on at the time that played a role in this?”

Current drinking pattern

• Assess the patient’s current drinking pattern:
• “How often do you drink alcohol?”
• “Do you drink alcohol every day?”
• “Do you drink alcohol every week?”
• “Do you drink alcohol at a particular time of the day?”
• Quantification of alcohol intake
• Quantify the patient’s alcohol intake:
• “How much do you drink on an average day?”
• “How much do you drink in an average week?”
• “What kind of alcoholic drinks do you drink?”
• “Is there anything that makes you drink more or less in a day?”
• “How much do you spend on alcohol each week?”

It may be useful to write down alcohol intake on a piece of paper (Monday – Sunday with approximate timings and drinks had). This ensures a history which is as comprehensive as possible and accounts for varied intake across the week.

Drinking behaviours

Ask about the patient’s drinking behaviours:

• “Where do you drink?”
• “Who do you drink with?”

Previous attempts at abstinence

Ask if the patient has previously attempted to stop drinking:

• “Have you ever tried to stop drinking before?”
• “What happened when you tried?”
• “Did you have any support?”
• “Why do you think it was unsuccessful?”

Impact of alcohol

• Dependence
• Screen for evidence of alcohol dependence including biological and psychological signs.
• Biological signs of dependence

Screen for biological signs of dependence:

• “If you stop drinking, do you…get the shakes/sweat a lot/feel sick/notice any physical changes?”
• “Do you have to drink more than you used to, to get the same effects?”

Psychological signs of dependence

Screen for psychological signs of dependence:

• “Do you feel a compulsion/need to drink?”
• “How important is drinking to you?”
• “If you stop drinking, do you notice that you…feel down/angry/anxious?”
• Effects on day to day life
• Relationships
• Ask if alcohol has impacted the patient’s relationships with others:
• “Has alcohol impacted any of your personal relationships?”
• “How has it affected them?”

Occupation

• Ask if alcohol has impacted the patient’s job:
• “Has alcohol had any impact on your job or ability to work?”

Driving

• Explore of the patient currently drives, as this has significant safety and legal implications:
• “Do you currently drive?”
• “What kind of vehicle do you drive?”
• “Do you drive for work?”
• “Have you ever driven whilst under the influence of alcohol?”

Diet

Ask what the patient’s diet looks like on an average day and if they feel alcohol is negatively affecting it:

• “What does your diet look like on an average day?”
• “Do you feel that alcohol impacts the way in which you eat?”
• Alcohol-related crime
• Ask if the patient has ever had involvement of the police for alcohol-related issues:
• “Have you ever committed a crime or had the police involved as a result of your drinking?”

Psychological assessment

• Perform a brief assessment of the patient’s current mood to identify signs of depression:
• “During the past month have you felt low, depressed or hopeless?”
• “Have you recently had little interest or pleasure in doing things?”

Screen for thoughts of self-harm or suicide:

• “Have you had any thoughts of hurting yourself?”
• “Have you ever thought of ending your life?”
• Screen for thoughts of harming others:
• “Do you ever have thoughts of harming others?”
• Past medical history
• Ask if the patient has any medical conditions:
• “Do you have any medical conditions?”
• “Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Ask if the patient has previously undergone any surgery or procedures (e.g. banding of oesophageal varices):

• “Have you ever previously undergone any operations or procedures?”
• “When was the operation/procedure and why was it performed?”

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).

• Alcohol-related medical conditions
• Alcohol-related medical conditions include:
• Alcoholic hepatitis
• Liver cirrhosis
• Epistaxis
• Upper gastrointestinal bleeding
• Pancreatitis
• Dilated cardiomyopathy

Drug history

• Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:
• “Are you currently taking any prescribed medications or over-the-counter treatments?”
• If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.
• Identify medications whose side effects are potentiated by alcohol (e.g. benzodiazepines).

Ask the patient if they’re currently experiencing any side effects from their medication:

• “Have you noticed any side effects from the medication you currently take?”

Social history

• Explore the patient’s social history to understand their social context.
• General social context
• Explore the patient’s general social context including:
• the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
• who else the patient lives with and their personal support network (if children at home, consider if social services need to be involved)
• what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
• if they have any carer input (e.g. twice daily carer visits)

Smoking

• Record the patient’s smoking history, including the type and amount of tobacco used.
• Recreational drug use
• Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.

Gambling

• Ask the patient if they gamble and if they feel this is a problem.
• Gambling is causative of several decrements to health directly, such as increased sedentary behaviour during the time spent gambling, poor sleep, reduced levels of self-care and anxiety. Patients with a gambling problem are also more likely to have substance misuse issues.1
• Problematic gambling can be assessed via the Problem Gambling Severity Index (PGSI).

Closing the consultation

• Thank the patient for their time.
• Offer leaflets about alcohol dependence and the negative health impact of alcohol.
• Offer referral to an alcohol rehabilitation service if appropriate.
• Dispose of PPE appropriately and wash your hands.

Question 63

What are complications of alcohol use disorder?

Answer 63

Question 64

What is delirum tremenens ? When does it present? What symptoms are common in this situation

(what is the most complication associated with this that leads to death)?

What is wernickes-korastoff syndrome? what is it caused by? How is it treated? What are common risk factors and findings on hx and examination for these patients:

Answer 64

Alcohol-use disorder - Complications |

Delirium tremens (DT) is a clinical condition that appears in about 5% of patients affected by severe alcohol withdrawal syndrome. It usually develops 2 to 4 days after decrease or discontinuation of chronically high alcohol intake.

DT is characterised by signs and symptoms including confusion, perceptual disturbances, and hallucinations (in particular micropsia and macropsia), tremor, altered sleep-wake cycle, changes of psychomotor activity, paroxysmal sweating, emotional lability, fever, autonomic hyperresponsiveness with hypertension, and tachycardia.

Respiratory complications or cardiac arrhythmias are the most common cause of death in patients with DT. Aggressive treatment with benzodiazepines is the recommended intervention.

Wernickes/korastoffs:

• Alcohol-use disorder is often associated with a thiamine deficiency.
• Severe thiamine deficiency may result in the development of Wernicke’s encephalopathy, which is characterised by ocular motility disorders, ataxia, and mental status changes (confusion).
• When patients with Wernicke’s encephalopathy are inappropriately treated with low doses of thiamine, mortality rates average about 20% and Korsakoff’s psychosis develops in about 85% of survivors.
• Korsakoff’s psychosis is characterised by anterograde and retrograde amnesia, disorientation, and confabulation.
• Because of the close relationship between these clinical entities, the two disorders are usually referred to as the Wernicke-Korsakoff syndrome

Treated with IM/IV thiamine

Question 65

What are major risks associated with alcohol withdrawal

What are the key recommendations for the treatment of alcohol detoxification

Answer 65

• Status elipeticus
• oversedation
• Electrolyte abnormalities

Alcohol withdrawal seizures: these patients require urgent treatment to reduce the likelihood of further seizures.

• Ensure a patent airway immediately.
• Give intravenous lorazepam (4 mg intravenously as a single dose). Give a second dose after 10 minutes if seizures continue

Key Recommendations

Supportive care

• Manage patients in a quiet room and use a calm approach.[3] Monitor closely for deterioration.
• Rehydrate the patient.
• Give intravenous fluids if needed.
• Correct any electrolyte imbalances.[
• There may be low levels of potassium, magnesium, calcium, and phosphate.
• Consult local protocols to determine the doses for electrolyte replacement.
• Correct hypoglycaemia and continue to monitor blood glucose levels.
• If you give glucose, give it at the same time or after thiamine. However, do not delay glucose for life-threatening hypoglycaemia while waiting for thiamine administration.

Ensure regular observation, especially if pharmacological treatment is given.

• Acute pharmacological treatment
• Not all patients with symptoms of alcohol withdrawal will need acute pharmacological treatment.
• Use your clinical judgement to decide which patients need treatment.
• Do not routinely give treatment if the patient scores <10 on CIWA-Ar score or <2 on GMAWS.
• Patients with mild to moderate alcohol withdrawal symptoms (CIWA-Ar score <10 or GMAWS <2) can generally be managed with supportive care only.[3]
• Consider monitoring these patients for 4 to 6 hours to ensure no worsening withdrawal symptoms and to provide supportive care.
• Review all patients after they receive a second dose of any benzodiazepine.
• If they are still highly symptomatic, request a senior review.

Review the diagnosis of alcohol withdrawal and ensure other causes have been considered and ruled out.

Benzodiazepine-resistant alcohol withdrawal

• In practice, for patients who need approximately ≥130 mg of chlordiazepoxide (or equivalent dose of another benzodiazepine) in the first hour of treatment:
• Involve senior support and consider causes other than alcohol withdrawal

Nutritional support

• Give thiamine (vitamin B1) to any patient with acute alcohol withdrawal to prevent or treat Wernicke’s encephalopathy.[2][1][3]
• Give at least one intravenous dose of a high-potency vitamin B preparation (e.g., Pabrinex® in the UK) to any patient who attends hospital with alcohol withdrawal.
• Give this treatment even if the patient has mild symptoms of alcohol withdrawal and is being discharged.

Monitoring

• Monitor all patients who have been admitted every hour until they are stable; in particular:
• Use the CIWA-Ar score or GMAWS to monitor response to drug treatment
• Check blood glucose
• Check vital signs using a validated scoring system recommended by your local protocols, such as the National Early Warning Score 2 ( Score 2

Outpatient management

• Refer all people who need assisted alcohol withdrawal to specialist alcohol services for assessment for community-based alcohol withdrawal.

The patient should not be advised to suddenly stop or reduce their alcohol intake while waiting for outpatient services as this could precipitate severe withdrawal symptoms.[1]

If possible, the patient should gradually reduce their intake over several weeks/months. Advise them to decrease their level of drinking by not more than 25% every 2 weeks.

Do not prescribe medication to patients being managed in the community unless they have adequate assessment and support as successful withdrawal is unlikely and there are considerable associated clinical risk

Question 66

What is following for Alcohol withdrawl

1. clinical presentaiton
2. Screening tools
3. History and assessment
4. Investigations

Answer 66

Key Recommendations

• Suspect acute or imminent alcohol withdrawal in any patient who is alcohol dependent and has stopped or reduced their alcohol intake within hours or days of presentation.[1][2][3]

Clinical presentation

• Anxiety
• Nausea and vomiting
• Autonomic dysfunction
• Tremor
• Tachycardia
• Sweating
• Palpitations
• Insomnia.
• Screen for alcohol-use disorder and alcohol dependence
• Use a formal screening tool, such as AUDIT-C ( Alcohol Use Disorders Identification Test - Consumption ), FAST ( Fast Alcohol Screening Test ), or PAT ( Paddington Alcohol Test 2011 ), to screen patients for alcohol-use disorder.
• Identify patients at risk of alcohol withdrawal by assessing the level of alcohol dependence of patients who have tested positive for alcohol-use disorder.[2]
• Use a formal screening tool such as SAD-Q ( Severity of Alcohol Dependence Questionnaire ) or CAGE.
• If using CAGE, ask four questions:[42]
• C: Have you felt the need to cut down on your drinking?
• A: Have you ever felt annoyed by someone criticising your drinking?
• G: Have you ever felt bad or guilty about your drinking?
• E: Have you ever had an eye-opener - a drink first thing in the morning to steady your nerves?
• History
• Ask about the subjective features of alcohol withdrawal. These include:
• Anxiety
• Nausea
• Insomnia
• Headache
• Tactile, visual, and auditory disturbances
• Blackouts, unexplained loss of consciousness, or seizures.

Assess cognition.

• Assess orientation to time, person, and place.
• Ask about other current substance misuse and other medical comorbidities, including a psychiatric and social history.[1]
• Identify the reason for cessation or reduction of alcohol intake.
• Ask about risk factors for hepatitis B, hepatitis C, and HIV infection.
• These can co-exist with or complicate alcohol withdrawal.

Physical examination

• Assess for signs of alcohol withdrawal including a tremor.[1][2][3]
• Look for signs of Wernicke’s encephalopathy. These include nystagmus, ataxia, and confusion. See our topic Wernicke’s encephalopathy.
• Look for signs of head injury. See our topic Assessment of traumatic brain injury, acute.

Investigations

Alcohol withdrawal is a clinical diagnosis. However, use test results to help add weight to a suspicion of alcohol-use disorder.

Always order:

• Venous blood gas
• Blood glucose
• Full blood count
• Urea and electrolytes including magnesium and phosphate
• Liver function tests including GGT
• Bone profile
• Coagulation studies.

Always interpret test results in the context of the patient’s clinical history and other findings.

It is important to rule out significant concurrent physical illness that may have led to a reduction in alcohol intake

Consider additional tests based on individual presentations and to rule out other causes.

Question 67

What are the contraindications to outpatient detoxification?

What must you assess and know about each patient prior to determining in vs outpatient treatment?

Answer 67

inpatient/residential specialty treatment

• Treatment recommended for ALL patients in selected patient group

Inpatient or residential alcohol treatment is utilised in the following patient circumstances:

1. Previous episode of significant alcohol withdrawal complications (alcohol withdrawal seizures or delirium tremens).
2. Concurrent moderate-to-severe medical conditions (cardiovascular, pulmonary, hepatic, or infectious conditions; uncontrolled diabetes; hypertension).
3. Concurrent moderate-to-severe psychiatric conditions (depression with suicidality, marked od instability, psychosis).
4. Highly adverse life circumstances (homelessness, living with active substance users, victim of ongoing abuse).

Optimally, treatment is multi-modal in nature and inclusive of comprehensive substance use assessment, treatment engagement, medical and psychiatric evaluation and management, and psychological support.

Inpatient treatment is typically short-term in nature (days), while residential treatment may occur over a more extended time frame (weeks to months). Ideally, either treatment path will lead to ongoing patient participation in an outpatient or intensive outpatient substance abuse treatment programme.

Treatment recommended for ALL patients in selected patient group

Outpatient or intensive outpatient alcohol treatment is utilised in the following patient circumstances:

1. No previous history of significant alcohol withdrawal complications (alcohol withdrawal seizures, delirium tremens)
2. Without unstable medical conditions (cardiovascular, pulmonary, hepatic, or infectious conditions; uncontrolled diabetes; hypertension)
3. Without unstable psychiatric conditions (severe depression, suicidality, marked mood instability, psychosis).
4. Stable life circumstances (safe housing, supportive relationships, financial stability).

Optimally, treatment is multi-modal in nature and inclusive of comprehensive substance use assessment, treatment engagement, medical and psychiatric evaluation and management, and psychological support.

• Outpatient/intensive outpatient treatment will typically include treatment sessions once- or twice-weekly to several times a week and will extend over several weeks to several months (or longer). Such programmes are designed to assist the patient in maintaining abstinence. They utilise educational, psychological, behavioural, and pharmacological interventions.
• Patient participation in self-help groups such as Alcoholics Anonymous can provide additional support. Alcoholics Anonymous

Question 68

What supportive treatment is recommeneded for patients going through AWS?

Answer 68

• Supportive medical care typically consists of frequent reassurance, low-stimulation environment, hydration (as needed), and vitamin infusion (especially thiamine supplementation or infusion for the prevention/treatment of Wernicke’s encephalopathy).
• If intravenous fluids are administered, thiamine should be given before glucose is administered to prevent depletion of thiamine reserves and precipitation of Wernicke’s encephalopathy.
• The overall goal of treatment of AWS is to facilitate the entry of the patient into a treatment programme in order to achieve and maintain long-term abstinence from alcoho

Question 69

What are the three main medications for relapse prevention in AUDs?

Answer 69

Disulfiram

• blocks the catabolic pathway of alcohol by inhibiting aldehyde dehydrogenase, thereby increasing acetaldehyde levels following alcohol ingestion. The disulfiram-alcohol reaction can produce a number of somatic effects: vasomotor symptoms (flushing), cardiovascular symptoms (tachycardia, hypotension), digestive symptoms (nausea, vomiting, diarrhoea), headache, respiratory depression, and malaise

Acamprosate

• is an agent that normalises glutamate and gamma-aminobutyric acid neurotransmitter systems in the central nervous system. It is thought that these actions reduce ongoing symptoms associated with alcohol abstinence (e.g., anxiety, insomnia) and craving.
• A systematic review has shown that acamprosate, in conjunction with psychosocial behavioural treatments, is efficacious in promoting abstinence in patients with alcohol-use disorder who have stopped drinking. In a meta-analysis of 22 studies, acamprosate was superior to placebo in increasing rates of abstinence and decreasing heavy drinking, in addition to improving rates of treatment completion and medication complianc

Naltrexone

• is an opioid receptor antagonist that may help decrease alcohol use by attenuating the rewarding and reinforcing effects of alcohol. Specifically, naltrexone blocks stimulation of the opioid receptor by endogenous opioids and decreases dopamine release in the ventral tegmental area.[74] It has been found to be particularly useful in patients with a family history of moderate-to-severe alcohol-use disorder and in those with significant alcohol craving.

Question 70

What are the goals of treatment with a patient who you hasve assessed to have Moderate to severe AWS? What scoring system is used to determine this?

Answer 70

Moderate-to-severe alcohol-use disorder

• Alcohol withdrawal treatment (detoxification)

People with moderate-to-severe alcohol-use disorder may experience significant symptoms of alcohol withdrawal on reduction or cessation of alcohol use.

• The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is the standard instrument used to determine the severity of the alcohol withdrawal syndrome (AWS).
• Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA- Ar)
• People whose total scores are 8 to 10 or greater are prescribed benzodiazepines to reduce the severity of AWS.
• People with a history of alcohol withdrawal complicated by seizures and/or delirium tremens are treated in hospital settings, as are those with complicating medical, psychiatric, or psychosocial factors.
• People without a history of complicated alcohol withdrawal or other complicating factors can be detoxified in an outpatient setting where medical monitoring is available.
• Regardless of the setting, the overall goal for treatment of AWS is to facilitate the entry of patients into longer-term residential or outpatient/intensive outpatient treatment programmes, in order to assist them in initiating and maintaining an extended period of abstinence

Question 71

How do you identify and treat Wernicke’s encephalopathy?

Answer 71

Wernicke encephalopathy results from inadequate intake or absorption of thiamin plus continued carbohydrate ingestion. Severe alcoholism is a common underlying condition. Excessive alcohol intake interferes with thiamin absorption from the gastrointestinal tract and hepatic storage of thiamin; the poor nutrition associated with alcoholism often precludes adequate thiamin intake

Giving a carbohydrate load to patients with thiamin deficiency (ie, refeeding after starvation or giving IV dextrose-containing solutions to high-risk patients) can trigger Wernicke encephalopathy.

• The classic clinical triad of mental status changes, ophthalmoplegia, and gait dysfunction is present in only 10% of cases

History

• The majority of patients who present with this condition have a degree of altered level of consciousness or cognitive dysfunction.
• It can vary from mild irritability, mental slowing, impaired concentration, and apathy, to frank confusion, delirium, coma, and death .
• Patients may also present with various psychiatric manifestations, including acute psychosis.
• A history of alcohol dependence, poor dietary intake, vomiting, diarrhoea, fever, co-existing conditions, immunodeficiency, or recent abdominal surgery should be elicited.
• Wernicke’s encephalopathy has been described following restrictive and malabsorptive bariatric surgery

Examination

• A rapid and focused examination to assess mental status,
• cranial nerve function (especially the optic and ocular motor nerves),
• vestibular and gait function,
• strength
• reflexes, and fundoscopy is necessary.

While the classic triad describes ophthalmoplegia, nystagmus is a more common finding.

• Other ocular motor findings on examination include gaze palsies, sixth nerve palsies, and impaired vestibulo-ocular reflexes.
• Patients may also have miosis, anisocoria, light-near dissociation, papilloedema, and retinal haemorrhages.
• Gait dysfunction presents mainly as truncal ataxia due to loss of equilibrium
• If untreated, patients may have hearing loss, seizures, hypo- or hyperthermia, and spastic paraparesis. At any time patients may also have co-existent tachycardia and hypotension related to the cardiovascular manifestations of thiamine deficiency.

Investigations

Presumptive treatment should not be delayed pending the results of laboratory investigations.

A fingerprick should be obtained for glucose, and blood should be sent for FBC, serum electrolytes, renal and hepatic function tests, serum thiamine, serum magnesium, blood alcohol level, serum ammonia, and urine and serum drug screens in all patients with clinical presentation of Wernicke’s encephalopathy. A lumbar puncture may be performed if there is a clinical suspicion for encephalitis or meningitis.

The sensitivity and specificity of the lab tests and imaging have not been studied in a rigorous manner and have not been validated. The tests are helpful in patients with multiple simultaneous illnesses (e.g., immunocompromised patients or those with malignancies who may have neurological manifestations due to multiple aetiologies).

Question 72

What are clinical manifestations of severe alcohol withdrawal and delirum tremens?

Answer 72

Clinical manifestations of severe withdrawal and delirium tremens

• — Approximately 5 percent of patients who undergo withdrawal from alcohol suffer from DT.
• DT is defined by hallucinations, disorientation, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis in the setting of acute reduction or abstinence from alcohol.
• DT typically begins between 48 and 96 hours after the last drink and lasts one to five days
• DT and alcoholic hallucinosis are not synonymous, and symptoms that occur a few hours after the cessation of drinking, even if severe, are usually not manifestations of DT.
• Virtually all patients who develop DT experience some symptoms of minor alcohol withdrawal prior to the onset of DT. (See ‘Alcoholic hallucinosis’ above.)

Patients with DT have significantly elevated cardiac indices, oxygen delivery, and oxygen consumption

• Arterial pH rises due to hyperventilation, which may be a rebound effect related to the respiratory depressant properties of alcohol.
• Hyperventilation and consequent respiratory alkalosis in this setting result in a significant decrease in cerebral blood flow
• There is a correlation between the length of the preceding alcohol binge, the degree of clouding of the sensorium, and the size of the average decrease in cerebral hemispheric blood flow, although there is no association between blood flow parameters and hallucinations or tremors

Severe alcohol withdrawal is often associated with fluid and electrolyte abnormalities.

• Almost all patients in acute withdrawal are hypovolemic as a result of diaphoresis, hyperthermia, vomiting, tachypnea, and decreased oral intake.
• Hypokalemia is common due to renal and extrarenal potassium losses, alterations in aldosterone concentrations, and changes in potassium distribution across the cell membrane
• Hypomagnesemia is common in patients with DT and predisposes them to dysrhythmias and seizures .
• Hypophosphatemia results from malnutrition, may be symptomatic, and, if severe, can contribute to cardiac failure and rhabdomyolysis.

Risk factors — Risk factors for the development of DT include

• A history of sustained drinking
• A history of alcohol withdrawal seizures
• A history of DT
• Age greater than 30
• The presence of a concurrent illness
• The presence of significant alcohol withdrawal in the presence of an elevated blood alcohol concentration
• A longer period since the last drink (ie, patients who present with alcohol withdrawal more than two days after their last drink are more likely to experience DT than those who present within two days)

The best predictor for clinically significant alcohol withdrawal is a Prediction of Alcohol Withdrawal Severity Scale (PAWSS) score greater than or equal to 4

Question 73

What are is the DSM criteria for AUDs?

Answer 73

Question 74

What pharmacological and psychological treatments can be offered for alcohol use disorder after detoxification to prevent relapse?

Answer 74

Treatment

Despite the high prevalence, mortality, and economic costs of AUD, in 2015, only 8.3% of the 15.8 million adults who reported needing treatment for an alcohol problem received specialty alcohol treatment

• Common sources of help for people with an AUD are 12-step groups (eg, Alcoholics Anonymous) and outpatient treatment by medical or nonmedical health care practitioners.
• Alcohol-specific psychosocial treatment has strong favorable effects on drinking outcomes.

Combining Psychosocial Treatments With Alcohol Treatment Medications (relapse prevention medications)

• Psychosocial interventions have been shown to be efficacious in treating heavy alcohol use or AUD.
• These include brief interventions, motivational enhancement therapy, cognitive behavioral therapy, behavioral approaches, family therapies, and 12-step facilitation (to approximate the 12-step treatment in a study environment)
• Of these, brief interventions, which are commonly 15 to 20 minutes long, are most feasible in medical settings.
• When more intensive psychosocial therapy is needed (eg, cognitive behavioral therapy), it may be most feasible for a therapist trained in the specific method to provide it in concert with a medical practitioner who can prescribe an alcohol treatment medication

Question 75

Week 6 (Theme: Personality Disorders and Trauma related disorders)
Trigger warming: car accident.

Scenario: A 60 year old man had a road traffic accident three months before presenting for assessment. Another driver collided with his vehicle. His daughter and grandchild were sitting in the back seat. The car spun twice and the man believed his family had died. He himself suffered a back injury. He presented with flashbacks, he was avoiding travelling by car, and experienced low mood and irritability.

• What differential diagnoses would you consider?
• Name the diagnostic criteria for PTSD (see DSM-V).
• What are the major treatments for PTSD using a biopsychosocial approach?
• What are the common comorbid conditions with PTSD and how would you screen for them?

Resource: Australian guidelines for PTSD

Answer 75

Differentials to consider:

In the differential diagnosis of PTSD, it is important to consider

1. acute stress disorder
2. dissociative disorders
3. depression
4. generalized anxiety
5. panic disorder
6. phobias
7. substance abuse
8. psychiatric manifestation of medical conditions, and malingering

Question 76

What is the DSM V criteria for PTSD? What are the 6 major criteria? What are the major symptoms?

How long do these symptoms have to be present?

Answer 76

Table 2.2: DSM-5 diagnostic criteria (paraphrased) for posttraumatic stress disorder in adults, adolescents, and children older than six (DSM-5 code 309.81)* A. B. C. D. E.

The person was exposed to actual or threatened death, serious injury, or sexual violence as follows.

1. Directly exposed

. 2. Witnessed (in person).

3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.
4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies or pictures.

One or more of the following intrusion symptoms associated with the traumatic event(s), with onset after the traumatic event.

1. Recurrent, involuntary, and intrusive recollections of the event(s). (Note: In children, this symptom may be expressed in repetitive play.)
2. Traumatic nightmares. (Note: Children may have disturbing dreams without content related to the traumatic event(s).)
3. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. (Note: Children may re-enact the event in play.) 4. Intense or prolonged distress after exposure to traumatic reminders.
4. Marked physiological reactivity after exposure to trauma-related stimuli.

Persistent effortful avoidance of one or more of the following distressing trauma-related stimuli.

1. Trauma-related thoughts, feeling or memories.
2. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

At least two of the following negative alterations in cognitions and mood that began or worsened after the traumatic event.

1. Inability to recall key features of the traumatic event (usually due to dissociative amnesia and not to head injury, alcohol or drugs).
2. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., “I am bad,” “the world is completely dangerous”).
3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
4. Persistent negative emotions (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest in significant activities.
6. Feeling alienated from others (e.g., detachment or estrangement).
7. Constricted affect: persistent inability to experience positive emotions.

At least two of the following trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event.

1. Irritable or aggressive behaviour.
2. Self-destructive or reckless behaviour.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance.

F. Persistence of symptoms (in Criteria B, C, D, and E) is more than one month.

G.

H. The symptoms cause clinically significant distress or functional impairment. The symptoms are not attributable to substance use or a medical condition.

Specify whether: With dissociative symptoms: the individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

1. Depersonalis ation: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream, feeling a sense of unreality of self or body or of time moving slowly).
2. . Derealisation: Persistent or recurrent experiences of unreality of surroundings (e.g., world around the individual is experienced as unreal, dreamlike, distant, or distorted).

Question 77

What are screening questions to ask in primary care about PTSD?

Answer 77

Question 78

What are the major treatments for PTSD using a biopsychosocial approach?

Answer 78

Approach

Although some people with PTSD may recover with no (or limited) intervention, many who do not receive effective treatment will over time develop chronic problems. Most people presenting with PTSD have usually had symptoms for many months, or even years. The duration of the disorder in itself does not prevent people from benefiting from effective treatment. The severity of the initial response to the trauma is a reasonable indicator of the need for early intervention. PTSD responds to a variety of psychological and pharmacological interventions.

Goals of treatment

1. The goals of treatment are to
2. Reduce severity of symptoms
3. Prevent or treat trauma-related comorbid conditions that are present or may emerge
4. Improve adaptive functioning and restore sense of safety and trust
5. Prevent relapse
6. Limit generalisation of the danger experienced as a result of the traumatic event.

Strong recommendation for use

Cognitive processing therapy (CPT)

• Cognitive processing therapy (CPT) is a form of cognitive therapy refined specifically for the treatment of PTSD. CPT is a 12-session cognitive-behavioural manualised treatment for PTSD that systematically addresses key posttraumatic themes, including safety, trust, power and control, self-esteem, and intimacy. The primary goal of treatment is to create more balanced, adaptive, multifaceted trauma appraisals and beliefs (both looking back on the traumatic experience and in the present). Treatment helps the person to identify unhelpful thoughts and beliefs (‘stuck points’), challenge them, and replace them with rational alternatives in an adaptation of standard cognitive therapy approaches. It has a smaller exposure component than imaginal exposure therapy (restricted to writing an account of the experience). It also helps to address associated problems such as depression, guilt, and anger.

Cognitive therapy

• (CT) Cognitive therapy (CT) is a variant of trauma-focussed CBT in which the therapist and patient collaboratively develop an individualised version of Ehlers and Clark’s model of PTSD,21 which serves as the framework for therapy. Ehlers and Clark (2000) suggested that PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious, current threat. The sense of threat is hypothesised to arise as a consequence of excessively negative appraisals of the trauma and/or its sequelae, and a disturbance of the autobiographical memory for the trauma which leads to involuntary reexperiencing of aspects of the trauma. The problem is maintained by unhelpful behavioural and cognitive strategies that are intended to control the symptoms and perceived threat.
• Accordingly, CT for PTSD aims to modify excessively negative appraisals, correct the autobiographical memory disturbance, Classification and grouping of interventions the problematic behavioural and cognitive strategies.
• CT is generally administered for 12 weekly treatment sessions (of 90 minutes for the initial sessions, and 60 minutes for the following sessions.

EMDR

• EMDR is a standardised, eight-phase, trauma-focussed therapy involving the use of bilateral physical stimulation (eye movements, taps, or tones).
• EMDR is based on the assumption that, during a traumatic event, overwhelming emotions or dissociative processes may interfere with information processing. This leads to the experience being stored in an ‘unprocessed’ way, disconnected from existing memory networks.
• In EMDR the person is asked to focus on the trauma-related imagery, and the associated thoughts, emotions, and body sensations while bilateral physical stimulation, such as moving their eyes back and forth, occurs. Processing targets may involve past events, present triggers, and adaptive future functioning. It is proposed that this dual attention facilitates the processing of the traumatic memory into existing knowledge networks, although the precise mechanism involved is not known.

Prolonged exposure (PE)

• Exposure therapy is long established as an effective treatment for a range of anxiety disorders. The key objective of exposure therapy is to help the person confront the object of their anxieties. A fundamental principle underlying the process of exposure is that of habituation, the notion that if people can be kept in contact with the anxiety-provoking stimulus for long enough, their anxiety will inevitably reduce. This may occur within an exposure session (within-session habituation) or across a series of sessions (betweensession habituation). More contemporary models emphasise information processing as a key mechanism

Psychoeducation

• about common reactions to trauma, breathing retraining, in vivo exposure (approaching safe situations that patients avoided due to trauma-related fear), imagery exposure (repeated recounting of trauma memories during sessions and listening to recordings of the recounting made during therapy sessions), and processing (discussion of thoughts and feelings related to the exposure exercises).

Trauma focussed CBT (TFCBT)

• Trauma-focussed cognitive behavioural therapy (TF-CBT), is a broad term that encompasses any treatment that employs the standard principles of CBT combined with some form of trauma processing. Generally, TF-CBT involves the integration of CBT principles with components of exposure therapy, including imaginal exposure and graded in vivo exposure. Across most studies from the systematic review that underpins these Guidelines, the typical format of TF-CBT involves psychoeducation, breathing/relaxation training (arousal reduction strategies), imaginal exposure, in vivo exposure, and cognitive restructuring.

Question 79

What are the common comorbid conditions with PTSD and how would you screen for them?

Answer 79

Treatment of comorbidities

Depression:

• When a person presents with PTSD and depression, healthcare professionals should consider treating the PTSD first, as depression often improves when PTSD is successfully treated.
• If the depression is so severe as to make psychological treatment of PTSD very difficult (e.g., when the person has extremely low energy, poor concentration, inactivity, or high suicide risk), depression should be treated first.
• When assessment identifies a high risk of suicide or harm to others, healthcare professionals should first focus on managing this risk.

Alcohol or drug misuse:

• Where alcohol or drug use or dependence is likely to significantly interfere with effective treatment, the drug or alcohol problem should be treated first. There is some evidence that trauma-focused psychological therapies with adjunctive interventions for substance use disorder may be effective.

Personality disorder:

• Duration of treatment may need extending when the person with PTSD has comorbid personality disorder.

Psychosis

• There is evidence that individuals with current psychotic disorders comorbid with PTSD can benefit from TFCBT or EMDR

Grief:

• When a person has lost a close friend or relative due to an unnatural or sudden death, he or she should be assessed for PTSD and traumatic grief. In most cases, PTSD should be treated first, although without avoiding discussion of the grief.

Question 80

What are the major differences between PTSD and its ddx? e.g Acute stress disorder?

Answer 80

Question 81

What are the key recommendation for management fo PTSD? (from guidelines)

Answer 81