Psychiatry Flashcards
1
Q
What plasma level of lithium is the target?
A
0.6-1mmol/L
2
Q
What are the contraindications to Lithium?
A
Arrhythmia
Brugada Syndrome
Renal impairment (significant)
Hypothyroidism
Hyponatraemia
Addison’s disease
3
Q
Which groups of people should lithium treatment be used with caution in?
A
Elderly Epilepsy ECT QT interval prolongation Cardiac disease Myaesthenia Psoriasis Diuretics
4
Q
When should the dose of Lithium be reviewed?
A
Annual check up (or 3 month if starting) Diarrhoea Vomiting Intercurrent infection Following surgery
5
Q
List 3 adverse effects of Lithium.
A
Initial SEs: diarrhoea; nausea; vomiting; muscle weakness
Mnemonic: LITHIUM
- Leukocytosis
- Increased Weight/Dryness/ Increased risk of Renal tumours
- Taste/Thirst (Nephrogenic Diabetes Insipidus)
- Hypo and Hyperthyroidism/ Hyperparathyroidism/Hypercalcemia
- Increased Urine Output (Polyuria)/ Increased CK
- Movement/Memory change
6
Q
Which drugs my Lithium interact with?
A
Diuretics ACEi NSAIDs Antidepressants: SSRIs; TCAs; NSRIs Carbamazepine Haloperidol
7
Q
State 5 RFs for Mental Illness.
A
- ACE: 4 ≤ = 3x lung disease/14x suicide attempts/4.5x depression/4x begin intercourse by 15/ 2x liver disease
- Genetic
- Uncertainty
- Financial difficulty
- Physical ill health
- Unfavourable work/working environment
- Prejudice
- Social exclusion
- Pregnancy and birth: 1/5 mothers w/i 1 year post-partum
8
Q
Describe what CBT is.
A
Type of psychotherapy focusing on behaviours, thoughts and feelings and teaching coping skills for dealing with different problems – focus on behavioural therapy. Combination of cognitive therapy and behavioural therapy.
9
Q
What is the Cognitive Triangle in CBT?
A
• Cognitive Triangle: Behaviour, Feelings and Thought
10
Q
What are the 6 thought distortions?
A
- Magnification: Blowing things out of proportion
- Overgeneralisation: Sweeping generalisations based on single event
- Personalisation: Personal responsibility for events beyond their control
- Self Abstraction: Drawing conclusions from just one element of many
- Arbitrary interference: Conclusions when little or no evidence
- Minimisation: Downplaying importance of positive thoughts, emotions or events
11
Q
Describe Mindfulness.
A
Type of psychotherapy using mindfulness (awareness of thoughts, feelings and actions hindering daily life) to promote good mental, physical and social healthy. Can often be couples with other therapies – CBT, ACT etc.
12
Q
What is Sleep Hygiene?
A
behaviours and practices to change the environmental factors which may be beneficial or detrimental to sleep
13
Q
Outline the stages of change.
A
1) Pre-contemplation = No need to change behaviour
2) Contemplation = Consider behaviour is problematic
3) Preparation = Evaluate how to make a change
4) Action = Engage in real efforts to change
5) Maintenance = Successful at changing behaviour and attempting to maintain new skills
6) Termination = Eradicated old behaviours through adopted behavioural changes and continue to maintain these positive changes
14
Q
What class of drug is Phenelzine?
A
MAOi
15
Q
What is the MOA of Phenelzine?
A
• Inhibit MAO enzymes ≈ reduce breakdown of NE/serotonin and dopamine ≈ increase levels of serotonin/dopamine/NE
16
Q
State the side effects of Phenelzine/Selegeline.
A
- Weakness
- Headache
- Weight gain
- Dizziness
- Fatigue
- Impotence
17
Q
What food types should you be careful with when taking Phenelzine?
A
• High-tyramine foods (cheese/venison/meats/alcohol/green vegetables) as may lead to a hypertensive crisis
18
Q
What class of drug is Moclobemide?
A
RIMA
Reversible mono amine oxidase type A
19
Q
What are the side effects of Moclobemide?
A
- Weakness
- Headaches
- Dizziness
- Fatigue
- Weight gain
- Impotence
20
Q
What class of drug is Nortriptyline?
A
TCA
21
Q
What is the MOA of Nortriptyline?
A
Blocks 5HT, NE reuptake and mACHR thus inhibits re-uptake and increases levels of serotonin and NE whilst blocking effect of ACh
22
Q
What are the main side effects of Nortryptiline?
A
Anticholinergic (thus SLUDGE Sx)
- Blurred vision
- Dry mouth
- Constipation
- Bronchodilation
- Reduced bronchial secretions
- Urinary retention
- Weight gain/loss
- Hypotension
- Rash
- Hives
- Tachycardia
23
Q
What class of drug is Paroxetine?
A
SSRI
24
Q
What class of drug is Escitalopram?
A
SSRIs
25
What class of drug is Fluoxetine?
SSRI
26
What is the MOA of Fluoxetine?
• Bind to Serotonin re-uptake transporter ≈ reduce reuptake ≈ increase [Serotonin]
27
What is the MOA of Citalopram?
• Bind to Serotonin re-uptake transporter ≈ reduce reuptake ≈ increase [Serotonin]
28
What are the main side effects of Citalopram?
* Nausea
* Rash
* Muscle aches
* Insomnia***
* Aggression
* Anxiety
* Cognition
* Learning memory
* Mood
* Sleep
* Sweating
* Epilepsy
* Reduced libido
* Sexual dysfunction
* LQTS (Citalopram)
* GI bleed risk increased
* Overdose
* Suicide
29
What class of drug is Duloxetine?
SNRI
30
What are the main side effects of SNRIs?
* Nausea
* Headaches
* Insomnia
* Hypersomnia/Drowsiness
* Dizziness
31
What class of drug is Mirtazipine?
Tetracyclic Antidepressants
32
What are he side effects of Mirtazapine?
* Low doses (15mg) taken at night -> drowsiness
* Higher doses (30/50mg) taken in morning -> stimulant
* Orexigenic Appetite ***
* Weight gain
33
Define drug Tolerance.
physiological reaction (neuroadaption) characterized by decrease in effects of drug with chronic administration
34
Define drug Dependence.
Induces a rewarding experience thus physiologically/physically required
35
Define drug Withdrawal.
Adverse effects (anxiety/depression exacerbation/disturbed sleep/pain/stiffness/convulsions) upon removal of a drug
36
What is the MOA of Diazepam?
Bind BZD binding site on pentameric GABA (GABRA1-3/GABRB1-2) ≈ Cl- ion influx ≈ hyperpolarisation
37
What class of drug is Lorazepam?
Benzodiazepine
38
What is the half life of Diazepam?
20-100 hours
39
What is the half life of Lorazepam?
10-20 hours
40
What is the half life of Zopiclone?
5-6 hours
41
What are the side effects of Benzodiazepines?
```
Reduced Alertness
Confusion
Dizziness
Drowsiness
Fatigue
Headache
Nausea
Hypotension
Muscle weakness
Respiratory depression
Sleep disorders
Tremor
Vision disorders
Withdrawal syndrome
```
42
What class of drugs is Zopiclone?
Z drugs
43
Describe Neuroleptic Malignant Syndrome.
Condition following treatment of Psychotic disorder such as Schizophrenia with antipsychotics caused by dopamine antagonists resulting in:
- Altered mental status: confusion; delirium; stupor
- Muscle rigidity
- Hyperthermia
- SNS lability: BP elevation; sweating; urinary incontinence
- Hypermetabolism
44
How do you manage a patient with Neuroleptic Malignant Syndrome?
Supportive: Stop offending dopamine antagonist; alert critical care team; IV fluids; cooling; Ibuprofen; Monitor (bloods and urine every 1-2 hours);
+
Diazepam
or
Dantrolene
45
Describe Serotonin Syndrome?
Excess of synaptic serotonin (due to a substance) which results in a triad of altered mental status, autonomic effects (tachycardia; brisk reflexes; diaphoresis; shivering) and neuromuscular excitation (clonus; muscle rigidity)
46
How may you diagnose Serotonin Syndrome?
Clinical diagnosis
47
How do you manage Serotonin Syndrome?
Supportive: Remove offending agent; Admit; IV Fluids; Monitor
+
Benzodiazepine: Chlorpromazine
± (Intoxication within last hour)
Activated charcoal
48
By what process does activated charcoal work?
Activated charcoal binds the toxic compounds via adsorption, allowing the toxic compounds to be taken up, and excreted via defaecation with the charcoal
49
What are the side effects of the Antipsychotics in general?
Antipsychotics have effects at 5HT3, D2, ACh, H1 and Alpha receptors thus pleiotropic adverse effects
Behavioural: apathy/ drowsy
Motor: Parkinsonian like (D2A - Parkinsonism features); Extrapyramidal symptoms
Endocrine: Gynaecomastia and galactorrhea (Increased PL secretion in Tuberohypophyseal pathway)
Antimuscarinic: SLUDGE
Alpha adrenoceptor: Orthostatic hypotension/Dizziness
H1 Blocking actions: Sedative and anti-emetic actions
50
How may you describe someones general appearance?
* Age (concordant)
* Weight
* Personal hygiene
* Clothing
* Objects
* Stigmata of disease
51
What types of gait are there?
Antalgic
Hemiplegic
Diplegic
Parkinsonian
Neuropathic (High-Stepping)
Ataxic
Trendelenberg
Hyperkinetic
Sensory
52
How may you describe psychomotor activity?
Reduced or Increased
Reduced:
- Retardation
- Stupor
Increased:
- Hyperactivity
- Agitation
53
How may you describe mood?
Depression (low)
Irritable
Anxious
Panic attacks
Apathy
Affective blunting
Elation
Emotional lability
Euphoria
Ecstasy
54
What disorders of perception are there?
Sensory
Illusions
Hallucinations
55
What is the difference between an illusion and a hallucination?
Illusion is a misinterpretation of stimuli from a perceived object whereas a hallucination is a false perception in the absence of a stimulus
56
What is the difference between depersonalisation and derealisation?
Depersonalisation is being detached from yourself whereas derealisation is being disconnected from reality
57
State and explain 3 types of hallucinations.
A hallucination is a distortion of perception in which you anticipate an event in the absence of a stimulus.
Sensory - tactile hallucinations
Gustatory - taste
Olfactory - smell
Reflex - misinterpretation of stimuli in a different sensory modality (synaesthesia)
Doppleganger
Extracampine - misperception of stimuli outside normal limits of sensory fields/detection
58
What 3 areas are there for thought?
Content
Form
Possession
59
How can you describe disorders of thought in Psychiatry?
Thought speed, content and possession was normal
Speed
Thought blocking - interruption and pause of speech
Retardation - thinking is slowed and idea generation reduced
Flight of ideas - ideas flow rapidly and spontaneous connections are understandable
Form:
Poverty - restricted speech
Poverty of content
Neologism - new words or phrases
Circumstantiality - tedious detail, indirect and delayed
Tangentiality - thoughts and speech are oblique, loose and random
Derailment = combination of flight of ideas and loose associations
Thought content:
Delusions = fixed, false beliefs
Overvalued ideas = pre-occupied beliefs with strong affective response threatening goal/objective of belief
Obsessions = intrusive, recurrent thoughts
Possession:
Though alienation = involuntary thoughts and beliefs - insertion; broadcasting; withdrawal; echo
60
What types of delusions are there within Psychiatry?
Grandeur
Reference
Bizarre
Religious
Persecution
Guilt
Hypochondriacal
Love
Infidelity
Nihilistic
Doubles
Infestation
Shared delusions
61
How can you classify a patients insight?
Unaware
Conscious
Aware
62
What descriptive types of cognition exist in Psychiatry?
Comatose
Lethargic
Somnolent
Clouded
Alert
63
How may judgement be described in Psychiatry?
Abnormal
Impaired
Normal
64
What process is used to conduct a Mini-MSE?
Mnemonic: ASEPTIC
Appearance + Behaviour: weight/age/appearance/ dressed appropriately
Behaviour: psychomotor activity; Gait
Emotions: ecstasy/ elated/apathy/ affective blunting/depressive/ anxious/ irritable/ emotional lability
Perception: Sensory/ False (illusions/ hallucinations/ pseudohallucinations)
Thought: Speed; Form; Content; Possession
Insight: Aware; Conscious; Unaware
Cognition: Alert; Somnolent; Lethargic; Clouded; Comatose
Judgement: Normal; Impaired; Abnormal
65
Describe a Learning Disability?
Umbrella term for a significantly reduced ability to understand and acquire knowledge (understand new/complex information), impaired intelligence (new skills), impaired social functioning (coping independently) which started prior to adulthood and has a lasting effect on development
66
What is the normal IQ Test score?
70-130
67
What is a categorises as a mild learning disability?
• Mild Learning Disability = 50-69
68
What is categorised as a moderate learning disability?
• Moderate Learning Disability = 35-49
69
What is categorised as a severe learning disability?
• Severe Learning Disability = 20-34
70
How do you diagnose a learning disability?
• IQ Test: ≤ 70 = Learning Impairment cf ≤ 50 = Severe Learning Impairment
71
How do you manage a learning disability?
• Supportive: Education/Family/CBT/Counselling/
±
• Tx any MHDs
72
What is ADHD?
Chronic neurodevelopmental disorder characterised by inattention, hyperactivity and impulsivity which is present in early childhood and persists into adult life. Often, comorbidities exist such as: Autism Spectrum Disorder/Oppositional Defiant Disorder/Conduct disorder/Substance abuse/Mood disorders (Depression/Anxiety/Mania/Psychosis)
Triad of features: Hyperactivity + Inactivity + Impulsivity
73
What is the management for ADHD?
• Behavioural therapy: Behavioural parenting training (younger)/Behaviour management programme (Older)
+
• Stimulant: Methylphenidate
74
Should a patient experience tics due to the as a side effect of the Methylphenidate used to treat ADHD, what pharmacological management is there?
• Guanfacine/Clonidine
75
What are the adverse effects of Methylphenidate?
Appetite suppression
Weight loss
Insomnia
Mood
76
What is Conduct Disorder?
Outline the types
Behavioural child psychiatric condition typified by persistent difficult behaviour outside of social norms
- Socialised conduct disorder (involves peers at same level)
- Unsocialised conduct disorder (not involving peers)
- Oppositional defiant disorder (frequent anger towards a person of authority)
77
How do you manage Conduct Disorder?
• Supportive: Parental training/Family therapy/Individual therapy (Counselling/Mindfulness/CBT)
78
What is Autism Spectrum Disorder?
Neurodevelopmental condition typified by impaired social communication, restricted behavioural pattern, interest or activity with abnormal development (speech/regression). The disorder can usually have comorbidities such as epilepsy, ADHD and MHDs.
Features: Impaired social communication + Restricted behaviour pattern/interest; Abnormal development
79
What are the clinical features of Autism?
* Communication impairment: Verbal + Non-verbal -> Not play social games; reduced pointing; mood difficult to interpret/show
* Social impairment -> Uninterested in others + not socially motivated
* Repetitive/stereotyped interests: Verbal rituals/Behavioural rituals way of living + ∆ = distress
* Abnormal development: language delay or regression
* Motor stereotypies: repeated gestures (‘stimming’)
* Insomnia/Disturbed sleep
* MHDs: Anxiety/Depression
80
How is Autism managed?
What is used to manage any relevant co-morbidities?
• Applied Behaviour Analysis (ABA): Behavioural programme reinforcing positive behaviour and discouraging negative behaviours
±
• Pharmacological behavioural: For relevant morbidity Risperidone (neuroleptic)/Aripiprazole (neuroleptic) /Fluoxetine (SSRI)/Methylphenidate (stimulant)/Atomoxetine (NRI)/Melatonin (3-alkylindoles)
+ (Anxiety/OCD)
• SSRIs: Sertraline/Fluoxetine
+ (Psychosis/Aggression)
• Neuroleptics: Risperidone/Aripiprazole
+ (Sleep dysfunction/Insomnia)
• 3-alkindoles: Melatonin
81
What is the fundamental difference between Asperger's Syndrome and Autism?
Asperger's is mild autism with no language delay, and is often diagnosed later (7/8) cf Autism features neurodevelopmental delay, restricted interest and hobbies, impaired social activity and is diagnosed earlier (3-5)
82
Describe Encopresis?
Passage of normal stools in abnormal places
83
How may you manage Encopresis?
• Supportive: Behavioural therapy (star charts/regimes)/Family therapy
+
• Dietary: Increased fibre
± Constipation
• Oral laxative (stool softener): Magnesium citrate/Polyethylene glycol
+
• Oral laxative (stimulant): Senna glycoside
± Diarrhoea
• Antidiarrheal agent: Loperamide (opioid receptor agonist to increase anal sphincter pressure)
84
Describe Enuresis.
Involuntary passage of urine in the absence of physical abnormalities after 5 years old
85
What are the clinical features of Enuresis?
* Increased fluid intake at night
* Bladder irritants: Caffeine/Food colourings
* Urinary frequency
* Urinary urgency
* Constipation
* Abnormal voiding habits
* Abnormal breathing habits at night: Upper Airway Obstruction associated with enuresis
86
How is Enuresis managed?
• Supportive: Lifestyle change (reduce intake prior to bed/remove precipitants/toilet training/bladder training)
+
• Alarm Therapy: Bed-wetting alarms
± Stress Urinary Incontinence
Duloxetine
± Urgency Urinary Incontinence
Oxybutynin; Tolterodine
87
What is a Tic?
Rapid, involuntary, repetitive, stereotyped motor movements or phonic production
88
Describe Tourettes Syndrome.
Neurodevelopmental disorder beginning in childhood characterised by tics (motor + vocal) ± other psychiatric problems (OCD/ADHD) with presentation in childhood, persisting for at least 1 year, and attenuating later in adolescence.
Diagnosis: 2 motor + 1 vocal for 1 year
89
What are the clinical features of Tourettes Syndrome?
* Abnormal non-rhythmic, repetitive movements: Eye blinking/Facial grimacing/Shoulder shrugging
* Ritualistic behaviours: Desire to repeat behaviour
* Copropraxia (obscene gestures)
* Self-harm
* Repetitive sounds: Sniffing/Coughing/Throat clearing/Coprolalia (obscene language)/Echolalia (repeated language)/ Palilalia (repeating yourself)
* Echopraxia (repetition of another person’s behaviour or movements)
90
How is Tourettes Syndrome diagnosed?
Clinical diagnosis
91
How may Tourettes be managed?
How may the associated comorbidities be managed?
• CBT
+ (Tics)
1st
• Alpha agonists: Guanfacine/Clonidine
+ (ADHD)
• Stimulant: Methylphenidate
+ (OCD)
• CBT
±
• SSRI: Fluoxetine/Sertraline/Clomipramine
92
Describe Elective Mutism.
Child psychiatric condition typified by marked reduction in speaking which is emotionally determined
93
Describe elective mutism.
Child psychiatric condition typified by marked reduction in speaking which is emotionally determined
94
How is elective mutism diagnosed?
* Hearing Test
| * Clinical Diagnosis
95
How may you manage elective mutism?
• Supportive: SLT/CBT
±
• Anti-depressants (SSRIs): Citalopram/Sertraline/Fluoxetine
96
What types of child maltreatment are there?
Physical
Emotional
Sexual
Neglect
97
What are the clinical features of physical abuse?
* Vague account
* Incongruent stories
* Story incompatible to injury
* Delay in seeking help
* Parent does not reflect level of caring: Too little or Too much
* Child’s affect: Sad/Withdrawn/Fearful/Trusting in strangers
98
What are the clinical features of sexual abuse?
* Persistent/recurrent dysuria
* HBV/HDV
* Anogenital warts (HPV)
* STIs
* Unusual sexualised behaviours in prepubertal child
99
What are the clinical features of Emotional Abuse?
* Fearful emotional state
* Habitual body rocking
* Indiscriminate contact
* Failure to seek comfort when distressed
* Age-inappropriate responsibilities
100
What are the clinical features of Neglect?
* Inadequately fed
* Poor dress
* Poor hygiene
* Deprived of satisfactory contact with parents/guardian
* Deprived of social contact with friends and children
* Failure to meet milestones
101
Describe Munchausen Syndrome by Proxy.
Syndrome whereby a parent fabricates illness in her child and presents for medical attention
102
Describe what Insomnia is.
sleep disorder by which you have trouble falling asleep ± staying asleep.
103
Outline the clinical features of Insomnia.
* Partner sleep complaints
* Delayed sleep onset
* Multiple/long awakenings
* Accidents
* Impairments of functioning
* Decreased sleep time
104
What is the gold-standard investigation used to diagnose Insomnia?
• Epworth Sleepiness Scale: ≥ 9
105
How is Insomnia managed?
```
Supportive: Sleep hygiene; Relaxation techniques
+
CBT
+
Z-Drugs: Zolpidem
```
106
What is a personality disorder?
The accentuation of personality traits under stress which encompasses behaviours, thoughts, feelings which is independent of organic illness or psychotic disorders causing significant personal and social distress
107
How can Personality disorders be classified?
Classified by 'Cluster'
Cluster A = Schizoid type; Paranoid; Schizotypal
Cluster B = Dissocial; BPD (EUPD); Histrionic; Narcissistic
Cluster C = Dependent; Anxious; OCD;
108
How is Personality disorder diagnosed?
Clinically
109
How do you manage Personality Disorder?
Supportive: Relationship management strategies/Communication/CBT/Psychotherapy
± Cluster A (schizoid/schizotypal/paranoid)
Antipsychotics: Aripiprazole
± Cluster B (dissocial/narcissistic/histrionic/ borderline)
MSD: Topiramate/Valproate/ Lithium
± Cluster C (obsessive/ anxious/ dependent)
Antidepressants: Fluoxetine/Sertraline/Venlafaxine
110
Describe what Panic Disorder is.
Outline the diagnostic criteria for this.
Form of Anxiety disorder characterised by recurring unexpected panic attacks over 1-month period and associated worry about recurrence or implications thus behavioural change – e.g. fear avoiding. Panic symptoms must be organic and not attributable to substance abuse or another medical condition.
111
Outline the clinical features of Panic Disorder.
* Rapid onset
* Discrete time period
* Worry/Fear/Apprehension
* Behavioural avoidance: External + Internal situations
* Nausea and vomiting
* Dizziness
* SOB
* Tachycardia
* Palpitations/Pounding heart
* Tremulous
* Sweating
* Hyperventilation/SOB/Choking
* Chills/Hot flushes
* Muscle shaking
112
How is Panic Disorder diagnosed?
• Clinical Diagnosis
113
How is Panic Disorder managed?
• Supportive: Reassurance/CBT
±
• SSRIs/SNRIs: Sertraline/Paroxetine/Fluoxetine/ Citalopram/ Venlafaxine
114
Describe Agoraphobia.
Anxiety disorder typified by intense fear of a specific place from which escape may be difficult in addition to fear avoiding behaviour which is not caused by substance or other disorder
115
What is the first line treatment for Agoraphobia?
Exposure-based therapy
116
What is a Specific Phobia?
Specific intense fear of specific objects or situations that are triggered upon exposure to phobic stimuli resulting in fear avoiding behaviour of phobic cues
117
What is Acrophobia?
Fear of heights
118
What is Haemophobia?
Fear of blood
119
What is Claustrophobia?
Fear of confined spaces/places
120
What is Hydrophobia?
Fear of water
121
What is Zoophobia?
Fear of animals
122
What is Autophobia?
Fear of being alone
123
What is Aerophobia?
Fear of flying
124
What is the fear of snakes called?
Ophidiophobia
125
What is the management of a specific phobia?
• Supportive: Education + Monitoring/ CBT + Exposure therapy
+ (Concurrent vasovagal syncope)
• Applied tension: Tensing and releasing large muscle groups to increase BP and promote circulation
± (Frequent Sx interfering in Life)
• Benzodiazepines: Diazepam/Lorazepam/Clonazepam/Alprazolam
126
Describe OCD?
Anxiety disorder characterised by obsessions, unwanted excessive or impulsive desires, compulsions, repetitive mental acts and behaviours to reduce obsessions and emotional distress, which causes significant distress and impairment on daily functioning.
127
What is the difference between an Obsession and a Compulsion?
Obsession = Unwanted excessive or impulsive desires and thoughts which are seen as irrational or unwanted
Compulsions = Repetitive behaviours which aim to neutralise obsessions and emotional distress
128
How are compulsions and obsessions linked?
An obsession is an unwanted excessive desire whilst a compulsion is the urge to act on these desires which causes emotional distress
129
What is the first line investigation to diagnose OCD?
Clinical Diagnosis
130
How do you manage OCD?
• CBT
±
SSRIs: Fluoxetine/Paroxetine/Sertraline/Clomipramine
131
Describe PTSD.
Anxiety disorder characterised a traumatic event(s) causing 1-month of symptoms of intense fear, helplessness or horror, intrusive recollection of event, acting as if the event were occurring, distress from exposure to event cues, avoidance of trauma-associated stimuli and persistent increased arousal which wasn’t present prior to traumatic event.
132
How long do you have to experience symptoms before PTSD can be diagnosed?
1 month of intense fear, helplessness, intrusive memories, hyperarousal at cues and disturbed sleep with fear-avoidance behaviour
133
Outline the clinical features of PTSD.
Mnemonic: TRAUMA
Traumatic event
Re-experience: intrusion; flashbacks; sensory impressions; reacting to external and internal cues
Avoidance: avoidance behaviour
Unable to function -> Sx
Month (at least)
Arousal: hyperarousal; hypervigilant; easily startled; irritable
134
How is PTSD diagnosed?
Clinical diagnosis using PTSD Checklist (DSM-5)
135
How do you manage PTSD?
≤ 3 months = Monitor
≥ 3 months =
• TFCBT + Pharmacotherapy: 12 sessions with cognitive triad regarding trauma and aftermath
±
• SSRIs: Paroxetine/Fluoxetine/Sertraline/Venlafaxine
OR
• Exposure therapy: Confront traumatic memories
• Trauma-focused cognitive therapy: ID misrepresentation of trauma and aftermath resulting in perception of threat
136
How long must a patient have PTSD for before being offered TFCBT?
3 months of symptoms
137
What are the clinical features of Generalised Anxiety Disorder?
* Excessive worry ≥ 6 months
* Poor concentration
* Restlessness
* Irritability
* Muscle tension
* Easily Fatigued
* Sleep disturbance
* Headache
* Sweating
* Dizziness
* GI Symptoms: Nausea/Vomiting/Increased urinary urge/Tenesmus
* Rash
* Muscle aches
* SOB
* Trembling
* Exaggerated startle response
138
How is Generalised Anxiety Disorder diagnosed?
Clinical diagnosis: ≥6 months of intense worry/fear + 3/6 of diagnostic criteria
```
Poor concentration
Restlessness
Irritability
Muscle fatigue
Easily fatigued
Sleep disturbance
```
139
How is Generalised Anxiety Disorder managed?
• Lifestyle: Reduce caffeine/Reduce alcohol/Sleep hygiene/Exercise/Self-help
• Psychotherapy: CBT/ Mindfulness
±
• SSRI/SNRI/Antidepressant: Escitalopram/Duloxetine/Venlafaxine/Sertraline/Fluoxetine/ Mirtazapine
140
Define a Psychosis.
Umbrella term for a disorder whereby patient loses contact with external reality, associated with abnormal functioning of frontal and temporal lobes and disorganised thoughts and actions
141
What are the two main categories of Psychosis.
Primary
Secondary
142
Describe Schizophrenia.
MHD characterised by co-occurrence of: delusions, hallucinations, disorganised speech, catatonic/disorganised behaviour or negative symptoms (anhedonia/affective flattening/avolition/cognitive deficit or alogia) occurring for significant proportion of 1 month period (active phase), associated with continuous problems over ≥ 6 month period.
Positive Sx + Negative Sx for 1 month with continuous symptoms over a 6 month period
143
What are the clinical features of Schizophrenia.
Mnemonic: THREAD LESS
```
Tangentiality/ Thought processing
Hallucinations (auditory/visual)
Reduced reality (Delusions)/Repetition of words (Verbigeration)
Emotional control: Incongruous effect?
Arousal
Disorganised/ Catatonic Behaviour
```
```
Loss of volition/social settings/ Pleasure
Emotional flatness (Affective Blunting)
Speech reduced (Alogia)
Slowness in thought (cognitive deficit)/Somatisation (physical Sx – expressed in body)
```
144
How is Schizophrenia managed?
• Anti-psychotic medication: Aripiprazole
+
• Psychological Interventions: Family/CBT/Social-skills training
± Acute Attack
• Diazepam
145
What is the main difference between Schizotypal Behaviour and Schizophrenia?
Outline the clinical features of Schizotypal behaviour.
Schizotypal Disorder ≠ Schizophrenia as Schizotypal Disorder have insight into illness and awareness that experiences are false cf delusions in Schizophrenia
* Eccentric behaviour
* Aloofness
* Asocial behaviour
* Depersonalisation
* Derealisation
* Illusions
* Transient auditory hallucinations
* Obsessive ruminations
* Paranoia
146
How do you manage Schizotypal behaviour?
• Aripiprazole (10-15mg PO OD)/Risperidone (1mg PO BD)/ Quetiapine (25mg PO BD)
+ (adjunct)
• Diazepam (2-10mg PO BDS-QDS)/ Clonazepam (0.25mg BD)
+
• Psychotherapy: CBT
147
Describe Schizoaffective Disorder.
Outline the types of Schizoaffective Disorder.
Mental health illness characterised by schizophrenia symptoms concurrent with affective symptoms lasting for ≥ 1 months - which may be present in the absence of schizophrenia symptoms at times.
Schizophrenia symptoms AND symptoms of mania or depression
- Schizomanic Disorders: Manic Sx prominent
- Schizodepressive Disorders: Depressive Sx prominent
148
How is Schizoaffective Disorder diagnosed?
Clinical diagnosis using DSM-V criteria
149
How is Schizoaffective disorder managed?
• Anti-psychotics: Aripiprazole (10-15mg PO OD)/Risperidone (1mg PO BD)/ Quetiapine (25mg PO BD)
± (Mania)
• Mood-stabilisers: Lithium/Sodium Valproate/Carbamazepine
± (Depression)
• Anti-depressants: Onlazapine + Fluoxetine/ Citalopram/ Paroxetine
± (Acute Agitation)
• Benzodiazepines: Lorazepam/Diazepam/Onlazapine/Haloperidol
150
Describe Brief Psychotic Disorder.
MHD characterised by co-occurrence of: delusions, hallucinations, disorganised speech, catatonic/disorganised behaviour or negative symptoms (anhedonia/affective flattening/avolition/cognitive deficit or alogia) occurring for between one day and one month.
151
How may Brief Psychotic Disorder be managed?
• Aripiprazole (10-15mg PO OD)/Risperidone (1mg PO BD)/ Quetiapine (25mg PO BD)
+ (adjunct)
• Lorazepam: 1-2mg IM per 8 hours
152
What is the key difference between Brief Psychotic Disorder and Schizophrenia?
Both have positive and negative symptoms however Brief Psychotic Disorder gives symptoms for 1 day to 1 week whereas Schizophrenia is 1 month of symptoms in a period of 6 months whereby symptoms are also experienced during that time
153
What is a Persistent Delusional Disorder?
Umbrella term for mental health disorders typified by persistent, often life-long, delusions which have an insidious onset usually in later adult life. The conditions may be stratified as Eponymous or Non-Eponymous e.g. Capgras Syndrome or Paranoia.
154
How are persistent Delusional Disorders managed?
* Mood-Stabilisers: Lithium/Olanzapine/Valproic Acid/ Sodium Valproate
* Neuroleptics: Aripiprazole/ Risperidone
* Anti-depressants: Sertraline/Citalopram/Escitalopram/ Fluoxetine/ Paroxetine/ Duloxetine/ Venlafaxine
155
Describe depression.
Depressive orders (MHD), characterized by persistent low mood, anhedonia, neurovegetative disturbance, reduced energy and varying levels of social and biological dysfunction.
156
What are the subtypes of depression?
- Major Depressive Disorder: ≥ 5 Sx
- Minor Depression: 2-4 Sx for 2+ weeks
- Persistent Depressive Disorder (Dysthymic Disorder): ≥ 2 years of ¾ dysthymic symptoms for more days than not
157
What are the clinical features of depression?
• Persistent Low Mood
• Anhedonia (marked loss of interest/pleasure)
• Anergia
+
* Tearfulness
* Irritability
* Poor concentration
* Anxiety (Physical + Mental components)
* Slowed thought (cognitive impairment/decline) ‘Depressive pseudodementia’
* Thought blocking
* Reduced speech
* Reduced tone of voice
* Thought content (negative cognitive triad): Self-blame (self)/ Negativism (world)/ Pessimism (future)
* Suicidal ideation
* Sleep disturbance: insomnia/hypersomnia
* Weight gain
* Psychomotor agitation/retardation (restlessness)
* Fatigue
158
What are the triad of symptoms involved in Depression?
Persistent low mood
Anhedonia
Anergia
159
What is the management for Depression?
Supportive: Self-help; Exercise; Diet
+
SSRI: Citalopram (20mg PO OD); Escitalopram (10mg PO OD)
160
When is ECT used?
Depressive illness refractory to multiple treatments
Catatonia
Schizophrenia
161
What does ECT involve?
Outline what happens before, any adjuncts and potential side-effects.
Pre-op consultation abd assessment
Consent
Administration of Short acting anaesthetic; Administration of a muscle relaxant e.g. Suxamethonium (reduce risk of convulsions); attach to EEG machine for monitoring
ECT may be unilateral (non-dominant part of brain) or bilateral
Electrical charge passed for 5 seconds with seizure lasting around 20 seconds
After ECT - wake up. Side effects: retrograde amnesia; anterograde amnesia; headache; drowsiness/confusion
162
A patient requires ECT counselling. They ask:
- What is ECT?
- How does it work?
- What will happen after?
Advise them accordingly
Pre-op consultation abd assessment
Consent
Administration of Short acting anaesthetic; Administration of a muscle relaxant e.g. Suxamethonium (reduce risk of convulsions); attach to EEG machine for monitoring
ECT may be unilateral (non-dominant part of brain) or bilateral
Electrical charge passed for 5 seconds with seizure lasting around 20 seconds
After ECT - wake up. Side effects: retrograde amnesia; anterograde amnesia; headache; drowsiness/confusion
163
What are the key aspects of Dysthymia?
Form of unipolar depression with same symptoms only the symptoms last for 4/7 days and are present over an overall period of 2 years
164
What is the difference between Dysthymia and Cyclothymia?
Dysthymia is fluctuant depressive symptoms for more days than they are absent (4/7) over a period of 2 years cf Cyclothymia is a chronic, fluctuating course of mood disturbance featuring hypomania and depressive episodes
165
What types of Bipolar disorder are there?
- Bipolar I Disorder (At least 1 manic/mixed episode)
- Bipolar II Disorder (At least 1 hypomanic + 1 major depressive disorder)
- Cyclothymia (Chronic, fluctuating course of mood disturbance – numerous periods of hypomania and depressive episodes)
166
What are the clinical features of Bipolar Disorder?
* Grandiosity
* Decreased need for sleep
* More talkative
* Flight of ideas
* Increase in goal-directed activity
* Risk-taking behaviours: buying sprees/sexual indiscretions/foolish business investments
* No underlying medical cause
167
How is Bipolar Disorder managed?
• Aripiprazole (10-15mg PO OD)/Risperidone (1mg PO BD)/ Quetiapine (50mg PO BD)/Lithium (300mg BDS-TDS)/ Olanzapine (5mg PO OD)/ Carbamazepine (100-400mg/day PO BD)
+ (adjunct)
• Clonazepam (1mg/day in 2-3 doses)
168
What is Alcohol Use Disorder?
Mental health condition featuring maladaptive pattern of alcohol use featuring dependence, characterised by ≥ Sx in 12 months of: increased consumption; increased duration; impulses alcohol; craving alcohol; missing obligations/roles; hazardous alcohol use; development of tolerance and withdrawal symptoms.
169
How is alcohol metabolised?
* Common pathway: Ethanol (+ Alcohol Dehydrogenase - ADH) --> Acetaldehyde (+ Aldehyde Dehydrogenase – ALDH)
* Microsomal Ethanol-Oxidising System via cyt. P450 2E1 (CYP2E1): Ethanol (+ CYP2E1) -> Acetaldehyde
* Catalase: Ethanol (+ Catalase) -> Acetaldehyde
170
Calculate the amount of units in 3x 25mL shots of 40% vodka.
25 x 3 = 75
0.075 x 40 = 3 units
171
Outline the clinical features of alcohol dependence.
• Withdrawal (hyperexcitability develops when use reduced - AWS): Seizures/Delirium/Hallucinations/Mood swings/Depression/Anxiety
* Tolerance (physiological adaptation)
* Recurrent intoxication/Admissions
* Impulsivity: Drink driving/Accidents/Crime/Domestic violence
* Anxiety
* Insomnia
* Nausea + Vomiting: Alcohol-related gastritis / Pancreatitis
* Abdominal pain: Alcohol-related gastritis / Pancreatitis
* Haematemesis: Alcohol-related gastritis / Pancreatitis
* Muscle cramps/Pain/Tenderness/Paraesthesia: Peripheral neuropathy from B1 (thiamine) deficiency
* Skin changes: Telangiectasia/Spider naevi/Flushing/Psoriasis/Pruritus
* Hepatosplenomegaly: Steatosis/Hepatitis
* Liver shrinking: Cirrhosis
* Jaundice
* Ascites
* Tremor
* Sweating
* Malnutrition: Sarcopenia/Atrophy
172
How may alcohol dependence be diagnosed?
CAGE Questionnaire:
1) Cut down (suggested)
2) Annoyed (others)
3) Guilty (felt guilty)
4) Eye-opener (drink in the morning)
Note: Positive = ≥ 2 Yes responses
FAST Screening Tool
1) Fucked (Binge Drinking)
2) Anti-social (Unable to complete activity)
3) Shit memory (forgetful)
4) Thought (others concerned)
Alcohol levels
173
How do you manage acute alcohol withdrawal?
• Supportive care: Reassurance/Low-stimulation environment/Hydration/Vitamin infusion (Pabrinex – Vitamin B and C) for 3/5 or Oral Thiamine (B1) TDS
+
• Detoxification: Chlordiazepoxide/Diazepam/Lorazepam + Thiamine (IV 100mg OD)
±
• Skeletal muscle relaxants: Baclofen
174
How do you manage alcohol dependence?
• Supportive: Advice to reduce intake (motivational interviewing + SMART goals)
±
• Therapy: AA/CBT/MET
+
• Alcohol antagonist: Disulfiram (“Antabuse”)
or
• Sulfonic Acid: Acamprosate
175
What is a drug?
Psychoactive substance causing alteration in mood, behaviour, perception and consciousness
176
What is tolerance?
State of reduced responsiveness resulting in increased doses of substance to feel effects previously felt due to repeated administration
177
What is dependence?
State of psychological or physiological dependence from psychoactive substance characterised by impulses and motivations to take the drug to seek resulting effects
178
What is addiction?
Dependence on a substance whereby tolerance increases (amount needed to detect substance’s effects) and removal of substance leads to withdrawal effects (unpleasant physiological side-effects).
179
What are the clinical features of Opiate overdose?
* Sedation
* Nausea
* Vomiting
* Mood change: Euphoria/Intense pleasure
* Analgesia
* Pupillary constriction
* Respiratory depression
* Bradycardia (Decreased SNS outflow)
* Hypotension (Decreased SNS outflow)
* Hypothermia
* Cough reflex suppression
* Analgesia
180
How do you manage Opioid overdose?
Supportive: admission; A-E assessment; monitoring
+
Naloxone
181
How do you manage a patient with Opioid Dependence?
• CBT: 3Ps (Predisposing + Ppt + Protective) + Situation + Cognitive Triad (Thoughts/Feelings/Behaviours)
+
• Opiate analgesics: Methadone
-> Competitive antagonist of Mu receptor
OR
• Partial agonist: Buprenorphine
-> Partial mu-receptor agonist with ceiling effect
182
What are the clinical features of Amphetamine ingestion?
* Euphoria
* Hyperarousal: Energy + Alertness
* Self-confidence
* Reduced inhibitions + Impulsive behaviour
* Reduced appetite (Appetite suppression)
* Pupillary dilation
* Blurred vision
* Dry mouth
* Tachycardia
* Arrhythmia
* Hypertension
* Hyperthermia
* Hyperhidrosis
* Tremor
* Dehydration -> Xerostomia
183
What is the management for amphetamine dependence?
• CBT
184
What are the symptoms of Cocaine abuse?
* Euphoria
* Hyperarousal: Energy + Alertness
* Self-confidence
* Reduced inhibitions + Impulsive behaviour
* Reduced appetite (Appetite suppression)
* Pupillary dilation
* Blurred vision
* Tachycardia
* Arrhythmia
* Hypertension
* Hyperthermia
* Hyperhidrosis
* Tremor
* Dehydration
* Agitation
185
What is the management for a patient with Cocaine overdose?
• Benzodiazepines: Lorazepam/Diazepam
+
• CBT
186
What are the clinical features of MDMA ingestion?
* Euphoria
* Nausea
* Vomiting
* Hallucinations: Visual + Auditory
* Insomnia
* Impulsivity
* Anorexia
* Weight loss
* Psychological Sx: Anxiety/Paranoia/Psychosis Suicidal feelings
* Low mood (come down)
* Dilated pupils
* Blurred vision
* Dry mouth
* Teeth grinding
* Jaw tightening (bruxism)
* Tachycardia
* Hypertension
* Tachypnoea
* Hyperthermia
* Hyperhidrosis
* Dehydration
* Tremor
* Psychomotor activity increased
* Agitation
187
What is the management of MDMA dependence?
• CBT
188
What are the clinical features of LSD ingestion?
* Hallucinations: Visual + Auditory
* Illusions
* Micropsia/Macropsia
* Synaesthesia
```
Higher doses… -> Sympathomimetic effects
• Dilated pupils
• Tachycardia
• Hypertension
• Hyperreflexia
• Hyperthermia
```
189
What is the management for a patient on LSD?
• Supportive: Sugar/Safe environment/Reassuring
±
• Anxiolytics: Lorazepam/Diazepam
190
What are the clinical features of ketamine use?
* Hallucinations/Near-death
* Out-of-body experience: Derealisation/Depersonalisation
* Psychosis
* Emergence phenomena
* Cognitive impairment
* Synaesthesia
* Hypersalivation
* Tachycardia
* Hypertension
191
How doyle manage a patient who has a Ketamine addiction?
• Supportive: Sugar/Safe environment/Reassuring
192
What is the active substance in magic mushrooms?
Psilocybin and Psilocin
193
What are the clinical features of Magic Mushroom use?
* Hallucinations: Visual + Auditory
* Illusions
* Micropsia/Macropsia
* Synaesthesia
* Panic
* Amnesia
* Psychosis
* Mydriasis
* Acute stuporous state
194
How do you manage a patient who is showing clinical features of Magic Mushroom use?
• Supportive: Sugar/Safe environment/Reassuring
±
• Anxiolytics: Lorazepam/Diazepam
195
Give an example of a Benzodiazepine.
- Chlordiazepoxide
- Diazepam
- Lorazepam
- Temazepam
- Clonazepam
- Alprazolam
196
What are the clinical features of benzodiazepine intoxication?
* Impaired mental status: Attention; Memory; Inappropriate behaviour
* Drowsiness
* Slurred speech
* Ataxia
* Respiratory depression
* Coma
* Decreased deep tendon reflexes
* Nystagmus
197
How do you manage Benzodiazepine toxidrome?
```
• Supportive: Airway maintenance; Cardiorespiratory monitoring; IV fluids/ Dose-tapering
+
• BZD antagonist: Flumazenil
+
• CBT
```
198
What is the reversal agent for Benzodiazepine overdose?
Flumazenil
199
What are the clinical features of Cannabis?
* Euphoria
* Increased appetite
* Sedation
* Perceptual awareness
* Hallucinations -> Psychosis
* Tachycardia
* Hypertension
* Bronchodilation
200
What is the management for Cannabis toxidrome?
• Supportive: Nutrition/Reassurance/Calm environment
±
• Anxiolytics: Lorazepam/Diazepam
201
How do you calculate a MUST score?
Use the malnutrition universal screening tool
1) BMI (0-2): ≥ 20/ 18.5-20/ ≤ 18.5
2) Weight loss (0-2): ≤5%/ 5-10%/ ≥ 10%
3) Acutely unwell/no nutritional intake ≥ 5 days (0 or 2): Yes/ No
4) Add scores
5) Stratify (0/1/2 ≤): Low risk/ Medium/ High
202
What framework can be used when taking a Social History from an Adolescent?
Mnemonic: HEEADSSS
```
Home
Education + Employment
Eating
Activities + hobbies
Drugs (Alcohol + Tobacco)
Sex
Self-harm + self-image
Safety
```
203
Describe Avoidant-Restrictive Food Intake Disorder.
Eating disorder characterised by lack of interest in food, fears of negative consequences of eating and selective eating with 1 Sx ≤ weight loss, nutritional deficiency, supplement dependency and interference with psychosocial functioning.
204
What are the clinical features of ARFID?
* Selective eating (fussy eating)
* Fear of negative consequences of eating
* Dependence on nutritional supplements
• Weight loss
205
What is the management of ARFID?
• Family-based therapy
±
• Nutrition
206
What is Anorexia Nervosa?
Eating disorder characterised by caloric intake restriction leading to low body weight, intense fear of gaining weight, body dysmorphia
Sx Triad: Weight + Fear + Body
207
What are the clinical features of Anorexia Nervosa?
* Low body weight: ≤ 18.5 kg/m2
* Fear of gaining weight
* Disturbed body image (body dysmorphia)
* Calorie restriction
* Purging (behaviours to counteract food): Psychogenic vomiting; Diet pills; Laxatives; Diuretics)
* Fatigue
* Poor concentration
* Amenorrhoea
* Loss of libido
* Orthostatic hypotension
* Non-specific GI: Constipation/Fullness/Bloating/Cramping gas
* Cardiac Sx: QTc prolongation/1st degree AV heart block; T-wave changes
* Decreased SC fat
* Lanugo
* Cracked nails
* Hair thinning
208
The fine, light hair which appears in Anorexia is called?
Lanugo
209
What group of questions may be used to aid the diagnosis of Anorexia Nervosa?
SCOFF Qs
```
Sick
Control
One stone
Fat
Food
```
210
What is the general management for Anorexia Nervosa?
• Nutritional Rehabilitation: Dietary assessment; Balanced meal plan (1500-1800kCal); Fluid intake; Vitamin + Mineral replenishment (+ monitoring)
±
• Psychotherapy: Counselling/CBT
211
What is the management of Anorexia Nervosa in a medically unstable scenario?
• Admission: Oral/Enteral/Parenteral nutrition
±
• Fluid intake correction
±
• Potassium Repletion: 40-100mEq PO OD or IV PRN
-> KCl
±
• Magnesium Repletion: 10-20mmol IV OD
-> Mg(SO4)2
±
• Calcium Repletion: 100-1000mg IV every 6 hours
-> Calcium gluconate
±
• Sodium Repletion: Fluid restriction + balanced nutrition/ Hypertonic Saline (if severe Sx – seizures; confusion; coma)
212
Describe Bulimia Nervosa.
Eating disorder typified by recurrent episodic binge eating in conjunction with compensatory purging behaviours (– psychogenic vomiting; fasting; excessive exercise; misuse of laxatives; diuretics; enemas or other medication), lasting at least weekly for 3 months.
213
What are the clinical features of Bulimia Nervosa?
• Recurrent episodic binge eating: Discrete period time + ≥ Normal intake – speed/amounts/fullness/cephalic/embarrassed/guilty
* Purging behaviour: Psychogenic vomiting/Laxatives/ Enemas/ Suppositories
* Compensatory behaviour: Fasting/ Excessive exercise
* Body dysmorphia: Weight/Shape-conscious
* Depression: Persistent low mood + Anergia + Anhedonia
* Menstrual irregularity
* Misuse of insulin
* Self-harm
* GI Sx: GORD/Diarrhoea/Constipation/Abdominal pain
* Dental erosion: Abrasive food/ HCl/ Night-grinding
* Russel Sign: Calluses on dorsum of hand from psychogenic vomiting
* Parotid hypertrophy
* Arrhythmia
214
What is the term for the calluses/plaques present in the knuckles in Bulimia Nervosa?
Russel Sign
215
How do you manage Bulimia Nervosa?
• Nutritional Rehabilitation: Dietary assessment; Balanced meal plan (1500-1800kCal); Fluid intake; Vitamin + Mineral replenishment (+ monitoring)
±
• Psychotherapy: CBT
+ (Depression)
• SSRI/SNRI: Fluoxetine/ Sertraline/ Venlafaxine
216
Describe Binge Eating Disorder.
Eating disorder characterised by regular, episodic binge eating which may be planned and commonly leads to weight gain.
217
Outline the clinical features of Binge Eating Disorder.
* Impulsivity: Buying large quantities/Eating rapidly/Eating when not hungry
* Obsession: Organising life around food/ Eating when not hungry/ Time talking about food
* Asocial behaviour: Eating in isolation
* Irritability
* Mood lability: Mood swings
* Low self-esteem/confidence
* Co-morbid MHDs
* Tiredness
* Fatigue
* Weight gain
* Bloating
* Constipation
* Abdominal pain
218
How is binge eating disorder managed?
• CBT
+ (Depression)
• SSRIs/SNRIs: Sertraline/Citalopram/Fluoxetine/Venlafaxine
219
Describe the concept of Gender Dysphoria?
mismatch between gender and sex assigned at birth
220
What are the clinical features of Gender Dysphoria?
* Gender dysphoria: Dissatisfaction with gender + desire to live as another gender
* Transvestitism
* Altered appearance
* Reduced libido
* Atypical speech + vocal quality
221
What is the management involved in Male to Female transitions?
• Observation: 1 year + Capacity + Gender dysphoria + Controlled PMHx + 1 year continuous hormone therapy
• Successful role change ≥ 1 year
±
• Augmentation mammoplasty
±
• Genital Surgery: Transfeminine bottom surgery Vulvoplasty + Vaginoplasty
•
• Oestrogens: Estradiol transdermal OR Estradiol valerate
±
• Androgen suppression therapy: Goserelin
±
• Hair removal: Electrolysis + Laser
±
• Head and Neck surgery: Thyroid cartilage reduction (Cricothyroid approximation procedure)
222
What is the management involved in Female to Male transitions?
• Observation: 1 year + Capacity + Gender dysphoria + Controlled PMHx + 1 year continuous hormone therapy
```
• Androgens: Testosterone
±
• Bilateral mastectomy
±
• Hysterectomy + Bilateral oophorectomy
±
• Phalloplasty
±
• Craniofacial surgery
```
223
What is the criteria for detention under the mental health act?
Mental disorder
No capacity (poor decision making)
Significant risk
Informal/voluntary care not appropriate
Determining treatment required
224
What are the options for detaining someone under the Mental Health Act in Scotland?
Emergency detention
Short-term detention
Compulsory treatment order
225
Which of the following is false regarding emergency detention orders?
A. Allows 72 hours of assessment
B. You can never give treatment
C. There is no right to appeal
D. An F2 can authorise this
B
226
Which of the following is false regarding short term detention orders?
A. Allows 28 days of assessment and treatment
B. You believe there is a likely mental disorder
C. There is a right to appeal
D. An F2 alone can authorise this
D. F2 < + MHO required
227
Which of the following is false regarding Compulsory Treatment Order?
A. Allows 6 months of treatment
B. Mandatory tribunal occurs
C. You can renew this at 6 months
D. You suspect a mental disorder is present
D, a mental disorder must be present
228
Give 3 RFs for Suicide.
Gender - males are three times as likely to take their own life as females
Age - people aged 35-49 years now have the highest suicide rate
Mental illness
The treatment and care they receive after making a suicide attempt
Physically disabling or painful illnesses including chronic pain
Alcohol and drug misuse
The loss of a job
Debt
Living alone - becoming socially excluded or isolated;
Bereavement
Family breakdown and conflict including divorce and family mental health problems
Imprisonment
229
When do alcohol withdrawal symptoms occur?
Rule of 6s
Symptoms = 6-12 hours
Seizures = 36 hours
Delirium tremens = 72 hours
230
How long should antidepressants be continued for following symptom remission?
6 months
