Past Papers Flashcards
Indications for ECT
• Major Depressive Disorder o Treatment resistant depression o Immediate suicide risk o MDD with psychotic features o MDD in patients with comorbidities (pregnancy, elderly) • Bipolar Disorder o Treatment resistant (depressive) o Treatment resistant (mania) o Mania with potential danger to life • Schizophrenia o Treatment resistant o Schizophrenia in patients with co-morbidities (pregnancy, elderly, previous NMS) • Other o Life-threatening insufficiency of fluid or food from MDD/catatonia o Prolonged/severe maina o Psychomotor stupor/catatonia o Depression in the setting of Parkinsons, MS, Huntington’s disease
Presentation and management of Alcohol withdrawal
• Present after cessation/reduction of heavy alcohol use with (usually within 6-8 hours):
o Autonomic hyperactivity (sweating, tachycardia, hypertension)
o Hand tremor
o Nausea/vomiting
o Transient hallucinations/illusions
o Psychomotor agitation
o Anxiety
o Generalized tonic-clonic seizures
o Insomnia
o Craving
• Fatal complication = delirium tremens (fluctuating level of consciousness)
• Management
o Rule out other causes (LP, CTB, glucose)
o Benzodiazepines
Diazepam 10mg PO stat, then 5mg 6 hrly for 3 days, then 5mg 12hrly for 2 days, then 5mg daily for 2 days, then stop
o IV fluids if dehydrated
o Thiamine, folate and glucose (prevent Wenicke’s encephalopathy)
Thiamine, 300mg po daily for 2 weeks
o Correct electrolyte imbalances
o Nutritional supplementation
o Put them in a quiet place
o If delirium tremens
May need IV diazepam
If severely agitated and restless, can give IV/IM haloperidol
Side-effect profile of Sodium Valproate
- GIT (nausea, vomiting, diarrhea, constipations)
- Fatigue, sedation, ataxia, dysarthria
- Tremor
- Increased appetite
- Irregular periods
- Aggression, hyperactivity, depression
- Hepatoxicity, liver failure and pancreatitis (Rare)
- Thrombocytopenia, leucopenia, red cell hypoplasia
- Alopecia, skin rashes, curly hair
Side effects of carbamazepine
• Common
o Sedation
o Dry mouth
o Dizziness, ataxia
o GI (nausea, anorexia, constipation)
• Uncommon
o Skin reactions (erythema, photosensitivity, urticaria, SJS)
o Osteomalacia
o SIADH (hyponatraemia + water retention)
o Agranulocytosis, thrombocytopenia, aplastic anaemia
o LVF, cardiac conduction defects
o Nystagmus, diplopia, ataxia, drowsiness, ,blurred vision, confusion
Side effects of SSRIs
- Nausea, vomiting, abdo pain, constipation, diarrhea
- Agitation, anxiety, insomnia, tremor
- Sexual dysfunction
- Hyponatraemia
- Weight gain
- Increase risk of GI bleed
- QT prolongation
- Rare: serotonin syndrome
Side effect profiles of typical and atypical antipsychotics with examples
• Typical antipsychotics (haloperidol, chlorpromazine, fluphenazine, flupenthixol, zuclopenthixol)
o EPSEs
o CVS: QT prolongation, hypotension
o Anticholinergic: dry mouth, blurry vision, tachycardia, constipation, urinary retention, aggravation of closed angle glaucoma
o Endocrine: gynaecomastia, menstrual disturbances, weight gain
o GIT: anorexia/hyperphagia, diarrhea, constipation
o Sexual: loss of libido, erectile dysfunction , anorgasmia
o Blood dyscrasias
o Photosensitivity and hyperpigmentation
• Atypical antipsychotics (olanzapine, clozapine, risperidone)
o Less likely to cause EPSEs
o More metabolic (weight gain, impaired glucose metabolism, impaired lipid metabolism)
o Blood dyscrasias
Diagnostic criteria of Borderline Personality Disorder (7)
• A pervasive pattern of instability of interpersonal relationships, self-image and affects, with marked impulsivity, starting in early adulthood and present in a variety of contexts, with 5 or more:
- Frantic efforts to avoid real or imagined abandonment
- Pattern of unstable/intense interpersonal relationships with alternating idealization and devaluation
- Identity disturbance (unstable self-image)
- Impulsivity in at least 2 areas that are potentially self-damaging (spending, sex, driving)
- Recurrent suicidal behaviour, gestures, threats or self-mutilating behaviour
- Affective instability (reactivity of mood)
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress-related paranoid ideation or severe dissociative symptoms
Core presenting symptoms of PTSD (10)
• Exposure to actual/threatened death, serious injury or sexual violence
• Intrusion symptoms
1. Recurrent, involuntary and intrusive distressing memories of the event
2. Recurrent distressing dreams related to the event
3. Dissociative reactions (flashbacks), feel like the event was recurring
4. Intense or prolonged psychological distress at exposure to internal/external cues related to event
5. Marked physiological reactions to internal/external cues
• Persistent avoidance
1. Avoidance of or efforts to avoid distressing memories, thoughts and feelings
2. Avoidance of or efforts to avoid external reminders
• Negative alterations in cognition and mood
1. Inability to remember an important aspect of the event (dissociative amnesia)
2. Persistent and exaggerated negative beliefs/expectations about onself/others
3. Persistent distorted cognitions about the cause/consequences of the traumatic events that lead the individual to blame themselves/others
4. Persistent negative emotional state (fear, horror)
5. Markedly diminished interest or participation in activities
6. Feelings of detachment or estrangement from others
7. Persistent inability to experience positive emotions
• Marked alterations in arousal and reactivity
1. Irritable behaviour/angry outbursts
2. Reckless/self-destructive behaviour
3. Hypervigilance
4. Exaggerated startle response
5. Problems concentrating
6. Sleep disturbances
• Duration for >1month
• Causes distress
• Not due to physiological effects of a substance/GMC
Cortical vs subcortical dementia
• Cortical dementia
o Degeneration of the neocortical association areas
o Preserved motor speech skills
• Subcortical dementia
o Degeneration in basal ganglia, thalamus and brainstem
o Preserved language skills
Good vs bad prognostic features in Schizophrenia (10)
• Poor prognosis o Illness features Insidious onset Long first episode Previous psychiatric history Family history No obvious precipitants Negative symptoms Young age at onset No mood component o Patient features Male Low IQ Single, separated, divorced Abnormal previous personality Poor employment record Social isolation Poor support system Poor compliance History of perinatal trauma • Good prognosis o Illness features Acute onset No family history Positive symptoms Obvious precipitant Mood symptoms o Patient features Female High IQ Married Good premorbid social, sexual and work life Good support system Compliance to medication
Suicidal risk assessment (
• Risk profile o S: sex male o A: age <19 or >45 o D: depression or hopelessness (2) o P: previous attempts or psychiatric care o E: excessive alcohol or drug use o R: rational thinking loss (2) o S: separated/divorced/widowed o O: organized or serious attempt (2) o N: no social support o S: stated future intent (2) • Interpretation o 0-2: No real problems, keep watch o 3-4: send home but check frequently o 5-6: consider hospitalization o 7-10: definitely hospitalize
Side effects of Clozapine (5)
• CNS o Drowsiness, fatigue, headach, agitation, seizure, EPSEs • CVS o Myocarditis o Cardiomyopathy o Tachyarrhythmias o Orthostatic hypotension • Endocrine o Excessive salivation o Weight gain o Hyperglycemia o Hypercholesterolaemia • Gastrointestinal system o Constipation o Toxic megacolong o Pancreatitis o Nausea vomiting • Genito-urinary o Urinary retention/incontinence • Hematologic o Agranulocytosis o Neutropenia • Dermatologic o Rash, sweating • Respiratory o PE • Hepatic o Hepatitis o Hepatic failure
Symptoms of depression and side-effects of TCAs (15)
• Symptoms of depression o Depressed mood o Anhedonia (diminished interest/pleasure) o Significant weight loss (5% in a month) or decrease/increase in appetite) o Insomnia/hypersomnia o Psychomotor agitation/retardation o Fatigue/loss of energy o Feelings of worthlessness/ excessive or inappropriate guilt o Decreased concentration or indecisiveness o Recurrent thoughts of death/ suicidal ideation/attempt • TCA side effects (Amitriptyline): o Anticholinergic Dry mouth Blurry vision Tachycardia Arrhythmias Confusion Urinary retention constipation o Antihistaminic Sedation/drowsiness Weight gain from increased appetite o Antiadrenergic Hypotension (postural) Arrhythmias o Epileptogenic
Discuss understanding of Motivational Interviewing (10)
• Useful interpersonal communication style
• Based on the model for the stages of change:
o Pre-contemplation (unaware of problem)
o Contemplation (begin to weigh up continuing vs changing)
o Determination (decision to do something)
o Action (strategy for change is taken and pursued)
o Maintenance (efforts made to maintain gains)
o Relapse
• Patients need to have insight into undesirability of their behaviour
• Other elements in MI
o Support self-motivation
o Express empathy
o Avoid arguments
o Develop discrepancy (between behaviour and goals)
o Roll with resistance
o Support self-efficacy
Bio-psycho-social management of Panic disorder (8) and symptoms
Symptoms • Recurrent unexpected panic attacks o Panic attacks Spontaneous, discrete episodes of intense fear that begin abruptly and last for several minutes/an hour Often have autonomic symptoms (CVS, resp, GI) • Present for more than 1 month o Worry about the future or significant maladaptive behaviour change related to attacks Management • Bio: o Antidepressants: SSRIs, SNRIs, TCAs and MAOIs SSRI • Fluoxetine 20mg • Citalopram 20mg • Paroxetine 20mg • Sertraline 50mg SNRI • Venlafaxine 75mg • Duloxetine 60mg TCAs • Imipramine 75mg • Amitriptyline 75mg o Usually extremely sensitive to antidepressants Start low and go slow Kept on for 8-12 months and then tapered o Can use benzos for acute attack Usually max 2 weeks Anxiolysis while SSRIs work Lorazepam 1mg bd Propranolol 10-40mg in SAD • Psychosocial o CBT is effective o Systemic desensitization: gradual exposure to feared stimuli o Breathing exercises
Presentation and management of Delirium
• Presentation
o Disturbance in attention (reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment)
o Disturbance develops over a short period of time (hours to days)
Represents a change from baseline
Tends to fluctuate throughout the day
o Additional disturbance in cognition (memory deficit, disorientation, language, visiospatial ability or perception)
o Not better explained by pre-existing neurocognitive disorder
o Evidence from history, physical exam or lab findings that the disturbance is a direct consequence of a medical condition, substance intoxication/withdrawal or toxin, or has multiple aetiologies
• Management
o Identify and address predisposing and precipitating factors
o Supportive care
Reorientation
Sleep
Mobilization
Vision
Hearing
Hydration
o Non-pharmacologic
o Pharmacotherapy
Benzo if substance withdrawal (and thiamine)
If hypoactive, cans use low-dose haloperidol
• If contraindicated, use olazapine or risperidone
If severely agitated
• Can use a benzo
If hyperactive
• Avoid benzos
• Sedate with haloperidol
• If persists, use quetiapine or olanzapine
Possible reasons for patient with Schizophrenia not improving on treatment (10)
• Underdosing of medication • Malabsorption (can change to a depot) • Drug interactions • Wrong diagnosis • Non-compliance o Lack of insight (consider depot) o Adverse effects (consider changing class)
Management of enuresis (10)
• Biological
o Increase bladder capacity and strengthen sphincter muscle with fluid retention exercises in the day and stopping midstream while urinating
o Limiting fluids at night
o Voiding before bedtime
o Waking during sleep to void
o Urine alarm (moisture pad)
o Medication
Imipramine (often relapse when discontinued)
Methylphenidate
• Pyschological
o Reflect and acknowledge child’s emotions (shame, frustration)
o Facilitate sense of control over problem
o Encourage responsibility for behaviour (help clean up)
o Motivate with positive reinforcement (star charts, praise)
• Social
o Encourage supportive parental involvement
o Psychoeducation about causes and management
o Reflect and acknowledge parent’s frustration
o Discourage teasing
o Address family problems (increase parents awareness)
o Modify environment (night light)
Presentation of lithium toxicity, side-effects of lithium (10)
• Lithium side effects o GIT: nausea and vomiting, diarrhea o Fine tremor o Weight gain o Oedema and sodium retention (increased aldosterone secretion) o Goiter o Hypothyroidism o Polyuria and polydipsia • Toxicity o Ataxia o Lethargy o Weakness o Drowsiness o Thirst o GI intolerance o Confunsion o Tremor o Hyperreflexia o Convulsions o Coma
Psychiatric drugs and risks of teratogenicity (5)
• Most psychiatric drugs are teratogenic to some effect
• Benzodiazepines are mostly category D
o Major congenital malformations (oral clefts)
• Mood stabilizers
o Carbamazepine (D): spina bifide, cleft palate
o Lamotrigine (C): Ebstein’s anomaly
o Valrpoate (D)
• Antidepressants
o Tricyclics (C)
o SSRIs (C/D): generally don’t increase the risk of major congenital malformation
• Antipsychotics
o Typicals
Chlorpromazine: generally no risk
Rest are C
o Atypicals
Generally class C
Clozaine is class B
• Category C = animal reproduction studies have shown an adverse effect on fetus and no studies in humans, but benefits may outway the risk
• Category D = positive evidence of human fetal risk, but benefits may still outway risk
Discuss understanding of somatoform and related disorders
• According to DSM 5, classified under somatic symptom disorder and related disorders
o Somatic symptom disorder
o Illness anxiety disorder
o Conversion disorder
o Psychological factors affecting a medical condition
o Factitious disorder
o Other specific and non-specific somatic symptom disorders
• All have prominent somatic symptoms associated with significant distress and impairment
• Commonly encountered in primary health care settings
• Risk factors:
o Female, low education, low SES with social stressors, history of chronic childhood illness, history of sexual abuse/trauma, concurrent psychiatric disorder, family history of chronic illness
• Can present with a range of symptoms (often non-specific)
• Suspect if:
o Vague/inconsistent history
o Concerns are not alleviated by high utilization of medical care
o Attributing normal physical sensations to medical illnesses
o Repeatedly checking body for abnormalities
o Avoiding physical activity
o Unusually high sensitivity to medication side effects
o Seeking care from multiple doctors for same symptoms
Common features of NCD
- Grandiose sense of self-importance
- Preoccupied with fantasies of unlimited success, power, beauty
- Believes he/she is special and unique
- Requires excessive admiration
- Sense of entitlement
- Interpersonally exploitative
- Lacks empathy
- Often envious of others or believes that others are envious of them
- Shows arrogant, haughty behaviour
List four features of NMS (4)
- Fever
- Muscle rigidity
- Altered mental status (drowsiness, agitation, confusion, delirium, coma)
- Autonomic instability (BP fluctuations, tachycardia, diaphoresis, flushing)
3 commonly used mood stabilizers and side effects
- Lithium: nausea, tremor, weight gain, polydipsia, sexual dysfunction
- Valproate: nausea, gastric irritation, diarrhea, reduced platelets and WCC
- Carbamazepine: nausea, drowsiness, dizziness, skin reaction
Differential diagnosis for patient with decline in cognitive function
- Depression/bereavement
- Dementia
- Organic medical condition
- Schizophrenia
- Alcohol or drug abuse
Biopsychosocial management of major depressive disorder
• Biological o SSRI, TCA, SNRI, MOAI o If psychotic, add anti-psychotics o ECT if indicated o Transcranial magnetic stimulation • Psychosocial o Psychoeducation o CBT o Address substance use o Liase with employers o Emotional support o Make use of social support structures
Biopsychosocial management of alcohol dependence
• Biological
o Naltrexone (50mg dly)
o Disulfiram (200-400mg)
Makes them feel horrible if they consume alcohol
o Antidepressants (SSRIs)
• Psychosocial
o CBT (help to improve self control and social skills)
o Behavioural therapies (indivisual and family)
o Psychodynamic/interpersonal therapies
o Brief intervensions and motivational interviewing
o Marital and family therapy
o Group therapy
o Aftercare
o Self-help groups
Medical causes of panic attacks
• Vascular o Angina o Cardiac arrhythmias o MI • GIT o Peptic ulcer o Hiatus hernia • Respiratory o Asthma o PE o Pneumothorax • Medications o Stimulants or sympathomimetics o Alcohol/benzo withdraeal • Endocrine o Hypoglycemia o Hyperthyroidism o Phaeochromocytoma o Carcinois • CNS o Epilepsy o Vertigo
Pathological brain changes in Alzheimers dementia
- Decreased brain mass
- Enlarged ventricles
- Increased sulcal widening
- Increased amyloid plaques
- Neurofibrillary tangles
Medications useful for slowing progression in dementia
- Anti-cholinesterase inhibitors (donepezil)
* NSAIDs (aspirin)
Underlying causes for delirium
• Infection • Metabolic disturbance o Uraemia o Electrolyte imbalance o Hepatic or renal failure o Hypoxia • Endocrine o Hypoglycemia o Hyperglycemia o Cushings o Thyroid disorders • Intracranial o Trauma o TIA o Stroke o Subdural o Epilepsy o Infection o Abscess o Tumour • Drug intoxication o Anticonvulsants o Anxiolytics/hypnotics o Opioids o Drug/alcohol withdrawal o Vitamin deficiency
Management of delirium
• Investigations o Bloods (FBC, U+E, glucose, LFTs, calcium, B12, T4, blood culture o ECG o CXR, CTB • Treat underlying cause • Nurse carfuly • Communicate clearly • Orientate • Hydrate • Sedate if necessary (IM haloperidol) • Paracetamol if febrile • Review drugs and stop anything non-essential
Discuss presentation of childhood depression and compare to adult presentation (10)
Childhood • Irritability (temper tantrums, non-compliance) • Reactive affect • Somatic complaints • Comorbid anxiety, behavioural problems, ADHD Adults • Anhedonia • Lack of affective reactivity • Psychomotor agitation or retardation • Diurnal variation of mood • Early morning waking Adolescents • Irritability • Reactive affect • Hypersomnia • Increased appetite weight gain • Somatic complaints • Extreme sensitivity to rejection
Depression in pregnancy (risk factors and treatment
• During pregnancy
o 10% in the first trimester
o At risk = past history and conflicting feelings about pregnancy
o 10-15% third trimester pregnancies
o Suicide reduced in pregnancy, if occurs, associated with substance use
o Drugs have adverse effects on fetus (litihium, carbamazepine, valproate)
o Must weight up potential risks
o Antidepressants are usually safe
• Postpartum depression
o 10-15% within first 6 weeks after delivery
o May persist for a year or more in 25%
o Risk factors
Personal history of depression
Family history of depression
Previous postpartum depression
Premenstrual dysphoric disorder
Psychosocial problems
o Management: relieve, stress factors and emotional support
o Anti-depressants = first line, but expressed in breastmilk
o ECT
o TCAs also an option
Postpartum psychosis
- Rare (1/1000 deliveries)
- Usually within 2 weeks
- Sudden onset
- Often has history of BMD
- Manic symptoms (impulsive, grandiose)
- Psychotic symptoms (paranoid, often about baby)
- Risk of suicide and infanticide
- Rapidly changing course
- Could be due to GMC
- May need emergency measures (restraint, sedation)
- Breastfeeding contraindicated
- ECT effective
- Good short term prognosis, but risk of recurrence
Premenstrual dysphoric disorder
• Disturbance of mood, often accompanies by insomnia, poor concentration, irritability, poor impulse control, food craving
• Physical complaints (headache, breast tenderness, bloating)
• Onset after ovulation
o Rapid relief after 24 hours from onset of menstruation
• Possible etiologies
o Decrease in serotonin
o Fluctuation in electrolytes and sex hormone levels
o Neurotransmitter changes
o SSRIs beneficial
Biological management of PTSD
• SSRIs (help to decrease intrusive and avoidant symptoms, reduce anger and improve mood)
• Benzos not very helpful
• Anticonvulsants can help with mood symptom
• Psychotherapies
o Crisis intervention
o Debriefing
o Brief psychotherapies (support and stabilization)
o Education
o Behaviour therapies
CBT
Desensitization techniques
o Stress management, relaxation techniques
o Trauma focus work
o Relapse prevention and maintenance
Substances of abuse that can cause a presentation similar to mania
- Alcohol
- Cannabis
- Tik
- Cocaine
DSM 5 criteria for dementia
• Significant cognitive decline in one or more cognitive domain (complex attention, executive function, learning and memory, language, perceptual-motor and social cognition), base on:
o Concern of individual, other of clinician
o Impairment documented by standardized neuropsychological testing
• Cognitive decificts interfere with independence in everyday activities
• Do not occur only in the context of a delirium
OCD psychological management
- Response prevention
- Thought stopping
- CBT
- Self-help groups
Biological management of OCD
• Clomipramine (TCA) • SSRIs o Fluoxetine o Citalopram o Paroxetine o Sertraline o Escitalopram • Response is often slower (12 weeks) and needs higher doses (increases risk of cardiac arrhythmias)
Features to differentiate delirium from psychosis
• Delirium o Disturbance in cognition o Fluctuating course o History of GMC o Illusions are common o Acute onset • Psychosis o Delusions o Hallucinations o Thought disorder o Catatonia o Disorganized behaviour
Management of childhood depression (psychotherapy and pharmacological
• Stress reduction interventions o School liaison o Supportive individual therapy o Family interventions o Address bullying • Psychological o CBT o IPT o Social skills training o Problem solving o Remedial help with learning problems • Meds o SSRIs Fluoxetine (risk of increasing suicide) • Inpatient treatment o Severe suicidality o Psychotic symptoms o Refusal to eat or drink
Indications for lithium
- Bipolar prophylaxis
- Depression
- Acute mania
- Aggression and self-injurious behaviour
Routine checks on Lithium
- Lithium levels
- U+E 3 monthly
- TSH annually
Drug interactions with lithium
- Diuretics (hydrochlorothiazide)
- NSAIDs (brufen)
- ACE inhibitors (enalapril)
Typical clinical presentation of a child with ADHD
- Inattention (6 or more)
o Fails to give close attention to details
o Difficulty sustaining attention
o Does not seem to listen when spoken to directly
o Does not follow though on instructions
o Difficulty organizing tasks and activites
o Avoids tasks that require sustained mental effort
o Often loses things necessary for tasks
o Easily distracted by other stimuli
o Forgetful in daily activities - Hyperactivity and impulsivity (6 or more)
o Fidgets with or taps hands or feet
o Leaves seat when expected to remain seated
o Runs about or climbs inappropriately
o Unable to play quietly
o “driven by a motor”
o Talks excessively
o Blurts out answer before question completed
o Difficulty waiting their turn
o Interrupts or intrudes on others
Differentials for ADHD
- Conduct disorder
- Learning disorder
- Depression
- Anxiety disorder
- Adjustment disorder
Differential diagnosis for hopelessness (5)
- Major depressive disorder
- Borderline personality disorder
- Depressive pole of bipolar disorder
Psychological management of social anxiety disorder
- CBT
o Gradually desensitizing to feared situation
o Cognitive restructuring to correct dysfunctional thoughts about humiliation and embarrassment - Group therapy
- Psychoeducation
- May need high dose SSRIs
Lithium contraindications
- Cardiac disease
- Renal impairment
- Urinary retention
- CNS disorders
- Pregnancy
Alzheimer’s risk factors
- Increasing age
- Family history
- Smoking
- High blood pressure
- Obesity
- Cognitive inactivity
- Physical inactivity
