Psychiatry Flashcards

Question

How is ADHD treated in children and adults?

Answer 1

Age 4-6: 1st line - Parent training in behaviour management (PTBM) and/or behavioural classroom intervention + psychoeducation. 2nd line - Methylphenidate 3rd line - Guanfacine Age 6-18: 1st line - Psychoeducation + behavioral therapy in all lines. Consider methylphenidate or amfetamine/lisdexamfetamine (stimulant) 2nd line - Atomoxetine (selective norepinephrine reuptake inhibitor) 3rd line - Guanfacine or clonidine (alpha-2-adrenergic agonists) - especially effective for hyperactivity Adults: 1st line: Lisdexamfetamine or methylphenidate 2nd line: Atomoxetine (non-stimulant) Off licence: Bupropion, venlafaxine etc

Answer 2

Medication induced: anorexia, insomnia, headache, cardiac issues, growth delay, mood lability Untreated: Suicidal behaviour, obesity ADHD symptoms persist into adulthood but the majority enter a partial remission. Symptoms in adulthood often lead to academic/professional difficulty, maladaptive relationship, antisocial behaviours, increased accident risk.

Answer 3

Depression and depressive disorders are characterised by persistent low mood, loss of interest, anhedonia and reduced energy. Causing varying levels of social and occupational dysfunction

Answer 4

1. Depression is a major global cause of disability and premature death. 2. Incidence in women is double to men 3. Risk of depression is 2-3 fold in people who have a 1st degree family member affected.

Answer 5

Multifactorial although exact cause still unknown 1. Genetic - strong evidence but no specific factors 2. Psychosocial/environmental - trauma, loss, stressful life events 3. Neurobiological - dysregulation of neurotransmitters e.g serotonin

Answer 6

Not fully understood, probably due to a combination of complex mechanisms. Including dysregulation of the HPA which leads to disturbance in neurotransmitter activity in the CNS, including low levels of serotonin.

Answer 7

1. FHx of depression/suicide 2. Personal Hx of depression/other mental illness 3. Female sex 4. Chronic health condition - Dementia 5. Medications - corticosteroids, propranolol, oral contraceptive 6. Postnatal status

Answer 8

Core: - Persistent depressed/low mood - Anhedonia (reduced pleasure) - Low energy/fatigue Additional: - Weight change - Reduced libido - Sleep disturbance - Psychomotor change - Excessive guilt - Poor concentration - Functional impairment - Suicidal ideation - Substance/medication SE excluded - Manic episode in bipolar patient excluded - Medical illness excluded

Answer 9

A patient must have at least 5 of 9 symptoms during the same 2 week period, which is different to normal. At least one of the symptoms must be low mood or anhedonia. Symptoms should occur in all areas/nearly everyday 1. Depressed/low mood 2. Anhedonia 3. Significant weight change 4. Sleep disturbance - in/hypersomnia 5. Psychomotor symptoms -agitation/retardation 6. Fatigue/low energy 7. Feelings of worthlessness/excessive guilt 8. Poor concentration/indecisiveness 9. Thoughts of death, suicidal ideation, or suicide attempt Further criteria - - Functional impact - Not better explained by substance abuse, medication side effects, or other psychiatric or somatic medical conditions.

Answer 10

1. Clinical diagnoses based on a MSE - according to the DSM-V or ICD 11 criteria 2. Metabolic panel - should be normal 3. FBC - rule out other causes of fatigue 4. TFTs - rule out hypothyroidism 5. PHQ 9 6. Other scales - e.g Edinburgh postnatal, geriatric or cornell dementia scale where appropriate

Answer 11

ICD 11 criteria requires 1 symptom of (low mood, anhedonia, fatigue) + additional symptoms. No minimum amount of symptoms and focuses on severity and impact on function. Relies more on clinical judgement.

Answer 12

Also known as persistent depressive disorder is a chronic form of depression which lasts at least 2 years, usually milder symptoms but cause a significantly reduced QofL.

Answer 13

In patients with subthreshold/mild depression non-pharmacological options should be offered 1st line. This includes: 1. Psychotherapy - CBT, low or high intensity 2. Computer based interventions 3. Lifestyle factors - exercise, diet, sleep hygiene etc 4. Social support - especially for people with caring roles 5. Safety net - support groups, helplines 6. Early follow up - 2-4 weeks

Answer 14

Non-suicidal, non-pregnant, no psychosis or severe psychomotor symptoms: 1st line - Antidepressant Consider immediate management with benzodiazepine (+/-) antipsychotic 2nd line - switch antidepressant class Treatment resistant cases: 1st line: Consider combination antidepressant therapy, antipsychotic therapy and lithium 2nd line: MAOI (monoamine oxidase inhibitor) 3rd line: ECT

Answer 15

Psychiatric referral (+/-) hospitalisation + antidepressant or ECT (in some severe cases) Consider immediate management with benzodiazepine (+/-) antipsychotic

Answer 16

- Bipolar disorder - will have manic symptoms - Anxiety disorders - Hypothyroidism - Cushing's - Adjustment disorder w/ depressed mood - Substance/medication induced or somatic illness

Answer 17

Treatment should be continued for 9-12 months - 1/3 of patients will have a recurrence within a year of stopping treatment - More than 50% will have a recurrence in their lifetime - Maintenance therapy may be required for people who have relapsed 3 times

Answer 18

ASD is a neurodevelopmental condition characterised by persistent impairments in social communication/interaction and restricted/repetitive patterns of behaviour, interests or activities.

Answer 19

1. Prevalence is around 1% of children in the UK 2. More common in males (3-4 times) 3. Coexisting ADHD, learning disability, sleep difficulty and other mental health conditions are common

Answer 20

Development of ASD is associated with genetic and environmental factors: Genetic - specific factors are found in 20-25% of patients. Including known genetic syndromes (fragile x, retts, Downs) Environmental - Advanced paternal age, maternal medication, infections, traumatic birth These factors result in modified brain development and abnormalities in neural connections.

Answer 21

1. Male sex 2. Positive FHx 3. Gestational valproate exposure 4. Genetic variants 5. Increasing age 6. Prematurity/antenatal complications

Answer 22

Symptoms: - Language regression/delay - Verbal/Non-verbal communication impairment (limited eye contact and facial expressions) - Social impairment (play alone, inappropriate, one sided) - Repetitive, rigid, stereotyped behavior, interests + activities - Motor stereotypies - Sensory sensitivity Signs: - Placid or very irritable baby - Feeding difficulties

Answer 23

1. ASD diagnosis are done by trained specialist (e.g community paediatrician, psychiatrist). 2. Initial screening tools in primary care can be useful (e.g SCQ, CAST, CARS) Further tests: Hearing and language assessment - if delayed speech Genetic testing - to test syndromic causes like fragile X EEG or MRI brain - in some cases e.g language regression

Answer 24

1. Other causes of disordered development, LD 2. ADHD 3. Social pragmatic communication disorder 4. Schizoid personality disorder

Answer 25

No specific medication: 1. Behavioural & educational interventions (e.g. high staff-to-student ratio, highly supportive teaching environment, predictability and structure) 2. Psychosocial interventions (e.g. be appropriate for the child or young person’s developmental level and sensitive and responsive to their patterns of communication and interaction, include techniques to expand communication, interactive play and social routines) 3. Interventions for life skills (e.g. coping strategies for leisure activities, public transport and employment) 4. Interventions for speech and language problems (e.g. involvement of speech and language team) 5. Intervention for sleep disorders 6. Managing comorbidities

Answer 26

A. Persistent deficits in social communication and social interaction (all 3 of): - Deficits in social-emotional reciprocity. (conversation, communicating emotion) - Deficits in nonverbal communicative behaviors used for social interaction (e.g. eye contact, body language). - Deficits in developing, maintaining, and understanding relationships. B. Restricted, Repetitive Patterns of Behavior, Interests, or Activities (at least 2 of the following): - Stereotyped or repetitive motor movements, use of objects, or speech. - Insistence on sameness, inflexible adherence to routines, or ritualized patterns. - Highly restricted, fixated interests that are abnormal in intensity or focus. - Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment. C. Symptoms must be present in the early developmental period, but may not fully manifest until social demands exceed limited capacities. D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of functioning. E. These disturbances are not better explained by intellectual disability. Intellectual disability and ASD frequently co-occur, but to diagnose ASD, social communication should be below that expected for general developmental level.

Answer 27

Complications: - Epilepsy - Anxiety - Depression - Developmental regression With appropriate support patients will have fulfilling lives. - Depends on severity of ASD - ASD patients with higher IQ have less severe symptoms in adulthood

Answer 28

Bipolar disorder is an episodic mood disorder characterised by manic, or hypomanic, and depressive episodes. Two subtypes are recognised: bipolar I disorder and bipolar II disorder.

Answer 29

- Lifetime prevalence of 1-2% in the UK - Onset is usually adolescence to early adulthood (usually before 30) - Misdiagnosis with Major depressive disorder is common - Equal sex prevalence (slight female predominance in bipolar II)

Answer 30

Exact cause is unknown, likely due to a combination of genetic and environmental factors. Genetic - 8 fold increase if 1st degree relative is affected Environmental - Childhood trauma/abuse, adverse life events, history of substance use disorder Biological - Hormone abnormalities (HPA issues), also systemic inflammatory pathways

Answer 31

1. FHx of bipolar or schizophrenia 2. Onset of mood disorder (depression) <20 years 3. Adverse life events 4. Childhood trauma/adversity 5. Hx of Depression 6. Hx of substance use disorder 7. Presence of anxiety disorder 8. Hx of obesity or CVD

Answer 32

Symptoms: - Major depressive episode - Mania (elated mood/energy, psychotic symptoms, affect social function) - Hypomania (milder symptoms, no psychotic features, few days) - Inflated self esteem/grandiosity - Decreased need for sleep - Racing thoughts + speech - Disinhibition - excessive spending, sexual behaviour - Psychotic features - delusions/hallucinations (auditory) - No underlying cause - substance misuse, underlying medical cause, medication (steroids)

Answer 33

Based on discrete episodes: - Manic episode: abnormal and persistently elevated, expansive, or irritable mood. Symptoms last >1 week, 3 additional symptoms for mania. - Hypomanic episode: abnormal and persistently elevated, expansive, or irritable mood. (lasting at least 4 days) - Depressive episode: depressed mood or loss of interest/pleasure in nearly all activities. Symptoms last ≥2 weeks. - Mixed episode: rapid alternating between manic and depressive symptoms. (manic/hypomanic criteria + 3 depressive for 1 week or opposite for 2 weeks)

Answer 34

1. Bipolar I - at least one manic episode (lasting 1 week or requiring hospitalisation). Depression episode not required for diagnosis. 2. Bipolar II - at least one major depressive episode and one major hypomanic episode. 3. Cyclothymic disorder - At least 2 years (1 year in children), numerous periods of hypomanic and depressive symptoms that don't meet full criteria for hypomanic or major depressive episodes.

Answer 35

Made by specialist assessment. Using DSM 5 In primary care: - Primary care eval of mental disorders (PRIME-MD) - PHQ-9 - Mood disorder questionnaire (MDQ) - FBC - TFT - Vit D - Toxicology

Answer 36

1. Major or persistent depressive episode 2. Cyclothymic disorder 3. Substance induced 4. Medical disorder induced (thyroid,cushing's,MS) 5. Other mental health disorders (Schizophrenia,Schizoaffective,ADHD,OCD, PTSD) 6. Iatrogenic (antidepressants, levodopa, steroids)

Answer 37

1st line: Atypical antipsychotic (olanzapine, risperidone, quetiapine) 2nd line: Valproate, Lithium, lamotrigine or combination therapy Consider ECT if no response

Answer 38

- Olanzapine w/ fluoxetine - Quetiapine alone - lamotrigine - Combination therapy Be careful using SSRIs. Consider ECT if no response

Answer 39

Non pharmacological: - Psychoeducation - CBT - Mood diary, regular sleep pattern Pharmacological: - Lithium - Antipsychotic (e.g. olanzapine, quetiapine or risperidone) - Sodium valproate (teratogenic) - Combination therapy (sodium valproate + antipsychotic)

Answer 40

Can cause mania or lead to a rapid cycling mood (frequent, distinct episodes)

Answer 41

The medications have many complications: 1. Lithium - renal impairment, thyroid dysfunction, cardiotoxicity, lithium toxicity (tremor, confusion, coma, seizures) 2. Sodium Valproate - Hepatotoxicity, pancreatitis, weight gain, teratogenicity 3. Antipsychotics - Metabolic syndrome (weight gain, T2DM), tardive dyskinesia (EPS), cardiac arrhythmias.

Answer 42

- Bipolar episode relapse - Higher mortality (from CVD and suicide) - Difficult management, often patients are not well over maintenance therapies

Answer 43

OCD is a mental health condition characterised by persistent obsessions and/or compulsions that are performed in response to the obsessions. It causes significant distress and impact on function.

Answer 44

1. Equal sex prevalence 2. Age of onset - late adolescence to early 20s 3. Earlier presentation in boys 4. 1-3% of UK affected

Answer 45

Multifactorial aetiology 1. Genetic - genes related to serotonin, dopamine + glutamate neurotransmission 2. Environmental - Childhood trauma, stress, PANDAS (paediatric autoimmune neuropsychiatric disorders associated w/ Strep), pregnancy,

Answer 46

Male sex Higher frequency of compulsions Early age of onset Previous OCD hospitalisation Comorbid psychiatric disorders (tic, schizotypal personality disorder)

Answer 47

Intrusive, unwanted thoughts that caused marked stress/anxiety. (e.g. contamination, harm, sexual, symmetry)

Answer 48

Repetitive behaviours (e.g. handwashing, checking) or mental acts (e.g. counting, repeating words) which are aimed at reducing the anxiety caused by obsessions.

Answer 49

Using the DSM-V or ICD 11 criteria: DSM: 1. Obsessions and/or compulsions 2. These are time consuming (>1 hour/day) 3. Not attributable to substance use, medical conditions, or other mental disorders. ICD-11: Same Symptoms present for at least several weeks Both include insight specifiers (Delusional/absent to good)

Answer 50

Yale-Brown Obsessive compulsive scale (0-40) Clinical Global Impression (0-7)

Answer 51

- Obsessive compulsive personality disorder - Body dysmorphic disorder - compulsions connected to appearance - ASD - Delusional disorder - Substance/medication induced - Trichotillomania

Answer 52

Non-pharmacological: For mild -moderate symptoms - CBT - Exposure + response prevention Pharmacological: 1st line: SSRI 2nd line: Clomipramine (tricyclic) Consider atypical antipsychotic if unresponsive

Answer 53

- Treatment resistance - Severe symptoms, significantly limiting function - Safeguarding concerns - Suicide/self harm risk - Significant comorbidities

Answer 54

Refers to the development of a depressive illness following childbirth and may form part of a bipolar or, more usually, a unipolar illness.

Answer 55

1. Baby blues - seen in the majority of women in the first week or so after birth. (No treatment, reassurance/support) 2. Postnatal depression - seen in about 1/10 women, with a peak around three months after birth. 3. Puerperal psychosis - seen in about 1/1000 women, starting a few weeks after birth.

Answer 56

1. Affects 10-15% of women 2. Onset usually within 4-6 weeks, can occur within 1st year 3. More common with history of anxiety/depression

Answer 57

Combination of hormonal changes, genetic predisposition, psychosocial stressors (e.g., relationship problems, lack of support), and pre-existing mental health conditions.

Answer 58

- PHx/FHx of depression or anxiety - Lack of social support - Traumatic birth experience - Relationship difficulties - Socioeconomic stressors - Discontinuing psychopharmacological treatments - Sleep deprivation

Answer 59

Clinical: - Edinburgh PN depression scale - score above 10/30 suggests mild to severe depression - PHQ-9 Other tests: - TFTs - FBC - other causes of fatigue - Urine drug screen

Answer 60

Minor mood disorder (baby blues) Postnatal psychosis OCD Bipolar disorder Thyroid dysfunction Anaemia

Answer 61

Mild: 1st line - Self help strategies, CBT Moderate - Severe: 1st line - SSRIs (like sertraline) +/- high intensity psychological intervention (CBT) - Consider admission if risk to self/or baby

Answer 62

1. Impaired bonding with infant 2. Neglect of baby or infanticide 3. Suicide 4. Bipolar disorder

Answer 63

- History of bipolar disorder or schizophrenia. - Previous episode of postpartum psychosis. - Family history of psychotic disorders.

Answer 64

1. 90% of women have onset within 1 week 2. Delusions 3. Hallucinations 4. Depression - catatonia or psychomotor retardation 5. Mania 6. Confusion 7. Thought disorder

Answer 65

- Psychiatric emergency, admission to mother and baby unit. - Medications: antipsychotics, mood stabilizers (e.g., lithium), and possibly antidepressants. - Electroconvulsive therapy (ECT) may be considered in severe or treatment-resistant cases.

Answer 66

PTSD is a relatively common mental condition that develops following exposure to 1 or more traumatic event involving actual or threatened death, serious injury or sexual violence.

Answer 67

PTSD develops after a single or short term traumatic event. Complex PTSD develops after prolonged/repeated exposure to trauma which are difficult to escape from. CPTSD has additional symptoms (emotional, interpersonal and negative self worth).

Answer 68

- Affects around 3-5% of adults in the UK - Higher prevalence in women - Higher frequency in conflict-affected and inner city areas

Answer 69

Triggered by exposure to traumatic events: - War - Physical/sexual assault - Severe accidents (e.g RTA) - Natural disasters Genetic predisposition, structural brain changes and altered neurochemicals (increased noradrenaline)

Answer 70

1. Increased likelihood of exposure (emergency workers, refugees, armed forces) 2. Severity and duration of trauma 3. Multiple traumas 4. Female sex 5. Younger age 6. Hx of mental disorder 7. Low social support

Answer 71

A. Exposure to a traumatic event B. Intrusive (re-experiencing) - 1 or more C. Avoidance - 1 or more D. Negative cognitions/mood - at least 2 E. Arousal/reactivity - at least 2 B-E - duration >1 month Causes significant distress and impairment to function Not due to medication, substance use

Answer 72

A.1st month defined as acute stress disorder B.1-6 month - typical onset of PTSD C. After 6 months - PTSD w/ delayed expression

Answer 73

1. Active monitoring in mild/subthreshold symptoms 2. Trauma-focused CBT 3. Eye-movement desensitisation and reprocessing 4. Pharmacotherapy - SSRIs, venlafaxine, beta-blockers, antipsychotics (risperidone)

Answer 74

- Increased distress due to exposure therapy - CVD - Dementia - Depression - Psychosis - Suicide

Answer 75

- Acute stress disorder - Anxiety - Major depressive disorder - Dissociative disorder - Specific phobias - Psychosis

Answer 76

Schizophrenia is a chronic, severe mental health disorder characterised by episodes of psychosis, which involves distortions in thinking, perception, emotions and behaviour.

Answer 77

1. Affects 1% of global population 2. Most often presents between 15-30 years 3. Women tend to present later (late 20s) 4. Similar sex prevalence (1.4:1 - M:F)

Answer 78

Multifactorial: 1. Genetic - Highly heritable (around 60-80%) 2. Environmental - social adversity, childhood trauma, urban residence, cannabis use, migration 3. Neurodevelopmental - maternal infections, obstetric complications, preterm birth, hypoxia, low IQ

Answer 79

Not fully understood: 1. Dopamine theory - Overactive in the mesolimbic pathway (positive symptoms - hallucinations) and underactivity in the mesocortical pathway (negative symptoms - reduced motivation) are implicated. 2. Structural brain changes - Enlarged ventricles, reduced grey matter, and abnormalities in the prefrontal cortex and temporal lobes are associated with schizophrenia. 3. Inflammation and Immune Dysregulation: Elevated pro-neuroinflammatory markers are observed in some patients.

Answer 80

These are the core features of psychosis, and refer to excesses or distortions of normal functions. 1. Hallucinations: Perceptions without external stimuli, commonly auditory (hearing voices), but can also be visual, olfactory, gustatory, or tactile. 2. Delusions: Strongly held false beliefs that are resistant to reasoning, despite evidence. Common types include persecutory, grandiose, and referential delusions. 3. Disorganised Speech: Incoherent or tangential speech that reflects disordered thought processes (e.g., word salad, loose associations). 4. Disorganised or Catatonic Behavior: Unpredictable, inappropriate, or erratic behaviors. Catatonia involves motor disturbances ranging from complete immobility to excessive agitation.

Answer 81

These involve a reduction or loss of normal functions. Including flattened affect, apathy, anergia, social withdrawal, alogia and anhedonia (these can be difficult to differentiate from comorbid depression).

Answer 82

The prodromal phase is characterised by subtle changes in behavior, cognition, and functioning that precede the first psychotic episode (e.g. social withdrawal, poor memory, mood swings, disturbed sleep). Identifying this early has been associated with more favourable outcomes.

Answer 83

DSM V: 2 or more of the following symptoms, each present for a significant portion of 1-month period. At least one of symptoms 1-3. 1. Delusions 2. Hallucinations 3. Disorganised speech 4. Grossly disorganised or catatonic behavior 5. 'Negative' symptoms

Answer 84

1. Schizoaffective disorder - prominent mood symptoms combined with psychosis 2. Depression w/ psychosis - mood congruent 3. Bipolar w/ psychosis - clear presence of mania/hypomania 4. Substance induced psychosis 5. Munchausen's syndrome 6. Delusional disorder 7. Organic psychosis (encephalitis, syphilis, b12 deficiency)

Answer 85

1. Ensure safety of patient and others - Mental health act 2005 2. Oral benzodiazepine - lorazepam or midazolam 3. Consider rapid tranquillisation if patient is aggressive/violent - IM lorazepam or promethazine + haloperidol Refer to specialist to start antipsychotic

Answer 86

Psychosocial, CBT + family interventions should be offered to all patients 1st line: Non-clozapine antipsychotic (Monitor physical health) 2nd line: Try alternative non-clozapine antipsychotic 3rd line: Clozapine (under specialist care)

Answer 87

- Antipsychotic SEs - Suicidal tendencies - Substance use - Tobacco use - Depression

Answer 88

- Good recovery following 1st episode of psychosis - 20% will make a full recovery, 35% have long periods of remission - Mean life expectancy is around 15 years lower - 20-30% of cases are considered treatment resistant - Increased suicide risk

Answer 89

Strong family history gradual onset low IQ prodromal phase of social withdrawal lack of obvious precipitant

Answer 90

Is characterised by a combination of schizophrenia symptoms and a prominent mood disorder (depression or mania).

Answer 91

1. Uninterrupted period of illness, during which there is a major depressive or manic episode concurrent with symptoms meeting criterion A for schizophrenia. 2. Two weeks of delusions or hallucinations in the absence of prominent mood symptoms. Rules out mood disorders w/ psychotic features. 3. Mood symptoms are present for the majority of the illness duration (during the active and residual phases).

Answer 92

- Bipolar type - if manic episode is present, depressive may also be present. - Depressive type - only major depressive episode is present.

Answer 93

CBT + general health maintenance Consider anxiolytics (diazepam, clonazepam) Consider lithium (manic symptoms or poor response) Consider antidepressants (with depressive symptoms) 1st line: Atypical antipsychotics (olanzapine, risperidone, quetiapine) 2nd line: Clozapine (if 2 a. antipsychotics fail) 3rd line: Typical antipsychotic (haloperidol) 4th line: Long acting IM antipsychotic (Risperidone, olanzapine) 5th line: ECT

Answer 94

Refer to persistent maladaptive personality traits that adversely affect how an individual functions. Affects a person's thought, behaviour and emotions.

Answer 95

- Borderline and antisocial PD are the most diagnosed - Onset in late childhood or early adolescence - Prevalence - 1/20 people

Answer 96

- Early life trauma/abuse - FHx of Schizophrenia - Negative parenting interactions - Disruptive disorder in childhood

Answer 97

10 individual PDs in 3 clusters: A - Odd or eccentric B - Dramatic or erratic C - Anxious or fearful

Answer 98

Cluster A 'Weird' - Paranoid, Schizotypal, Schizoid Cluster B 'Wild' - Borderline, Antisocial, Narcissistic, Histrionic Cluster C 'Worried' - Obsessive compulsive, Avoidant, Dependant

Answer 99

1. Paranoid - Pervasive distrust and suspiciousness of others. Suspicious without reason, doubts loyalty, reluctance to confide, reads hidden/threatening meaning, persistent grudges, perceives character attack and responds angrily, recurrently suspects partner infidelity

Answer 100

2. Schizotypal - Pervasive pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentric behavior. Includes odd beliefs, magical thinking, unusual perceptual experiences, inappropriate affect, odd thinking/speech, excess social anxiety and paranoid ideation.

Answer 101

3. Schizoid - Pervasive detachment from social relationships and a restricted range of emotional expression. Prefers solitude, lacks interest in social or sexual relationships, appears indifferent to praise or criticism, emotional coldness and few interests.

Answer 102

1. Borderline Instability in relationships, self-image, and emotion with marked impulsivity. Symptoms include fear of abandonment, unstable interpersonal relationships, identity disturbance, self-damaging and impulsive behavior, suicidal/self harming behavior, and emotional instability (intense anger, affective instability).

Answer 103

2. Antisocial Disregard for, and violation of, the rights of others. More common in men Requires evidence of conduct disorder before age 15 and includes criteria like deceitfulness, impulsivity, aggression/violence, difficult relationships and lack of remorse.

Answer 104

3. Narcissistic Pervasive grandiosity, need for admiration, and lack of empathy. Includes self-importance, fantasies of success, belief in being special, exploitative behavior, and arrogant attitudes.

Answer 105

4. Histrionic Pervasive attention-seeking behavior and excessive emotionality. Includes criteria like discomfort when not the center of attention, provocative/sexual behavior, shallow emotions, and exaggerated expressions.

Answer 106

1. Obsessive compulsive Preoccupation with orderliness, perfectionism, and control at the expense of flexibility, openness, and efficiency. Includes rigidity/inflexible about matters of morality, ethics and values, over-conscientiousness, hoarding behavior, and reluctance to delegate tasks.

Answer 107

2. Avoidant Pervasive social inhibition, feelings of inadequacy, and hypersensitivity to criticism. Criteria include avoiding social situations due to fears of rejection, being preoccupied with being criticised, and feelings of inferiority.

Answer 108

3. Dependant Pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation. Includes difficulty making decisions, needing others to assume responsibility, and difficulty expressing disagreement.

Answer 109

CBT/DBT for all patients. Treat comorbid depression/anxiety. Hospitalisation for self harm/suicide. Suicide prevention. 1. Cluster A - Psychotherapy (CBT/DBT), consider low-dose antipsychotics. 2. Cluster B - Psychotherapy (CBT/DBT), consider mood stabilisers/anticonvulsants (lithium, lamotrigine, topiramate) 3. Cluster C - Psychotherapy (CBT/DBT), consider antidepressants (SSRI, SNRIs)

Answer 110

- High risk of self harm/suicide especially BPD, ASPD. - Severe social impairment - Some symptoms may attenuate with age

Answer 111

Repetitive harmful pattern of substance use that leads to negative consequences.

Answer 112

1. Initial Use: Driven by factors such as curiosity, peer pressure, or self-medication for stress/anxiety. 2. Reward Pathway Activation: Most substances increase dopamine release in the mesolimbic system, which includes the ventral tegmental area (VTA) and the nucleus accumbens (NAc). 3. Positive Reinforcement: The surge in dopamine causes feelings of euphoria or pleasure, reinforcing the behavior of substance use. 4. Conditioning: Over time, the brain starts associating environmental cues (like places, people, or emotions) with substance use, leading to cravings even when not using the substance.

Answer 113

Neuroadaptation: With repeated use, the brain adapts by reducing the natural production of dopamine and altering receptor sensitivity. Leading to tolerance and withdrawal symptoms. Homeostatic Disruption: The brain becomes reliant on the substance to maintain normal dopamine levels, resulting in compulsive use despite negative consequences. Broader Brain Impact: The prefrontal cortex (decision-making and impulse control) becomes impaired, reducing the ability to resist urges. The amygdala (involved in emotions) also changes, leading to increased stress and anxiety when the substance is unavailable. Dopamine Dysregulation: The chronic activation of the mesolimbic pathway alters dopamine signaling, making natural rewards (like food or social interaction) less pleasurable compared to the substance.

Answer 114

Opioids: Strongly activate the mesolimbic system by binding to opioid receptors, which also affects pain pathways and other brain regions, leading to profound euphoria and risk of severe withdrawal symptoms. Stimulants (e.g., Cocaine, Amphetamines): Directly increase dopamine levels in the synaptic cleft by blocking dopamine reuptake (cocaine) or increasing dopamine release (amphetamines), causing intense activation of the reward pathway and rapid addiction potential. Cannabis: Primarily acts on the endocannabinoid system by binding to CB1 receptors, which modulate dopamine release. The effect is more subtle but can still lead to changes in reward processing and long-term changes in brain function with chronic use.

Answer 115

A natural (codeine, morphine) or semi synthetic agent (fentanyl, heroin, methadone) that stimulates opioid receptors and produces opium like effects.

Answer 116

- Significant public health issue - Prevalence is highest in people aged 25-34 years - Opioid dependence is associated with a high risk of overdose, infections (HIV, hepatitis C), and social harm.

Answer 117

- FHx of substance use genetic predisposition - Comorbid psychiatric conditions - Social/Environmental - peer influence, availability, homelessness, hx of criminal activity, social deprivation

Answer 118

- Miosis (absent in synthetic opioids - fentanyl) - Shallow/slow respirations - Memory impairment - Disturbed consciousness, cognition, perception - Mood changes - euphoria/dysphoria - Itching/scratching - Sedation - Bradycardia

Answer 119

- Needle track marks - Dilated pupils - Chronic constipation/abdominal cramps - Weight loss - Nausea/vomiting - Insomnia - Yawning - Rhinorrhoea/sneezing - Tachypnoea - Agitated/restless - Backache/muscle spasm - Watery eyes

Answer 120

- Young age/ male gender - Hx of mental illness - Childhood trauma - homelessness, neglect, abuse - Social disadvantage - Genetic predisposition - Peer substance use/availability

Answer 121

Clinical signs to suspect opioid dependancy Initial investigations: - Urine or saliva drug screen - GC-MS - to detect specific opioid - FBC - raised WBC in infections - U&E/creatinine + LFTs - renal/hepatic impairment - Hep/HIV serology - beta HCG

Answer 122

IV or IM naloxone: has a rapid onset and relatively short duration of action

Answer 123

Detoxification (4-12 weeks) or harm minimisation Maintenance therapy: 1st line: Buprenorphine +/- Naloxone or Methadone (for high opioid use - hard to come off) Symptom relief Psychosocial counselling: CBT, recovery coordinator, education

Answer 124

1. Opioid withdrawal + Overdose 2. Hepatitis A,B and C 3. Scarred or vein collapse 4. Endocarditis/Osteomyelitis 5. Arthritis/other rheum conditions 6. Obstetric/neonatal complications 7. Hypogonadism/cortisolism 8. DVT

Answer 125

Chronic disorder, relapse rate is >90% in untreated individuals. High % of comorbidities.

Answer 126

- Miosis - Bradypnoea (<12 breaths/minute) - Altered mental status - Frothy pink sputum (ARD) - Pulmonary rales (ARD) - Seizures

Answer 127

Refers to a pattern of alcohol consumption that increases the risk of harmful consequences for the user. It does not yet cause significant physical or mental health problems but is likely to lead to them if continued.

Answer 128

A pattern of alcohol consumption that is already causing damage to health, whether it be physical (e.g., liver disease) or mental (e.g., depression). May or may not involve alcohol dependence, but the drinking has clear and negative effects on the individual’s well-being.

Answer 129

Encompasses both harmful drinking and alcohol dependence characterised by craving, tolerance, a preoccupation with alcohol, and continued drinking in spite of harmful consequences.

Answer 130

Volume (ml) x Alcohol Content (%) ÷ 1000 = Units of Alcohol

Answer 131

No more than 14 units of alcohol a week, spread across 3 days or more. 2 alcohol free days a week Not more than 5 units a day

Answer 132

- Harmful use is responsible for 5.3% of deaths globally - Higher prevalence in men (2:1) - Around 20-25% of people in the UK drink in excess - Alcohol use-disorder has a lifetime prevalence of 7-10% in most western countries

Answer 133

1. Genetic factors 2. Psychosocial - Stress, trauma, mental health disorders, social influence, peer pressure 3. Environmental - Availability, cultural attitudes, SES 4. Chronic use - Continued exposure leads to requirement of alcohol to feel normal

Answer 134

Alcohol (ethanol) is a depressant. It stimulates GABA receptors which have a relaxing effect on the brain. It also inhibits glutamate receptors (also known as NMDA receptors), causing a further relaxing effect on the electrical activity of the brain (glutamate is an excitatory neurotransmitter). Long-term alcohol use results in the GABA system becoming down-regulated and the glutamate system becoming up-regulated to balance the effects of alcohol. The patient must continue drinking alcohol, or they will experience unpleasant, uncomfortable and potentially dangerous withdrawal symptoms.

Answer 135

Symptoms range from mild to severe: 1. CNS depression - slurred speech, incoordination, unsteady gait, impaired memory, stupor/coma (severe) 2. Behavioral - Euphoria, disinhibition, aggression, mood lability 3. Physiological - Flushed face, tachycardia, hypotension, vomiting, hypoglycaemia, resp depression

Answer 136

Occurs after the cessation or reduction in heavy and prolonged alcohol use: Symptoms due to autonomic hyperactivity 6-12 hours: sweating, tachycardia, hypertension, tremor, anxiety, N&V. 36 hours: Withdrawal seizures 48-72 hours: Delirium Tremens - Confusion, delusions, coarse tremor, visual/auditory hallucinations, fever, tachycardia.

Answer 137

CAGE questionnaire - 4 questions AUDIT - (Alcohol Use Disorders Identification Test) for initial screening to assess pattern and severity of alcohol misuse. Score of 8> indicates risk. Severity of Alcohol Dependence Questionnaire (SADQ) can be used to assess the severity of alcohol dependence.

Answer 138

Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA-Ar) scale. Absent or minimal withdrawal: score 0-9 Moderate withdrawal: score 10-19 Severe withdrawal: score > 20

Answer 139

Clinically significant impairment, defined by 2 of these criteria in the same 12 month period: - Alcohol Consumption (large/long periods) - Persistent Desire (can't cutdown) - Time Spent (obtaining, using, or recovering) - Craving/strong desire - Failure to Fulfill Major Roles (work, school, or home) - Social or Interpersonal Problems - Reduction in Important Activities - Use in Hazardous Situations (e.g,driving, poor health) - Physical or Psychological Problems - Tolerance (more needed to be intoxicated) - Withdrawal symptoms Mild: 2-3 Moderate: 4-5 Severe: 6 >

Answer 140

1. LFTs - Raised ALT, AST, GGT (especially) 2. FBC - Raised MCV, macrocytic anaemia 3. Carbohydrate-deficient transferrin (CDT) - Increased, very sensitive

Answer 141

Medical emergency associated with alcohol withdrawal, if untreated mortality is 35%. GABA system under active and glutamate system over functions causing extreme excitability and excessive adrenergic (adrenaline-related) activity.

Answer 142

- Drink 30 or more units a day - SADQ score more than 30 - Hx of epilepsy, DTs or withdrawal seizures - Concurrent withdrawal from benzos - Vulnerable - homeless, young etc

Answer 143

CIWA-Ar scale above 10: 1st line - Benzodiazepine (Chlordiazepoxide or Lorazepam in hepatic failure) Given as fixed reduced dose or PRN (symptom triggered) . 2nd line - Anticonvulsants (Carbamazepine) 3rd line - Clomethiazole - inpatient alone, very addictive. Supportive care - Oral/IV fluids High-dose B vitamins (Pabrinex) - prevent/treat WE Treat concurrent acute medical illness Beta blockers (tachycardia, hypertension)

Answer 144

Psychosocial treatment - CBT, AA, specialist alcohol services, motivational interviewing. Manage medical comorbidities Medication: Naltrexone (50mg od) - opioid receptor antagonist Acamprosate (666mg tds) - Reduce cravings by normalising glutamate and GABA neurotransmission. Disulfiram (200mg od) - For patients wanting to abstain. Causes unpleasant reaction when consuming alcohol, mental anticipation prevents use.

Answer 145

Cognitive impairment (e.g., memory loss, confusion) Peripheral neuropathy (tingling, numbness in limbs) Wernicke-Korsakoff syndrome (due to thiamine deficiency) Seizures (including alcohol withdrawal seizures) Alcohol-related dementia Subdural haematomas (more common)

Answer 146

Depression and anxiety disorders Suicidality Alcoholic hallucinosis (visual or auditory hallucinations) Insomnia Psychosis

Answer 147

Intentional act of 1) self injury or 2) self poisoning regardless of the motivation.

Answer 148

1) 2014 6.4% of people (16-74) reported having self harmed. 2) More common in women 1.5:1 3) More common in adolescents. Peak incidence - Females 15-19 and Males 20-24. 4) 50-100X greater suicide risk self harmers

Answer 149

1) Self injury (10% of cases) - Cutting, burning, slashing. Less common methods include Jumping in front of vehicles, from heights or drowning. 2) Self poisoning (90% of cases) - Paracetamol/Aspirin ingestion most common. Also anxiolytics + antidepressants. (many DSH have depression)

Answer 150

Paracetamol/salicylate levels. U&Es, LFTs, clotting Urinalysis - toxicology CT head/LP - Rule out head injury/infection causing symptoms

Answer 151

1. Intentions before/during the act 2. Suicidal ideation 3. Current problems (life stressors) 4. Other psychiatric disorders 5. Collateral history

Answer 152

Acute management - Antidotes, suturing, surgery Suicide/repeating self harm risk assessment - crisis team or hospitilisation +/- MHA Treat any psychiatric disorders - e.g antidepressants Manage psychosocial needs - drug/alcohol services, financial/occupational advice etc Managing future crisis - Follow up, limit drug supply, samaritans/mental health team

Answer 153

1. Activated charcoal - In first hour for most drugs to reduce absorption 2. N-acetylcysteine - paracetamol 3. Opiates - Naloxone 4. Benzos - Flumazenil 5. Beta blockers - Glucagon 6. TCAs - Sodium bicarbonate

Answer 154

- Around 5000 deaths/year in the UK - Men are more likely to commit suicide than women - Highest completed suicide seen in 45-49 years both M+F - Increasing in young men and old men

Answer 155

- Hanging, suffocation and strangulation - especially in men - Poisoning - more common in women

Answer 156

Very difficult to predict - around 50% suicides occur in 'low risk' Demographics - Male, Age (F -16-24, M - 25-34), LGBTQ, migrants/refugees, prisoners. Social/environmental - Unemployed, social isolation, marital status (divorce, widow etc), low SES, alcohol/drug use, stressful life event (domestic violence, bereavement etc) Clinical - Previous SH or suicide attempt, chronic illness (terminal), mental health disorder (depression, bipolar, schizophrenia), childhood abuse, FHx of suicide

Answer 157

Children at home, pregnancy, strong religious convictions, social support, positive coping skills

Answer 158

Explore: 1. Suicidal ideation 2. Suicidal intent 3. Risk factors 4. Mental state exam 5. Protective factors 6. Risk to others/from others 7. Formulate management plan

Answer 159

1. Ensure personal + patient safety - Regular and easily observable, remove access to objects, verbally de-escalate. Medical stabilisation of suicide attempt. 2. Treat any self harm or physical illness. 3. Determine treatment setting - Consider hospitilisation with MHA or crisis resolution and home team. 4. Safety plan in place 5. Psychotherapy assessment 6. Treat underlying psychiatric illness

Answer 160

Severe mental health disorder characterised by restriction of caloric intake leading to low body weight, an intense fear of gaining weight and distorted body image.

Answer 161

- More common in females (10:1) - Highest incidence ages 15-19 - Most commonly begins in adolescence and young adulthood (15-25) - Increased prevalence in high income countries and in groups who value thinness (athletes, models)

Answer 162

1. Genetic - FHx of ED and mood disorders 2. Female gender 3. Adolescence 4. History of trauma, stressful life events 5. Obsessive and perfectionist traits 6. Low self esteem 7. Cultural/peer pressure (western media, athletes, family)

Answer 163

- Feeling overweight despite evidence against - Restriction of energy intake causing low body weight - Intense fear of gaining weight - Binge eating and/or purging - Misuse of laxatives, diuretics, diet pills - Distorted body image - Preoccupation with food/cooking - Denial of problem

Answer 164

Significantly reduced BMI Amenorrhea + loss of libido Lanugo hair General fatigue, weakness, poor concentration Hypotension/Bradycardia Nonspecific GI symptoms Cold peripheries

Answer 165

1. Cardiovascular - Bradycardia, arrhythmias, hypotension 2. Endocrine - Amenorrhea, female infertility, osteoporosis, growth delay, thyroid issues 3. Psychological - Depression, anxiety, poor QofL, low mood, suicidal ideation 4. Metabolic - Dehydration, refeeding syndrome, electrolyte abnormality 5. Acute and chronic renal failure 6. Derm - Dry skin, alopecia, chilblains, lanugo hair 7. MSK - Reduced muscle mass, osteopenia/porosis, fractures, growth retardation Highest rate of mortality in psychiatric conditions primarily due to complications and suicide.

Answer 166

Criteria: A. Restriction of energy intake relative to requirements, leading to significantly low weight for age, sex, developmental trajectory, and physical health. BMI <17.5 or less than 15% expected BW. B. Intense fear of gaining weight or persistent behaviour that interferes with weight gain, despite being a significantly low weight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Answer 167

Thorough history, examination and follow-up: 1. History 2. Examination - BMI, vital signs, muscle strength (sit up-squat-stand) 3. Investigations - FBC (anaemia, leucopenia, thrombocytopenia) LFTs (elevated) TFTs (low T3) ECG (bradycardia, prolonged QT, arrhythmias), Urinalysis (ketonuria) U&Es DEXA scan Blood glucose

Answer 168

Bulimia Nervosa Hyperthyroidism Depression ARFID T1DM OCD Crohn's or UC

Answer 169

Structured eating plan with oral nutrition Psychotherapy - CBT, anorexia focused family therapy Consider oral potassium supplements - result of purging and/or laxative use Monitoring - Continued assessment tools, BMI, BP, blood tests

Answer 170

Inpatient admission (+/-) oral, enteral or parenteral nutrition. Daily bloods Psychotherapy Consider fluid/electrolyte correction Consider antidepressants and antipsychotic Referral for comorbidities

Answer 171

50% have a full recovery 20-30% have chronic illness Mortality rates are very high

Answer 172

During prolonged starvation, cell metabolism reduces to conserve energy and intracellular phosphate (first), potassium and magnesium shifts into the blood. During refeeding, particularly carb intake, these electrolytes and glucose shift into the cells leading to reduced electrolytes and fluid overload. This can be fatal due to arrhythmias, cardiac failures, seizures, coma.

Answer 173

An eating disorder characterised by recurrent episodes of binge eating, followed by behaviours aimed at compensating for the binge. Including inducing vomiting, fasting, excessive exercise, laxative or diuretic use.

Answer 174

Many people with ED don't present to health services. - More common in women - Less common in children + adolescents - Peak onset 15-25, common in women 20-35.

Answer 175

- Female sex - Impulsivity (Hx of impulse control disorder) - Past obesity - Hx of sexual abuse - Depression, anxiety, low self esteem - Sociocultural factors - Family, athletes, etc - FHx of alcoholism, depression, ED - Early onset of puberty

Answer 176

SCOFF questionnaire: S – Do you ever make yourself Sick because you feel uncomfortably full? C – Do you worry that you have lost Control over how much you eat? O – Have you recently lost more than One stone in a 3-month period? F – Do you believe yourself to be Fat when others say you are too thin? F – Would you say that Food dominates your life?

Answer 177

DSM V: 1. Recurrent episodes of binge eating, defined by both: a) Eating an excessive amount of food in a discrete time period. b) A sense of lack of control during the episode. Recurrent compensatory behaviors to prevent weight gain, such as vomiting, laxative use, or excessive exercise. 2. Binge eating and compensatory behaviors occur at least once a week for 3 months. 3. Self-evaluation is unduly influenced by body shape and weight. 4. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Answer 178

Partial remission: full criteria for BN previously met, but now only some criteria met for sustained period. Full remission: full criteria for bulimia nervosa were previously met, but now no criteria met for a sustained period. Severity: Frequency of inappropriate behaviours Mild: Average of 1-3 episodes/week. Moderate: Average of 4-7 episodes/week. Severe: Average of 8-13 episodes/week. Extreme: Average of 14> episodes/week.

Answer 179

- Recurrent episodes of binge eating (discrete time period) - Presence of inappropriate compensatory behaviours Physical: - Dental erosion - Parotid hypertrophy - Normal/overweight BMI (often) - Russell's sign (scarring on dorsum of hand) - Arrhythmias - Abdominal pain, bloating - Electrolyte disturbance Psychological: - Depression/low self esteem - Preoccupation with body shape/weight - Fear of weight gain

Answer 180

Hypovolemia Tooth erosion Hypomagnesaemia and kalemia Cardiac dysrhythmia Haematemesis Oesophagitis/barrett's Hypotension/arrhythmias - electrolyte imbalances

Answer 181

CBT-ED focus - self guided or standard. Family based therapy in children/adolescents Plus nutrition and meal counselling SSRI - Fluoxetine high dose Regular monitoring of physical health, manage comorbid mental health conditions

Answer 182

Blood tests - U&Es, LFTs, magnesium, glucose, TFTs Venous blood gas - May show metabolic alkalosis, due to repeated vomiting of HCl from stomach. ECG

Answer 183

Anorexia nervosa - with binge eating/purging type Binge eating disorder - No compensatory behaviour Other specified feeding or eating disorders (OSFED) - Not all of the criteria for bulimia nervosa Borderline personality disorder Kleine-levin syndrome - sleep disorder in adolescent males, characterised by binge eating + hypersomnia

Answer 184

Acute and fluctuating change in mental status with inattention, disorganised thinking, and altered levels of consciousness. It is a potentially life-threatening disorder characterised by high morbidity and mortality.

Answer 185

- Older age - Dementia or cognitive impairment - Visual or hearing impairment - Functional impairment or immobility - History of delirium - Decreased oral intake (e.g., dehydration) - Polypharmacy - Co-existing medical illness - Physical frailty - Surgery

Answer 186

HE IS NOT MAAD: - Hypoxia (Resp failure, MI, PE) - Endocrine (Hyper/hypo thyroid, hypoglycaemia, cushings) - Infection (UTI, pneumonia, meningitis, encephalitis) - Stroke/other intracranial events - Nutritional (Low thiamine, nicotinic acid, B12) - Other (Severe pain, sleep deprivation) - Theatre (Anesthetics, post-op complications) - Metabolic (Hepatic/renal impairment, electrolyte disturbance) - Abdominal (faecal impaction, malnutrition, urinary retention, catheters) - Alcohol (intoxication, withdrawal) - Drugs (steroids, anti-parkinson drugs, opiates)

Answer 187

1. Hypoactive (40%) - Lethargy, reduced motor activity, apathy. Underdiagnosed, confused with depression. 2. Hyperactive (25%) - Agitation, irritability, aggression, delusions, hallucinations. May be confused with psychosis. 3. Mixed (30%) - Both subtypes co-exist.

Answer 188

DSM V and ICD 11: 1. Disturbance in attention and awareness 2. Acute onset (hours to days) 3. Disturbance in cognition (memory deficit, perception change, language disturbance) 4. Evidence of a cause 5. Not explained by another neurocognitive disorder

Answer 189

DELIRIUM: D - disordered thinking: slowed, irrational, incoherent thoughts E - euphoric, depressed, apathy, fearful, angry L - language impaired - rambling, repetitive, disruptive I - Illusions, delusions, hallucinations R - reversal of sleep-wake cycle I - inattention U - unaware/disoriented - to time, place, person M - memory deficits

Answer 190

Routine: Urinalysis Bloods - FBC, U&Es, LFTs, calcium, glucose, CRP, B12 ECG CXR Blood/urine culture Specific - ABG (hypoxia), CT head, LP, EEG Diagnostic questionnaire - AMT (Abbreviated mental test), Confusion assessment method (CAM), MMSE

Answer 191

Treat underlying cause Environmental - Quite, well lit room, reassure, reorientation. Agitation/hyperactivity (last resort): Antipsychotics - short term Haloperidol, or olanzapine. Avoid benzos unless alcohol withdrawal.

Answer 192

Very high mortality, increased risk of long term cognitive impairment. Dependant on rapid identification and treatment of underlying cause. Differentials - Psychosis, dementia, depression

Answer 193

A neurological emergency resulting from thiamine deficiency (vitamin B1) with varied neurocognitive manifestations, typically involving mental status changes and gait and oculomotor dysfunction.

Answer 194

- Chronic alcohol abuse: most common due to malabsorption, increased requirements, poor diets. - Malnutrition - prolonged fasting, anorexia - Severe diarrhoea - Hyperemesis (gravidarum) - HIV/AIDS

Answer 195

Thiamine is essential for ATP production and stores of thiamine only last around 18 days. This deficiency results in neural cell death, especially in areas where high energy requirements are needed, such as the mammillary body, brainstem, cerebellum, thalamus. Damage to these areas is associated with the symptoms of WE.

Answer 196

Triad: - Confusion: Disorientation, memory impairment, cognitive dysfunction. - Ataxia: Gait abnormalities, wide-based stance, and incoordination. - Ocular abnormalities: Nystagmus, ophthalmoplegia (paralysis of eye muscles), and diplopia (double vision). Other symptoms: GI symptoms, tachycardia, apathy, agitation, hypo/hyperthermia, altered consciousness/coma

Answer 197

- Alcohol intoxication/withdrawal - Hepatic encephalopathy - Stroke/intracranial event - Viral encephalitis

Answer 198

Urgent high dose IV thiamine (500mg TID for 2-3 days) followed by 250 mg daily for 5 days. Continue with oral thiamine long term.

Answer 199

Mortality of 20% if untreated. Korsakoff's syndrome occurs in 80% if left untreated. Even if treated permanent neurological damage can occur. (hearing loss, ataxia, horizontal nystagmus)

Answer 200

A chronic and severe memory disorder resulting from untreated Wernicke’s encephalopathy. It is marked by profound memory impairment (anterograde and confabulation. Treatment with 100mg oral thiamine/day.

Answer 201

- Memory impairment (anterograde and retrograde) - Confabulation - Lack of insight - Apathy

Answer 202

Examples: Sertraline, Citalopram, Fluoxetine, Escitalopram, Paroxetine. MoA: These are inhibitors of the serotonin transporter (SERT) which prevent reuptake of serotonin (5-HT) from the synaptic cleft, increasing its availability and potentiating its action. Takes 4-6 weeks for full effect. Indications: Depression, anxiety disorders, OCD, PTSD Contraindications: Mania Side effects: Common - Nausea, insomnia, sexual dysfunction, weight changes, headaches. Serious - Increased risk of suicide in younger populations (initially), serotonin syndrome (rare).

Answer 203

Examples: Venlafaxine, Duloxetine MoA: Inhibit reuptake of both serotonin (5-HT) and noradrenaline (NA) in synaptic cleft Indications: Depression, generalised anxiety disorder (GAD), neuropathic pain. Contraindications: Conditions with high risk of arrhythmias, uncontrolled hypertension. Side effects: Similar to SSRIs, but with additional risk of hypertension (dose-dependent). Sweating, dry mouth, dizziness. Important Notes: Can be more effective in severe depression. Monitor blood pressure regularly.

Answer 204

Examples: More sedative: Amitriptyline, Clomipramine, Dosulepin, Less sedative: Nortriptyline, Imipramine MoA: Block reuptake of serotonin and noradrenaline. Also antagonises various receptors (e.g., histamine, muscarinic, alpha-1 adrenergic). Indications: Depression (second-line), chronic pain, insomnia. Contraindications: Recent MI, arrhythmias (especially heart block), mania, severe liver disease, agranulocytosis Side Effects: Common: Dry mouth, constipation, urinary retention, sedation, weight gain, hyponatremia. Serious: Cardiotoxicity (QT prolongation), arrhythmias, orthostatic hypotension. Important Notes: Risk of overdose can be fatal due to cardiac toxicity. Not recommended as first-line due to side effect profile.

Answer 205

Examples: Irreversible: Phenelzine, isocarboxide Reversible: Moclobemide, Tranylcypromine MoA: Inhibits monoamine oxidase, the enzyme that breaks down serotonin, norepinephrine, and dopamine. Indications: Refractory depression, atypical depression, social phobia Contraindications: Acute confusional state, pheochromocytoma Side Effects: Orthostatic hypotension, weight gain, sexual dysfunction, insomnia. Serious: Hypertensive crisis if taken with tyramine-rich foods or certain medications.

Answer 206

Examples: Haloperidol, Chlorpromazine, Fluphenazine MoA: Block dopamine D2 receptors, primarily affecting the mesolimbic pathway. Indications: Schizophrenia, acute psychosis, mania, delirium, psychomotor agitation. Contraindications: Parkinson’s disease, CNS depression, severe hypotension. Side effects: Extrapyramidal symptoms (EPS), tardive dyskinesia, neuroleptic malignant syndrome, sedation, anticholinergic effects, weight gain. Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation. Raised prolactin: galactorrhoea, impaired glucose tolerance. Prolonged QT interval (particularly haloperidol). Important notes: Clozapine specific side effects hypersalivation and agranulocytosis.

Answer 207

1. Dystonia - Sudden, involuntary muscle contractions that can lead to painful, abnormal postures. 2. Parkinsonism - Tremor, bradykinesia (slowed movements), rigidity, shuffling gait. 3. Akathisia - A feeling of inner restlessness with a compulsion to move. 4. Tardive Dyskinesia - Late symptom after long term use of antipsychotics. Involuntary, repetitive movements, particularly of the face and tongue. Can be irreversible.

Answer 208

A rare but potentially life-threatening neurological disorder that occurs as a reaction to antipsychotic medications (dopamine antagonists). More common with 1st gen antipsychotics. Usually occurs in first 10 days of initiation/dose change.

Answer 209

Characterised by: Hyperthermia - >38, sometime >40 (severe) Muscle rigidity Altered mental status - confusion, delirium, stupor Dysautonomia - Raised HR, RR, labile BP, sweating (greasy), urinary incontinence, pallor

Answer 210

- Low index of suspicion in patient taking antipsychotics. - Characteristic features - Creatinine Kinase - supporting feature, high levels (at least 4X baseline, typically >1000 units/L)

Answer 211

- Serotonin syndrome (history - Malignant hyperthermia - Severe infections (sepsis, meningitis) - Recreational drug use (MDMA, cocaine)

Answer 212

Discontinue offending agent Supportive care: Rehydrate, cooling, treat rhabdomyolysis. Consider benzodiazepine - agitation, severe hyperthermia Consider dopamine agonist (Bromocriptine) Dantrolene - ryanodine receptor antagonist (causes skeletal muscle relaxation) Follow up: most patients recover within 1-2 weeks. May require reinitiation of antipsychotic

Answer 213

Examples: Olanzapine, Risperidone, Quetiapine, Aripiprazole (partial agonist at D2), Clozapine MofA: D2 receptor antagonism and 5-HT2A receptor antagonism (serotonin). The additional serotonin receptor blockade helps reduce the risk of EPS and improves efficacy for treating negative symptoms. Indications: Schizophrenia, bipolar disorder, psychosis in Parkinson’s disease Contraindications: Severe liver disease, cardiovascular disease. Side effects: Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation Sedation, weight gain Raised prolactin: galactorrhoea, impaired glucose tolerance Neuroleptic malignant syndrome (less common) Reduced seizure threshold (greater with atypicals)

Answer 214

Examples: Lithium, Sodium valproate, Lamotrigine, carbamazepine. Indications: Bipolar disorder (mania, maintenance), augmentation in treatment-resistant depression, schizoaffective disorder. Epilepsy for SV and L.