Psychiatry Flashcards

Question

**DEPRESSION** Inpatient treatment indications:

Answer 1

- depression with psychosis (ie with delusions or hallucinations); - significant risk of suicide, or homicide (eg ‘altruistic homicide’ by a woman suffering severe perinatal depression); - inadequate support at home; - seriously physically unwell ## Footnote When the patient's depression puts themselves or others at significant risk and the patient is not competent to agree to treatment, involuntary hospitalisation under the relevant mental health legislation must be considered

Answer 2

- SSRIs - SNRIs - Mirtazapine

Answer 3

after 2 to 4 weeks of treatment

Answer 4

- increase the dose ⬇︎ - reassess in 2 to 4 weeks ⬇︎ - if no addtional response ➡︎ switch drug (first-line) - if additional response, but effect is still inadequate: ➡︎ increase the dose further if possible within the recommended dose range ➡︎ reassess in 2 to 4 weeks ➡︎ If a further dose increase is not possible, switch to a different drug (first-line)

Answer 5

- increase the dose ⬇︎ - reassess in 2 to 4 weeks ⬇︎ - if no addtional response ➡︎ switch drug (first-line) - if partial response, but effect is still inadequate: ➡︎ increase the dose further if possible within the recommended dose range ➡︎ reassess in 2 to 4 weeks ➡︎ If a further dose increase is not possible, switch to a different drug (first-line)

Answer 6

6 weeks or longer

Answer 7

If single episode of major depression = 6-12 months

Answer 8

- 2 or MORE more depressive episodes within 5 years - 3 previous episodes, - single severe episode of psychotic depression - serious suicide attempt

Answer 9

at least 3 to 5 years (including continuing work on vulnerability factors) ## Footnote Some patients may require lifelong antidepressant therapy.

Answer 10

after **unsuccessful trials of at least two first-line treatments** (either drug or psychological)

Answer 11

- TCAs - MAOIs both require specialist support

Answer 12

- insomnia, nausea - postural imbalance - sensory disturbances - hyperarousal - flu-like symptoms. ## Footnote SOME PATIENTS CAN EXPERIENCE THESE SYMPTOMS even after missing just 1 or 2 doses

Answer 13

these symptoms are mild, last 1 to 2 weeks (usually does not require specific treatment) ## Footnote If withdrawal symptoms occur due to abrupt discontinuation, symptoms are rapidly extinguished with the reinstitution of the antidepressant

Answer 14

As a general rule - dose should be 1/2 every week ⬇︎ - until the daily dose is half of the lowest unit strength available ⬇︎ antidepressant can be stopped after 1 week on this dose. ## Footnote In general, antidepressants should be tapered slowly, rather than stopped abruptly, to reduce the risk of discontinuation syndrome. Antidepressant discontinuation syndrome is more likely to occur with a higher dose, a longer duration of treatment

Answer 15

- **Adding an antidepressant to the prophylactic mood stabilizer**: the choices of the drug would be the same as for major depression. **SSRls first line**. - Increasing the dose of prophylactic mood stabilizer (ONLY if the patient's psychosis is indicated in coming back, otherwise continue same dose)

Answer 16

FLUOXETINE ## Footnote **ABSOLUTE CONTRA-INDICATIONS** ARE: - TCAs = should not be used in children < 16 years. - Mirtazapine = due to its effects of sedation and weight gain, may cause problems in this age group - Venlafaxine = increased reports of hostility and suicide-related adverse effects such as suicidal ideation and self-harm.

Answer 17

- treatment trials should last: -- for 3 to 4 weeks before considering a dose increase (**as oposed to 2-4 weeks in adults**) -- and for 8 to 12 weeks before a change of therapy. - **discontinuation** trial should be considered **within 1 year **of starting treatment in children who have achieved a marked reduction in symptoms.

Answer 18

Stop interferon, start SSRI. (Treat depression first. Recomence interferon once the depression is managed)

Answer 19

Sertraline ## Footnote Sertraline, citalopram, fluoxetine and mirtazapine in particular have been shown to be safe and effective for treating depression in cardiac patients. However, certain SSRIs, such as fluvoxamine, fluoxetine and paroxetine, can interact with antihypertensive medications, such as metoprolol and captopril, and should therefore be used with caution

Answer 20

Body dysmorphic disorder Anorexia Nervosa Hypochondriasis

Answer 21

**Elevated Mood + 3 of DIG FAST** or **Irritability + 4 of DIG FAST** FOR **1 week or more**

Answer 22

- D -- **DISTRACTIBILITY** - I -- **IMPULSIVITY** (please seeking behaviours) - G -- **GRANDIOSITY** (can border on the psychotic delusions and hallucinations. - F -- **FLIGHT OF IDEAS** - A -- **ACTIVITY** (psychomotor agitation/goal direct activity) - S -- **SLEEP** = decreased need - T -- **TALKATIVINESS**

Answer 23

- Minimum 7 days of symptoms (**4 days for hypomania**) - Marked functional impairment (**no functional impairment in hypomania**) - Delusions and hallucinations (psychotic features) (**absent in hypomania**) - Patient often requires hospitalisation (**less commonly required in hypomania**) - Insight and judgment are usually impaired in mania "ELEVATED MOOD IS SEEN BOTH"

Answer 24

≥ 2 years of fluctuating, mild hypomanic & depressive symptoms that do not meet criteria for hypomanic or major depressive episodes

Answer 25

- Psychomotor retardation. - Increased appetite (hyperphagia) - Increased sleep (hypersomnia) - Positive family history of bipolar disorder - Early onset of first depression before 25 years of age. - Delusions and hallucinations (psychotic features)

Answer 26

- 15 x more likely to commit suicide - 25% of BD patients will attempt suicide - history of drug taking is an important finding as it can be considered as suicide attempt

Answer 27

***NATURE of delusions - grandiose - reward-oriented vs - conspiratorial thinking - paranoia - thought manipulation/control by outside force ***DISTINGUISHING SYMPTOMS - flight of ideas, distraction vs - thought disorganisation + negative sx ***PATTERN - episodic vs - progressive

Answer 28

Some symptoms of hypomania overlap with histrionic personality disorder. These include: - shallow emotions - flirty nature However: - flirting in hypomania = increased sexuality - flirting in histrionic personality disorder = attention seeking behaviour

Answer 29

1st OLANZAPINE VO OR 1st RISPERIDONE VO OR 2 HALOPERIDOL VO OR 2 LITHIUM VO

Answer 30

Lithium + CBT

Answer 31

12 months ## Footnote If an antipsychotic is used for acute treatment, it should be withdrawn within a few months after remission

Answer 32

- ensure that maximum tolerable drug concentration has been achieved. - switch to a different drug (eg from a second-generation antipsychotic to lithium) - combine drugs (eg a second-generation antipsychotic + lithium) - electroconvulsive therapy (ECT)—this is a proven treatment for mania and may be extremely effective even when patients fail to respond to one or more antimanic drugs

Answer 33

1st Antidepressant (SSRI preferably) + Mood stabiliser OR 1st Quetiapine Monotherapy ## Footnote Mood-stabilising agents are SGAs (which carry the risk of metabolic syndrome. Although, for the acute resolution of symptoms agents from both classes have similar efficacy, SGAs may be slightly faster (possibly because of easier administration) and within the two classes of agents there is a slight gradient of efficacy from lithium.

Answer 34

preferably within 1 or 2 months of successful resolution

Answer 35

QUETIAPINE ## Footnote Antidepressant monotherapy should be avoided due to the risk of inducing rapid cycling mania.

Answer 36

- change to a different antidepressant or a different prophylactic drug - (ECT) —this is an effective treatment for bipolar depression and should be considered especially if the patient is psychotically depressed or displays significant psychomotorretardation or agitation

Answer 37

- 2 Sx (**(at least ONE POSITIVE sx)**) - for at least 6 months ## Footnote symptoms rarely have an acute onset. Instead, there is often a prodromal state followed by a progressive worsening of the symptoms

Answer 38

- Psychosis is a loss of contact with reality - loss of insight into the fact that one is mentally ill - Some people with psychosis have false beliefs that can best be described as **fearfulness** and **suspiciousness** (paranoia); - They may have vague fears or complaints about others controlling their lives, but many describe consistent suspicions of very specific, elaborate, and persistent plots against THEM. Very often, these beliefs are directed at family members or friends.

Answer 39

false beliefs that are inconsistent with patient's background and cannot be corrected by reasoning (result of an illness or illness process)

Answer 40

false perceptions in the absence of any external stimuli (e.g. auditory, visual) - no one else feels them

Answer 41

misperceptions of genuine stimuli, a specific form of sensory distortion because: - individuals have been deliberately misled (e.g. by a magician); - if their attention is diminished (e.g. delirium, fatigue, boredom or laziness) - there is a lack of visual clarity (e.g. dim lighting, semi-darkness, fog) - if they are intensely aroused by fear, passion or depression. Some people have vivid imaginations and may see faces or figures in ordinary environmental features such as clouds, tree trunks, rock formations etc. This is quite common in children and is not considered

Answer 42

'HD BS' - Hallucinations (auditory most common) - Delusions (paranoid or persecutory) - Thought Disorganisation = Behaviour (disorganised) + Speech (disorganised)

Answer 43

- comes from **OUTSIDE** of the head (as opposed to inside) - **RIGHT side** - commentary between speakers (as opposed to one voice) - mix of male and female voices - intermittent (rather than continuous) Person will find specific REDUCING BEHAVIOURS (e.g. listening to radio/watching TV/talk to others very loud, wear headphones) Person may seen reacting to what the voices are telling them ("RESPONDING TO INTERNAL STIMULI")

Answer 44

- Motor perseveration (repeating same motions over and over) - echopraxia (copying someone's movements) - **Catatonia**

Answer 45

Stupor Mannerism Catalepsy Stereotypy Agitation Mutism Grimacing Negativism Echolalia Echopraxia | http://www.empathic-resonance.org/catalepsy-vs-cataplexy.html ## Footnote **CATALEPSY** = Rigid tone and posturing, Waxy flexibility (esistance to movement and the ability to maintain imposed positions for extended periods, as if the limbs were made of wax)

Answer 46

- clang association ( words based on its sound/ phonetics, like rhyming, rather than the actual meaning) - neologism - echolalia - perseveration (say the same word repeatedly w/o a purpose) - word salad (non-sense words) - concrete thinking (inability to think in abstract terms) - loosening association (Rapidly shifting from topic to topic, with no connection between one thought and the next) - Circumstantiality - an inability to answer a question without unnecessary and excessive detail

Answer 47

The 5 A's - Affect (flat/blunted) - Ambivalence/Avolition (difficulty making decisions/executing commands/poverty of thoughts) - Alogia (decreased or even absent speech) - Anhedonia - Asociality (social withdrawal) ## Footnote Although **Lack of insigh** does't fit under the P-ve or N-ve category system, it is the **most common symptom present in Schizophrenia**. More common than hallucinations, delusions, flattened affect, or ideas of reference.

Answer 48

Lack of insight ## Footnote Impaired insight is characteristic of schizophrenia. Most patients do not accept that they are ill and ascribe their experiences to the actions of other people or agencies. This usually results in lack of cooperation with doctors and nurses and an unwillingness or refusal to have treatment.**Insight is a matter of degree and involves an awareness of one's own mental condition.**

Answer 49

- incidence general population 1/100 (1%) - men more affected than women 3/2 (1.5x) - earlier in men (18-25) than for in women (25-35) - men tend to exhibit more severe form and worse outcome - earlier onset - chances of recurrence after first episode (90% - similar to bipolar disorder) - SUICIDE: when it occurs, tends to happen in early stages when the insight is still preserved - negative symptoms are least likely to respond to medication.

Answer 50

- **Monozygotic** twin **>50%** chance of developing - **Dizygotic** twin has a **15%** chance. - There is **48%** chance if **both parents** are affected - There is **12 -13%** chance if **one birth parent** is affected - There is increased risk with **advanced paternal age**, where the parent was aged **over 55** - If **second degree relative** the risk is **5-6%** - **Winter birth** - Foetal hypoxia (Pre-eclampsia and emergency c-section) - use of illicit drugs (cannabis, amphetamines, cocaine, LSD) - Urban areas - stressful life experiences/migrants - physical/sexual abuse in childhood

Answer 51

YOUNG PATIENTS (15-35 yo) - spontaneous remission more common - requires higher doses - more likely to have "negative symptoms" LATE ONSET (> 40-45 yo) - less likely to remit spontaneously - respond to lower doses - persecutory delusions is most common symptom, along with accusative or abusive auditory hallucinations - less likely to have thought disorder and negative symptoms > 60 yo - less likely to remit spontaneously - visual hallucinations - less likely to have thought disorder and negative symptoms

Answer 52

- **Irritability or depressed mood** (FIRST) - **Deteriorating social or school function** -- **Withdrawal from friends and family** -- **A drop in performance at school** - **Increase in suspisciouesness** - **Hypervigilance** - **Ideas of reference and unsual rhoughts** - Trouble sleeping - Lack of motivation - Strange behavior - Sudden and bizarre changes in emotions - Severe problems in making and keeping friends - Difficulty speaking, writing, focusing or managing simple tasks.

Answer 53

- Brief Psychotic disorder: > 1 day & < 1 month - Schizophreniform Disorder: > 1m & < 6 m - Schizoaffective Disorder

Answer 54

HATS: - H: HALF or more of the time ill must be spent with mood sx - A: psychotic sx must occur ALONE (i.e. w/o mood sx) - T: psychotic sx must occur TOGETHER (i.e during an episode of mood disorder) - S: exclude effect of SUBSTANCES or other medical conditions

Answer 55

- stable or improving level of disfunction after early adulthood (as opposed to progressive decline over time seen in Schizophrenia) - affect instability of BPD involves rapidly emotional shifting (as opposed to weeks to months changes) - psychotic sx tend to be an sign of distress (experienced during times os stress) - Auditory hallucinations- if present - are described as inside (as opposed to outside) and vague/unclear (as opposed to clear/vivid)

Answer 56

Demented patients usually have: - - late onset - lack of prior psychiatric sx or signs - match average population in social milestones (school, work, marriage) - visual hallucinations - loss of recall of learnt information and visuospatial ability (schizophrenic patients have these intact)

Answer 57

* Metabolic/electrolyte disturbances * Urea cycle disorders * Acute intermittent porphyria * Wilson disease * Renal/liver failure * Hypoglycemia * Sodium/calcium/magnesium disturbances * SLE * Thyroiditis

Answer 58

- Also called delusional misidentification syndrome - Disorder in which a person believes that an identical-looking has replaced a friend, spouse, parent, or other close family member impostor - commonly occurs in patients with paranoid schizophrenia, dementia and brain injury

Answer 59

patient believes they have lost important body parts, blood, internal organs, or even their soul - prevalent in schizophrenia, bipolar disorder, non-dominant temporo-parietal lesions and migraine.

Answer 60

Delusional infestation with parasites or worms in schizophrenic patients **≠** Willis-Ekbom disease (WED); Witmaack-Ekbom syndrome or Restless leg syndrome (RLS) is characterised by a ‘compulsive’ restlessness or need to move the legs, often associated with paraesthesiae or dysaesthesiae. Symptoms at rest or disturbing sleep, quickly but temporarily relieved by standing and walking, with nocturnal worsening of symptoms. | formication ## Footnote https://litfl.com/karl-axel-ekbom/

Answer 61

 **Shared psychotic disorder** ("madness in two")  Delusion developing in a person in close relationship with another person who has an established delusion (more common in mother-daughter or sister-sister relationships)  Dominant person and submissive or dependent person in the relationship is clearly established.  Delusion similar in content.  HAPPENS IN FAMILIES – GROUPS OF PEOPLE – example is a cult. Treatment:  biggest challenge is getting the pair (or system) to accept the need for treatment.  FIRST STEP IS to separate the person or people with the secondary disorder from the person with the primary disorder, as the secondary’s delusions often don’t persist following separation.  Atypical antipsychotics aripiprazole and quetiapine most effective

Answer 62

Sufferers may believe that: - they are a person is special - people are noticing, watching or gossiping about them - they are being talked about on the radio - they are referred to in newspapers or television programmes - they are being followed and their movements are being constantly monitored and that what they say is recorded they do not recognise their beliefs are false. It is a form of paranoid thinking that may progress to paranoid or grandiose delusions involving complex and bizarre plots, or special powers, talents and abilities

Answer 63

* Amisulpride OR * Aripiprazole OR * Olanzapine OR * Paliperidone OR * Quetiapine OR * Risperidone OR * Ziprasidone

Answer 64

- monitor for adverse drug effects - Shared-care programs - cognitive behavioural therapies (eg medication compliance therapy, motivational interviewing for substance abuse, coping strategies enhancement, symptom control interventions) - cognitive remediation for cognitive deficits, social skills programs, supported employment programs, accommodation and disability support options, education and training assistance, and social interventions to combat isolation - Manage comorbidities - monitor substance use - Maintain physical health and target cardiovascular risk factors - Work with family/carers - Carer assistance programs

Answer 65

- **Agitation** = settles within **days** - **Positive symptoms** = may require **several weeks**, but some treatment response can be expected early (ie within 1 to 2 weeks of starting an antipsychotic) - Negative symptoms of schizophrenia are responsive to antipsychotics, but less so than positive symptoms

Answer 66

**3 weeks** - Increase dose of the initial medication first, - wait until 4-6 weeks **after 4-6 weeks** 1 change to an alternate SGA, preferably (depending on positive/negative symptoms) OR 2 change to FGA: Haloperidol OR Chlorpromazine

Answer 67

**crossover phase** of at least **1 to 2 weeks**

Answer 68

- **2 years** (Following a first psychotic episode) - ONLY if there has been full remission ## Footnote Indefinite continuation of maintenance therapy is required for the majority of people with schizophrenia.

Answer 69

- the antipsychotic can be cautiously tapered and discontinued **over a period of at least 3 months**. - monitor for early warning signs of relapse during this process and for a further 12 months after drug cessation. - If relapse occurs after cessation of maintenance therapy, longer-term treatment (ie at least 5 years) is required.

Answer 70

drug discontinuation due to poor concordance

Answer 71

- poor insight into the purpose of medication - psychosocial stressors - substance use (alcohol, cannabis, amphetamines more common) - premature lowering of the dose - discontinuation of antipsychotic treatment

Answer 72

- commencing a depot antipsychotic - initiation of proceedings for involuntary community treatment

Answer 73

**identify any reasons for treatment resistance:** - Is the diagnosis correct? - assess treatment concordance - Have possible underlying medical causes been identified and treated? - Is the patient reacting adversely to a current medication? - Have the drug dose and duration of administration been adequate? - assess abuse of alcohol and other drugs (eg cannabis, amphetamines) - Could an interacting drug be compromising the response? - Urine drug screening may be indicated, but this only identifies recent use and does not constitute a diagnosis of drug abuse or dependence,

Answer 74

- reasons in step one excluded PLUS - **drug trial of 6 to 12 weeks' duration** on optimal doses of **at least TWO different antipsychotics**

Answer 75

* augmenting strategies: (no drug has demonstrated to be the best) -- amisulpride VO -- haloperidol VO -- lamotrigine VO -- omega-3 fatty acids (in particular formulations high in eicosapentaenoic acid) 2 to 3 * A trial of adjunctive ECT should be considered (However, the relapse rate is high after ceasing an acute course of ECT)

Answer 76

- severe and persistent positive and/or negative sx - persistent or frequently recurrent suicidal ideation and/or behaviours - severe and persistent EPS (eg tardive dyskinesia) - marked aggressive behaviour - severe comorbid substance abuse.

Answer 77

**Change to**: 1 Amisulpride OR 1 Clozapine OR 1 a SGA other than clozapine PLUS an antidepressant (**fluoxetine** preferred) OR 2 clozapine ( PLUS an antidepressant (fluoxetine preferred) OR 2 clozapine PLUS Lamotrigine

Answer 78

Patients with hyperactive delirium demonstrate features of restlessness, agitation and hyper-vigilance. They often experience hallucinations and delusions but have no insight.

Answer 79

- verbal de-escalation and early negotiation (including the offer of VO medication) - ‘show of force’ (involves having a sufficient number of staff visibly backing up the clinician who is attempting to negotiate with the patient) - physical restraintv (immobilisation) - chemical restraint **NOTE**: when weapons are involved or there is a high likelihood of extreme violence), security staff and/or police will be required to disarm and restrain the patient.

Answer 80

-**Tranquillisation** = defined here as a state of calmness (ie not showing anxiety, anger or other emotions) -**Sedation** = defined here as a state of rousable drowsiness.

Answer 81

- **Diazepam** VO (preferred in drug withdrawal and stimulant intoxication) - **Olanzapine** VO (preferred in acute psychosis)

Answer 82

- **DIAZEPAM** IV OR - **MIDAZOLAM** IV If patient tolerant to benzodiazepine or if failure of first-line benzdiazepine USE: (in combiantion or single) - **HALOPERIDOL** IV OR - **OLANZAPINE** IV ## Footnote If combination therapy is considered appropriate, each drug should be administered separately (ie do not combine drugs in the same syringe)

Answer 83

- **MIDAZOLAM** IM If patient tolerant to benzodiazepine or if failure of first-line benzdiazepine USE: (in combiantion or single) - **HALOPERIDOL** IM OR - **OLANZAPINE** IM ## Footnote Diazepam is not recommended for intramuscular injection as absorption is poor and erratic.

Answer 84

 Excessive anxiety/worry occurring on most days for at least **6 months** ("chronic")  Associated with 3 or more of the 6 symptoms.

Answer 85

"**MISERA**-ble"  M - **Muscle** tension  I - **Irritability**  S - **Sleep** (decreased)  E - **Energy** (easy fatigue)  R - **Restlessness**, feeling keyed up, on the edge  A - **Attention** (Mind going blank or difficulty concentrating) Not due to medical/ substance abuse/other psychiatric disorders.

Answer 86

 **Therapy CBT/SPS **(structured problem solving) - should always be **first-line treatment**  **If severe or CBT ineffective after 3 months, then SSRI can be introduced.** (SSRIs are decreased and ceased if patient is symptom free for 6 months)  Other options - **Buspirone** - anxiolytic - **Benzodiazepines** (short term of 2 weeks and tapered over next 2 weeks; although it has a more rapid effect it can easily lead to physical dependence and should not be used as long-term treatment) - SNRI - Beta blockers (**PROPANOLOL**) - if associated palpitation, tremors, for performance-only subtype ## Footnote Individuals with performance-only social anxiety disorder do not fear nonperformance social situations and are not socially avoidant in general. The pharmacologic treatment of performance-only social anxiety disorder includes as-needed beta blockers or benzodiazepines rather than maintenance medication. - Beta blockers (eg, propranolol) on an as-needed basis help control the associated autonomic response (eg, tremors, tachycardia, diaphoresis). - Due to their addictive potential, benzodiazepines (eg, diazepam, lorazepam) are generally avoided in patients with a personal or family history of substance use disorder. In addition, they are not preferred when performance could be impaired by sedation and cognitive side effects (eg, giving a presentation, as in this case)

Answer 87

- Intense *ACUTE* fear or discomfort - in which 4 or more symptoms develop abruptly - reaches a peak in 5-10 minutes (crescendo-decrescendo pattern)

Answer 88

STUDENTS Fear C's  S - Sweating  T - Trembling - shaking  U - Unsteadiness or Dizziness/Faintness  D - Derealisation/depersonalisation/ dissociation  E - Elevated HR (Tachycardia/Palpitations)  N - Nausea  T - Tingling (Paresthesia)  S - Shortness of breath/ smothering sensation  FEAR - Fear of dying, Fear of loosing control or going crazy  C'S = Choking feeling = Chills - hot flushes = Chest pain/tightness

Answer 89

1/6 people with panic attacks will develop panic disorder Panic Disorder results from anxiety about having future panic attacks that impact one's ability to lead a normal life "**SURP**-rise"  S - Sudden (without a trigger)  U - Unexpected  R - Recurrent  P - Panic attacks Rise anxiety Not associated with substance abuse

Answer 90

 **FIRST**: exclude medical condition. (acute MI, asthma, thyrotoxicosis).  **At the time of attack**: - slow breathing technique (if hyperventilating) - distraction methods - benzodiazepines **Treatment to prevent further attack** - CBT (stress management, exposure and desensitisation) - avoid caffeine  if Psychotherapy is not working - **SSRI or buspirone**. - should be used in conjunction with CBT

Answer 91

- A phobia is a persistent unreasonable fear of and wish to avoid a specific object, activity or situation. - The person _recognises that the fear is irrational and is out of proportion_ to the real danger (ego-dystonic) - _ Phobias are powerful and compelling by nature_ - _They are repetitive and resistance is typically minimal and unsuccessful._ - _Although the sufferers recognise that their origin is internal from within themselves, they may feel controlled by them._ ## Footnote The fear may be of external stimuli, such as animal phobias, social phobia or agoraphobia, or internal stimuli of illness or contamination. The anxiety generated may lead to avoidance, which maintains the fear. Occasionally what begins as a specific phobia, for example 'of an animal or reptile', may generalise to a persistent dread of situations which have only a tenuous link with the original stimulus.

Answer 92

It is generally a specific coping mechanism that arises in response to : - fear of crowds, getting trapped and not having an escae alternative. - it can occur in **panic attacks/disorder where one begins to avoid going out at all preferring to stay in the safety of their own home** (become housebound) where they feel less vulnerable to panic attacks ## Footnote It is generally a specific coping mechanism that arises in response to having **panic attacks/disorder where one begins to avoid going out at all preferring to stay in the safety of their own home** (become housebound) where they feel less vulnerable to panic attacks. it develops in about 1/4 of people with Panic Disorder (it is a marker of severe Panic Disorder

Answer 93

Persistent fear of **interpersonal rejection** Affected individuals avoid social or performance situations in fear they'll embarrass themselves or be judged as anxious or stupid

Answer 94

The treatment of choice in phobic disorders is **CBT + EXPOSURE THERAPY** (anxiety-management skills + systematic desensitisation). Benzodiazepines have little or no place in the routine management of phobias and their usage may delay or impede efforts to master symptoms using behavioural techniques. ## Footnote his involves the graduated exposure of the person to the feared stimulus or situation while practising relaxation and controlled breathing until the level of anxiety experienced is manageable or has dissipated. This is systematic desensitisation.

Answer 95

- OCD (obsessional thoughts) - Somatisation ( anxiety to physical sx) - PTSD (re-experiencing trauma)

Answer 96

 Pheochromocytoma (rare)  Diabetes Mellitus (**Hypoglycaemia** is the **commonest** **underlying organic cause** of **anxiety symptom**s)  Arrhythmias (Paroxysmal supraventricular tachycardias)  Temporal epilepsy  Hyperthyroidism  Alcohol withdrawal  Drug intoxication or withdrawal **NOTE:** Carcinoid does not cause anxiety. Carcinoma of the bronchus and hyperparathyroidism are more likely to present with depression.

Answer 97

Compulsive behaviours are: - **repetitive actions driven by anxiety or distress** (purposeless); - They often serve as a coping mechanism to alleviate stress or prevent a feared event or situation through a repeated behaviour - Associated with negative reinforcer (taking something - ie anxiety - away) ≠ Impulsive behaviour are: - spontaneous actions performed without forethought or consideration of the consequences - These behaviours are **driven by immediate desires** - Associated with positive reinforcer ( often meaning is pleasurable)

Answer 98

**Ego-dystonic** = recognise one's intrusive thoughts are not reflective (**discordant**) of their true desires (**insight is preserved**)

Answer 99

- **obsessive thoughts and compulsive rituals** - Compulsions are "repetitive purposeful", "intentional" behaviours conducted to prevent an adverse outcome - While OBSESSIONS are REQUIRED for the diagnosis, COMPULSIONS are OPTIONAL (not everyone with obsessions will develop compulsions; however, everyone with compulsions will have obsessions) ## Footnote - Obsessions: Recurrent, intrusive, anxiety-provoking thoughts, urges, or images - Compulsions Response to obsessions with repeated behaviors or mental acts. Behaviors not connected realistically with preventing feared event

Answer 100

"**I MURDER**"  I - Intrusive  M - Mind-based (not thought insertion)  U - Unwanted  R - Resistant  D - Distressing  E - Ego-dystonic  R - Recurrent ## Footnote * Time-consuming (>1 hr/day) or causing significant distress or impairment

Answer 101

- Men and women are "EQUALY" affected - once of symptoms often during childhood or young adulthood (< age of 20-30)

Answer 102

**optimal management always include a combination** of both: CBT **(ERP = exposure & response prevention) ** + SSRI NOTE: Alcohol makes OCD symptoms feel better for a while, however, it is not recommended as a therapy due to the risk of alcohol abuse NOTE: "**CLOMIPRAMINE**" is a TCA and can be used as a second-line alternative if CBT+SSRI have failed or in more severe cases of OCD NOTE Neurosurgery (i.e cynguloctomy) is reserver for severe/refractory cases ## Footnote SINGLE THERAPY IS NOT EFFECTIVE IN CBT - combination therapy is always the first line treatment Exposure treatments are aimed at confronting patients with what is feared (and is causinganxiety), while encouraging them to block any behaviours which may prevent or terminate the exposure (response prevention). A review of their fears is encouraged, so that patients realise that the catastrophic or terrible consequences which they fear, do not occur.

Answer 103

- Anxiety - Depression - Alcohol or substance misuse - Eating disorders - Body dysmorphic disorders - Chronic physical health problems (skin problems due to excessive hand washing)

Answer 104

"**FIX ME DOC**"  FIX - Fixation on perceived flaw  M - Medical care-seeking  E - **Ego-Syntonic**  D - Disabling  O - Obsessive thoughts  C - Compulsive behaviours

Answer 105

Ego-syntonic Patient does not admit that their fears and preoccupations are extreme or excessive

Answer 106

CBT ± SSRI

Answer 107

- Anxiety - Social Phobia - OCD - Delusional disorder - Alcohol or substance misuse

Answer 108

* Experiences persistent (>6 months) incongruence between assigned & felt gender * Desires to be another gender * Dislikes own anatomy, desires sexual traits of another gender * discomfort with the development of unwanted secondary sexual characteristics. * Believes feelings/reactions are of another gender * Feels significant distress/impairment

Answer 109

* Assessment of safety * Support; psychotherapy (individual, family) * Referral to specialist Gender identity-affirming care services (medical & mental health multidisciplinary)

Answer 110

fears and symptoms persist for ≥ 6 months

Answer 111

- Hy**p**ocondriasis = **P**reoccupation with or **fear of having** (as opposed to getting) **a serious disease**, despite medical reassurance, leading to significant distress/impairment. - often present with a (self)-diagnosis - Ego-syntonic (involuntary/non-volitional & unconsciously) - Often involves history of prior physical disease.

Answer 112

- group therapy ± SSRI - schedule regular appointments with the patient’s primary caregiver (if existing)

Answer 113

Hypochondriasis: patient presents with a diagnosis focus on the disease, not a particular symptom **failure to respond to reassurance** Somatisation: - presents with a variety of unexplained sx - primary focus of preoccupation/concern with the symptoms themselves

Answer 114

CBT and SSRI ## Footnote nonetheless, patient usually don't respond well

Answer 115

- squalor and decline in personal hygiene - sometimes hoarding useless items - significant frontal lobe impairment

Answer 116

"**TRAUMA**"  T - Trauma **core**  R - Re-experiencing **core**  A - Arousal **core**  U - Unable to function  M - Month ( present > 4 weeks)  A - Avoidance **core**

Answer 117

Must be: - life-threatening - actual or threatened physical and/or sexual violence - secondary exposure to a traumatic event (such as about a spouse or family member) also qualifies NOTE: other non-life-threatening events such as **harassment** and **non-violent bullying** do **not "qualify" as trauma per DSM-5** (despite these being distressing and resulting in S/S indistinguishable from PTSD) and ADJUSTMENT DISORDER with ANXIOUS MOOD should be considered

Answer 118

Persistent (chronic) and generalised - Hyper-arousal State: increased anxiety and awareness - hyper-vigilance: constant scanning of their environment for clues to the presence of danger - MISERA-ble = MUSCLE tension, IRRITABILITY, trouble with SLEEP, low ENERGY, RESTLESSNESS, inability to pay ATTENTION (poor concentration and memory) to non-trauma related stimuli

Answer 119

**Symptoms must be present for at least 1 month** **NOTE**: it does not necessarily mean that symptoms have to present in the first month after the trauma occurs (delayed onset is more characteristic) **ACUTE**: symptoms last < 3 months **CHRONIC**: symptoms last > 3 months **DELAYED ONSET**: Sx appear at least 6 months after traumatic event

Answer 120

When the core trauma-related symptoms have **not yet reached ONE month in length** NOTE: the presence of ASD immediately following a traumatic event does not rule in later development of PTSD, nor does its absence rule it out ## Footnote NOTE: the presence of ASD immediately following a traumatic event does not rule in later development of PTSD, nor does its absence rule it out

Answer 121

– physical avoidance (people, places, things) – Psychological avoidance (emotional numbing) an attempt to self-protect against strong negative emotions; however, interferes with ability to experience positive emotions such as joy (flattening affect), satisfaction, love (detachment from others)

Answer 122

- alcohol and drug abuse - previous history of depression - previous history of sexual abuse. - Victims of domestic violence

Answer 123

- the intentional nature of the trauma (eg sexual abuse/rape/assassination attempt) - Experiencing the trauma alone - lack of social support network - presence of at least one pre-trauma psychiatric diagnosis NOTE: Onset of symptoms soon after the traumatic event (ie ACUTE DISTRESS DISORDER)

Answer 124

- CBT (***FIRST-LINE TREATMENT***) * trauma-based psychotherapy, crisis intervention therapy, * EMDR (eye movement desensitisation and reprocessing therapy) - Life-style modifications (sleep hygiene, relaxation techniques) **NEXT STEP** - If not responding, then **SSRI** (it does not help specifically with either sleep or nightmares)

Answer 125

- provide a comforting and consoling presence - to listen empathically Most people following traumatic events recover spontaneously without specific psychological interventions **NOTE:** **the current consensus is that debriefing is not clinically indicated as an immediate intervention and may even be harmful**.

Answer 126

Diagnostic criteria: onset of **anxiety/depression symptoms within 3 months of identifiable psychosocial stressor**(s) which: - are time-limited (Once the stressor or its consequences have terminated, the symptoms do not persist for more than 6 months) - Aren't severe enough to meet criteria for MDD or GAD and incurs in response to as stress that isn't life-threatening or violent enough to be trauma - are in excess of normal expectations of reaction to the stressor(s) - are not due to another identifiable mental disorder - are not part of a continuing pattern of overreaction to stress impair social or occupational functioning. - Significant impairment in social, occupational, or other important areas of functioning

Answer 127

- primary interventions = psychological supportive therapy including counselling, relaxation, problem solving, stress management, and (CBT) - **short-term pharmacotherapy** (**usually < 2 wks**) with **BZ** = if the symptoms are severe, if significant impairment of functioning and there is inadequate response to psychological interventions. **NOTE: Most drugs used to treat anxiety (ie [SSRIs]) take a number of weeks to produce an effect, thus in this situation the use of a BZP may be appropriate** ## Footnote NOTE: Intermittent use, on occasional days when there is a severe exacerbation of anxiety, may suffice and is preferable to continuous treatment.

Answer 128

- Repeated use - Reinforcers (Positive) - Repercussions (Njuegative)

Answer 129

**Compulsive** vs. **Impulsive**: The primary difference between compulsive and impulsive behaviours lies in their motivation and execution. - **Compulsive** behaviours stem from an internal drive to alleviate the fear and anxiety triggered by obsessive thoughts - **Impulsive** behaviours are spontaneous and often driven by desires.

Answer 130

the **5A**s framework — **ask** (about smoking) — **assess** (motivation & nicotine dependence) — **advise** (to quit) — **assist** (with cessation) — **arrange** follow-up

Answer 131

— high dependence — moderate dependence — low-to-moderate dependence — low dependency

Answer 132

waking at night to smoke or smoking within the first 5 minutes after waking = usually smokes > 30 cigarettes daily

Answer 133

smoking within 30 minutes after waking = usually smokes 20- 30 cigarettes daily

Answer 134

not needing to smoke within the first 30 minutes after waking usually smokes 10-20 cigarettes daily

Answer 135

not needing to smoke in the 1st hour after waking usually smokes < 10 cigarettes daily.

Answer 136

Recommended for: - **moderately to highly** nicotine-dependent smokers **&** - who **express an interest** in quitting

Answer 137

Best results are usually achieved when **pharmacotherapy is combined with counselling and support**

Answer 138

- Nicotine Replacement Therapy (NRT) - Varenicline - Bupropion

Answer 139

– Combination NRT (ie patch and oral form) preferred (*Combination NRT is as effective as varenicline and more effective than single types of NRT.) - can be used by people with **cardiovascular disease** (Caution is advised for people in hospital for acute cardiovascular events, but NRT can be used under medical supervision if the alternative is active smoking.) - NRT may be considered in women who are pregnant if they were unsuccessful in stopping smoking without pharmacotherapy. If NRT is used, the benefits and risks should be explained carefully to the patient by a suitably qualified health professional. The clinician supervising the pregnancy should also be consulted. - NRT (ie patch, intermittent) is considered an **option** for **breastfeeding mothers**. Infant exposure to nicotine can be reduced further by taking intermittent NRT immediately after breastfeeding. - cannot be used in children aged < 12 years

Answer 140

- The **most effective single-form** pharmacotherapy for smoking cessation - **not recommended for pregnant and breastfeeding** women, nor for **adolescents.** - causes nausea in 30% of patients - **requires caution in CKD patients**

Answer 141

* less effective than varenicline for smoking cessation. * **contraindicated in patients with a history of seizures, eating disorders and those taking monoamine oxidase inhibitors** * **not recommended** for women who are **pregnant or breastfeeding** * Should be used with caution in people taking medications that can lower seizure threshold (eg antidepressants, antimalarials, oral hypoglycaemic agents)

Answer 142

"YES" to 2 or more is a POSITIVE screen:  C - **CUT** Have you ever felt you should Cut down on your drinking?  A - **ANNOYED** Have people Annoyed you by criticising your drinking?  G - **GUILTY** Have you ever felt bad or Guilty about your drinking?  E - Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (**Eye-opener**)

Answer 143

Treatment of intoxication and overdose is **supportive** and **symptomatic**, with careful monitoring of: - BAC - airway - level of consciousness and responsiveness - oxygen saturation - hypoglycaemia and metabolic acidosis - Alcoholic Hallucinations Stimulants should not be given.

Answer 144

Symptoms usually appear within **6-24 hours** of the last consumption of alcohol (BAC ≤ 0.1%). can last up to **72 hours** The signs and symptoms may be grouped into three major classes: autonomic, gastrointestinal, and CNS changes that represent manifestations of sympathetic hyperactivity. AUTONOMIC: - Sweating - Fever - Tachycardia - Hypertension - Tremor GASTROINTESTINAL: - nausea and vomiting - Dyspepsia - Anorexia CNS - Anxiety - agitation - **Delusions/Hallucinations** - Insomnia and vivid dreams - **Seizures** (occasionally - 5% - observed, grand mal type = generalised, not focal) LAB - **↑ GGT** - **↑ AST/ALT RATIO** ## Footnote Seizures is the hallmark feature of Acute Alcohol Withdrawal (in contrast to Delirium Tremens which normally does not present with seizures) and the most concerning intercurrence

Answer 145

- Diazepam VO -- Oxazepam VO (if liver disease) - Thiamine (IM or IV) - AVOID antipsychotics (which lower seizure threshold). If hallucinations are not responding to Benzodiazepines alone, add: - Olanzapine VO other meaures include: - Nursing in well-lit and quiet environment - Monitoring for and treating hypoglycaemia - Rehydration - High calorie high carbohydrate diet,

Answer 146

Alcoholic Hallucinosis * **develop 6 - 24 hours of the last drink** * typically persist for up to 72 hours * transient **auditory hallucinations** * Usually benign * **Associated with Alcohol intoxication** DTs * **occurs 24-72 hours after stopping/significantly reducing alcohol consumption** * Autonomic instability (↑ BP, ↑ HR) * **Usual course is 3 days, but persist for up to 14 days** * **Associated with withdrawal**

Answer 147

Delirium tremens is a diagnosis by exclusion, so before commencing treatment, screen for other factors contributing to delirium, in particular: - subdural haematoma - head injury - Wernicke’s encephalopathy - hepatic encephalopathy - hypoxia - sepsis - metabolic disturbances - intoxication with or withdrawal from other drugs

Answer 148

* IV Diazepam should be avoided if possible. -- Onset of action isn't much faster than with VO -- there is a greater likelihood of causing severe adverse effects such as respiratory depression. -- If an injection is necessary, it must not be diluted and it must be given slowly over several minutes to minimise the risk of respiratory depression or arrest. Close cardiorespiratory monitoring is essential. * If Severe liver disease -- Oxazepam VO * Severe chronic airflow limitation Use benzodiazepines with caution and with close monitoring. -- Midazolam IV or -- Short acting Benzodiazepine = Temazepam or Oxazepam

Answer 149

- Initial dosing is with IV or IM thiamine (absorption of oral thiamine is slow and may be incomplete in patients with poor nutritional status) - Administer thiamine before giving any form of glucose when possible. A carbohydrate load in the presence of thiamine deficiency risks precipitating Wernicke’s encephalopathy.

Answer 150

- acamprosate - naltrexone - disulfiram + best used in conjunction with psychosocial therapy For each of these drugs, treatment duration of **6 months** or more is recommended.

Answer 151

* started following cessation of the acute phase of alcohol withdrawal, ie approximately 1 week after cessation of drinking * Treatment should continue even if the patient lapses; INDICATIONS - moderate to severe AUD - Does not interact with alcohol - compliance may be challenging due to dosing regimen CONTRAINDICATIONS - hypersensitivity to the drug - renal insufficiency - severe hepatic failure - Tetracyclines may be rendered inactive by the calcium component in acamprosate. ## Footnote * **Modulates** GABA/glutamate

Answer 152

INDICATIONS - moderate to severe AUD CONTRAINDICATIONS - acute hepatitis or severe liver failure. - There are no well controlled studies of the safety of naltrexone during pregnancy or lactation. - not suitable for people who are opioid dependent or who have pain disorders/ require opioid analgesia ## Footnote * **blocks** the effect of endogenous opioids released following alcohol intake

Answer 153

* most effective with supervised administration * Careful monitoring of cardiac and liver condition is recommended if disulfiram treatment is started. Liver tests should be performed fortnightly for 2-3 months, particularly in those with abnormal tests at baseline. INDICATIONS - appropriate for patients who are motivated to ***ABSTAIN*** from alcohol. It should not be prescribed for patients who have a goal of reduced alcohol intake. - It is beneficial for patients that accept a need for an external control on their drinking and are prepared to be supervised in the daily dosing of the medication. CONTRAINDICATIONS - cardiovascular, hepatic or pulmonary disease - Safe use of disulfiram during pregnancy or lactation has not been established - Patient has not consumed alcohol in the previous 24 hours ## Footnote * primarily works by inhibiting the action of aldehyde dehydrogenase - enzyme involved in the second step in the metabolism of alcohol, that converts acetaldehyde to acetate. This leads to the accumulation of acetaldehyde following consumption of alcohol while on disulfiram. The resulting symptoms are unpleasant

Answer 154

- impulse control disorder (an impulse to set fires and involves deliberate and purposeful fire setting with anxiety prior to the act and gratification or relief following the act of setting the fire) - They do not do it to seek public attention. - They do not like to play with fire - The fire is not set for monetary gain out of any sense of revenge or anger (which is arsoning)

Answer 155

"**DETaILS OFF**"  D - Details are sloppy  E - Easily distracted  T/A - Task Avoidance  I - Ignores instructions  L - Loses things  S - Sustained attention (poor)  O - Organisation (poor)  F - Forgetful  F - Fails to finish tasks

Answer 156

"**HE RILED UP**"  H - Hiperactive  E - Energetic  R - Running around  I - Interrups/Impulsivity  L - Loud  E - Effusive  D - Delay Intolerance  U - Unseated  P - Prematurely answers questions

Answer 157

- Does not require symptoms of both domains (Inattention or Hyperactivity) to co-exist - It's a diagnosis of exclusion - ADHD = Inattention and hyperactivity that is excessive, unrelated to other disorders and has been observed in **multiple** settings from a young age (**in case of divorced parents, it is important to obtain colateral history from the other parent that is not present on the first assessment**) - symptoms are chronic (as opposed to episodic and fluctuating) - must be present for at least **6 monyhs** - symptoms must've been present before age of 7 y "**FIDGETY**"  F - Functionally impairing  I - Inattention  D - Disinhibition  G - Greater than normal  E - Exclude other disorders  T - TWO or more settings  Y - young age (12 or less) ## Footnote - **ADHD does not present with failure to achieve developmental milestones** - **ADHD can maintain the ability to focus on activities they find intrinsically interesting or enjoyable**

Answer 158

- Behavioral Rating Scale - Visual & Hearing Assessments - Classroom Observation - Psychometric Assessment ## Footnote Behavioural rating scales give an objective **measure of the symptoms** across various domains and can assist in determining if symptom criteria for ADHD have been met. It is recommended that they be obtained from home and school at least. However they are **not diagnostic**. **The person completing the scales should have known the subject person for at least a month**. Psychometric assessment can exclude **intellectual impairment **and learning disorders. ADHD has a high rate of comorbidity with learning disorders, so there will need to be a review of the child's academic competency.

Answer 159

- Male: Female 2:1 - Family history of ADHD - in utero tobacco exposure - maternal stress - premature delivery - low birth weight - poverty

Answer 160

- Predominant inattentive subtype is more common ( ~ 2/3) - Combined subtype 20% - Predominant hyperactive subtype 10% - Hyperactive subtype often prominent during school and decreases with age - Inattentive subtype persists at same level throughout life ## Footnote ***60% will continue to exhibit symptoms into adulthood***

Answer 161

Symptoms are more subtle, and are subject to change: - Hyperactivity may be replaced with restlessness - impulsivity may be replaced with inability to control emotions or social inappropriateness.

Answer 162

* CBT (behavioural management and training) + family therapy +/- * Pharmachological - 1st line: Stimulants (**methylphenidate, dexamphetamine**) - 2nd line: **Atomoxetine** | drugs alone may not have a longer-term benefit on academic performance ## Footnote The alternative stimulant should be considered if the maximum dose of the first drug is reached and there is no significant improvement - after ** ONE month ** of treatment or - if there are major adverse effects. **With rare exceptions, do not use stimulants in children aged younger than 4 years**

Answer 163

- STIMULANTS: Inhibition of dopamine and norepinephrine reuptake - ATOMOXETINE: Selective Noradrenaline reuptake inhibitor

Answer 164

- headache - abdominal discomfort *However, many children become tolerant to these effects without the need to reduce doses.* - Increased sleep latency - appetite suppression are common. *Due to the anorectic properties of these drugs, doses should be given at or after breakfast and lunch* - growth restriction (relatively minor) *The weight and height of children should be monitored routinely during their treatment. When there is concern about a child's growth, drug holidays may be appropriate at times when some increase in symptoms may be acceptable (eg weekends and school holidays)* - Social withdrawal and tearfulness *may be indicators of an excessive dose.*

Answer 165

- should be used with caution in children with: * structural cardiac abnormalities, serious heart problems or those with conditions that may be exacerbated by increased pulse rate or BP * family history of sudden death, syncope ---->>> An assessment by a cardiologist is suggested. ---->>> Promptly evaluate children who develop exertional chest pain, unexplained syncope or other cardiovascular symptoms. - Avoid stimulants in children with a history of psychosis as a psychosis may be precipitated.

Answer 166

- oppositional defiant disorder - conduct disorder - learning and language problems - autism - GAD - OCD

Answer 167

"**PAN LID NOISE**"  PAN - Parenting, Abuse, and Neglect  LID - Learning, Intellectual, and Developmental Disabilities (these conditions do not respond to the treatment for ADHD; in addition, they present with failure to reach milestones  N - Nutrition  O - Other conditions (DM, Seizures, MDD, ODD, CD)  I - Intoxication  S - Sleep  E - Environment

Answer 168

- ADH has no intention to misbihave or be disruptive - ADH have remorse if they realise they've upset others - ADH disruptive behaviours rarely escalate to the level of fraglant disregard to rules and others rights like in CD

Answer 169

- deficitis in social communication (Austistic **A**loness) - restrictive and repetitive interests & activities (Insistence upon **S**ameness) ## Footnote Two domains

Answer 170

both core symptoms social communication & Restricted interests and behaviours + **D**evelopmental (1-3 years old) onset ## Footnote "the criteria for diagnosing is in the name of the disorder: "**ASD**"

Answer 171

- speech delays/Lack of speech - difficult understanding and using non-verbal communication - Overly literal - indifference to the presence of others - Reciptocity (absent) - Turn-taking (absent) - Sharing (absent) ## Footnote ASD is most strongly associated with delays in speech-related milestones rather than motor milestones. These deficits often do not begin until the age of 1 at the earliest.

Answer 172

- paticular fixations and fascinations - stereotyped or repetitive movements or posturing of body, arms, hands or fingers

Answer 173

although common (occurring in 60-80% of cases), they are not required for a diagnosis - disturbance in sensory perception * hypersensitivity* = aversion to sounds or textures * hypopsensistivity* = high tolerance to pain or temperature - motor sings * poor coordination * low muscle tone * unusual gait

Answer 174

- patterns must be observed in multiple settings from early childhood FOR BOTH conditions - **ONLY ASD** is associated with **milestone delays**

Answer 175

- beihavioural training = teach specific adaptive skills - speech language therapy = teaching skills to overcome communication deficits ## Footnote medications play no role in improving outcomes in autism

Answer 176

- family history (1st degree relative) - childreen of older fathers - M>F (4x)

Answer 177

"APHASIC"  A - Autism  P - Physical deficits  H - Heating impairment  A - Abuse/neglect  S - Selective Mutism  I - Intelctual Disability  C - Cerebral Palsy ## Footnote For many patients, speech delay is the initial reason for a formal evaluation of autism. Hence, other causes of speech delay must be ruled out

Answer 178

"**OCEAN**"  O - **Openness** to experience  C - **Conscientiousness** (tendency to act in accordance with both personal and societal expectantions)  E - **Extroversion** (tendency to engage with the external environment/other people)  A - **Agreeableness** ( priority that one places on getting along with other people)  N - **Neuroticism** (tendency to experience negative emotions over positive ones)

Answer 179

The dysfunction seen in personality disorders is **chronic** and **enduring** - rather than *transient* and *episodic* the characteristic patterns of a disordered personality tend to develop early in life - *if it had started 2-3 yrs back in adulthood, it is likely not a personality disorder* ## Footnote As with all personality disorders, a diagnosis of histrionic personality disorder requires that the patient demonstrate a persistent pattern of problematic behavior since early adulthood and across multiple contexts. People with ONE personality disorder often meet criteria for ANOTHER

Answer 180

"**P**a**SS**" the invitation as they: tend to shy away from social interaction  P - Paranoid  S - Schizoid  S - Schizotypal | common shared base ## Footnote Cluster A resembles psychosis

Answer 181

"**BAHN**ed" from future parties for: engaging in overly emotional, self-centered, manipulative, or even downright antisocial behaviour  B - Borderline  A - Antisocial  H - Histrionic  N - Narcisitic | all but histrionic have a shared base ## Footnote Cluster B resembles mood

Answer 182

party will be "**DOA**" (Dead On Arrival) given their tendency: to be highly neurotic, which will drag down the spirit of the party  D - Dependent  O - Obsessive-compulsive  A - Avoidant | no shared bases between disorders ## Footnote Cluster C resembles anxiety

Answer 183

* **Low agreeableness** (tends to see people's motives with skepticism or suspisciousness) * fear * mistrust * suspiciousness * There some social engagement * usually labelled as "angry"

Answer 184

- Paranoia in Schizophrenia involves a **stable pattern sticking to one belief** (*fixed and enduring belief system*) - PPDs **tend to jump between various paranoid ideas** (*constant stream of new paranoid thoughts*)

Answer 185

* **Low extroversion** (lack of interest in social relationships) * preference for solitary activities (**the happy loner** fine being on their own) * Aloof * lack of self-confidence * indiference to praise or criticism from others

Answer 186

unlike in Avoidant Personality Disorder, the lack of social contact doesn't appear to bother one with Schizoid Personality Disorder. They generally find that being alone is preferable to the constant demands for connection and intimacy that others put upon them.

Answer 187

The Asociality in Schizoid Personality Disorder is more *conscious* and *intentional* - ego-syntonic. In contrast, someone with schizophrenia tends to avoid social connection due to a *lack of motivation* and inability to connect with others due to *negative symptoms*

Answer 188

* odd beliefs (magical) & ensitive perceptions (quasi delusional beliefs) * difficulty relating to other people (emotionally distant) * eccentric behaviour * loneliness/isolation ("**isolated hippie**")

Answer 189

In Schizotypal Personality Disorder, the social avoidance is often out of fear that others will judge them for their odd beliefs, strange maneirisms, or unconventional manner of dress

Answer 190

- **High Neuroticism** (focuses on negative stimulli, thinks about mistakes from the past) - inflated self-importance (grandiosity, superiority, entitlement) - repeatedly boasting about one's sefl-accomplishment - inability to empathise (haughty, aloof) - exploits others - craves for attention and admiration - dificulty tolerating criticism ## Footnote any peoplee with narcissistic personality disorder will exagerate their claims, the disorder does not preclude them from being highly successfu, and it should nnot be assumed that they are making up or embellishing their success Although patients with (NPD) also need to be the center of attention, they typically do not exhibit the dramatic emotional displays (seen in this patient) that are a key feature of histrionic personality disorder.

Answer 191

Look at the timing of signs and symptoms as these will be: - **enduring** in *Narcissistic Personality Disorder* - **episodic** in *Bipolar Disorder*

Answer 192

- excessive or exagerated behaviours intended to draw attention to one's self or to gain approval of others (*dramatic, flitartious, sexually provocative*) - although it comes shallow and provocative - Self-dramatisation, theatricality, exaggerated expression of emotions (with facial expressions and hand gestures) - **Shallow/vague speech and labile affectivity** - Continually seeking to be the centre of attention - Inappropriate disinhibition/flirtiness - Over-concern with their physical attractiveness (Uses appearance to draw attention) - easily influenced by others (suggestible) - Considers relationships more intimate than they are

Answer 193

- Approximately 2-3% of the population has HPD - least impairing disorder in Cluster B - **does not have association with child abuse** - F > M - **Tends to run in families** - **There's a genentic link between alcoholism and HPD**

Answer 194

* **high agreeableness** (place other's interests ahead of their own) * overreliance upon other people (clinging behaviour) * avoids conflcts * difficulty in making decisions in multiple areas of life (small and large) * seeks reassurance constantly * extremely deferential (reverential, respectful, obedient) * suggestible (can be easily influenced by other people)

Answer 195

* **high conscientiousness** (tend towards planned behaviours) * **low openness** to new experiences (value pragamatism) * emotional rigidity and controlling behaviour * reluctant to delegate * Scrupulous * Inflexible about matters of morality

Answer 196

* **OCPD** - ego-systonic (feel that they are right/correct) * **OCD** - ego-dyntonic (rituals that cause feelings of distress, rather than satisfaction)

Answer 197

- CBT - Interpersonal Therapy (addressing the effect that rigidity has on others)

Answer 198

* creepling sense of disaproval * avoidance of social engagements * unwilingness to meet new people * - alone but wants connection * tendency to avoid getting into intimate relatioships * constant worries about being criticised or rejected * inhibited behaviour in interpersonal situatiions * a view of oneself as inept or inferior * reluctance to take risks or do anything potentially embarrassing

Answer 199

* **Schyzoid** - happy loner * **Avoidant** - still desire human contact

Answer 200

- SSRIs - CBT

Answer 201

9 key criteria: **I DESPAIR**  I - **Identity**  D - **Dysphoria**  E - **Emotinal Instability** (affective lability)  S - **Suicide/Self-harm**  P - **Psychosis/Dissociative**  A - **Anger**  I - **Impulsivity**  R - **Relationships** (Unstable/Sensitivity to abandonment) = highly sensitive and specific

Answer 202

**Psychosis-like** symptoms are different from primary psychosis: -- auditory hallucinations - (voices come from *inside* and are *vague*, as opposed to the typical auditory hallucinations psychosis where they they com from *outside* their head and are *clear* - often transient and tend to occur in times of stress -- paranoid ideations related to extreme interpersonal sensitivity as opposed to complex delusinal belief system

Answer 203

**Impulsivity** Someone with extreme and erratic emotions would also engage in extreme and erractic behaviours these actions help to temporarily relieve the chronic state of dysphoria (as opposed to extreme bahaviours seen in mania where it is purely pleasure-seeking behaviours)

Answer 204

**Splitting** Tendency to see the world in extremes or black-and-white terms. Relatives, friends, and HCPs interacting with BPD patients often find themselves on one side or the other of a split: they are either "the best person ever" or "the cruelest person ever to walk on the face of the earth"

Answer 205

Is characterised by *chronic instability* in the domains of *identity*, *mood*, *affect*, *behaivour*, *relashionship*, and and one need **5 out of 9 sx** to be diagnosed.

Answer 206

BPD: - impulsivity in at least two areas that are potentially self-damaging - A pattern of **unstable and intense interpersonal relationships** characterized by alternating between extremes of idealization and devaluation Cyclothymic: - many periods of depressed mood and many episodes of hypomanic mood for at least **2 years** - During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time

Answer 207

* **Dysphoria** = **reactive state** people with dysphoria may express their disocontent through *anger outbursts*. They externalise their dissatisfaction thorough blaming others. * **Dysthymia** = **non-reactive** to circumstances people with depression/dysthymia may be more *passive* in their attempts to cope. They blame themselves and feel guilt

Answer 208

**Dialectical behaviour therapy (DBT)** - mindfullness - distress tolerance - emotional regulation - interpersonal effectiveness downsides - small pool of available providers (as it requires training) - Costly - time consuming (requires 1-2 years of treatment before meaningful improvements are seen) **Pharmacological** If medications must be be used, they should only be for symptomatic treatment of specific symptoms and are used adjunctively: - Anticonvulsants = reduce anger and impulsivity - Antipsychotics = alleviate paranoid or dissociative sx ## Footnote This teaches specific skills targeted towards core sympyoms that BPD patients tend to struggle with

Answer 209

People with BPD often meet criteria for multiple other conditions: - depression - anxiety - bipolar disorder - PTSD **Treatment of BPD should come first**. It tends to improve related symptoms. The only exception is if there is an immediate threat to the health of the patient or if not treating these conditions it would interfere with the ability of the patient to engage in therapy

Answer 210

- evident in adolescence/early adulthood - less common in old age groups - traumatic events in child are correlated (but not causative) - F=M (although in clinical settinhs it tends to be F>M) - Family history/high inheritability (50% risk) - Complete remission is quite rare (interpersonal sensitivity tends to persist)

Answer 211

8 criteria "**ACID LIAR**"  A - **Adult** (diagnosis > age of 18)  C - **Criminality**  I - **Impulsivity** (low conscientiousness)  D - **Disregard for safety**  L - **Lying**  I - **Irresponsibility**  A - **Aggression**  R - **Remorselessness**

Answer 212

- emotinal instability (anger, sadness, irritability) - impulsive aggression - difficulties in relationships - isolation and loneliness - premaditated acts

Answer 213

Adult age + 3 or more of the core symptms

Answer 214

DOs - Argumentativeness (frequently argues/stubbornness) - purposefully do things to upset others - vindictiveness - defiance/testing limits (ignore rules) - Failing to accept responsibility for one’s own actions and blaming others for one’s own mistakes. DON'Ts - violate others rights - no overt violence - no aggression - no theft ## Footnote must occur for at least 6 months

Answer 215

- average onset age 6-8 years (can continue into adolescence) - M > F (2x) - persistent anger and irritability (losing one’s temper) - believe that they are justified in their actions

Answer 216

- Flaglrant disregard to others' rights - overt violence (physical cruelty) - aggression (fights) - robbery, fire setting, property damage - sexual coercion ## Footnote conceptualised as a precursor to ASPD

Answer 217

- almost all patiets show signs by the age of 10 - M > F (4x) - believe that they are justified in their actions

Answer 218

- family therapy - behavioural training for the child - medications are geneerally not helpful CD reponds to a lesser extent than ODD to these therapies

Answer 219

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

Answer 220

"**UNDER**-exia"  U - **Underweight** (BMI < 17.5)  N - **Nervous/fearful** about gaining weight  D - **Distorted** self-perceptions about weight (ego-syntonic)  E - **Exercise/purging/other behaviours** to burn calories and lose weight  R - **Restricting** caloric intake

Answer 221

- Significant electrolyte disturbance (K < 3.0 or Na < 130) - Hypercholesterolemia - Raised liver enzymes and Albumin < 35g/L - Vitamin deficiencies - LOW WBC - Hypochloraemic Alkalosis - ESR is LOW or Normal

Answer 222

- Bradycardia. (< 40bpm) - Hypotension (< 90mmHg) - Dehydration (excessive exercise/abuse of laxatives) - osteoporosis - Amenorrhoea/Infertility (abscence of 3 consecutive cycles) -- secondary amenorrhoea due to low levels LH/FSH (hypogonadotropic Hypogonadism) - Constipation - Cachexia (less than 85% of ideal body weight) - Hypothyroidism -- Hypothermia -- Cold intolerance - mood swings, anxiety - **Suicide** (single most deadly mental ilness, with up to 20% of people dying) | https://pubmed.ncbi.nlm.nih.gov/22349551/ ## Footnote can be associated with: -Depression -OCPD

Answer 223

 Low weight (85% or less of expected weight and/or less than the third percentile for BMI) Physiologic decompensation including, but not limited to, the following:  severe electrolyte imbalance (life-threatening risks created by sodium and potassium derangements),  cardiac disturbances or other acute medical disorders  orthostatic differential > than 30/min  Temperature < than 36°C  Pulse < 45 bpm  Significant oedema  altered mental status or other signs of severe malnutrition  Psychosis or a high risk of suicide

Answer 224

- Anorexia = ego-syntonic (lack of insight) - OCD = ego-dystonic

Answer 225

- ego-syntonic - rigitiy of behaviour (little variation) - high conscientiousness (act in accordance with societal expectations ## Footnote Anorexia has a high rate of comorbity with OCPD

Answer 226

- F > M (10x) - begins around puberty (13-14y) and young adulthood (17-18y) - Associated with careers/hobbies that can produce extrem pressure to be thin (modeling, gymnastics, ballet, and running) - low self-esteem - high socioeconomic status (SES)

Answer 227

- nutritional rehabilitation - psychitherapy (CBT) - Medications are of no proven benefit for the primary anorexia nervosa itself.

Answer 228

**Refeeding Syndrome** ## Footnote The manifestations of refeeding syndrome are mainly caused by hypophosphataemia, precipitated by increased glycolysis when carbohydrate replaces body fat as the main source of energy. In chronic malnutrition, phosphate stores are already low. When the individual is suddenly fed again, insuline is released causing further uptake of phosphate into cells and leads to even grater hypophosphatemia. The low availability of phosphate prevents metabolic intermediates from being produced, leading to hypoxia and muscle disfunction.

Answer 229

- cardiovascular collapse, cardiac failure - rhabdomyolysis and muscle weakness (which in turn may lead to ventilatory failure, seizures or delirium) - Hypokalaemia and hypomagnesaemia can cause cardiac arrhythmias - glycolysis-induced thiamine depletion can lead to Wernicke encephalopathy

Answer 230

**one or more of the following**: - BMI < 16 - loss > 15% of body weight in the last 3-6 months - little or no nutritional intake for > 10 days - low concentrations of potassium, phosphate or magnesium before reintroduction of nutrition OR **two or more of the following**: - BMI < 18.5 - loss > 10% of body weight in the last 3-6 months - little or no nutritional intake > 5 days - history of hazardous alcohol use or drug use (including insulin, chemotherapy, antacids or diuretics).

Answer 231

- **Give thiamine** (at least 100 mg IV or 300 mg VO, daily) before starting and for the first 7-10 days of feeding. - **Measure serum electrolytes** (including potassium, phosphate, and magnesium) before starting feeding, and supplement as required. Check serum electrolytes at least daily for the first week after reintroduction of nutrition. - **Start feeding slowly** (30-50% of estimated caloric requirement) then, if electrolytes are stabilised, increase gradually over 5 to 7 days to the patient’s estimated needs. For severely malnourished patients, start at 5-10 kcal/kg/day. - **Give a multivitamin** (once daily for at least 7 days). - In the first week of refeeding, **monitor vital signs** and (in high-risk patients) cardiac rhythm, and look for signs of oedema, heart failure and a deteriorating mental state.

Answer 232

**Bowl**-emia  B - **Binge eating** (impulsive/out of control)  O - **Off-setting** behaviours (purging)  W - **Weekly** (or more) **for** a period of **3 months**  L - **Linked** to self-steem ## Footnote Purging (methods inteded to rid the body of the effects of calories) can take form in different behaviours: - self-induced vominting (most common) - Laxatives/diuretic/enema abuse - driven exercise and/or fasting

Answer 233

- Kidney injury due to dehydration - Metabolic Alkalosis (loss of stomach acid) - gastric ulcers - Boerhaave Syndrome - changes in hormone levels (amenorrhoea is common, but no hirsutism) - abnormalities in liver and thyroid function, and anemia are a result of malnutrition seen in Anorexia nevorsa, hence less likely Bulimia Nervosa Physical exame: - Patients have normal weight or are overweight (BMI > 18) - erosion of dental enamel/dental decay - swollen salivary glands - injury of the knuckles (Russell's sign) ## Footnote The menstrual and ovulatory abnormalities are due to suppresed sex hormone secretion as a consequence of fasting and prolonged dietary restriction

Answer 234

- F > M (10x) - peak onset at 18 (but can begin in adolescene, or as old as 25 years) - Family history of eating disorder - associated with sexual abuse - often comorbid with BPD

Answer 235

- CBT + Interpersonal Therapy - SSRIs (for both depressed and not depressed patients)

Answer 236

Bupropion - Increases the risk of seizures

Answer 237

History of many physical complaints begining before the age of 30 "**SOME-ATTIC**"  S - **Symptoms**  O - **One** or multiple  M - **Medically** unexplained ("no outward sign")  E - **Excessive**  A - **Anxiety** about health or symptoms  T - **Thinking** about the seriousness of symptoms  T - **Time** and energy devoted to these symptoms or health concerns  I - **Impaired** or distressed resulting in significant disruption of daily life  C - **Chronic** the state of being symptomatic is persistent, lasting months to years (typically more than 6 months) ## Footnote -gastrointestinal tract is the most commmon location for somatic symptoms in ALL PATIENTS -gynecologic complaints are the second most common symptom IN WOMEN 1. **FOUR Pain symptoms**: Headaches, abdominal pains, back and joint pain, pain during menstruation or sexual intercourse, chest pain. 2. **TWO GI symptoms**: Nausea, bloating, vomiting other than during pregnancy, diarrhea or intolerance to several foods. 3. **ONE sexual symptom**: Erectile dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout the pregnancy. 4. **ONE Pseudoneurologic symptom**: Conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty in swallowing, lump in throat, aphonia, hallucinations, loss of sensations, visual problems, urinary retention etc. Either of the following: 1.After appropriate investigations, symptoms not adequately explained by known general medical condition. 2.When related to a general medical condition, symptoms are In excess of what would be expected from history, physical examination and investigations.

Answer 238

- Regular visits (minimises the idea of only seeing the doctor when sick) - CBT - Midnfulness therapy - physiotherapy & rehabilitation - TCA's and SNRIs (smaller effect) ## Footnote Analgesia is usually not helpful

Answer 239

"**CAN'T**-version  C - **Clinically** unexplained  A - medical **Abnormality**  N - involving **Nervous System**  T - usually (~50%) brought on by a **Trigger** ## Footnote Patient is not manufacturing or faking the symptoms (*unconscious & Involuntary*)

Answer 240

- subjectively reported symptoms (blindness, blurry vision, loss of sensation) - objectively observed signs (weakness, imbalance, shaking) OR - absence of function (as in motor paralysis) - presence of dysfunction - (as in convulsions) ## Footnote NOTE: given the features above, the conversion disorder diagnosis would not be appropriate a patient presenting with abdominal pain or chest discomfort)

Answer 241

- Educate patient about conversion disorder - overall majority of cases resolve spontaneously - physical/occupational therapy can be helpfu for patients with motor deficit (even in the absence of objective neurologic pathology) - 25% relapse within a year NOTE: CBT and medication are **not helpful**

Answer 242

unexplained symptoms intentionally feigned - **intentional** production of symtpoms voluntary - **Unsconscious** goal is primary gain (desire the sympathy and attention that accompanies having an illness) - Recurrent presentations - rejects being discharged - Knowledge of illness (50% work in the medical field)\ - No insight (can hurt themselves; desire to remain in the sick role over and above preserving their own bodily integrity) "**FAC**" - F - Factitious - A - Always - C - come back as their primary motivation is in the medical care itself

Answer 243

- Munchausen Syndrome (intentional self-inflicted harm to provide evidence of illness. Can also be someone who knownly has a condition but refuses treatment to gain others' sympathy) - Munchausen Syndrome by proxy (harm imposed on another)

Answer 244

- poor prognosis - neither medications nor psychotherapy are effective - Refer to specialist

Answer 245

**intentional** and **Conscious** production of signs and symptoms for obvious secondary gains. - - goal is extrinsic to the role of being sick (disability payments, excuse from work/military service, lighter sentence in a criminal case, financial compensation from a fake injury, admission to hospital) "**MAL**" - M - Malingering - A - Always - L - Leave once their need has been met, because there is no longer reason for them to seek medical care

Answer 246

No clear treatment

Answer 247

Complicated grief: - symptoms persist longer than six months - Avoidance of situations that serve as reminders of the loss is also common Avoidant Personality Disorder:

Answer 248

- lmmobility or excessive purposeless activity - Mutism, stupor (decreased alertness & response to stimuli) - Negativism (resistance to instructions & movement) - Posturing (assuming positions against gravity) - Waxy flexibility (initial resistance, then maintenance of new posture) - Echolalia, echopraxia (mimicking speech & movements) Rx: Hospitalisation + Benzodiazepines

Answer 249

a mood disorder (eg, bipolar disorder, major depressive disorder)

Answer 250

identical symptoms: - rigidity - bradykinesia - postural instability Differentiating symptoms: - involuntary movements of face and tongue (tardive) - Stiffness

Answer 251

"**DIRE**"  D - **Decline** in cognition (memory, language, hability to plan) - screening tools (e.g. MMSE, MoCA)  F - Functional **Impairment** (IADLs 1st > ADLs 2nd)  R - **Rule** out Delirium  E - **Exclude** other mental health conditions

Answer 252

Normal aging **Preserved** cognitive domains - language - recognition of faces and situations - awareness of memory loss Normal aging **Impaired** cognitive domains - deficits in short-term memories - declarative memories (recalling) - attention - processing speed - concrete thinking (as opposed to ability to think abstractly)

Answer 253

Intrumental Activities of Daily Living (first signs of the impact of cognitive impairments) "**SHAFT**"  S - **Shopping**  H - **Housekeeping**  A - **Accouting**  F - **Food Preparation**  T - **Transportation**

Answer 254

Activities of daily living: (signs of late stage cognitive impairment) "**DEATH**"  D - **Dressing**  E - **Eating**  A - **Ambulating**  T - **Toileting**  H - **Hygiene**

Answer 255

**Screening** tool to assess **cognitive** skills

Answer 256

"**ORRAL**"  O - **Orientation** (time/space)  R - **Registration** ("name 3 objects)  R - **Recall** (ask for the 3 objects repeated above)  A - **Attention/Concentration & Calculation**  L - **Language**

Answer 257

- serial 7's (from 100 - 0) **not a memory test** - spelling a word backwards **not a memory test** - serial 3's (from 100-70) **not a memory test** - Digit span **memory test** - Recitation of the days of the week/mothns of year in reverse order) **not a memory test**

Answer 258

pseudodementia/depression

Answer 259

Cognitive impairment due to the presence of a mood-related mental health concern, most often depression (giving up). Pseudodementia have **INSIGHT**

Answer 260

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

Answer 261

Cognitive decline

Answer 262

it is improtant to: - rule out delirium - exclude other psychiatric conditons (e.g. depression) - CT (PET) scan (the presence of brain tissue degeneration, such as atrophy, can confirm dementia)

Answer 263

Although it is part of a screening tool for congnitive impairment (MoCA), the CDT t is a tool that **measures dementia severity** strong indicator of early dementia, but it can't diagnose the type of dementia or rule out other conditions

Answer 264

- Frontal functioning - Temporo-parietal Functioning

Answer 265

- Alzheimer's Dementia (50% to 70%) - Non-Alzheimer's Dementias -- Frontaltemporal dementias (up to 10%) -- Dementia with Lewy Bodies and Parkinson disease dementia (up to 10%) -- Vascular Dementia (10% to 20%) -- alcohol-related dementia (up to 5%).

Answer 266

No single test to diagnose Alzheimer’s "**GRANdPA U OK**"  G - **Gradual** decline  R - **Relentless** (unremiting, steady downward Trajectory)  A - **Amnesia** ( + Neurocognitive deficits = 4 A's)  Nd - **Neurocognitive deficits**  P - **Psychiatric** (mood changes, psychosis-like sx)  A - **Activity** (losses in complex behaviours, increase in purposeless behaviours)  U - **Unable** to function  O - **Objective** biomarkers  K - **Knowledge** of Illness (patients are unware of their cognitive defits)

Answer 267

 4 A’s of Alzheimer's: -- **Amnesia** (EARLY SYMPTOM defining feature of the condition) -- **Aphasia** (LATER FINDING; language impairment - sepaking, reading, writing, and receptive) -- **Apraxia** (LATER FINDING; inability to perform motor activities) -- **Agnosia** (LATER FINDING; inability to translate what we percieve with our senses into a cohesive signal to be acted upon) ## Footnote Progression of cognitive impairment follows this order: Amnesia > Aphasia, > Apraxia > Agnosia

Answer 268

- FIRST and MOST affected cognitive domain - both retrograde and anterograde memories affected (with the former being impacted earlier and more severely) these distintinctions tend to breakdown as the disease progresses

Answer 269

State of confused restlessness/agitation/wandering that is more prominent in the evening Endeavour to manage sundowning through nonpharmacological interventions.

Answer 270

 *CT scan* -- widespread cortical atrophy -- widespread decrease in brain cells metabolic activity -- hypocampus atrophy (low Acetylcholine activity)

Answer 271

 pathology (not routinely done) * cerebral spinal fluid -- B-amyloid protein -- Tau Protein * biopsy -- senile plaques (clumps of B-amiloid ptrotein) -- neurofibrilary tangles (Tau Protein)

Answer 272

 genetic testing (autosomal dominant) * APOE4 gene (codes for a poorly fuctioning version of APO-LIPOPROTEIN E which clears B-amyloid protein) --- 1 copy = 3x more risk --- 2 copies = 15x more risk

Answer 273

- early onset considered < 65 years - risk 3% in population > 65 years - risk doubles every 5 years - Steadily progressive; No cure - highly lethal (death occuring with 10 years of dx)

Answer 274

****goals of treatment are: - paliative - symptom reduction - preservation of function Psychotherapy not effective (cognitive deficits prevent patient from meaningfully engaging in treatment)  Behavioural modifications -- education -- self-care (bathing, dressing, toileting) -- exercise  Sensory stimulation- music, pets.  Social interaction- regular visits from family, friends. ## Footnote Patients with a clinical suspicion for dementia should not be permited to driveor operate complex machinery that could potentially put their own lives or the lives of others at risk.

Answer 275

1. Cholinesterase inhibitors (AChEi) (**donepezil, galantamine, rivastigmine**) 2. NMDA receptor antagonist (memantine) ## Footnote * These drugs improve alertness and function and can maintain cognitive scores at or above the baseline for up to 12 months; * Not all patients benefit from cholinesterase inhibitors; some have modest benefit and a few show significant improvement. * Patients should be treated for at least 2 months at the maximum recommended dose (if tolerated) before a final assessment of response is made. * If patients tolerate and appear to benefit from cognitive enhancing drugs then the drug should not be ceased until the patient is in an advanced state of dementia (usually having lost independent mobility)

Answer 276

"**DUMBBEELSS**"  D - **Diarrhoea**  U - **Urination** (urinary incontinence)  M - **Miosis**  B - **Bradycardia**  B - **Bronchocontriction**  E - **Emesis**  E - **Excitation** (tremor, insomnia,vivid dreams)  L - **Lacrimation**  S - **Salivation**  S - **Sweating** other side associated with prominent adverse effects are: * anorexia, weight loss * depression * lethargy, fatigue, drowsiness Take care when introducing these drugs in patients with: - asthma, chronic obstructive pulmonary disease (**Bronchoconstricion**) - cardiac conduction abnormalities (particularly atrioventricular block) (**Bradycardia**) - **peptic ulcer disease**

Answer 277

- confusion - dizziness - drowsiness - headache - insomnia (If present, memantine can be taken earlier in the day) - agitation and hallucinations NOTE: reduce dose in kidney failure (RENAL EXCRETION)

Answer 278

"**C'N STUPH**"  C - **Cognitive deficits** fluctuation (memory isn't the most prominent cognitive domain that is affected - in contrast to Alzheimer's)  N - **Neuroleptic sensitivity** ( poor response and at higher risk of developing side effects to antipsychotics) AVOID!  S - **Sleep bahviour** (REM Sleep Behaviour disorder - patients acting out on their dreams) - **very specific sign**  T - **Timing** (earlier onset, rapid decline)  U - **Unstable** (rapid fluctiation in cognition, waxing and waning alertness and lucidity) - very specific  P - **Parkinsonism** (tremor, rigidity, slow movement, postural imbalance, ataxic gait)  H - **Hallucinations** (visual)

Answer 279

**Alzheimer's** - onset usually > 65 - gradual and progressive decline (years) - memory is usually the first cognitive domain to be affected **DLB** - earlier onset (~50s) - rapid cognitive decline (months) - cognitive domains other than memory are prominently affected - Fluctuating confusion - visual hallucinations - EPS

Answer 280

**DLB** - insight is usually preserved (patient not bothered) - Typically visual hallucinations **Schizophrenia** - no insight, severely disturbed - Auditory hallucinations are prevalent

Answer 281

Similar to Alzheimer's dementia (but less effective and impose greater side effect burden) - anti-Parkinson's drugs to treat motor symptoms

Answer 282

 Intact cognition/preserved insight  Ocular Pathology (BLIND or, commonly, macular degeneration) or occipital disease - NOT psychiatric  Visual Hallucination - vivid, colourful, and well-organised hallucinations - experience may last for seconds or hours at a time - patient has good insight - hallucinations are not distressing, but may be quite engaging

Answer 283

"**OH DEAR**"  O - **Obliviousness** (loss of sympathy and empathy, tactlessness)  H - **Hyperorality** (preference for carbohydrate-rich foods, consumption of inedible objects)  D - **Disinhibition** (impulsivity, hypersexuality, loss of social awareness)  E - **Executive dysfunction** (language difficulty, inability to plan and execute complex ideas)  A - **Apathy**  R - **Restrictive/ritualistic behaviour** * **Insidious onset and slow progression** * early changes are in personality & behaviour * memory and visuospatial abilities are relatively preserved (to laste-stage disease) - *in constrast* with Alzheimer's * not same fluctiation seen in DLB

Answer 284

- (Clock Drawing Test) CDT is a screening tool and a cognitive deficit score (SCORE ≥ 3) on this test can indicate FDT

Answer 285

- tailored behavioural management strategies - TG does not recomend any pharmacotherapy for FTD

Answer 286

- **sudden cognitive decline in a step-wise manner (each drop in functional ability represents another ischemic event)** - emotinal lability - gait abnormalities - urinary dysfunction - Parkinson motor features - Hallucinations are rare/not present - Vascular lesions on CTI/MRI

Answer 287

- HAS - DM - CVD - smoking - hyperlipedemia

Answer 288

"**DEMENTIAS**"  D - **Dringking & Drugs**  E - **Endocrine** (thyroid, parathyroid, pituitary, adrenal)  M - **Metabolic** (disglycemia, electrolytes, vitamin b12 deficiency)  E - **Ears & Eyes** (sensory impairment)  N - **Neoplasias**  T - **Trauma** (subdural hematoma)  I - **Infection** meningitis, encephalitis, Endocarditis, syphilis, HIV)  A - **Autoimmune**

Answer 289

Triad "**DIG**"  D - **Dementia**  I - **Incontinence**  G - **Gait** ## Footnote Mx: shunt to drain excess fluid

Answer 290

- **AVOID** First-Generation Antipsychotics (FGA) * **Anxiety and agitation** -- Oxazepam VO * **hallucinations, delusions or seriously disturbed** -- 1 Risperidone VO OR -- 2 Olanzapine VO * **Depression** -- **Avoid** antidepressants with anticholinergic adverse effects (i.e. **TCA's**) (exaggerate the cognitive deficits due to central acetylcholine deficiency in Alzheimer disease)

Answer 291

**Acute** neuropsychiatric reaction to severe thiamine deficiency. It is a type of delirium and is usually reversible

Answer 292

TRIAD: - CONFUSION - GAIT ATAXIA (Lack of coordination) - OPHTHALMOPLEGIA (horizontal nystagmus, abducens palsy, or conjugate gaze disorder all typical). -- **All three elements of this triad need not be present in order to make the diagnosis. **

Answer 293

Thiamine deficiency may be secondary to: - alcoholism - Hyperemesis gravidarum - restrictive eating disorders + vomiting - cannabis hyperemesis Syndrome - dietary deficiency associated with Mg insufficiency - gastric carcinoma

Answer 294

urgent IV thiamine

Answer 295

but the majority will develop a chronic Korsakoff syndrome.

Answer 296

**Irreversible** damage to the mammillary bodies (region associated with memory and recall) leading to **Dementia**

Answer 297

- profound **anterograde** amnesia - Confabulation (due to memory gaps)

Answer 298

- 20 - 50 years old - Dementia - Chorea

Answer 299

According to international guidelines: * people ≥ 18 years or older **AND** * have a blood relative who has been diagnosed with HD ## Footnote https://www.genetics.edu.au/PDF/Huntington_disease_genetic_testing_booklet-CGE.pdf

Answer 300

- mid-aged adults - rapidly progressive dementia (weeks - months) - **Myoclonus**

Answer 301

The Confusion Assessment Method (CAM) considers that a diagnosis of delirium is likely if the following are present: - acute onset and fluctuating course - impaired attention span (or inattention) - disorganized thinking or an altered level of consciousness.

Answer 302

- age > 65 years - pre-existing dementia

Answer 303

 D - **Drugs** & **Drug Withdrawal** -- prescription and over-the-counter medicines, and alcohol and illicit drugs -- withdrawal states - alcohol and benzodiazepines; (suspect alcohol withdrawal if tremors, sweating and visual hallucinations are present)  E - **Epilepsy** & **Endocrine** -- seizures and postictal states -- DM, Thyroidism  L -  I - **Infections** (UTI most common in AUS)  R -  I - **Intracerebral** events (subdural haematoma, haemorrhage, stroke)  U - **Unpleasantness** (pain and discomfort, urinary retention, constipation)  M - **Metabolic disturbance** & **Malignancy** (hypoglycaemia, hyperglycemia, hyponatraemia)  organ failure: kidney failure, liver failure, and respiratory failure with hypoxia/hypercapnia  cardiac events: MI, arrhythmia, CHF ## Footnote Deafness is a well documented predisposing factor to paranoid illness in elderly people. Characteristically, this complicates severe bilateral deafness resulting from middle ear disease and chronic mastoiditis.

Answer 304

 A - **alcohol and illicit drugs** (eg cannabis, methamphetamine).  A - **Anticholinergics**  B - **Benzodiazepines**  C - **corticosteroids**  D - **dopaminergic drugs** - NSAIDs - Opioids - sotalol and propranolol (unlikely with other beta blockers)

Answer 305

DRABCDE + TONGF ## Footnote The delirious patient must be observed at all times.

Answer 306

Haloperidol VO (single dose) OR olanzapine VO (single dose) OR Risperidone VO (single dose) ## Footnote *onset of action can be delayed from 30-60 minutes after administration *second doses should not be given for at least 30 minutes

Answer 307

Haloperidol IM (single dose) OR Olanzapine IM (single dose) ## Footnote *onset of action can be delayed from 30-60 minutes after administration *second doses should not be given for at least 30 minutes

Answer 308

**benzodiazepines** should be avoided in delirium (especially in patients with significant respiratory depression) *except for cases due to alcohol withdrawal or seizures*

Answer 309

- It usually commences **72 to 96 hours (3-7 days)** after cessation of drinking. - characterised by: -- **gross tremors** -- fluctuating levels of agitation -- **hallucinations (usually tactile)** -- disorientation and impaired attention -- Fever -- tachycardia -- hypertension -- dehydration it is usually associated with: -- infections -- anaemia -- metabolic disturbances -- head injury

Answer 310

1 diazepam VO 2 midazolam IV (if **agitation**) If an **antipsychotic** drug is required, use: - VO Haloperidol **AVOID chlorpromazine** (it lowers seizure threshold) If **extrapyramidal adverse effects** (EPS) emerge: - benztropine VO or IM ## Footnote IV diazepam should be avoided if possible -- Onset of action is not much faster than with VO -- there is a greater likelihood of causing severe adverse effects such as respiratory depression -- If an injection is necessary, it must not be diluted and it must be given slowly over several minutes to minimise the risk of respiratory depression or arrest.

Answer 311

- - Haloperidol IM, as a single dose. (less likely to lower seizure threshold) OR - - Droperidol IM, as a single dose (similar to haloperidol but is more sedating)

Answer 312

- Idiopathic (Primary) Insomnia - Secondary Insomina According to duration: - Acute Insominia (< 30 days) - Chronic Insomina (> 30 days)

Answer 313

- over-reactivation of HPA axis - Hypervgillance about falling asleep

Answer 314

A symptom of other disorders * due to somatic symptoms (pain) * Psychiatric Conditions (mood and anxiety disorders) * Drug use (caffeine, alcohol, nicotine being more common) * Intrisic Sleep Disorders ( sleep apnoea, restless legs syndrome)

Answer 315

Primary treatment goals are to improve sleep quality and quantity, and to relieve insomnia-related daytime impairment. - Management of underlying problems - Good sleep practices (sleep Hygiene) -- Sleep–wake activity regulation -- Sleep setting and influences -- Sleep-promoting adjuvants - Psychological and behavioural interventions (most often used for chronic insomnia as they do not work immediately and require practise and persistence) -- Relaxation therapy --- e.g. hypnosis, meditation --- can be of benefit for both acute and chronic problems -- Cognitive therapy (CBTi - "i" for insomnia) --- targets dysfunctional beliefs about sleep -- Stimulus control --- limit the amount of time spent in bed awake --- useful for people who have difficulty falling asleep -- Sleep restriction --- goal is to reduce the amount of time spent awake --- suitable for people who have difficulty staying asleep due to poor sleep drive.

Answer 316

- short-term management of **acute insomnia** - **chronic insomnia** when the nonpharmacological strategies are not effective.

Answer 317

1 Temazepam VO (before bedtime) (idel for patients with sleep onset insomnia) OR 1 Zolpidem VO (less morning sedation) OR 1 Zopiclone VO OR 2 Melatonin VO (before bedtime) for patients > 55 years (there is insufficient evidence to support treatment > 3 wks) ## Footnote Contra-indicated if history of: - addiction and dependence - OSA - use of other substances (e.g alcohol, CNS depressants) Complaints of use of BZ include: - sleeping is not refreshing - reduced daytime alertness

Answer 318

- treatment should be limited to < 2 weeks. - Intermittent therapy may be considered in severe longstanding insomnia that is not relieved by non-pharmacological management ## Footnote The patient with chronic insomnia should be reviewed weekly for 4-6 weeks period for these psychological and behavioural treatments.

Answer 319

Dysfunctions associated with sleep, sleep stages or partial arousal + abnormal motor, behavioural or sensory experiences.

Answer 320

- occurring in **non-REM sleep** -- associated with stages 3 and 4 -- typically occur in the first half of the sleep period -- eg sleepwalking, sleep terrors - associated with **REM sleep** (eg nightmares, REM sleep behaviour disorder)

Answer 321

* sleeper performs some repetitive activity in bed * sleeper can walk freely from the bed * more common in children * can be associated with some hypnotics

Answer 322

- Usually no treatment is required - if frequent, and presents danger sleeper, the sleeping environment should be made safe. - Adults with recurring episodes may need to seek specialist assistance. Hypnotics may be considered if: * have injured themselves or others * serious risk of doing so * whose quality of life is significantly affected.

Answer 323

- sharp screams - violent thrashing movements - autonomic discharge with sweating and tachycardia. - **The subject may or may not wake** - **there is usually no recall of the event** (as they occur in non-REM sleep states)

Answer 324

- Usually no treatment is required (vast majoirty do not persist into adulthood) - reassurance is typically sufficient - Adults with recurring episodes may need to seek specialist assistance. Hypnotics may be considered if: * have injured themselves or others * serious risk of doing so * whose quality of life is significantly affected.

Answer 325

- dream-related anxiety episodes - Recurrent stereotyped nightmares are commonly associated with PTSD - can be associated with the discontinuation of REM-suppressing drugs (eg alcohol, antidepressants and some hypnotics) - A number of drugs can also cause vivid dreams or nightmares (eg B-blockers, SSRIs, benzodiazepines, levodopa)

Answer 326

- Psychological evaluation and therapy are required if associated with PTSD

Answer 327

- complex and elaborate motor activity in association with dreams - may result in violent behaviour during sleep - **frequently associated with neurodegenerative (eg Parkinson's and Lewy Bodies Dementia ** Diagnosis can be made by a sleep study and specialist evaluation is recommended.

Answer 328

- reassurance - improving sleep practices - interventions as necessary to address safety issues - If more **severe**, and if there is concern about physical injury occurring ->>> **low-dose clonazepam**.

Answer 329

- appear between adolescence and the age of 30 years - chronic daytime sleepiness + "**CHAP**"  C - **Cataplexy** - **specific sign** (sudden loss of muscle tone during wakefulness, associated with or without strong emotion)  H - **Hallucinations** (often visual) on falling asleep (hypnagogic) or waking (hypnopompic)  A - **Attacks** (sudden unpredictable episodes of sleep; it can last secs to mins) - **most common sign**  P - Sleep **Paralysis** muscle paralysis on falling asleep or waking ## Footnote all symptoms need not to be present

Answer 330

- clinical history - absence of other sleep disorders (particularly OSA) on overnight sleep study - objective evidence of excessive daytime sleepiness (using a multiple sleep latency test or maintenance of wakefulness test)

Answer 331

* **Non-pharmacologic** -- Scheduled naps can help, but seldom suffice as primary therapy -- Advise the patient to follow good sleep practices. -- Advise patients with severe sleepiness to avoid dangerous activities at home and at work. They should not operate a motor vehicle until sleepiness is adequately managed and they satisfy the Australian standards of fitness to drive * **Pharmacologic** -- Modafinil (first-line drug therapy for reducing daytime sleepness and sleep attacks) OR -- dexamphetamine and methylphenidate. If Cataplexy, sleep paralysis and hallucinations -- TCAs or SSRI can be added -- GHB is also effective (not mentioned by the ATG)

Answer 332

"**SAD BBANG TF**"  S - **Snoring**  A - **Apnoea** (observed by someone else)  D - **Daytime** sleepness/irritability/ poor attention  B - **BP** (HIGH)  B - **BMI** (HIGH)  A - **Age** (OLDER)  N - **Neck** Circumference (LARGE)  G - **Gender** (MALE)  T - **Thyroid** disease  F - **Family History**

Answer 333

- overnight in-laboratory polysomnogram (**standard**) - Simplified home-based assessments may be appropriate in some settings as a screening tool for patients with **high pre-test probability of obstructive sleep apnoea (eg sleepy obese patients who snore and take antihypertensive drugs)** -- Home-based tests can be useful to rule in OSA in these patients, but not to rule out OSA (the tests have high specificity and low sensitivity) - patients who require urgent assessment are those with: -- unstable cardiovascular status (eg nocturnal angina or recurring cardiogenic pulmonary oedema) -- hypercapnic respiratory failure -- high pre-test probability of OSA who are about to undergo major surgery -- history of significant drowsiness while driving. A polysomnogram calculates the number and severity of obstructive apnoeas and hypopnoeas with desaturation and arousal.

Answer 334

* **Minimal OSA** -- is indicated by an apnoea–hypopnoea index of LESS than 5 events per hour * **Significant OSA** -- is indicated by an apnoea–hypopnoea index of MORE than 5 events per hour * **Severe OSA** -- more than 30 events per hour.

Answer 335

* Mild disease WITHOUT intercurrent HAS or CVD and NO DAYTIME DYSFUNCTION -- General Measures — Weight reduction — Avoidance of alcohol and drugs that affect sleep — Positional therapy (supine --> lateral position) — Reduced nasal resistance (with smoking cessation and using intranasal corticosteroid spray) * CPAP + General Measures * Mandibular advancement splints + General Measures (effective only in mild to moderate OSA)

Answer 336

* severe OSA (apnoea–hypopnoea index > 30) * mild to moderate OSA with symptoms of daytime dysfunction * mild to moderate OSA with HAS or other CVD.

Answer 337

"**URGE**"  U - **Urge** to move  R - **Rest** worsens  G - **Gets better** with activity  E - **Evening** is worse

Answer 338

- limb discomfort at rest, followed by an **urge to move the affected part** -- Symptoms affect both arms and legs in about 50% -- symptoms confined to the arms are uncommon -- can be bilateral (more common) and unilateral - may describe the sensation as creeping, crawling, itching, burning, searing, tugging, pulling, drawing, aching, hot and cold, electric current–like, restless or painful. - Usually, symptoms occur when the patient has been **lying quietly**, and last for a few minutes or an hour - can also occur when the patient is sitting quietly, but this is rare - When the patient is more **mentally rested and physically quiet, the symptoms are more intense** - The syndrome is **worse from the evening** to the early hours of the morning, whether or not the patient is asleep.

Answer 339

- **clinical criteria (a sleep study is not usually needed)** - can be idiopathic or secondary (more common)

Answer 340

— iron deficiency (most common cause seen in 20%) — DM — pregnancy — end-stage kidney disease (ESKD) — Some drugs (eg antidepressants, antihistamines) can exacerbate the condition.

Answer 341

- Most cases are mild and don't need treatment - Mild, infrequent symptoms --->>> lifestyle changes: -- physical exercise -- good sleep practices - Exclude iron deficiency -- Replace iron so the serum ferritin > 50 micrograms/L.

Answer 342

- Mild, infrequent (if LSC not sufficient) -- Levodopa PO - More severe symptoms -- Pramipexole PO (dopamine agonist) OR -- Gabapentine PO OR -- Pregabalin PO

Answer 343

**DENIAL** From event to hours to several days -- disbelief -- emotional numbness ## Footnote Anxiolytics or hypnotics may be helpful for a brief period in acute grief to control excessive anxiety or assist with sleep for a few nights (usually for fewer than 7 nights), but there is a risk that ‘brief’ use can become long-term

Answer 344

**Grief and despair** few weeks to 6 months -- separation distress—preoccupation with thoughts or images of the deceased, especially yearning for the deceased -- intense sadness, tearfulness, guilt, blame -- loss of usual levels of activity and capacity to undertake normal tasks -- withdrawal from others --physical symptoms, including fatigue and loss of appetite -- sleep disturbance, restlessness -- fleeting images (illusions, even hallucinations) about the deceased -- anxiety (about the future) -- anniversary reaction (resurgence of acute grief triggered by the anniversary of the death)

Answer 345

**ACCEPTANCE** After 6 months following the death (usually resolves within 12 months) - Only memories of good times left.

Answer 346

- Supportive psychotherapy and counselling. - Short acting sleeping agents, if severe problem with sleep

Answer 347

Symptoms of stage 2 that: -- persist more than 6 months after the death -- impact on day-to-day functioning Clinical features of complicated grief include: - Persistent, intense yearning, longing, and sadness. - maladaptive thoughts and behaviours related to the death or the deceased - Rumination is common and is often focused on angry or guilty recrimination related to circumstances of the death. - continuous emotional dysregulation about the death - social isolation - Hallucinations - suicidal ideation.

Answer 348

-History of mood or anxiety disorders. -History of alcohol or drug abuse. -Multiple losses -History of depression -Development of depression early in bereavement -there are concurrent losses and other significant stresses -the relationship with the deceased was ambivalent, conflicted or overly interdependent -family/friends are unsupportive or in conflict.

Answer 349

 Psychiatrist referral  CBT and counselling (First-Line)  SSRI/ Antipsychotics.  ECT

Answer 350

* severe depression -- if features of severe depression are present; -- if ECT is the preferred method of treatment in a voluntary patient with severe depression -- If previous good response to ECT in patients with severe depression * treatment-resistant mania * treatment-resistant bipolar depression * treatment-resistant acute schizophrenia * schizoaffective psychoses in the acute phase

Answer 351

* psychotic depression (**ECT is more effective than antidepressants combined with antipsychotics**) * melancholic depression unresponsive to antidepressants * depressive stupor, severe psychomotor retardation (catatonia) leading to severe self-neglect, or life-threatening anorexia * severe postnatal depression and psychosis * strong suicidal ideation ## Footnote **ECT** is **superior** to any other therapy (ie CBT an/or Antidepressants) in the treatment of **Severe Depression**

Answer 352

Raised Intracranial pressure (ICP) - ONLY ABSOLUTE CONTRAINDICATION  SITUATIONS OF HIGH RISK: (warrants specialist review) - Hypertension - Myocardial Infarction <3 m - Bradyarrythmias - Cardiac Pacemakers - Intracranial Pathology (Aneurysms, Epilepsy) - Skull Defect - Retinal Detachment - Osteoporosis

Answer 353

Mental Health Act in Australia * Patient is able to give **CONSENT** -- at least two authorized medical practitioners, **one of them must be a psychiatrist**, should agree that ECT is indicated and right treatment option. -- The same rule aplies even if a voluntary patient presents for ECT -- If medical practitioner is concerned about the capacity of the patient to decide, an application to **Mental Health Review Tribuna**l should be made * Patient is **INCOMPETENT** which precludes their ability to consent or refuse treatment -- must be **detained involuntarily** in hospital and kept safe with 24 hour constant nursing supervision and given supportive care while application to a Mental Health Review Tribunal (or equivalent independent statutory authority) is made -- **Relatives must be informed** of the treatment plan -- **Relatives are not legally able to consent or refuse on patients behalf** even under enduring power of attorney

Answer 354

Most common adverse effects - muscle aches and pains (from the muscle relaxant) - headaches and transient confusion for ~ 1 hour after treatment. other adverse effects include - reversible short-term retrograde memory loss (particularly of autobiographical memories (memories of personal experiences), for the period of treatment and to a lesser degree for antecedent events. - in generall, new learning appears unaffected after ECT and is often improved after recovery from depression. - Cognitive adverse effects are greater with bilateral than right unilateral treatment. - Some patients with post-ECT confusion have ongoing ictal activity (non-convulsive status epilepticus) than can be shown on EEG monitoring, and it can be stopped with agents like **midazolam** - **There is NO CONTINUED memory impairment once treatment is completed** - **DEMENTIA IS NOT LISTED AS AN ADVERSE EFFECT**

Answer 355

**Where possible, it is usually desirable to cease psychotropic drugs ** * **Benzodiazepines** should be tapered and **ceased** --- they raise the seizure threshold and may impair the efficacy of ECT * taper and **discontinue** all **antidepressants** -- There is little to be gained from continuing failed antidepressants during acute ECT and there is some evidence it may increase adverse effects. * **Lithium** should be **ceased** -- Although Lithium does not impair the effectiveness of ECT, it may occasionally result in severe postictal confusion even at a low serum concentration * **Antiepileptics** -- In patients with **epilepsy**, **not usually withdrawn** (high risk of spontaneous seizures) -- In patients taking antiepileptics for the management of **bipolar disorder**, are **preferably withdrawn** (before or early in the course of ECT). They can be quickly reinstated at the conclusion of the course of therapy if necessary, with the exception of lamotrigine, which requires the usual slow dose titration to reduce the risk of skin rash. * **Antipsychotics** -- may be continued unless clearly ineffective or interacting adversely with ECT (eg prolonged seizures with clozapine) * **Non-benzodiazepine hypnotics** (eg. Zolpidem, Zopiclone) can be used if needed (eg. procedure-related anxiety)

Answer 356

- cognitions may control feelings and behaviour ↓ - behaviours affect thought patterns and emotions

Answer 357

– Psychosis. – Depression. – Anxiety – Phobias (Exposiure Therapy) – Personality diosrder.(DBT in BPD) – Eating disorders – Insomnias (but not Parasomnias) – Grief

Answer 358

 **S** - **SEX MALE** **(1)**  **A** - **AGE** < 20 & > 45 **(1)**  **D** - **DEPRESSION** **(2)**  **P** - **PYSCHIATRIC HX** **(1)** (PREVIOUS ATTEMPTS)  **E** - **EXCESSIVE DRUG USE** **(1)**  **R** - **RATIONALITY LOSS** **(2)** (PYCHOSIS or SEVERE DEPRESSION)  **S** - **SEPARATED** **(1)**  **O** - **ORGANIZED PLAN** **(2)**  **N** - **NO SUPPORT** **(1)**  **S** - **SICKNESS** **(1)**

Answer 359

On discharge from the hospital ## Footnote - The risk of suicide in the 4 weeks after psychiatric inpatient care is around 100 times greater than that for the general population. - This risk declines rapidly over subsequent weeks. - The strongest risk factor for self-harm after discharge is an admission for self-harm in the previous 12 months.

Answer 360

1. Do you feel hopeless? 2. Have you felt that you've lost interest in your usual activities?

Answer 361

- **Acting out** (externalisation of regression, thus imature) -- **Acting in** (internalisation of anxiety) - **Passive aggression** (demonstrating hostile feelings in a nonconfrontational manner) - **Regression** (reversion to an earlier stage of development) **------------------------------------------------------------------------------** - **Sppliting** (an individual is unable to integrate mixed feelings (eg, seeing others as alternately "all bad" and "all good") **------------------------------------------------------------------------------** - **denial** (refuse to recognise or acknowledge a threatening situation) -- **compensation** or **counter dependency** (respond to limits being recommended on one's behaviour by taking on even more work/responsibilities. - a renunciation is adopted to evade anxiety out of one's impulses) - **Projection**(disguising one's own unacceptable impulses/thuoghts/feelings/motives by **attributing** to another person. Eg, one is angry but say the other person is angry) - **Rationalisation** (attempting to justify or excuse a behavior or decision rather than acknowledging the true motives, significance, or consequences of it- The subject avoids feelings of guilt or shame) **------------------------------------------------------------------------------** - **Neurotic** (displacement, Dissociation, reaction formation, regression, intellectualisation)

Answer 362

- **displacement** (**redirection** of emotions or impulses onto a neutral person or object unrelated with the episode) - **reaction formation** (transforming an unacceptable feeling or impulse into its extreme **opposite** - **it does not provide satisfaction**) - **Intellectualisation** (transformation of a distressing event into a situation devoid of emotion to avoid confrontation of uncomfortable emotional components)

Answer 363

"**SASH**" - S - **SUBLIMATION** (person channels unacceptable thoughts or impulses into **socially acceptable behavior**, which is similar to the original thoughtlimpulse and **provides satisfaction**) - A - **ALTRUISM** (alleviating nrgative feelings via unsolicited generodity, through unselfish devotion, or service to others - which provides **gratification**) - S - **SUPRESSION** (intentionally withholding an idea/feeling from conscious awareness but only **temporarily** (vs repression which is permanently) and **no changes in personality** (vs dissociation which is accompanied by drastic changes) - H - **HUMOR** (Lightheartedly expresing uncomfortable feelings to shift the internal focus away from the distress)

Answer 364

 **O** - **Oral** **first stage**, which takes place from **birth-one year old**  **A** - **Anal** **second stage**, which takes place from **1-3 years old**  **P** - **Phallic** **third stage**, which takes place from **3-6 years old**  **L** - **Latency** **fourth stage**, which takes place from **6-12 years old**  **G** - **Genital** **fifth stage**, which takes place from **13-18 years old**

Answer 365

1 Trust vs. Mistrust (0-18 months): Developing trust through consistent caregiving 2 Autonomy vs. Shame (18 months-3 years): Learning independence and self-control 3 Initiative vs. Guilt (3-5 years): Exploring and taking action in the world 4 Industry vs. Inferiority (5-12 years): Developing competence through achievements 5 Identity vs. Role Confusion (12-18 years): Forming personal identity and life direction 6 Intimacy vs. Isolation (18-40 years): Building meaningful relationships 7 Generativity vs. Stagnation (40-65 years): Contributing to society and future generations 8 Integrity vs. Despair (65+ years): Reflecting on life and finding meaning

Answer 366

Choice of treatment depends on the couple's preference. - **Topical preparations** -- (lidocaine+prilocaine) 10 to 20 minutes before intercourse. - **SSRIs** -- *single dose before sexual activity* (less likely to be associated with adverse effects (eg anorexia, reduced libido and/or anejaculation) >>> DAPOXETINE VO OR >>> PAROXETINE VO OR >>> SERTRALINE VO -- *continuous/daily dosing* >>> PAROXETINE VO OR >>> SERTRALINE VO ## Footnote NOTE: - Relaxation - squeeze method - sex therapy with partner **HAVE DUBIOUS LONGTERM BENEFIT**

Answer 367

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

Answer 368

Several impulse control disorders

Answer 369

1. A self-reported complaint of poor sleep quality 2. Sleep difficulties occur despite adequate sleep opportunity. Impaired sleep produces deficits in daytime function. 4. Sleep difficulty occurs **three nights per week** and is present **for three months**

Answer 370

3 days (monitoring for serotonin syndrome)

Answer 371

Grief usually occurs after loss of something like any close relative or property, however, there are l**ess behavioural symptoms **and it is a self-limiting condition

Answer 372

one's ability to accurately take in information about the world. Most common: - illusions - Hallucinations

Answer 373

- Guns - Recent suicide attempts - Ongoing thoughts of suicide - Self-harm - Ethanol - Substances mnemonic "Guns & ROSES"

Answer 374

- Paroxetine - Fluoxetine ## Footnote Concern about harm–benefit analysis for their use in the perinatal period is commonly encounteredconcern about harm–benefit analysis for their use in the perinatal period is commonly encountered however, there is no evidence to recommend any particular SSRI over another during pregnancy. There are six areas of concern: terato-genicity, spontaneous abortion and premature labour, low birth weight/small-for-gestational age, poor neonatal adaptation, persistent pulmonary hypertension of the newborn, and neurodevelopmental difficulties in older children. There were limitations and inconsistencies in published findings, and the overall consensus is that concern about teratogenicity should not deter prescription of SSRIs during pregnancy for treatment of moderate-to-severe major depression and anxiety disorders - **Paroxetine** is linked to reports of increased risk of **cardiovascular malformations**. As the **absolute risk is low**, women who find themselves unexpectedly pregnant should not be advised to abruptly stop the drug. - **Fluoxetine** (due to its longer half-life)

Answer 375

**OLANZAPINE** increased risk of maternal gestational diabetes ## Footnote There is not sufficient evidence to recommend any one antipsychotic over another during pregnancy. Drug choice should be made with consideration of previous effective treatment and patient preference. During pregnancy, switching from one antipsychotic to another puts the patient at risk of relapse and of potential adverse effects to the fetus from exposure to multiple drugs. There are extensive data available about the safety of haloperidol used as an antipsychotic. However, first-generation antipsychotics may lead to extrapyramidal symptoms in the neonate Anticholinergic drugs should be avoided if possible during pregnancy.

Answer 376

- Slow withdrawal of Lithium (3-4 weks) before conception (if stable, and not severe symptoms) - If relapse of symptoms: -- Antipsychotics OR -- Lithium can be reinstated ~ 50 days of conception (**after cardiogenesis**) OR -- ECT

Answer 377

- continue with Lithium - consider ECT ## Footnote The benefits of lithium prophylaxis during pregnancy, in cases of severe bipolar disorder, may outweigh the risks, and lithium has been considered as a first-line treatment during pregnancy for some such women. For patients who are currently treated with valproate or carbamazepine, it is suggest switching treatment avoid the teratogenic effects of these two antiepileptics. The absolute risk of teratogenesis is much less with lithium than that found with valproate, carbamazepine and lamotrigine. According to Royal Australian and New Zealand College of Psychiatrists guidelines, if the use of a mood stabiliser is essential, lithium is the safest option as compared to other treatment options.

Answer 378

- Continue treatment - investigate for any anomaly

Answer 379

Ebstein's anomaly - Lithium use during the first trimester of pregnancy ## Footnote Tricuspid valve are displaced downwards towards the apex of the right ventricle of the heart.

Answer 380

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

Answer 381

- High-resolution US at around 18-20 weeks Refer to Ebstein Centre if any anomaly is detected

Answer 382

- 24 to 48 hours before delivery (if the delivery is planned) - withheld at the onset of labour (if delivery is not planned) - Restart lithium at the prepregnancy dose after delivery ## Footnote To avoid floppy baby syndrome due to neonatal toxicity

Answer 383

For anxiety and insomnia, the first-line treatment should be nonpharmacological.

Answer 384

* First trimester exposure to benzodiazepines is associated with increased **risk of cleft lip and/or palate**. ## Footnote * The first 8 weeks of pregnancy is the period of highest risk. A high-resolution US examination at 18 to 20 weeks.

Answer 385

If benzodiazepines taken in late pregnancy, they can cause - neonatal drowsiness - respiratory depression - poor temperature regulation - poor feeding - hypotonicity (the ‘floppy infant syndrome’). - Neonatal withdrawal symptoms can present

Answer 386

- postpartum blues: ~ 5 days after delivery - postpartum depression: within weeks/months after delivery - postpartum psychosis: within 2-4 weeks after delivery

Answer 387

* **First-line:** CBT + counselling * NRT can be added if CBT not effective ## Footnote The available evidence suggests that, for pregnant women, counselling may exert more influence on smoking than pharmacological interventions. Nicotine replacement therapy (NRT) during pregnancy is controversial, as nicotine itself has been linked to some in-utero problems (excluding growth restriction but including neurotoxicity) in animal studies. However, there is an emerging consensus that with NRT the level of nicotine exposure to the fetus is less than that in women who continue to smoke heavily. Moreover, cigarette smoke is known to contain a large number of other potentially harmful ingredients, which are avoided in successful NRT. Unfortunately the randomised controlled trials to date have not clearly established the efficacy or safety of NRT during pregnancy, largely due to the low adherence to therapy. NRT can be used as an adjunct to counselling, especially in women smoking more than 10 cigarettes per day. However, it is usually not started unless a trial of psychological interventions has failed.

Answer 388

- **peak** within **4-5 days** - generally **time-limited** - spontaneously **remit with 10-14 days** - if symptoms last for more than 2 weeks, postpartum depression should be considered ## Footnote - Occurs in 80% of mothers following delivery (considered normal)

Answer 389

- **peak** at **12 weeks** - occurs between 6-12 months after the delivery, Sx: - marked mood swings - irritability towards the family - guilty thoughts about being a bad mother, - excessive anxiety about the wellbeing of the baby - irritability towards the family - agitation - poor memory and concentration - depressed mood and weight loss ## Footnote - prevalence 10-15%

Answer 390

SSRI (Sertraline || Paroxetine) ## Footnote From published data, **sertraline and paroxetine** appear to have the **lowest transmission** into breastmilk and **fluoxetine, escitalopram and citalopram the highest**. Venlafaxine gives a higher mean relative infant dose than the SSRIs; however, for some women venlafaxine may have been prescribed during pregnancy or earlier due to lack of efficacy of other antidepressants. For these women, if they have a full-term infant who is otherwise well, breast-feeding should be encouraged.

Answer 391

- Fluoxetine (due to its longer half-life) - Citalopram - Escitalopram ## Footnote - Fluoxetine, escitalopram and citalopram have the highest transmission into breastmilk - Fluoxetine has the potential to accumulate in the breastfed infant, and been associated with low weight gain, irritability, difficulty settling and infant gastrointestinal dysfunction.

Answer 392

- previous episode of postpartum psychosis - **history of bipolar disorder** (highest risk). - **maternal suicide** (20%) = rule out by psych eval first (notify child services & consult psychiatrist) - child harm & Infanticide (4%) ## Footnote Postpartum psychosis is rare (1 to 2 cases per 1000 live births);

Answer 393

- postpartum psychosis: within** 2-4 weeks** after delivery  Symptoms include: - agitation - elation (if an episode of bipolar disorder) - confusion - thought disorganisation - sleep disturbance - psychosis (hallucinations and delusions) - affective symptoms.

Answer 394

 The presentation is acute and usually requires inpatient management. Treatment in ACUTE MANIA – PSYCHOTIC EPISODE is: - antipsychotics and/or ECT, (for quick resolution)  depending on the underlying Dx – antipsychotics + Lithium/antiepileptics may be added or antidepressants.  If (+) hx of previous episode of postpartum psychosis = PROPHYLACTIC USE LITHIUM after delivery reduces the likelihood of a recurrence.

Answer 395

Haloperidol ## Footnote - In lower dose, ie less than 10 mg haloperidol daily or equivalent, they are usually regarded as safe

Answer 396

- Olanzapine - Clozapine ## Footnote - Additional studies are required to definitively establish safety, and the association of **OLANZPINE** with some reversible adverse effects (jaundice, impaired weight gain, sedation, irritability and tremor) in a small series of breastfed babies has led the manufacturer to recommend **against breastfeeding while taking olanzapine**. - **CLOZAPINE** should not be used while breastfeeding (due to high concentration in breastmilk and the theoretical risk of agranulo-cytosis occurring in the infant). - The first-generation antipsychotics, especially at high dose, have occasionally been associated with adverse reactions in breastfed infants (eg urinary retention, dystonic reactions).

Answer 397

- **continuation** of clozapine for maternal wellbeing PLUS - the **use of formula feeding** rather than breastfeeding.