Psychiatry Flashcards

Question 1

Q

Mental Status Examination
categories

https://www.ncbi.nlm.nih.gov/books/NBK546682/

Answer

A

appearance
behavior
motor activity
speech
mood
affect
thought
process
thought content
perceptual disturbances (delusions, illusions, Hallucionations)
cognition (MMSE, MoCA)
insight
judgment.

Question 2

Q

Mental Status Examination
Irregular thought processes types

Answer

A

circumstantial
tangential
the flight of ideas
loose/disorganised
perseveration
thought blocking

Question 3

Q

Mental Status Examination
Circumstantial thought process

Answer

A

describes someone whose thoughts are connected but go off-topic before returning to the original subject

Question 4

Q

Mental Status Examination
Tangential thought process

Answer

A

Is a series of connected thoughts that go off-topic but do not return to the original topic.

Question 5

Q

Mental Status Examination
Flight of ideas thought process

Answer

A

Flight of ideas is a type of thought process similar to a tangential one in which the thoughts go off-topic, but without completing the thought or train of thoughts; and the connection between the thoughts is less obvious and challenging for a listener to follow.

Common in MANIA

Question 6

Q

Mental Status Examination
loose, disorganised thought process

Answer

A

No connection occurs between the thoughts AND no train of thought to follow.

it most often occurs in schizophrenia

Question 7

Q

Mental Status Examination
Perseveration

Answer

A

Perseverations are a thought process where the patient returns to the same subject, regardless of topic or question

May occur in DEMENTIA

Question 8

Q

Mental Status Examination
Thought Blocking

Answer

A

observed in psychosis when a patient has interruptions in their thoughts, making it challenging to either start or finish a thought.

Question 9

Q

Mental Status Examination
Affect - definition

Answer

A

affect reflects the person’s EXTERNAL emotional expression - which can be evaluated by the interviewer. It can be described as:
- EUTHYMIC (normal, well-balanced mood)
- DYSTHYMIC (sullen, flat)
- EUPHORIC (intensely elated mood)

Question 10

Q

Mental Status Examination
Mood - Definition

Answer

A

mood reflects person’s INTERNAL emotional experience (e.g. good, ok, frustrated, angry)

Question 11

Q

Mental Status Examination
Insight - Definition

Answer

A

It refers to a patient’s understanding of their illness and functionality. Insight is typically described as poor, limited, fair, or if a previous comparison depicts worsening versus improving

Question 12

Q

DEPRESSION Dx

Answer

A

2 core symptoms (depressed mood, low energy, anhedonia)
+
2 or more of the other symptoms
(<2 = mild; >2 + <5 moderate; >5 severe)
+
for at least 2 weeks

Question 13

Q

DEPRESSION Sx

Answer

A

Depressed mood (CORE) + SIGECAPS

– S = Sleep (decreased overall pattern and architecture)
– I = Interest/Enjoyment/
Anhedonia (low) (CORE)
– G = Guilt/Hopelessness/Pessimist/Self-blaming/Nihilistic
– E = Energy (low) (CORE)
– C = Concentration (decreased)
– A = Appetite (usually low, but can be increased)
– P = Psychomotor retardation
– S = Suicidal thoughts

typically, in depression, mood is worse in the morning and betters as the day progressed (this is called “diurnal variation”)

Question 14

Q

DEPRESSION
major depression with ATYPICAL features

Answer

A

mood remains reactive (lifting of depressive symptoms during happy life events)
reversed diurnal variation (i.e. evening are the most difficult time of the day for the mood)
feeling rejected and unloved (interpersonal rejection sensitivity)
leaden paralysis (dull/heavy limbs to lift)
hyperphagia/weight gain
hypersomnia

Rx: MAOi

Question 15

Q

Dysthymic Disorder (Persistent Depressive Disorder)

Answer

A

Chronic condition characterised by depressive symptoms that:
- occur for most of the day
- more days than not
- for > 2 years

common features:
- H: Hopelessness (despondency)
- E: Energy (decreased)
- S: Self-esteem (decreased)
- S: Sleep (decreased)
- A: Appetite (decreased)
- D: decision making (impaired)

Question 16

Q

DEPRESSION
Sleep disturbances features

Answer

A

MOST COMMON - waking up during the night and having trouble going back to sleep (also referred as middle insomnia). if successful [in going back to sleep], broken sleep thereafter

early morning wakening and being unable to get back to sleep at all (also referred as terminal insomnia)
increased REM stage
Decreased stage 3 non-REM stage (less stage 3 means less restorative periods => daylight tiredness)

LESS COMMON/UNCOMMON
- increased sleep latency (i.e. difficulty falling asleep) = MORE COMMON IN ANXIETY or associated with the use of nocturnal stimulants (e.g. caffeine)
- Hypersomnia and oversleeping
- Dramatic dreams (including dreams about death) ARE NOT TYPICAL OF DEPRESSION

Question 17

Q

DEPRESSION
Risk Factors

Answer

A

perfectionism
obsessionality
intellectual developmental delay
Family history of depression.
Family history of Autism
Substance Misuse.
Unemployment
Low socioeconomic status.
Elderly person with cognitive decline or bereavement.
All family members who have experienced family violence.
– Experience of child abuse

Question 18

Q

DEPRESSION
groups are at higher risk of depression

Answer

A

Women
Postpartum women
Young rural males
Adolescents

Question 19

Q

DEPRESSION
Features in children/adolescents

Answer

A

Anhedonia/Apathy may be as severe or more apparent than mood abnormalities (often expressed as severe boredom)
impaired concentration
sadness(sad appearance)
psychomotor agitation (“jumpy”, not relaxed)
despondency (hopelessness)
excessive irritability
feeling rejected, unloved, inadequacy, worhtlessness (interpersonal rejection sensitivity)
somatic complaints (eg, headaches, abdominal pain, insomnia), and persistent self-blame.
anorexia, weight loss (or failure to achieve expected weight gain)
sleep disruption (including nightmares)
suicidal ideation

Question 20

Q

DEPRESSION
Firstline choice of treatment in children/adolescents

Answer

A

Fluoxetine

TCA’s, Mirtazapine, Venlafaxine are not recommended/approved for use in adolescents

Question 21

Q

DEPRESSION vs SCHIZOPHRENIA

Answer

A

PATTERN

episodic

vs

progressive

Question 22

Q

DEPRESSION
Treatment according to the classification

Answer

A

Mild depression: CBT > antidepressants
Moderate depression: CBT = antidepressants
(initial choice of therapy based on patient preference)
Moderate to Severe depression: Antidepressants > CBT
(although concurrent psychological therapies may often be helpful if the patient can concentrate enough to participate in these.)

Question 23

Q

DEPRESSION
Antidepressants alone are ————— effective in patients with severe depression

Answer

A

50% to 60%

Question 24

Q

DEPRESSION
ECT indications

Answer

A

ECT indicated in some forms of severe depression:

psychotic depression
melancholic depression
voluntary patient with severe depression
If previous good response to ECT in patients
with severe depression

Question 25

Q

DEPRESSION
Inpatient treatment indications:

Answer

A

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

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

Question 26

Q

DEPRESSION
First-line drug options

Answer

A

SSRIs
SNRIs
Mirtazapine

Question 27

Q

DEPRESSION
When to assess response to antidepressant

Answer

A

after 2 to 4 weeks of treatment

Question 28

Q

DEPRESSION
% of patients with major depression that will respond to AT LEAST one antidepressant medication

Question 29

Q

DEPRESSION
Management if there is PARTIAL initial response

Answer

A

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)

Question 30

Q

DEPRESSION
Management if there is No initial response

Answer

A

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)

Question 31

Q

DEPRESSION
Antidepressant-free interval recommended when changing from one SHORT-ACTING SSRI to ANOTHER SHORT-ACTING DRUG or FLUOXETINE

Question 32

Q

DEPRESSION
Antidepressant-free interval recommended when changing from FLUOXETINE to a SHORT-ACTING SSRI

Question 33

Q

DEPRESSION
Full recovery after favourable response to first-line therapy

Answer

A

6 weeks or longer

Question 34

Q

DEPRESSION
How long should treatment be for

Answer

A

If single episode of major depression = 6-12 months

Question 35

Q

DEPRESSION
Indications for long-term prophylatic therapy

Answer

A

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

Question 36

Q

DEPRESSION
duration of long-term treatment

Answer

A

at least 3 to 5 years
(including continuing work on vulnerability factors)

Some patients may require lifelong antidepressant therapy.

Question 37

Q

DEPRESSION
When to consider failure to respond to initial antidepressant therapy?

Answer

A

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

Question 38

Q

DEPRESSION
Drug options for unsuccesful trial with First-line therapy

Answer

A

TCAs
MAOIs

both require specialist support

Question 39

Q

DEPRESSION
Discontinuation syndrome Sx

Answer

A

insomnia, nausea
postural imbalance
sensory disturbances
hyperarousal
flu-like symptoms.

SOME PATIENTS CAN EXPERIENCE THESE SYMPTOMS even after missing just 1 or 2 doses

Question 40

Q

DEPRESSION
Discontinuation Syndrome duration

Answer

A

these symptoms are mild, last 1 to 2 weeks
(usually does not require specific treatment)

If withdrawal symptoms occur due to abrupt discontinuation, symptoms are rapidly extinguished with the reinstitution of the antidepressant

Question 41

Q

DEPRESSION
Tapering regime to prevent Discontinuation syndrome

Answer

A

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.

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

Question 42

Q

DEPRESSION
If a patient, who has successfully been stable on prophylactic dose of a particular mood stabiliser, develops acute depression, what is the next best step in management?

Answer

A

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)

Question 43

Q

DEPRESSION
Whcih antidepressive is considered appropiate in childhood/adolescence depression

Answer

A

FLUOXETINE

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.

Question 44

Q

DEPRESSION
Considerations regarding pharmacological tretment in childhood/adolescence depression

Trail, change of therapy, discontinuation

Answer

A

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.

Question 45

Q

DEPRESSION
Patient with severe depression or suicidal ideation taking HCV treatment (interferon).
Management?

Answer

A

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

Question 46

Q

DEPRESSION
Drug of choice in post-cardiac depression

https://www1.racgp.org.au/ajgp/2023/november/incidence-and-impacts-of-post-cardiac-event-mental

Answer

A

Sertraline

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

Question 47

Q

Examples of Overvalued Ideas

Answer

A

Body dysmorphic disorder
Anorexia Nervosa
Hypochondriasis

Question 48

Q

BIPOLAR DISORDER
Dx

Answer

A

Elevated Mood + 3 of DIG FAST
or
Irritability + 4 of DIG FAST

FOR 1 week or more

Question 49

Q

BIPOLAR DISORDER
Sx

Answer

A

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

Question 50

Q

BIPOLAR DISORDER
MANIA ≠ HYPOMANIA by following features

Answer

A

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”

Question 51

Q

BIPOLAR DIORDER
Cyclothymia

Answer

A

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

Question 52

Q

BIPOLAR DISORDER
Features more commonly seen in Bipolar Depression than in Unipolar Depression

Answer

A

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)

Question 53

Q

BIPOLAR DISORDER
Suicidal Risk

Answer

A

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

Question 54

Q

BIPOLAR DISORDER
MANIA vs PSYCHOTIC DISORDERS

Answer

A

***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

Question 55

Q

BIPOLAR DISORDER
Hypomania vs HISTRIONIC PERSONALITY DISORDER

Answer

A

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

Question 56

Q

BIPOLAR DISORDER
treatment of acute mania

Answer

A

1st OLANZAPINE VO

OR

1st RISPERIDONE VO

OR

2 HALOPERIDOL VO

OR

2 LITHIUM VO

Question 57

Q

BIPOLAR DISORDER

Treatment maitenance and recurrence prophylaxis

Answer

A

Lithium + CBT

Question 58

Q

BIPOLAR DISORDER
Duration of treatment following an acute mania episode

Answer

A

12 months

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

Question 59

Q

BIPOLAR DISORDER
Acute mania Failure to respond to treatment

Answer

A

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

Question 60

Q

BIPOLAR DEPRESSION
Mx

Answer

A

1st Antidepressant (SSRI preferably)
+
Mood stabiliser

OR

1st Quetiapine Monotherapy

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.

Question 61

Q

BIPOLAR DEPRESSION
When to cease antidepressant

Answer

A

preferably within 1 or 2 months of
successful resolution

Question 62

Q

BIPOLAR DEPRESSION
Treatment of ACUTE bipolar depression

https://www.racgp.org.au/afp/2013/september/bipolar-disorder

Answer

A

QUETIAPINE

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

Question 63

Q

BIPOLAR DEPRESSION
Failure to respond to treatment

Answer

A

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

Question 64

Q

Schizophrenia
DX

Answer

A

2 Sx ((at least ONE POSITIVE sx))
for at least 6 months

symptoms rarely have an acute onset. Instead, there is often a prodromal state followed by a progressive worsening of the symptoms

Answer 62

A

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 63

A

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

Answer 64

A

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

Answer 65

A

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 66

A

‘HD BS’

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

Answer 67

A

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 68

A

Motor perseveration (repeating same motions over and over)
echopraxia (copying someone’s movements)
Catatonia

Answer 69

A

Stupor
Mannerism
Catalepsy
Stereotypy
Agitation
Mutism
Grimacing
Negativism
Echolalia
Echopraxia

http://www.empathic-resonance.org/catalepsy-vs-cataplexy.html

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 70

A

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 71

A

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)

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 72

A

Lack of insight

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 73

A

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 74

A

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 75

A

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 76

A

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 77

A

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

Answer 78

A

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 79

A

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 80

A

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 81

A

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

Answer 82

A

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 83

A

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 84

A

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

https://litfl.com/karl-axel-ekbom/

Answer 85

A

 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 86

A

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 87

A

Amisulpride

OR

Aripiprazole

OR

Olanzapine

OR

Paliperidone

OR

Quetiapine

OR

Risperidone

OR

Ziprasidone

Answer 88

A

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 89

A

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 90

A

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 91

A

crossover phase of at least 1 to 2 weeks

Answer 92

A

2 years (Following a first psychotic episode)
ONLY if there has been full remission

Indefinite continuation of maintenance therapy is required for the majority of people with schizophrenia.

Answer 93

A

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 94

A

drug discontinuation due to poor concordance

Answer 95

A

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 96

A

commencing a depot antipsychotic
initiation of proceedings for involuntary community treatment

Answer 97

A

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 98

A

reasons in step one excluded

PLUS

drug trial of 6 to 12 weeks’ duration on optimal doses of at least TWO different antipsychotics

Answer 99

A

Clozapine

Answer 100

A

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 101

A

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 102

A

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 103

A

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

Answer 104

A

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 105

A

-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 106

A

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

Answer 107

A

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

If combination therapy is considered appropriate, each drug should be administered separately (ie do not combine drugs in the same syringe)

Answer 108

A

MIDAZOLAM IM

If patient tolerant to benzodiazepine or if failure of first-line benzdiazepine USE: (in combiantion or single)

HALOPERIDOL IM
OR
OLANZAPINE IM

Diazepam is not recommended for intramuscular injection as absorption is poor and erratic.

Answer 109

A

 Excessive anxiety/worry occurring on most days for at least 6 months (“chronic”)

 Associated with 3 or more of the 6 symptoms.

Answer 110

A

“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 111

A

 **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

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 112

A

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

Answer 113

A

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 114

A

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 115

A

 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 116

A

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.

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 117

A

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

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 118

A

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 119

A

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.

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 120

A

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

Answer 121

A

 Pheochromocytoma (rare)

 Diabetes Mellitus
(Hypoglycaemia is the commonest underlying organic cause of anxiety symptoms)

 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 122

A

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 123

A

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

Answer 124

A

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)

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 125

A

“I MURDER”

 I - Intrusive
 M - Mind-based (not thought insertion)
 U - Unwanted
 R - Resistant
 D - Distressing
 E - Ego-dystonic
 R - Recurrent

Time-consuming (>1 hr/day) or causing significant distress or impairment

Answer 126

A

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

Answer 127

A

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

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 128

A

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

Answer 129

A

“FIX ME DOC”

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

Answer 130

A

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

Answer 131

A

CBT ± SSRI

Answer 132

A

Anxiety
Social Phobia
OCD
Delusional disorder
Alcohol or substance misuse

Answer 133

A

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 134

A

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

Answer 135

A

fears and symptoms persist for ≥ 6 months

Answer 136

A

Hypocondriasis = Preoccupation 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 137

A

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

Answer 138

A

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 139

A

CBT and SSRI

nonetheless, patient usually don’t respond well

Answer 140

A

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

Answer 141

A

“TRAUMA”

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

Answer 142

A

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 143

A

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 144

A

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 145

A

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

Answer 146

A

– 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 147

A

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

Answer 148

A

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 149

A

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 150

A

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 151

A

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 152

A

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

NOTE: Intermittent use, on occasional days when there is a severe exacerbation of anxiety, may suffice and is preferable to continuous treatment.

Answer 153

A

Repeated use
Reinforcers (Positive)
Repercussions (Njuegative)

Answer 154

A

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 155

A

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

Answer 156

A

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

Answer 157

A

waking at night to smoke

or

smoking within the first 5 minutes after waking

= usually smokes > 30 cigarettes daily

Answer 158

A

smoking within 30 minutes after waking

= usually smokes 20- 30 cigarettes daily

Answer 159

A

not needing to smoke within the first 30 minutes after waking

usually smokes 10-20 cigarettes daily

Answer 160

A

not needing to smoke in the 1st hour after waking

usually smokes < 10 cigarettes daily.

Answer 161

A

Recommended for:
- moderately to highly nicotine-dependent smokers
&

who express an interest in quitting

Answer 162

A

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

Answer 163

A

Nicotine Replacement Therapy (NRT)
Varenicline
Bupropion

Answer 164

A

– 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 165

A

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 166

A

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 167

A

“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 168

A

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 169

A

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

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 170

A

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 171

A

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 172

A

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 173

A

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 174

A

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 175

A

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 176

A

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.

Modulates GABA/glutamate

Answer 177

A

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

blocks the effect of endogenous opioids released following alcohol intake

Answer 178

A

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

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 179

A

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 180

A

“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 181

A

“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 182

A

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)

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 183

A

Behavioral Rating Scale
Visual & Hearing Assessments
Classroom Observation
Psychometric Assessment

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 184

A

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

Answer 185

A

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

60% will continue to exhibit symptoms into
adulthood

Answer 186

A

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 187

A

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

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 188

A

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

Answer 189

A

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 190

A

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 191

A

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

Answer 192

A

“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 193

A

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 194

A

deficitis in social communication (Austistic Aloness)
restrictive and repetitive interests & activities (Insistence upon Sameness)

Two domains

Answer 195

A

both core symptoms
social communication
&
Restricted interests and behaviours

+
Developmental (1-3 years old) onset

“the criteria for diagnosing is in the name of the disorder: “ASD”

Answer 196

A

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)

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 197

A

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

Answer 198

A

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 199

A

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

Answer 200

A

beihavioural training
= teach specific adaptive skills
speech language therapy
= teaching skills to overcome communication deficits

medications play no role in improving outcomes in autism

Answer 201

A

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

Answer 202

A

“APHASIC”

 A - Autism
 P - Physical deficits
 H - Heating impairment
 A - Abuse/neglect
 S - Selective Mutism
 I - Intelctual Disability
 C - Cerebral Palsy

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 203

A

“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 204

A

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

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 205

A

“PaSS” the invitation as they:
tend to shy away from social interaction

 P - Paranoid
 S - Schizoid
 S - Schizotypal

common shared base

Cluster A resembles psychosis

Answer 206

A

“BAHNed” 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

Cluster B resembles mood

Answer 207

A

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

Cluster C resembles anxiety

Answer 208

A

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

Answer 209

A

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 210

A

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 211

A

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 212

A

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 213

A

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

Answer 214

A

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 215

A

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

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 216

A

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

Answer 217

A

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 218

A

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 219

A

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 220

A

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 221

A

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

Answer 222

A

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

Answer 223

A

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 224

A

Schyzoid
- happy loner
Avoidant
still desire human contact

Answer 225

A

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 226

A

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 227

A

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 228

A

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 229

A

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 230

A

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 231

A

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 232

A

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

This teaches specific skills targeted towards core sympyoms that BPD patients tend to struggle with

Answer 233

A

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 234

A

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 235

A

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 236

A

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

Answer 237

A

Adult age + 3 or more of the core symptms

Answer 238

A

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

must occur for at least 6 months

Answer 239

A

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 240

A

Flaglrant disregard to others’ rights
overt violence (physical cruelty)
aggression (fights)
robbery, fire setting, property damage
sexual coercion

conceptualised as a precursor to ASPD

Answer 241

A

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

Answer 242

A

family therapy
behavioural training for the child
medications are geneerally not helpful

CD reponds to a lesser extent than ODD to these therapies

Answer 243

A

– 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 244

A

“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 245

A

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 246

A

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/

can be associated with:
-Depression
-OCPD

Answer 247

A

 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 248

A

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

Answer 249

A

ego-syntonic
rigitiy of behaviour (little variation)
high conscientiousness (act in accordance with societal expectations

Anorexia has a high rate of comorbity with OCPD

Answer 250

A

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 251

A

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

Answer 252

A

Refeeding Syndrome

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 253

A

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 254

A

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 255

A

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 256

A

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

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 257

A

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)

The menstrual and ovulatory abnormalities are due to suppresed sex hormone secretion as a consequence of fasting and prolonged dietary restriction

Answer 258

A

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 259

A

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

Answer 260

A

Bupropion

Increases the risk of seizures

Answer 261

A

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)

-gastrointestinal tract is the most commmon location for somatic symptoms in ALL PATIENTS
-gynecologic complaints are the second most common symptom IN WOMEN

FOUR Pain symptoms:
Headaches, abdominal pains, back and joint pain, pain during menstruation or sexual
intercourse, chest pain.
TWO GI symptoms:
Nausea, bloating, vomiting other than during pregnancy, diarrhea or intolerance to several foods.
ONE sexual symptom:
Erectile dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout the pregnancy.
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 262

A

Regular visits (minimises the idea of only seeing the doctor when sick)
CBT
Midnfulness therapy
physiotherapy & rehabilitation
TCA’s and SNRIs (smaller effect)

Analgesia is usually not helpful

Answer 263

A

“CAN’T-version

 C - Clinically unexplained
 A - medical Abnormality
 N - involving Nervous System
 T - usually (~50%) brought on by a Trigger

Patient is not manufacturing or faking the symptoms (unconscious & Involuntary)

Answer 264

A

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)

NOTE: given the features above, the conversion disorder diagnosis would not be appropriate a patient presenting with abdominal pain or chest discomfort)

Answer 265

A

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 266

A

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 267

A

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 268

A

poor prognosis
neither medications nor psychotherapy are effective
Refer to specialist

Answer 269

A

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 270

A

No clear treatment

Answer 271

A

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 272

A

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 273

A

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

Answer 274

A

identical symptoms:
- rigidity
- bradykinesia
- postural instability

Differentiating symptoms:
- involuntary movements of face and tongue (tardive)
- Stiffness

Answer 275

A

“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 276

A

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 277

A

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 278

A

Activities of daily living:
(signs of late stage cognitive impairment)
“DEATH”

 D - Dressing
 E - Eating
 A - Ambulating
 T - Toileting
 H - Hygiene

Answer 279

A

Screening tool to assess cognitive skills

Answer 280

A

“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 281

A

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 282

A

pseudodementia/depression

Answer 283

A

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

Pseudodementia have INSIGHT

Answer 284

A

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

Answer 285

A

Cognitive decline

Answer 286

A

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 287

A

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 288

A

Frontal functioning
Temporo-parietal Functioning

Answer 289

A

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 290

A

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 291

A

 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)

Progression of cognitive impairment follows this order:
Amnesia > Aphasia, > Apraxia > Agnosia

Answer 292

A

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 293

A

State of confused restlessness/agitation/wandering that is more prominent in the evening

Endeavour to manage sundowning
through nonpharmacological interventions.

Answer 294

A

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

Answer 295

A

 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 296

A

 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 297

A

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 298

A

**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.

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 299

A

Cholinesterase inhibitors (AChEi)
(donepezil, galantamine, rivastigmine)
NMDA receptor antagonist
(memantine)

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 300

A

“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 301

A

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 302

A

“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 303

A

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 304

A

DLB
- insight is usually preserved (patient not bothered)
- Typically visual hallucinations

Schizophrenia
- no insight, severely disturbed
- Auditory hallucinations are prevalent

Answer 305

A

Similar to Alzheimer’s dementia (but less effective and impose greater side effect burden)

anti-Parkinson’s drugs to treat motor symptoms

Answer 306

A

 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 307

A

“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 308

A

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

Answer 309

A

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

Answer 310

A

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 311

A

HAS
DM
CVD
smoking
hyperlipedemia

Answer 312

A

“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 313

A

Triad “DIG”

 D - Dementia
 I - Incontinence
 G - Gait

Mx: shunt to drain excess fluid

Answer 314

A

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 315

A

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

Answer 316

A

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 317

A

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 318

A

urgent IV thiamine

Answer 319

A

but the majority will develop a chronic Korsakoff syndrome.

Answer 320

A

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

Answer 321

A

profound anterograde amnesia
Confabulation (due to memory gaps)

Answer 322

A

20 - 50 years old
Dementia
Chorea

Answer 323

A

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

Answer 324

A

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 325

A

age > 65 years
pre-existing dementia

Answer 326

A

 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

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 327

A

 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 328

A

DRABCDE

+

TONGF

The delirious patient must be observed at all times.

Answer 329

A

Haloperidol VO (single dose)

OR

olanzapine VO (single dose)

OR

Risperidone VO (single dose)

*onset of action can be delayed from 30-60 minutes after administration

*second doses should not be given for at least 30 minutes

Answer 330

A

Haloperidol IM (single dose)
OR
Olanzapine IM (single dose)

*onset of action can be delayed from 30-60 minutes after administration

*second doses should not be given for at least 30 minutes

Answer 331

A

benzodiazepines should be avoided in delirium (especially in patients with significant respiratory depression)

except for cases due to alcohol withdrawal or seizures

Answer 332

A

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 333

A

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

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 334

A

- 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 335

A

Idiopathic (Primary) Insomnia
Secondary Insomina

According to duration:

Acute Insominia (< 30 days)
Chronic Insomina (> 30 days)

Answer 336

A

over-reactivation of HPA axis
Hypervgillance about falling asleep

Answer 337

A

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 338

A

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 339

A

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

Answer 340

A

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)

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 341

A

treatment should be limited to < 2 weeks.
Intermittent therapy may be considered in severe longstanding insomnia that is not relieved by non-pharmacological management

The patient with chronic insomnia should be reviewed weekly for 4-6 weeks period for these psychological and behavioural treatments.

Answer 342

A

Dysfunctions associated with

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

Answer 343

A

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 344

A

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 345

A

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 346

A

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 347

A

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 348

A

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 349

A

Psychological evaluation and therapy are required if associated with PTSD

Answer 350

A

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 351

A

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 352

A

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

all symptoms need not to be present

Answer 353

A

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 354

A

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 355

A

“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 356

A

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 357

A

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 358

A

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 359

A

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 360

A

“URGE”

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

Answer 361

A

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 362

A

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

Answer 363

A

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

Answer 364

A

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 365

A

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

Answer 366

A

DENIAL

From event to hours to several days

– disbelief
– emotional numbness

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 367

A

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 368

A

ACCEPTANCE

After 6 months following the death (usually resolves within 12 months)

Only memories of good times left.

Answer 369

A

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

Answer 370

A

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 371

A

-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 372

A

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

Answer 373

A

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 374

A

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

ECT is superior to any other therapy (ie CBT an/or Antidepressants) in the treatment of Severe Depression

Answer 375

A

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 376

A

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 Tribunal 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 377

A

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 378

A

**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 379

A

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

Answer 380

A

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

Answer 381

A

 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 382

A

On discharge from the hospital

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 383

A

Do you feel hopeless?
Have you felt that you’ve lost interest in your usual activities?

Answer 384

A

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 385

A

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 386

A

“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 387

A

 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 388

A

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 389

A

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)
&raquo_space;> DAPOXETINE VO
OR
&raquo_space;> PAROXETINE VO
OR
&raquo_space;> SERTRALINE VO– continuous/daily dosing
&raquo_space;> PAROXETINE VO
OR
&raquo_space;> SERTRALINE VO

NOTE:
- Relaxation
- squeeze method
- sex therapy with partner

HAVE DUBIOUS LONGTERM BENEFIT

Answer 390

A

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

Answer 391

A

Several impulse control disorders

Answer 392

A

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

Answer 393

A

3 days (monitoring for serotonin syndrome)

Answer 394

A

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 395

A

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

Answer 396

A

Guns
Recent suicide attempts
Ongoing thoughts of suicide
Self-harm
Ethanol
Substances

mnemonic “Guns & ROSES”

Answer 397

A

Paroxetine
Fluoxetine

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 398

A

OLANZAPINE

increased risk of maternal gestational diabetes

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 399

A

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 400

A

continue with Lithium
consider ECT

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 401

A

Continue treatment
investigate for any anomaly

Answer 402

A

Ebstein’s anomaly

Lithium use during the first trimester of pregnancy

Tricuspid valve are displaced downwards towards the apex of the right ventricle of the heart.

Answer 403

A

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

Answer 404

A

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

Answer 405

A

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

To avoid floppy baby syndrome due to neonatal toxicity

Answer 406

A

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

Answer 407

A

First trimester exposure to benzodiazepines is associated with increased risk of cleft lip and/or palate.

The first 8 weeks of pregnancy is the period of highest risk. A high-resolution US examination at 18 to 20 weeks.

Answer 408

A

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 409

A

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

Answer 410

A

First-line: CBT + counselling
NRT can be added if CBT not effective

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 411

A

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

Occurs in 80% of mothers following delivery (considered normal)

Answer 412

A

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

prevalence 10-15%

Answer 413

A

SSRI
(Sertraline || Paroxetine)

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 414

A

Fluoxetine (due to its longer half-life)
Citalopram
Escitalopram

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 415

A

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%)

Postpartum psychosis is rare (1 to 2 cases per 1000 live births);

Answer 416

A

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 417

A

 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 418

A

Haloperidol

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

Answer 419

A

Olanzapine
Clozapine

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 420

A

continuation of clozapine for maternal wellbeing

PLUS

the use of formula feeding rather than breastfeeding.