Psychiatry Flashcards

Question

What investigations are done for ADHD?

Answer 1

Diagnosis is done primarily done using the ICD-11/DSM-5 criteria. But the following can also help: * Comprehensive history and physical examination (**Clinical Interview**) * **10 week watch and wait** Observation of the individual's behaviour and see if Sx resolve * Teacher and parent reports or rating scales * Nurse observation in classrooms * Neuropsychological testing

Answer 2

**Non-Pharmacological** * Watchful waiting for up to 10 weeks * Healthy diet and exercise. * Behaviour management - including reward charts, positive redirection. * **Behavioural Therapies - CBT, Psychoeducation, interpersonal therapy** is first line for management **If symptoms persist** * Referral to CAMHS **Pharmacological: Stimulant Medications** (Amphetamines/Methylphenidate) * **First Line in children** in Severe/uncontrolled Sx: **Methylphenidate** on 6 week trial basis * Second line in children: Dexamfetamine or Atomoxetine * Cannot be given to children <5 years * Children should have weight and height monitored every **6 months** * **First Line in Adults**: Either **Methylphenidate/Lisdexamfetamine** * **Second line:** **Lisdexamfetamine**

Answer 3

**CNS Stimulants:** Dopamine and Noradrenaline re-uptake inhibitors

Answer 4

**Methylphenidate has appetite suppressing effects and so can lead to impacts in growth and weight** * Weight and Height should be monitored every 6 months. A baseline ECG should also be performed as these drugs are potentially cardiotoxic.

Answer 5

* **Cardiotoxic:** perform Baseline ECG before starting treatment * Insomnia * Nausea and Vomiting * Decreased Appetite * Increased Blood pressure.

Answer 6

**Major Depressive Disorder** It's a common mental health disorder typified by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable

Answer 7

* Lifetime risk is around 1 in 8 (12%) * Increased prevalence in Females (F:M 2:1) * Mean age of onset is 40 years (but becoming more present in younger people)

Answer 8

**Genetics** * Family history of depression * High concordance in twins * Personal history of depression **Environmental:** * Stressful life events * Childhood abuse * Substance abuse * Medical conditions

Answer 9

Potential triggers (e.g. loss of a family member) Home environment Family relationships Relationship with friends Sexual relationships School situations and pressures Bullying Drugs and alcohol History of self harm Thoughts of self harm or suicide Family history Parental depression Parental drug and alcohol use History of abuse or neglect

Answer 10

A Stressful event in a person with pre-existing vulnerability has a greater likelihood of developing depression. Therefore 2 people experiencing the same stressful event: one without pre-existing vulnerability may not develop depression whilst the other individual does.

Answer 11

**Monoamine Theory:** * Lack of monoamine neurotransmitters: Serotonin, Dopamine, Noradrenaline * However low serotonin in healthy people doesn't cause depression. **Hypothalamic Pituitary Axis Disturbance:** * Increase cortisol, Low dexamethasone suppression. **Immune System:** * Excessive cytokine release

Answer 12

**DSM-5** Must have 5 or more /9 features **Including at least 1 or more core features** for **2 weeks** and have **clinical distress/functional impairment** where the symptoms are **not due to substances/other conditions** **Core Features:** * Low Mood * Anhedonia **Other Features:** * Weight gain/loss * Sleep disturbance * Fatigue/low energy * Psychomotor retardation * Inappropriate guilt/worthlessness * Reduced concentration * Recurrent thoughts of death

Answer 13

**Core Symptoms** * Low mood * Anhedonia (a lack of pleasure or interest in activities) **Emotional symptoms include:** * Anxiety * Irritability * Low self-esteem * Guilt * Hopelessness about the future **Cognitive symptoms include:** * Poor concentration * Slow thoughts * Poor memory **Physical symptoms include:** * Low energy (tired all the time) * Abnormal sleep (particularly early morning waking) * Poor appetite or overeating * Slow movements

Answer 14

**Patient Health Questionnaire 9 (PHQ9)** * PHQ-9 < 16 = Less severe depression * PHQ-9 >16 = More severe depression **Severity** * 5-9 indicates mild depression * 10-14 indicates moderate depression * 15-19 indicates moderately severe depression * 20-27 indicates severe depression **Hospital Anxiety and Depression (HAD) Scale:** * 14 questions - 7 for anxiety and 7 for depression * Each question scored from 0-3 to produce a score out of 21. * 0-7 normal, 8-10 borderline, 11 case

Answer 15

**Bipolar Disorder** **Anxiety Disorders** **Substance/Medication-Induced Mood Disorder** Mood disturbance associated with intoxication or withdrawal from substances or side effects of medications. **Adjustment Disorders** Development of emotional or behavioural symptoms in response to identifiable stressors. Various **organic causes** also need to be considered: **Neurological disorders** E.g. Parkinson's disease, dementia, and multiple sclerosis. **Endocrine disorders** especially thyroid dysfunction and hypo/hyperadrenalism (e.g., Cushing's and Addison's disease). **Substance use or medication side effects** e.g. steroids, isotretinoin, alcohol, beta-blockers, benzodiazepines, and methyldopa. **Chronic conditions** like diabetes and obstructive sleep apnea. **Long-standing infections** **Neoplasms and cancers** low mood can theoretically be a presenting complaint in any cancer, with pancreatic cancer being a notable example.

Answer 16

Depression is primarily a clinical diagnosis using DSM-5 or ICD-11, with patients fulfilling the diagnostic criteria outlined above. Other investigations that are done can be: * Patient Health Questionaire - 9 (PHQ-9) * Hospital Anxiety and Depression Scale (HAD) * FBC * TFTs * U+Es * LFTs * Blood glucose * B12/Folate Levels * Cortisol levels * Toxicology Screen * CNS Imaging

Answer 17

**Lifestyle Advice** **First Line:** Psychotherapy * Favoured in Under 18s * Should be trialled first line in less severe depression **Second Line:** Mediation **in combination** with CBT * For more severe depression * For mild depression that hasn't responded to psychotherapy.

Answer 18

**Lifestyle Changes:** * Exercise and Diet changes * Reduce alcohol and stop smoking * Stop drug use * Regular Schedule **Psychotherapies:** Less severe depression: * Guided self-help * Group Cognitive Behavioural Therapy (CBT) * Interpersonal Therapy More severe depression: * Individual CBT (with medication) * individual behavioural activation

Answer 19

**First-line pharmacological treatment**: * **Selective Serotonin Reuptake Inhibitor (SSRI):** Sertraline, Citalopram, Fluoxetine * **Fluoxetine is first line in children** * **Selective Noradrenaline Reuptake Inhibitors (SNRI):** Duloxetine, Venlafaxine (Work well in patients with associated pain disorders) **2nd line pharmacological treatment** * Atypical Anti-depressants: Mirtazapine * Tricyclic Antidepressants (TCAs): Amitriptyline * Monoamine Oxidase Inhibitors: Selegiline

Answer 20

* Tend to take a few months to work where symptoms may get worse before they get better * Continuation of antidepressants for at least six months post-remission is recommended to mitigate relapse risk. * Tapering should be done gradually over a four-week period when discontinuing antidepressants.

Answer 21

Its defined as a failure to demonstrate an adequate response to an adequate treatment trial

Answer 22

* Antipsychotics: Olanzepine, Quetiapine * Lithium **Electroconvulsive Therapy (ECT)** (After all other approaches have been tried). is safe and effected for **Severe medication resistant and psychotic depression** * Requires a GA * Electrodes trigger a short generalised seizure * Side effects include: Headache, Muscle Ache, Memory loss (short term)

Answer 23

Involves Depression with Psychotic features: * Delusions * Hallucinations * Thought Disorder

Answer 24

Combination of: * Antipsychotics (Olanzapine, Quetiapine) * Antidepressants (Sertraline, Citalopram) * ECT is an option

Answer 25

ASDs are a set of complex neuro-developmental disorders, characterised by a spectrum of impaired social, communication, and behavioural deficits. and restrictive or repetitive patterns or interests

Answer 26

* Higher prevalence in Males (M:F 3/4:1) * Prevalence of 1-2% * Features normally present by **age 3** * Around 50% of children with ASD have intellectual disability

Answer 27

**Genetics:** * Male sex * Advanced parental age at the time of conception * Certain genetic mutations * Maternal exposure to specific drugs or infections during pregnancy **Environment:** * No current clear risk factors

Answer 28

* Lack of eye contact * Delay in smiling * Avoids physical contact * Unable to read non-verbal cues * Difficulty establishing friendships * Not displaying a desire to share attention (i.e. not playing with others)

Answer 29

* Delay, absence or regression in language development * Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest * Difficulty with imaginative or imitative behaviour * Repetitive use of words or phrases

Answer 30

* Greater interest in objects, numbers or patterns than people * Stereotypical repetitive movements. There may be self-stimulating movements that are used to comfort themselves, such as hand-flapping or rocking. * Intensive and deep interests that are persistent and rigid * Repetitive behaviour and fixed routines * Anxiety and distress with experiences outside their normal routine * Extremely restricted food preferences

Answer 31

DSM-5 criteria based on 2 major areas: Impairments in * **Social communication and Interaction** * **Restricted or Repetitive behaviour/interests/activities** With * Sx present in early developmental period * Sx cause significant impairment * Not better explained by intellectual disability **Diagnosis is made by an Autism Specialist**

Answer 32

* ADHD (35%) * Epilepsy (18%)

Answer 33

**Intellectual Disability** Characterised by generalised deficits in intellectual functioning and adaptive behaviour, typically lacking the social deficits seen in ASD. **Attention Deficit Hyperactivity Disorder (ADHD)** Exhibits symptoms of inattention, hyperactivity, and impulsivity, but does not exhibit significant social or language communication deficits as seen in ASD. **Specific Language Impairment** Characterised by difficulties in language acquisition in the absence of cognitive impairment. Unlike ASD, social interaction is not typically affected. **Childhood Schizophrenia** Characterised by hallucinations, delusions, and disorganised speech or behaviour, which are not typical in ASD.

Answer 34

Diagnosis should be made through a multidisciplinary assessment completed by a specialist in autism. This can involve: * Psychological evaluation * Speech and language assessment * Cognitive assessment * Thorough review of the child's behaviour in different settings (home, school, etc.).

Answer 35

Child and adolescent mental health services (CAMHS) Psychologists Speech and language specialists Dieticians Paediatricians Social workers Specially trained educators and special school environments Charity organisations (e.g., National Autistic Society

Answer 36

MDT approach: focussing on Behavioural interventions and Family support * **Applied Behavioural Analysis (ABA)** * ASD Preschool program * Family support and Counselling * Family education on interaction and acceptance of child's behaviour * **Medications:** like SSRIs may be helpful for some symptoms

Answer 37

Bipolar disorder is a chronic mental health disorder characterised by periods of **mania/hypomania** alongside episodes of **depression**

Answer 38

* Develops in the late teen years * Lifetime prevalence of 2% * Male:Female ration of 1:1

Answer 39

**Genetics:** * First degree family member = 10x risk * 1 parent affected = 15-30% risk * 2 parents affected = 50-75% risk **Environment:** * Stressors such as death, illness, relationships or financial problems

Answer 40

**Type I:** At least 1 episode of Mania with depression that follows (most common) **Type II:** At least 1 episode of Major depression and an episode of Hypomania **Cyclothymic Disorder** depressive and hypomania like episodes that do not meet the DSM-5 criteria

Answer 41

**Mania:** 3 or more features for >7 days **AND** impaired function or threat to others **Hypomania:** 3 or more features for >4 days that **do not** cause impairment but may be observable to others **Features:** * Diminished need for sleep * Sense of Grandiosity * Pressured Speech * Racing thoughts/ideas/Flight of ideas * Distractibility * Goal oriented behaviour * Excessive pleasures **Psychosis features (delusions and hallucinations)** suggest mania rather than hypomania

Answer 42

Mania: Excessively elevated mood and energy that **significantly impacts** normal functions (caring and work responsibilities) Hypomania: milder symptoms of mania **without a significant impact** on their function.

Answer 43

It depends on the phase of the disorder: **Depressive Phase** * Withdrawal * Tearfulness * Low mood * Poor sleep * Anhedonia * Potential suicidal ideation or attempts. **Manic Phase** * Elevated mood * Irritability * Disinhibition and sexual inappropriateness * Impulsivity * Reduced need for sleep * Mood congruent delusions * Pressured speech * Flight of ideas.

Answer 44

**Major Depressive Disorder** Characterised by low mood, loss of interest or pleasure, feelings of worthlessness, impaired concentration, and possible suicidality. **Schizoaffective Disorder** Presents with hallucinations, delusions, disorganised speech, disorganised behaviour, and symptoms of depression or mania. **Generalised Anxiety Disorder** Chronic and excessive worry, restlessness, fatigue, impaired concentration, and sleep disturbance. **Substance-Induced Mood Disorder** Mood disturbances caused by substance misuse or withdrawal.

Answer 45

ICD 10/11 * At least 2 episodes of significant mood disturbance **ICD10** * Where there is at least one or more episode of mania/hypomania * and one or more depressive episodes **ICD 11** * Where each of the two episodes includes both Mania/hypomania and Depressive episodes **AND** * Significant impairment in social, occupational or other important areas of functioning

Answer 46

**Acute Manic Episode:** * First Line: **Antipsychotic medications:** Olanzapine, Haloperidol, Risperidone * Existing antidepressants are **Tapered and stopped** * Other options: **lithium, Sodium Valproate** **Acute Depressive Episode:** * First Line: **Olanzapine PLUS Fluoxetine** * Lamotrigine * Psychotherapy: CBT

Answer 47

Long-term maintenance therapy is crucial due to high relapse risk: **Mood stabilisers** * First line: **Lithium** * Alternatives: Anti-epileptics (Sodium Valproate, Lamotrigine, Carbamazepine), Olanzapine **High-intensity Psychotherapies** * CBT, interpersonal therapy, or couples/family therapy better for managing depressive features **Resistant cases/very severe Bipolar disorder:** * Electroconvulsive therapy * Transcranial Magnetic Stimulation

Answer 48

Symptoms of hypomania then NICE recommend **routine referral** to Community Mental Health Team (CMHT) Symptoms of Mania or Severe depression then NICE recommend **urgent referral** to CMHT

Answer 49

LITHIUM: Level - 0.4-1 mmol/l - Leukocytosis Insipidus - Nephrogenic DI increasing ADH Tremors (fine) (de)Hydration - Dry mouth, Diarrhoea, Thirsty Increased weight, calcium, PTH hormone and memory problems Underactive thyroid (Decreased TSH) can also cause acute thyrotoxicosis Mums aware - Epstein's anomaly, Metallic Taste

Answer 50

**Renal and thyroid function** * Sodium restricted diet * Diuretics and NSAIDs should be used with caution

Answer 51

They can precipitate episodes of Mania Fluoxetine is commonly used in combination with Olanzapine

Answer 52

Monitoring for renal or thyroid dysfunction * Serum lithium levels taken 12 hours after the most recent dose. **Monitoring for Lithium Toxicity**

Answer 53

**Features of Toxicity** (TOXIC): * Tremor (coarse) * Oliguric renal failure * ataXia (affects coordination, balance and speech) * Increased reflexes * Convulsions / Coma / loss of Consciousness **Precipitants:** (4 D's): * Dehydration * Drugs (NSAIDS,ACEis) * Diuretics * Depletion of Sodium **Management:** * Stop and withdraw Lithium * Rehydrate with normal IV Saline Fluids

Answer 54

**Valproate Pregnancy Prevention Programme**

Answer 55

A state of apprehension, uncertainty or uneasiness in anticipation of a real or perceived threat. **When these feelings are persistent and impact an individuals ability to function, they may be termed Anxiety disorder**

Answer 56

* Generalised Anxiety Disorder * Specific Phobias * Panic Disorder * Agoraphobia * Social Anxiety Disorder * PTSD * Separation anxiety * OCD * Selective Mutism

Answer 57

Generalised anxiety disorder (GAD) is defined as **at least 6 months** of excessive worry about everyday issues that is **disproportionate to any inherent risk, causing distress or impairment**.

Answer 58

Higher prevalence in Females Higher prevalence in younger age groups (age of onset after 35 is more indicative of depressive disorder or organic disease).

Answer 59

**Comorbid anxiety disorders** **Females (F:M 2:1)** **Genetics: first degree relative** **Childhood adversity** * Maltreatment (e.g. sexual or physical abuse), neglect. * Maternal depression, family disruption (e.g. divorce). * Domestic violence, parental alcoholism, or drug use. **Physical, sexual, or emotional trauma** * Physical or sexual abuse or assault. * Motor vehicle accident. * Sudden bereavement. **Sociodemographic factors** * Separated, widowed, divorced. * Unemployment. * Low socioeconomic status. * Low education levels. * Substance dependence or exposure to organic solvents **Chronic physical condition**

Answer 60

**Symptoms of Anxiety** * autonomic - palpitations, sweating, nausea, dizziness * Motor Tension - headaches, fidgety * Apprehension **Present for about a month** **Panic Disorder** come on acutely, in extreme bursts, no anxiety in between **Phobias** come on in a particular situation/avoidance of that **GAD** pervasive features present majority of the time

Answer 61

DSM-5 Criteria where symptoms last for **6 months** with the anxiety being **disproportionate to threat** which has an **impact on the individuals ability to function** and these symptoms are **not due to another medical condition or substance use** 3 of the following 6 key symptoms are required for a diagnosis (only 1 in kids) * Restlessness or nervousness * Being easily fatigued * Poor concentration * Irritability * Muscle tension * Sleep disturbance **in combination with an inability to manage their worry**

Answer 62

**Generalised Anxiety Disorder Questionnaire (GAD-7)** * 5-9 indicates mild anxiety * 10-14 indicates moderate anxiety * 15-21 indicates severe anxiety

Answer 63

* Hyperthyroidism * Substance abuse/withdrawal * Panic disorder * Depression * Medications - Salbutamol, theophylline, corticosteroids, antidepressants and caffeine * Avoidant personality disorder

Answer 64

NICE suggest Step-wise approach: * **Step 1 (Mild GAD)**: Psychoeducation about Lifestyle (sleep, diet, exercise, smoking, alcohol, drugs) .Psychoeducation about GAD + active monitoring * **Step 2 (Mild GAD)**: low-intensity psychological interventions (individual non-facilitated self-help or **individual guided self-help** or psychoeducational groups) * **Step 3 (Moderate-severe GAD)**: high-intensity psychological interventions (**cognitive behavioural therapy** or applied relaxation) or **drug treatment**. * **Step 4 (Severe GAD)**: highly specialist input e.g. Multi agency teams

Answer 65

**First Line:** Sertraline **Second Line:** Alternative SSRI or an SNRI **Third Line:** Pregabalin **Propranolol** may be used to treat physical symptoms but doesn't control underlying anxiety **Patients under 30 years should be warned of increased risk of suicidal thinking and self-half when starting medication**

Answer 66

**Recurrent** panic attacks that may be due to a **specific situation or without a trigger** occurring for **at least 1 month** that leads to **impact beyond the attacks** (such as worry of having panic attacks)

Answer 67

* 1/3 people will suffer a panic attack * 10% of these may have Panic Disorder * Onset commonly in 20s * More common in females

Answer 68

Sudden onset intense **physical and emotional** symptoms of anxiety that come on within minutes and last for 10-20 minutes before the symptoms gradually fade.

Answer 69

Recurrent panic attacks for **at least 1 month** where there is a sudden surge of **fear/anxiety/physical discomfort** which leads to the **fear of having panic attacks and thus avoiding situations** plus at least 4 of: * Palpitations * Sweating * Trembling * Sensation of breathlessness * Sensation of chocking * Chest pain/discomfort * Nausea/abdominal discomfort * Light-headedness * Chills * Paraesthesia * Derealisation * Fear of losing control * Fear of dying

Answer 70

Stepwise approach: * Step 1: recognition and diagnosis * Step 2: treatment in primary care: **CBT or SSRI (sertraline)** * Step 3: review and consideration of alternative treatments (**No response after 12 weeks then try imipramine**) * Step 4: review and referral to specialist mental health services * Step 5: care in specialist mental health services

Answer 71

Separation anxiety School Phobia Selective Mutism

Answer 72

**4 week period** **Most common anxiety disorder under 10** * Developmentally inappropriate * Excessive worry about harm coming to primary care giver * Causing pronounced stress and agitation * Leading to inability to be separated (eg. school, bedtime)

Answer 73

**Period of at least 6 months occurring most days** * Selective mutism is related to social anxiety disorder * Fear of speaking in social contexts or situations

Answer 74

Significant anxiety symptoms Fear of a specific part of school Avoidance of School

Answer 75

Obsessive-compulsive disorder (OCD) is a mental health disorder characterised by the presence of **persistent obsessions and/or compulsions** These are time consuming (i.e. take more than 1 hour per day) and/or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Answer 76

Obsessions are unwanted and uncontrolled thoughts and intrusive images that the person finds it very difficult to ignore. E.g. an overwhelming fear of contamination with dirt or germs; or violent or explicit images that keep appearing in their mind.

Answer 77

**Contamination/Hygiene** **Harm** **Order/Symmetry and exactness (perfectionism)**

Answer 78

Compulsions are repetitive actions the person feels they must do, generating anxiety if they are not done. Often these compulsions are a way for the person to handle the obsessions. E.g. checking that all electrical equipment is turned off to settle the anxiety of obsessing about the house burning down.

Answer 79

Obsessions lead to anxiety, which leads to the compulsive behaviour, which leads to a temporary relief in the anxiety. Shortly after the temporary improvement in anxiety the obsession reappears, leading to further anxiety, further compulsive behaviour with a temporary relief. This cycle continues and each time gets more engrained in the person’s behaviour. Without doing the compulsions, the person feels they cannot get relief from their anxiety.

Answer 80

It affects Males and Females equally (although presents earlier and more severely in males) Affects around 3% of population More common in pregnant and post-partum women Bimodal age of onset, peaking at 10 and 21 years

Answer 81

* Family history * Age: peak onset is between 10-20 years * Pregnancy/postnatal period * History of abuse, bullying, neglect * History of anxiety disorders

Answer 82

OCD is a clinical diagnosis and according to the **DSM-5** or ICD-11: * Presence of **obsessions, compulsions or both** * **Time consuming** (>1 hour a day) which causes **clinically significant distress or functional impairment** * Cannot be attributed to substance use or medical condition * Not **better explained by another mental disorder**

Answer 83

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

Answer 84

Always give education and self help resources **Mild OCD** * First Line: CBT with exposure and response prevention ERP) * Second Line: Offer SSRI or more intensive CBT **Moderate OCD** * Referral to CAMHS in children * First line: Offer either SSRI (Sertraline, Fluoxetine, Paroxetine) or intensive CBT including ERP * Second line: consider Clomipramine (if patient has previously had good response to it or SSRI is contraindicated **Severe OCD:** * Referral to Secondary Care Mental Health Team for assessment * Offer combined treatment with SSRI and CBT (including ERP)

Answer 85

Used for OCD Psychological method involving exposing a patient to anxiety provoking situations and stopping them engaging in their compulsion. This helps to confront their anxiety and reduces the habituation of the response

Answer 86

It's a significant mood disorder that can **develop at any time up to one year** after the birth of a baby. This condition represents a considerable aspect of maternal mental health and extends beyond the common "baby blues". Typically presenting with persistent depressive symptoms that may interfere with daily functioning and parenting.

Answer 87

Development of postpartum depression is multifactorial with a combination of Biological, Psychological, and Social factors all contributing.

Answer 88

* Hormonal fluctuations post-delivery, including sudden drops in progesterone, estrogen, and thyroid hormones. * Alterations in melatonin and cortisol rhythms and immune-inflammatory processes * Genetic predispositions

Answer 89

* A history of mood or anxiety disorders * Previous episodes of postpartum depression * Certain personality traits such as neuroticism * Psychological stress from the transition to parenthood * Unrealistic expectations of motherhood

Answer 90

* Lack of social support * Relationship issues, * Life stressors * Low socioeconomic status

Answer 91

* Persistent lowering of mood and reduced enjoyment or interest in activities. * Lowering of energy levels. * Biological symptoms of depression like poor appetite and disturbed sleep patterns (not associated with normal disturbed sleep patterns with a baby) * Concerns related to bonding with the baby, caring for the baby, and in extreme circumstances, thoughts about harming oneself or the baby.

Answer 92

**Baby blues** Characterised by mild mood swings, irritability, anxiety, and tearfulness. However, these symptoms usually present within the first two weeks after birth and resolve spontaneously. **Postpartum Psychosis** **Adjustment disorders** These disorders may develop in response to a major life change or stressor, such as having a baby, but the emotional or behavioural symptoms are less severe than in depression. **Generalized Anxiety Disorder (GAD)**

Answer 93

Edinburgh Postnatal Depression Scale (EPDS) A cutoff score of over 10 is used as a positive result.

Answer 94

**First-line treatments**: * Self-help strategies and psychological therapies e.g. Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT). **Pharmacological treatments** * Antidepressants considered in high risk cases **In severe cases** admission to a mother and baby inpatient mental health unit might also be necessary.

Answer 95

It's a serious psychiatric disorder that typically develops within the first two weeks following childbirth. It is characterised by a range of psychological symptoms, including paranoia, delusions, hallucinations, mania, depression, and confusion.

Answer 96

* Prior history of severe mental illnesses such as schizophrenia or bipolar affective disorder * Family history of postpartum psychosis * Previous episode of postpartum psychosis

Answer 97

Paranoia Delusions Hallucinations Manic episodes Depressive episodes Confusion

Answer 98

Postpartum depression with psychotic features

Answer 99

Diagnosis is predominantly clinical, based on the presenting signs and symptoms. It requires a thorough psychiatric evaluation. Consideration should be given to other medical conditions that may cause similar symptoms, such as thyroid disorders or sepsis.

Answer 100

Pharmacotherapy with: * Antipsychotic medications * Mood stabilisers in some instances Potential referral to a specialist mother and baby inpatient mental health unit in very severe cases (when the mother experiences command hallucinations, thoughts of self-harm or suicide, or delusional beliefs regarding the baby's role or identity).

Answer 101

The mother's breastfeeding status and the potential for the transfer of drugs to the nursing infant.

Answer 102

A relatively common mental health condition resulting from traumatic experiences, with ongoing distressing symptoms and impaired function.

Answer 103

**Direct:** An individual experiences the trauma themselves **Indirect:** An individual learns about the trauma from another source, witnesses the trauma happening to someone else or a loved one is affected

Answer 104

* Violence (e.g., sexual assault, domestic violence, abuse or physical attacks) * Major car accidents * Major health events (e.g., traumatic childbirth, serious illness or death of a loved one) * Natural disasters * Military, combat and war zone events **Any event the individual finds traumatic has the potential to cause PTSD**

Answer 105

ICD-11 Criteria: * Exposure to a traumatic event * Development of **3 core symptom** clusters for at **least 2 weeks** * Re-experiencing * Avoidance * Persistent heightened current threat (hypervigilance) * **Causing Functional Impairment** * Not explained by another disorder or substance.

Answer 106

* Recurrent/intrusive thoughts relating to the evvent * Nightmares * Flashbacks * Physiological distress to reminders such as tachycardia, hypertension

Answer 107

* Avoiding stimuli such as people, events or places * This is to prevent reminders of the event

Answer 108

* Unable to recall certain aspects * Distorted sense of self * Fragmented recollection * Fear, anger and Guilt * Anhedonia

Answer 109

* Aggressive behaviour * Feeling on edge, irritable, easily startled * Hypervigilance * Poor sleep/concentration * Recklessness

Answer 110

**Acute Stress Disorder** * Symptoms last **less than 1 month** **Complex PTSD** * Exposure to prolonged trauma * Have PTSD symptoms **PLUS: Emotional dysregulation, significant negative identity disturbance**

Answer 111

* Type of Trauma: **Assault based > Natural disaster base trauma** * Females > Males * Pre-existing mental health conditions * Childhood adversity * Lack of social support

Answer 112

**H**yperarousal/Hypervigilance: Poor sleep, irritability, poor concentration **A**voidance behaviours: avoiding people, places, events **R**e-experiencing: Flashbacks, Nightmares, Repetitive and distressing intrusive images **D**ull/emotional numbing: Feeling detached.

Answer 113

PTSD tends to develop soon after the event. It may be delayed, but delayed onset greater than a year post-trauma is very rare.

Answer 114

**Acute Stress reaction** **Prolonged grief disorder** **Depression** **Adjustment disorders** **Enduring personality change after catastrophic experience**

Answer 115

**Trauma Screening Questionnaire (TSQ)** A set of 10 items covering re-experiencing and arousal symptoms. **DSM-5 PTSD Checklist** A 20 item checklist assessing the symptoms of PTSD according to DSM-5.

Answer 116

1. **watchful waiting** for 4 weeks if traumatic event happened within the last month 2. Psychotherapies: * **Trauma Focused Cognitive Behavioural therapy (TF-CBT)** * **Narrative/Prolonged exposure therapy** * **Eye Movement Desensitisation and Reprocessing (EMDR) Therapy** **First Line for PTSD is TF-CBT** **EMDR offered to patients presenting >3 months after non-combat related trauma**

Answer 117

**First line**: * SSRI (e.g. sertraline/paroxetine) * Venlafaxine In serious cases that haven't responded to previous drug or psychological therapies: * Antipsychotics (like risperidone) in addition to psychological therapies

Answer 118

It's a general umbrella term encompassing a range of different conditions that affect the ability of the child to develop new skills. Examples include: * Dyslexia * Dysgraphia refers to a specific difficulty in writing. * Dyspraxia * Auditory processing disorder * Non-verbal learning disability * Profound and multiple learning disability They can vary from very mild to severe

Answer 119

It refers to a specific difficulty in reading, writing and spelling.

Answer 120

It refers to a specific difficulty in writing.

Answer 121

Also known as **developmental co-ordination disorder.** It refers to a specific type of difficulty in physical co-ordination. More common in boys. It presents with delayed gross and fine motor skills and a child that appears clumsy.

Answer 122

It refers to a specific difficulty in processing auditory information.

Answer 123

It refers to a specific difficulty in processing non-verbal information, such as body language and facial expressions.

Answer 124

It refers to severe difficulties across multiple areas, often requiring help with all aspects of daily life.

Answer 125

The severity of the learning disability is based on the IQ (intelligence quotient): **< 70** 55 – 70: Mild 40 – 55: Moderate 25 – 40: Severe Under 25: Profound

Answer 126

* Family history of learning disability * Abuse * Neglect * Psychological trauma * Toxins * Certain conditions

Answer 127

* Genetic disorders such as Downs syndrome * Antenatal problems, such as foetal alcohol syndrome and maternal chickenpox * Problems at birth, such as prematurity and hypoxic * ischaemic encephalopathy * Problems in early childhood, such as meningitis * Autism * Epilepsy

Answer 128

The key is a multidisciplinary approach to support the parents and child: Health visitors Social workers Schools Educational psychologists Paediatricians, GPs and nurses Occupational therapists Speech and language therapists

Answer 129

* **Understand** the decision that needs to be made * **Retain** the information long enough to make the decision * **Weight up** the options and the implications of choosing each option * **Communicate** their decision

Answer 130

Psychosis is a term used to describe a person experiencing things differently from those around them as they have **lost contact with reality**

Answer 131

Psychosis can be due to: * Primary (“non-organic”) psychiatric disorders * Secondary to substance use or specific medical (“organic”) aetiologies

Answer 132

Schizophrenia (most common) Delusional disorder Schizoaffective disorder Schizophreniform disorder Brief psychotic disorder Bipolar disorder Puerperal Psychosis

Answer 133

* Brain tumours or cysts * epilepsy * Dementia * Parkinsons * MS * Thyroid dysfunction * Cushings * Addisons * CNS infections * Liver disease (korsakoff psychosis) * Substance induced * Alcohol

Answer 134

* Hallucinations (e.g. auditory) * Delusions * Thought disorganisation * Alogia: little information conveyed by speech * Tangentiality: answers diverge from topic * Clanging * Word salad: linking real words incoherently → nonsensical content

Answer 135

* Agitation/aggression * Neurocognitive impairment (e.g. in memory, attention or executive function) * Depression * Thoughts of self-harm

Answer 136

* Physical examination (detailed neurological examination and a complete mental status examination) * Complete psychiatric and medical history (review of head injury, seizures, cerebrovascular disease, sexually transmitted infections, and new or worsening headaches) * Laboratory work-up

Answer 137

FBC Comprehensive metabolic profile TFTs Urine toxicology Parathyroid hormone calcium vitamin B12 folate niacin Based on clinical suspicion, testing for HIV infection and hepatitis C,

Answer 138

It depends on the underlying cause. If Schizophrenia: 1st line is (2nd gen) atypical antipsychotics e.g. **Risperidone or Olanzapine** Haloperidol is also still used

Answer 139

It's a severe mental disorder characterised by chronic or relapsing episodes of psychosis. It involves altered perceptions of reality, disordered thinking, and social dysfunction.

Answer 140

Schizophrenia is a condition that affects how the brain processes information. Normally, the brain is very good at understanding reality, deciding what is important and what is not, and organising thoughts in a structured way. With schizophrenia, the brain struggles to understand the world, makes mistakes in deciding what information is important and organises thoughts in a confused way. This can lead to strong beliefs that do not fit with reality, called delusions. They may also experience voices that are not there, called hallucinations. The disorganised thoughts can lead to unusual speech and behaviours, which is called thought disorder. When these symptoms occur, it is called psychosis.”

Answer 141

* **Family History** * 10% if either a parent or sibling is affected * 50% if both parents or a monozygotic twin * Childhood trauma, like poor maternal bonding, poverty, or exposure to natural disasters * Heavy cannabis use in childhood * Maternal health issues, including malnutrition and infections like rubella and cytomegalovirus * Birth trauma, particularly hypoxia and blood loss * Urban living and immigration to more developed countries

Answer 142

* Auditory hallucinations * Thought disorders * Passivity phenomena * Delusional perceptions

Answer 143

**Auditory Hallucinations:** * Thought Echo: Hearing one’s own thoughts spoken aloud, as if they are echoing back. * Voices Commenting: Hearing voices that provide a running commentary on the person’s actions or thoughts. * Voices Conversing: Hearing multiple voices talking to each other, usually discussing the person in the third person. **Thought Disorder** * Thought Insertion: The belief that thoughts are being inserted into one’s mind by an outside force. * Thought Withdrawal: The belief that one’s thoughts are being taken out or removed by an external force. * Thought Broadcasting: The belief that one’s thoughts are not private but are being broadcasted or accessible to others. **Delusional Perception:** * The person has a normal perception (like seeing a particular object or event) but interprets it with delusional significance, such as thinking the perception has a unique or personal meaning (e.g., seeing a red car and concluding that it means they are being watched). **Passivity Phenomena (or Delusions of Control):** * Made Actions: Belief that one’s actions are controlled by an external force, as though someone else is “making” them move. * Made Impulses: Belief that impulses to act are not one’s own but are imposed by an external force. * Made Feelings and Emotions: Belief that one’s emotions or sensations are being controlled or influenced by someone else.

Answer 144

**Prodrome Phase** * Precedes full symptoms of psychosis * May experience Sx such as **poor memory, reduced concentration, mood swings, suspicion of others, sleep issues, social withdrawal** **Psychosis and positive symptoms: (ABCD)** * Auditory hallucinations * Broadcasting/insertion/blocking of thoughts * Control issues ie. passivity phenomena * Delusional perceptions * Ideas of reference **Negative Symptoms '4 A's'** * Alogia (Poverty of Speech) * Avolution (Lack of motivation) * Affect blunting or incongruity (Minimal emotional reaction) * Anhedonia (Lack of interest) **Miscellanous Symptoms '2 C's'** * Catatonia * Cognitive: impaired memory + attention deficit + reduced executive function

Answer 145

* Catatonia involves abnormal movement, communication and behaviour. It can present in a variety of ways. * Patients are awake but not behaving normally. * They may hold unusual postures, perform odd actions, repeat sounds or words, or remain blank and unresponsive. * The symptoms can vary in severity over time.

Answer 146

* **Auditory hallucinations** (hearing voices, particularly a voice narrating the patient’s actions) * **Somatic passivity** (believing that an external entity is controlling their sensations and actions) * **Thought insertion or thought withdrawal** (believing that an external entity is inserting or removing their thoughts) * **Thought broadcasting** (believing that others are overhearing their thoughts) * **Persecutory delusions** (a false belief that a person or group is going to harm them) * **Ideas of reference** (a false belief that unconnected events or details in the world directly relate to them) * **Delusional perceptions**

Answer 147

* **Affective flattening** (minimal emotional reaction to emotive subjects or events) * **Alogia** (“poverty of speech” – reduced speech) * **Anhedonia** (lack of interest in activities) * **Avolition** (lack of motivation in working towards goals or completing tasks)

Answer 148

* Continuous * Episodic (relapsing and remitting) * Single Episode Only

Answer 149

* **Schizoaffective Disorder** * **schizophreniform Disorder** **Others:** * Mania * Psychotic depression * Drugs (e.g., hallucinogens and cannabis) * Stroke * Brain tumours * Cushing’s syndrome (e.g., patients taking systemic steroids) * Hyperthyroidism * Huntington’s disease

Answer 150

1. Symptoms including the prodrome phase must have been present for **at least 6 months** 2. Symptoms of the active phase (delusions, hallucinations and thought disorder) must have been present for **at least 1 month**

Answer 151

1. **2 or more symptoms of:** * Delusions * Hallucinations * Disorganised Speech * Disorganised/Catatonic Behaviour * Negative Symptoms 2. Of which at least **one of of either:** * Delusions * Hallucinations * Disorganised Speech 3. Symptoms must have been **actively present** (most of the time) for **1 or more months** 4. Symptoms (including Prodrome) must have had **significant impact for at least 6 months** 5. Symptoms cannot be due to substances or other medical conditions

Answer 152

* Brain imaging (CT/MRI) to rule out structural abnormalities * Blood tests to exclude infectious (e.g.,HIV, syphilis) or metabolic causes (e.g., thyroid function tests) * Drug screening to identify substance misuse

Answer 153

**1st Line:** * Second-generation (atypical) antipsychotics e.g. **Risperidone** **In acute episodes:** * Sedatives (e.g. lorazepam, promethazine, or haloperidol) to manage dangerous behaviour. **when schizophrenia is resistant to other antipsychotics (2 have been tried)** * Clozapine is considered (Due to its potential lethal side effects, it requires intensive monitoring.) **Psychotherapy, such as cognitive-behavioural therapy** offered to all patients

Answer 154

* Quetiapine * Aripiprazole * Olanzapine * Risperidone **Depo IM injections** * Aripiprazole * Flupentixol * Paliperidone * Risperidone

Answer 155

Schizoaffective disorder combines the symptoms of schizophrenia with bipolar disorder. Patients have psychosis and symptoms of depression and mania.

Answer 156

Features of Schizophrenia lasting between 1 day and 1 month

Answer 157

**Somatic symptom disorder** or **Briquet's Syndrome** * A psychiatric condition characterized by the presence of multiple, recurrent and clinically significant somatic complaints that cannot be fully explained by any underlying medical conditions * Present for **at least 2 years**

Answer 158

* History of IBS * History of PTSD * History of sexual or physical abuse

Answer 159

Symptoms that are generally severe enough to affect work and relationships and lead the person to consult a doctor and take medication. A lifelong history of 'sickliness' is often present: Stress often worsens the symptoms. Examples include: * Cardiac (SOB, Palpitations, Chest Pain) * GI (Vomiting, Abdominal pain, nausea, diarrhoea) * MSK ( Back pain, Joint pain) * Neurological (Headaches, dizziness, amnesia, vision changes, paralysis or muscle weakness) * Urogenital (Pain during urination, low libido, dyspareunia, impotence).

Answer 160

Somatisation is **often a diagnosis of exclusion** but it's much more effective to pursue a positive diagnosis when the patient presents with typical features: * **multiple symptoms, often occurring in different organ systems.** * Symptoms are vague or that exceed objective findings. **At least 6 months** **cause significant distress and impairment** not attributed to specific medical or other psychiatric conditions

Answer 161

1st Line treatment is **Psychotherapy**, and Cognitive behavioural therapy shows the best outcomes Pharmacological interventions show little effect on the disease although psychiatric disorders associated with somatisation like anxiety and depression can be treated with antidepressants which will often improve somatic symptoms.

Answer 162

Typical Antipsychotics Atypical Antipsychotics (Developed due to Extrapyramidal side effects associated with first gen typical antipsychotics)

Answer 163

**Typical** * Dopamine D2 receptor antagonists blocking transmission via the mesolimbic pathway **Atypical** * Act of a variety of Dopamine receptors: D2, D3, D4, 5-HT

Answer 164

**Extrapyramidal Side Effects:** * Akathisia: Psychomotor restlessness and inability to stay still * Dystonia: abnormal muscle tone and posturing * Oculogyric Crisis * Pseudo-parkinsonism: tremor and rigidity * Tardive Dyskinesia: Abnormal movements affecting the face **Hyperprolactinaemia**

Answer 165

**Acute Dystonia** : Treat w/ Procyclidine **Akathisia** Treat w/ Propranolol **Parkinsonism:** Treat w/ L-Dopa **Tardive Dyskinesia** Treat w/ Tetrabenazine

Answer 166

Haloperidol Chlorpromazine

Answer 167

Clozapine Risperidone Olanzapine Quetiapine

Answer 168

**Metabolic Conditions** **Weight gain** **Hyperprolactinaemia** **Glucose intolerance** Drowsiness Hyperprolactinaemia Increased appetite Dyslipidaemia Galactorrhoea

Answer 169

Has many side effects It can only be started after two other antipsychotics have been trialled. Causes Agranulocytosis which can lead to severe infections **Adverse Effects:** C - constipation Lo - lower seizure threshold Z - zzz sedation A - **agranulocytosis** P - phat weight gain I - increased salivation N - neutropenia E - ECG changes (myocarditis/cardiomyopathy)

Answer 170

* Sedation * Antimuscarinic effects * Hyperprolactinaemia * Sexual dysfunction * Impaired glucose tolerance * Cardiac Arrhythmias * Reduction of seizure threshold * Prolonged QT (particularly Haloperidol)

Answer 171

* Increased risk of stroke * Increase risk of VTE * Increased risk of falls

Answer 172

**Haloperidol** Prolonged QT

Answer 173

**Neuroleptic Malignant Syndrome** **Clinical Features:** * **Hyporeflexia with Muscle Rigidity** * Hyperthermia * Altered consciousness * Autonomic Dysfunction (Tachycardia, fluctuating BP) **Blood Test Findings:** * Raised Creatinine Kinase * Raised White Cell Count

Answer 174

**Stopping causative mediations** **Supportive care** * IV fluids * Sedation with Benzodiazepines * Can use **Dantrolene** **May require Bromocriptine (Dopamine Agonist)**

Answer 175

Delusions are fixed, false beliefs that are maintained despite contradictory evidence. They are a prominent feature of numerous psychiatric conditions E.g. Schizophrenia, bipolar disorder, and psychotic depression.

Answer 176

**Nihilistic delusions** * Negative delusions typically congruent with the individual's depressed mood. Patients may believe that they are dead or that the world has ended. **Delusions of grandeur** * Patients believe they possess extraordinary traits or powers. Common in manic phases of bipolar disorder. **Delusions of control** * The individual experiences a sensation that an external entity is controlling their thoughts or actions. Frequently observed in psychotic conditions. **Capgras Delusions** * Misidentification syndrome characterised by the belief by the patient that the close person is replaced by an imposter who looks physically the same **Persecutory delusions** * The patient believes they are being persecuted or conspired against. Common in conditions like paranoid schizophrenia. **Somatic delusions** * Patients are convinced they have a physical, medical, or biological problem despite no medical evidence supporting their claim. These delusions can manifest as a wide range of physical symptoms.

Answer 177

**Bizarre Vs non-bizarre** (very strange or highly unusual) Vs (plausible but incorrect) Mood-congruent (consistent with the individual's emotional state) Vs mood-neutral

Answer 178

**Mood disorders with psychotic features** Delusions often mood-congruent. In depressive episodes, these might be nihilistic delusions; in manic episodes, they might be grandiose. **Neurocognitive disorders** Delusions can occur in conditions such as Alzheimer's disease or Parkinson's disease dementia. The delusions often involve theft or persecution. **Substance-induced psychotic disorder** Delusions might be part of a broader psychotic syndrome due to intoxication or withdrawal from substances such as alcohol, hallucinogens, or amphetamines.

Answer 179

**Clinical interview** Comprehensive psychiatric history, including onset, duration, and the impact of symptoms on functioning. **Mental state examination (MSE)** Evaluation of appearance, behaviour, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. **Neuropsychological assessment** To rule out neurocognitive disorders or to assess for any cognitive impairment.

Answer 180

**Pharmacological** Antipsychotic medication is the mainstay of treatment. The choice of medication depends on the underlying disorder. **Psychotherapy** Cognitive behavioral therapy (CBT) can be beneficial. **Psychoeducation** Providing information to the patient and their family about the nature and management of the disorder.

Answer 181

Personality disorders are a group of mental health conditions where a person’s thoughts, feelings, and behaviors differ significantly from what is typically expected, leading to difficulties in relationships and everyday functioning.

Answer 182

**Class A:** Suspicious **Class B:**Emotional or Impulsive **Class C** Anxious

Answer 183

**Suspicious, Odd, Eccentric disorders:** * Paranoid * Schizoid * Schizotypal

Answer 184

Paranoid personality disorder features difficulty in trusting or revealing personal information to others.

Answer 185

Schizoid personality disorder features a lack of interest or desire to form relationships with others and feelings that this is of no benefit to them. * Lack of interest in companionship, sexual interactions * few friends * Indifference to praise or criticism

Answer 186

Schizotypal personality disorder features unusual beliefs, thoughts and behaviours, as well as social anxiety that makes forming relationships difficult. * Odd beliefs or magical thinking * odd speech without coherence * Paranoid ideation and suspicions

Answer 187

**Dramatic, Emotional or Erratic Disorders:** * Antisocial * Borderline (Emotionally unstable) * Histrionic * Narcissistic

Answer 188

Antisocial personality disorder features reckless and harmful behaviour, with a lack of concern for the consequences or the impact of their behaviour on other people. It often involves criminal misconduct.

Answer 189

**Emotionally Unstable Personality Disorder (EUPD)** Borderline personality disorder features fluctuating strong emotions and difficulties with identity and maintaining healthy relationships. * Strong emotional responses * Unstable interpersonal relationships * Distorted sense of self * Fear of abandonment

Answer 190

Histrionic personality disorder involves the need to be the centre of attention and performing for others to maintain that attention. * Inappropriate sexual seductiveness * Centre of attention * Physical appearance used for attention

Answer 191

Narcissistic personality disorder features feelings that they are special and need others to recognise this, or else they get upset. They put themselves first. * Grandiose sense of self importance * Take advantage of others for own needs * Arrogant

Answer 192

**Anxious or fearful disorders:** * Obsessive-Compulsive * Avoidant * Dependent

Answer 193

Obsessive-compulsive personality disorder features unrealistic expectations of how things should be done by themselves and others and catastrophising about what will happen if these expectations are not met.

Answer 194

Dependent personality disorder features a heavy reliance on others to make decisions and take responsibility for their lives, taking a very passive approach.

Answer 195

Avoidant personality disorder features severe anxiety about rejection or disapproval and avoidance of social situations or relationships.

Answer 196

**BioPsychoSocial** * History of abuse * Family history of schizophrenia * Negative parenting interactions * Emotional/disruptive disorder in childhood

Answer 197

DSM-5/ICD-10 had the 3 categories (Type A, Type B and Type C) **New ICD-11 criteria has changed to Mild, Moderate and Severe**

Answer 198

**Mild Personality Disorder:** * Some difficulties in certain areas, like relationships or work. * Others may notice the symptoms, but they don’t cause major problems. * The person can still maintain stable relationships and jobs. **Moderate Personality Disorder:** * Struggles in several areas, including personal life, social interactions, and work. * It’s harder to maintain close relationships, with more noticeable social challenges. * Symptoms are distressing, but the person can manage daily life with effort or some support. **Severe Personality Disorder:** * Serious challenges across all areas of life. * Major problems with relationships, sense of self, and coping. * Daily life is very difficult, with high levels of distress and reduced quality of life. * Often needs ongoing, intensive therapy.

Answer 199

**Persistent Pattern:** individual's patterns of cognition, emotional experience, behaviour, and interpersonal functioning deviate from cultural expectations. These patterns are stable over time and span across various personal and social situations. **Impairment**: The deviation results in significant problems or dysfunctions in the person’s life, especially in relationships, work, or social functioning. **Duration**: These characteristics are stable over time, beginning in adolescence or early adulthood, and are not transient. **Distress or Dysfunction**: The impairment may result in distress to the individual or others. These patterns are not explained by another mental disorder, a medical condition, or substance misuse.

Answer 200

**Negative Affectivity:** * Tendency to experience a wide range of negative emotions such as anxiety, depression, guilt, and anger. * Individuals may be prone to mood swings, insecurity, and emotional lability. **Detachment:** * Avoidance of social interactions, emotional withdrawal, and limited pleasure from relationships. * Individuals may appear cold, aloof, and isolated. **Dissociality:** * Disregard for the rights and feelings of others, lack of empathy, and difficulty forming prosocial relationships. * Impulsivity and manipulative behaviours are common traits. **Disinhibition:** * Impulsiveness, risk-taking, and difficulty controlling behaviours. * Individuals may struggle with planning and foresight, leading to reckless or irresponsible actions. **Anankastia:** * Preoccupation with orderliness, control, and perfectionism. * Individuals may be rigid, stubborn, and excessively focused on rules and details. **Borderline Pattern:** * An additional qualifier for those showing emotional instability, intense and unstable interpersonal relationships, a fluctuating sense of identity, and impulsivity.

Answer 201

**Clinical Interview** Diagnosis of personality disorders is often difficult as as these patients don't come to the doctor for help with their personality difficulties, and may have little or no insight into their personality issues. Diagnosis will be based on symptoms detected in talks with the patient or present in their history, whether obtained from the patient him/herself or from others who know the patient (collateral sources).

Answer 202

**Dialectical Behavioural Therapy**, CBT and **psychotherapy** is the key management option of choice. **Risk Management:** such as ongoing self-harm, suicide or harm to others Medications are **not usually used** unless in CRISIS where Sedatives may be used.

Answer 203

* Selective Serotonin Reuptake Inhibitors (SSRIs) * Serotonin and Noradrenaline reuptake inhibitors (SNRIs) * Tricyclic Antidepressants (TCAs) * Others: Mirtazapine, Vortioxetine

Answer 204

TCAs block the reuptake of serotonin and noradrenaline by the presynaptic membrane. They also have additional actions, including blocking acetylcholine, alpha adrenergic and histamine receptors, **which give them anticholinergic and sedative side effects.**

Answer 205

SSRIs work by **blocking** the **reuptake of serotonin by the presynaptic membrane on the axon terminal.** This results in more serotonin in the synapses throughout the central nervous system, boosting the communication between neurones. SNRIs work by **blocking the reuptake of serotonin and noradrenaline by the presynaptic membrane.** This results in more serotonin and noradrenaline in the synapses throughout the central nervous system.

Answer 206

Sertraline Citalopram Escitalopram Fluoxetine Paroxetine

Answer 207

* Sertraline: Anti-anxiety effects but high rate of diarrhoea. Good in heart disease * Citalopram: prolong QT interval leading to torsades de pointes. bad in heart disease * Fluoxetine: long half life and safe in children * Paroxetine: cause weight gain and discontinuation symptoms but safer in pregnancy

Answer 208

**SSRIs** **S**tomach issues - Diarrhoea, nausea, vomiting, increased risk of GI bleeding **S**exual dysfunction - loss of libido, ED, orgasms **R**isk of suicidal thoughts and actions increased **I**rritability, agitation, anxiety (in first weeks) **S**IADH leading to hyponatraemia

Answer 209

**Duloxetine:** Treats neuropathic pain (eg in DM) **Venlaflaxine:** Used when there is an inadequate response to others. Causes discontinuation of symptoms.

Answer 210

Similar to SSRIs **Increase blood pressure and therefore contraindicated in uncontrolled hypertension**

Answer 211

**Sedative:** * Amitriptyline * Clomipramine * Dosulepin **Less Sedative:** * Imipramine * Nortriptyline

Answer 212

**Serotonin and Noradrenaline reuptake** * similar side effects to SSRI/SNRIs **Antagonism of histamine receptors** * Drowsiness **Antagonism of muscarinic receptors** * dry mouth * blurred vision * constipation * urinary retention **Antagonism of adrenergic receptors** * postural hypotension * lengthening of QT interval **Contraindicated in CVD due to causing** * Arrhythmias, * Tachycardia * Prolonged QT * Bundle branch block

Answer 213

* Those with previous heart disease * Can exacerbate schizophrenia * May exacerbate long QT syndrome * May alter blood sugar in T1 and T2 diabetes mellitus * May precipitate urinary retention, so avoid in men with enlarged prostates * Those on CP450 medications or those with liver damage (as it uses the CP450 metabolic pathway)

Answer 214

Those with a history of heart disease and high blood pressure

Answer 215

**Noradrenergic and specific serotonergic antidepressant (NaSSA)** * Blocking α2-adrenergic receptors, which increases the release of norepinephrine and serotonin. * Acting as an antagonist at specific serotonin (5-HT2 and 5-HT3) receptors, which helps reduce side effects commonly seen with SSRIs (such as nausea). * Also blocks H1 histamine receptors, which contributes to its sedative effects. **Highly Sedative and causes increased appetite/weight gain**

Answer 216

* Initial period of worsened agitation, anxiety, suicidal thoughts * Arrange review within **2 weeks** of starting or **1 week if aged 18-25** * Usually a noticeable response within 2-4 weeks of treatment. * If there is an inadequate response then either switch or try something new.

Answer 217

SSRIs and SNRIs can be **directly switched** from one day to the next. **except fluoxetine** Switching between SSRIs and mirtazapine requires **cross-tapering**

Answer 218

* Once started, they should be continued for **at least 6 months after the point of remission** * Should be reduced slowly over **4 weeks** to prevent **discontinuation symptoms**

Answer 219

**start within 2-3 days of stopping and resolve within 1-2 weeks** FINISH: * Flu-like symptoms * Insomnia, iritabilty * Nausea * Imbalance * Shock like sensations * Hyperarousal

Answer 220

**A condition caused by antidepressants which produces symptoms that can range from mild to life threatening** It is caused by excessive serotonin activity. It usually occurs with higher doses of antidepressants and when multiple antidepressants are used together.

Answer 221

* SSRI, SNRI and TCA overdose * Combinations of SSRIs * Monoamine Oxidase Inhibitors (MOAs) * SSRIs interactions with **St Johns Wort, Tramadol, antiemetics (ondansetron)** * **Ecstasy/MDMA, Amphetamines, cocain**, LSD can increase serotonin release

Answer 222

**Triad of Neuromuscular Excitation, Autonomic NS excitation and Altered mental State** **Neuromuscular excitation** * Hyperreflexia * Myoclonus * Tremor * Rigidity **Autonomic nervous system excitation** * severe Hyperthermia (> 40°) * Sweating * Tachycardia * Blood pressure * **Respiratory Failure** **Altered mental state** * Confusion * Seizures **Hyponatramia** **GI Bleeding**

Answer 223

Confusion, Seizures, Severe Hyperthermia (over 40 degrees) and respiratory failure

Answer 224

**Withdrawal of causative medication** **Supportive including IV fluids** * Benzodiazepines for sedation * More severe cases are managed using serotonin antagonists such as **cyproheptadine and chlorpromazine** * May require intubation

Answer 225

It is a extreme treatment method that induces a generalised seizure.

Answer 226

Its indicated for: * Severe depressive illness or refractory depression. * Catatonia. * A prolonged or severe episode of mania that does not respond to other treatments

Answer 227

* Electrodes are placed on the skull. Either on both side or only one side. * Patients are given a general anaesthetic and a muscle relaxant. * Subsequently, an electrical current is delivered to induce a generalised seizure. * The patient has about 6-12 sessions (twice a week). If the patient responds, then sessions are stopped.

Answer 228

**Immediate**: * Cardiovascular instability - eg, arrhythmias and hypotension. * Status epilepticus. * Laryngospasm. * Peripheral nerve palsies. * Headache. * Nausea. **Long term** Possible issues with short and long term memory

Answer 229

Phobia: an **intense, irrational fear** of an object, situation, place or person that is **recognised as excessive** or unreasonable. **Agoraphobia and Social anxiety are classified as their own disorder**

Answer 230

* **Acrophobia** - Fear of heights * **Arachnophobia** - Fear of Spiders * **Ophidiophobia** - Fear of Snakes * **Claustrophobia** - Fear of confined or tight spaces * **Glossophobia** - Fear of public speaking * **Aerophobia** - Fear of Flying * **Thalassophobia** - Fear of large or deep waters * **Trypophobia** - Fear of Holes * **Trypanoboia** - Fear of Needles

Answer 231

* **Irrational** excessive and persistant fear * Immediate anxeity response when exposed * **Recognition the fear is excessive** * **Avoiding** the phobia * Symptoms arent transient * Symptoms not accounted for by another medical or mental health condition * **Significant functional impairment**

Answer 232

Fear of being in a situation or place that an individual perceives as being **unsafe with no escape** * Open space * Closed space * Crowds * Public Transport **Closely liked to panic and social anxiety disorder**

Answer 233

Fear/anxiety of social or performance situations where they are exposed to **potential scrutiny** due to fear of humiliation and embarrassment. * Typically develops in late childhood/adolescence **Often following a specific triggering event where there was embarrassment**

Answer 234

* Significant Avoidance of social situations * Blushing * Fear of vomiting * Palpitations * Trembling * Sweating.

Answer 235

It can be specific (public speaking) or generalised (any social setting) Can be precipitated by stressful or humiliating experiences, parental death, separation, chronic stress. May lead to alcohol or drug abuse (perpetuating the problem). Mental state examination: may appear relaxed as the phobic object or situation is not present.

Answer 236

**1st Line: Cognitive Behavioural Therapy with graded eposure therapy** for all Phobias: * Exposure techniques are the most widely used, aiming for systematic desensitization * Flooding (exposing someone with a fear of heights to a tower) * Modelling (individual observes therapist interacting with phobic stimulus). **If ineffective/severe functional impairment** SSRIs are first-line medical management

Answer 237

Suicide Attempts Serotonin Syndrome Acute Dystonia Neuroleptic Malignant Syndrome Tyramine Induced Hypertensive Crisis Delirium Tremens

Answer 238

Refers to using a substance in a way that is not recommended or prescribed, but not necessarily to the level of causing harm or addiction. Misuse might involve taking higher doses, using medication for non-medical purposes, or using illegal substances recreationally.

Answer 239

use of a substance results in harm or significantly interferes with daily functioning, social obligations, or responsibilities. Abuse implies a pattern of use that leads to negative outcomes or risk of dependency.

Answer 240

The key difference between a person who misuses drugs and a person who abuses drugs is their intent. Someone who misuses a drug, takes the drug to treat a specific ailment. Whereas the latter uses a drug to elicit certain feelings.

Answer 241

Tolerance: **loss of effect** when taking the same dose. Person may keep increasing the dose to reach the desired effects Dependence: **Physiological and psychological need to keep using** a drug * Physiological changes: notable with alcohol, opiates, benzodiazepines * Psychological factors: cravings and compulsions

Answer 242

Symptoms that occur due to physiological adaptations that have taken place in response to a drug.

Answer 243

Brain has reward pathway **mesolimbic pathway** Primary neurotransmitter is **dopamine** Addictive substances and behaviours release dopamine within the mesolimbic pathway providing a pleasurable reward. Repeated exposure **reduces number and sensitivity** of dopamine receptors requiring an **increasingly strong stimulus** Cues for substance or behaviour are embedded in the **amygdala**. stress and other events can act as cues triggering cravings.

Answer 244

>3 features means dependence in a 12 month period * Withdrawal Sx - use drugs to avoid withdrawal Sx onset * Tolerance - require higher doses to achieve same effect * Narrow Repetoir * Cravings * Loss of Control * Rapid Reinforcement - Quick return to old levels after stopping briefly * Primacy - Takes precedence over physiological need (eg. spend money on drugs not food) * Continued use despite harm

Answer 245

**Examples** * Heroin * Morphine * Oxycodone * Codeine **Mechanism of Action:** * stimulates opioid receptors

Answer 246

**Examples** * Cocaine * MDMA (ecstasy) * Methamphetamine **Mechanism of Action:** * Cocaine blocks reuptake of dopamine by the presynaptic membrane * MDMA stimulates the release of serotonin and blocks its reuptake * Meth stimulates the release of dopamine and blocks its reuptake

Answer 247

**Examples** * Alcohol * Benzodiazepines **Mechanism of Action:** * Stimulates GABA receptors

Answer 248

**Examples** * LSD * Psilocybin **Mechanism of Action:** * Stimulates serotonin receptors particularly 5-HT2a

Answer 249

**Examples** * Cannabis **Mechanism of Action:** * Stimulates cannabinoid receptors CB1 and CB2)

Answer 250

**Examples** * Pregabalin * Gabapentin **Mechanism of Action:** * Blocks voltage-gated calcium channels in the presynaptic membrane reducing the release of excretory neurotransmitters

Answer 251

**Examples** * Cigarettes * Vapes **Mechanism of Action:** * Stimulates Nicotinic acetylcholine receptors

Answer 252

**Misuse:** * Low BP * Pinpoint pupils * Needle Trackmarks * Rhinorrhoea **Withdrawal** * Dilated Pupils * High BP * Muscle Aches/Cramps * Sweating

Answer 253

* **Respiratory Depression** * viral infection secondary to sharing needles: HIV, hepatitis B & C * Bacterial infection secondary to injection: infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis * Venous thromboembolism * Overdose may lead to respiratory depression and death * Psychological problems: craving * Social problems: crime, prostitution, homelessness

Answer 254

**Ventilatory Support** Is the most important intervention, and must be done as fast as possible. **Admission of Naloxone** Usually done IV If needed, repeated doses of Naloxone can be done every 2-3 mins

Answer 255

Agitation Anxiety Muscle aches or cramps Chills Runny eyes and nose Sweating Yawning Insomnia Gastrointestinal disturbance Dilated pupils 'Goose bump' skin Increased heart rate and blood pressure Symptoms usually occur within 12 hours of stopping the drug. The withdrawal syndrome is unpleasant but not life-threatening.

Answer 256

**First Line:** * Methadone: Full agonist * Buprenorphine: Partial Agonist **Second Line:** * Naltrexone: Opioid antagonist for relapse prevention as it blocks euphoria **Detoxification should last 4 weeks as inpatient and 12 weeks in community**

Answer 257

Drowsiness Impaired memory Slowed reflexes and motor skills Bloodshot eyes Increased appetite Dry mouth Increased heart rate Paranoia Cannabis acts at cannabinoid receptors.

Answer 258

* Nausea * Headache * Palpitations * Dry mouth * Drowsiness * Tremors

Answer 259

Rapid speech Large pupils Agitation and restlessness High BP.

Answer 260

Variable subjective experiences Impaired judgements which can lead to injury Amplification of current mood which leads to euphoria or dysphoria Agitation, appearing withdrawn - especially in inexperienced users Drug-induced psychosis

Answer 261

**First line:** Supportive reassurance, calm and stress free environment **Second Line:** Benzodiazepines **LSD induced Psychosis** may require antipsychotics

Answer 262

* Euphoria * Increased blood pressure * Increased heart rate * Increased temperature * A feeling of increased concentration and focus.

Answer 263

Psychosocial Interventions are the main treatment. These can include: Counselling Cognitive behavioural therapy Supportive help (for example with housing and benefits).

Answer 264

* History of alcohol or other drug misuse * History of mental illness * Male Sex * Family history of addiction * Unemployment/Homelessness

Answer 265

* Comprehensive history to establish the extent of the drug abuse problem / dependence. * Urine Toxicology * Blood tests - FBC, LFTs, U+Es, etc...

Answer 266

Referral to drug and alcohol services if the patient is open to this (Often self referral) * **Detoxification** (may be coordinated at home or as an inpatient) * **Medication** to help maintain abstinence * **Psychological** and behavioural therapies (e.g., cognitive behavioural therapy) * **Ongoing support** (e.g., a recovery coordinator and support groups)

Answer 267

1st Line: * Therapeutic Trial of Naloxone (Overdose patients will show improvement of symptoms) * ECG (can show things like QRS prolongation and evidence of myocardial ischaemia)

Answer 268

**GHB or GBL overdose** Very closely mimic an opioid overdose, but will show little / no responce to naloxone. **Clonidine/Imidazolines overdose** Presents with more profound bradycardia and hypotension than opioid overdose. And will also show only limited responce to naloxone. **Antipsychotic Overdose** Presents with hypotension and tachycardia, but will not have the profound bradypnoea seen in opioid overdose. No response to naloxone.

Answer 269

It's defined as a pattern of alcohol consumption causing health problems directly related to alcohol. This could include psychological problems such as depression, alcohol-related accidents or physical illness such as acute pancreatitis.

Answer 270

**ICD 10 Criteria for diagnosis requires 3 of the following:** * Craving (desire or compulsion to take the substance) * Difficulties in controlling intake * Physiological withdrawal * Tolerance (more needed to achieve the same effect) * Priority is given to substance, with neglect to other aspects of life * Persistence despite being aware of the harm the substance causes **Patients can be dependent but have no physiological dependence on alcohol (no withdrawal or tolerance)**

Answer 271

It's defined as clinically significant impairment or psychosocial stress in the previous 12 months as a direct result from alcohol? This term encompasses both harmful drinking and alcohol dependence.

Answer 272

* Alcohol is a depressant * Stimulates GABA receptors which have a relaxing affect. * Inhibits Glutamate receptors (NMDA) which also have a relaxing affect Long term alcohol use results in GABA system being down regulated and Glutamate system being upregulated to balance the alcohol effects.

Answer 273

* Not more than 14 units per week * Spread evenly over 3 or more days * Not more than 5 units in a single day

Answer 274

Men: 8 or more units in a single session Women: 6 or more units in a single session

Answer 275

[Volume (ml) X Alcohol Content (%)]/ 1000 = Units

Answer 276

Increased risk of: * Miscarriage * SGA * Preterm delivery * Fetal Alcohol Syndrome

Answer 277

* Family history of alcohol-use disorder * Antisocial behaviour (pre-morbid) * High trait anxiety level * Low response to the effects of alcohol * Depression

Answer 278

**AUDIT Questionnaire** * 10 questions with multiple choice * Score of 8 or more indicates harmful use **CAGE Questionnaire** * **C**UT DOWN? Do you ever think you should cut down? * **A**NNOYED? Do you get annoyed at others commenting on your drinking? * **G**UILTY? Do you ever feel guilty about drinking? * **E**YE OPENER? Do you ever drink in the morning to help your hangover or nerves? **TWEAK Questionnaire**

Answer 279

* Smelling of alcohol * Slurred speech * Bloodshot eyes * Dilated capillaries on the face (telangiectasia) * Tremor

Answer 280

* Raised mean corpuscular volume (MCV) * Raised alanine transaminase (ALT) and aspartate transferase (AST) * AST:ALT ratio above 1.5 particularly suggests alcohol-related liver disease * Raised gamma-glutamyl transferase (gamma-GT) (particularly notable with alcohol-related liver disease)

Answer 281

6-12 hours: tremor, sweating, headache, craving and anxiety, palpitations 36 hours: seizures 48-72 hours: delirium tremens

Answer 282

due to overactivation of the adrenergic system but glutamate upregulation following GABA downregulation **Simple Withdrawal** Insomnia Tremors Anxiety Agitation Nausea and vomiting Sweating Palpitations

Answer 283

It's a rare complication of alcohol withdrawal characterised predominantly by auditory hallucinations It typically presents 12-24 hours post drink

Answer 284

Is another rare complication of alcohol withdrawal and typically presents 48-72 hours post drink It is caused by the overactivation of the adrenergic system from glutamate up-regulation and GABA depression **Symptoms** * Severe agitation * Delusions and hallucinations * **Formication Hallucinations** feeling like bugs are crawling under the skin * Lilliputian Hallucinations (small people or objects) * Confusion * Coarse Tremor * Seizures **Signs** * Ataxia * Tachycardia * Hypertension * Hyperthermia * Arrhythmias

Answer 285

**Benzodiazepine withdrawal** Similar symptoms to alcohol withdrawal, but may also include perceptual changes, depersonalization, derealization, hypersensitivity to light and sound, and numbness/tingling in extremities. **Drug-induced delirium** Characterised by fluctuating mental status, inattention, and a disturbed sleep-wake cycle. **Other conditions causing delirium**

Answer 286

* Patients drinking >30 units per day * Scoring over 30 on the SADQ score * High risk of alcohol withdrawal seizures (previous alcohol withdrawal seizures or delirium tremens, or history of epilepsy) * Concurrent withdrawal from benzodiazepines * Significant medical or psychiatric comorbidity * Vulnerable patients * Patients under 18

Answer 287

**Screening for dependence** * AUDIT Questionnaire (AUDIT-C in time limited scenarious) * CAGE Questionnaire **Screening for Severity** * SADQ (Severity of Alcohol Dependence Questionnaire) * Leeds Dependence Questionnaire (LDQ

Answer 288

**CIWA-Ar (Clinical institute Withdrawal Assessment for Alcohol, Revised)** * **Chlordiazepoxide (Diazepam is a less commonly used alternative)** is a benzodiazepine used to combat the effects of alcohol withdrawal. It is given orally as a reducing regime * **High-dose B vitamins (Pabrinex)** are given intramuscularly or intravenously, followed by long-term oral thiamine. This is used to prevent Wernicke-Korsakoff syndrome.

Answer 289

**Oral Benzodiazepines** as the first-line treatment for delirium tremens. **Chlordiazepoxide, Lorazepam, Diazepam** With parenteral lorazepam offered if oral treatment is declined or symptoms persist.

Answer 290

* Specialist alcohol service * Alcohol detoxification programme * Oral thiamine (pabrinex) * Psychological therapy * Inform the DVLA **Medications:** * Disulfiram - increases sensitivity to alcohol - causes unpleasant symptoms after drinking (induces nausea, vomiting and facial flushing) * Acamprosate - reduces cravings (prevents alcohol relapse) * Naltrexone - reduces pleasurable effects of alcohol * Diazepam - anxiolytic but can also be used in reducing regime in drug detox

Answer 291

**Wernicke-Korsakoff Syndrome** * Alcohol excess leads to thiamine (vitamin B1) deficiency. * Thiamine is poorly absorbed in the presence of alcohol. * Alcoholics often have poor diets and get many of their calories from alcohol. * Thiamine deficiency leads to Wernicke’s encephalopathy and Korsakoff syndrome.

Answer 292

**Wernicke's Encephalopathy** (COAT) * Confusion * Ophthalmoplegia and Nystagmus * Ataxia * Thiamine Deficiency **Korsakoff Syndrome** (RACK) * Retrograde and anterograde amnesia * Altered temper/behavioural changes * Confabulation * Korsakoff Psychosis

Answer 293

Self-harm refers to an intentional act of self-poisoning or self-injury **without suicidal intent**, irrespective of the motivation or apparent purpose of the act. It is an expression of emotional distress

Answer 294

* A behaviour (eg, self-cutting) intended to cause self-harm. * Ingesting a substance in excess of the prescribed or generally recognised therapeutic dose. * Ingesting a recreational or illicit drug that was an act that the person regarded as self-harm. * Ingesting a non-ingestible substance or object.

Answer 295

It's most common among younger people, especially younger / teenage girls. Self-harm increases the likelihood that the person will eventually die by suicide by between 50- and 100-fold.

Answer 296

* Younger age <25 years * Females * Psychiatric problems like borderline personality disorder, depression, bipolar disorder, schizophrenia, eating disorders, drug misuse and alcohol abuse * Domestic violence * Socio-economic disadvantage

Answer 297

1. Emotional Suffering 2. Emotional Overload 3. Panic 4. Self-harming 5. Temporary relief 6. Shame and Guilt - causing emotional suffering

Answer 298

**Safety netting, a Safety Plan and follow up must be considered** **Safeguarding issues** may be considered * Urgent referral to the emergency department if required. Once there they will be seen by the **Mental Health Team** * For drugs taken in overdose / poisoning; **Activated charcoal** is the first line management (preferably within one hour of ingestion) for many substances

Answer 299

* Empathy, supportive communication and building rapport * Identifying triggers for episodes * Separating the means of self-harm (e.g., removing blades or medications from the environment) * Discussing strategies for avoiding further episodes (e.g., distractions, alternative coping strategies and getting help) * Providing details for support services in a crisis (e.g., mental health services, Samaritans and Shout) * Treating underlying mental health conditions (e.g., depression and anxiety) * Cognitive behavioural therapy

Answer 300

**Assessment of needs** Includes an evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment. **Suicide Risk Assessment** **Psychological Intervention** NICE recommends 3-12 sessions specifically structured for self-harm **Dialectical behaviour therapy (DBT)** It's based on cognitive behavioural therapy (CBT), but is specially adapted for people who feel emotions very intensely.

Answer 301

Paracetamol is the most common agent for intentional self-harm in the UK. Paracetamol overdose accounts for 44% of all adult self-poisoning cases in the UK.

Answer 302

A paracetamol overdose involves the buildup of a toxic substance called NAPQI (N-acetyl-p-benzoquinone-imine). Normally, NAPQI is inactivated by glutathione, but during an overdose, glutathione stores are rapidly depleted, leaving NAPQI unmetabolised and resulting in liver and kidney damage.

Answer 303

No symptoms Nausea and vomiting Loin pain Haematuria and proteinuria Jaundice Abdominal pain Coma Severe metabolic acidosis

Answer 304

**Acute gastritis/gastroenteritis** **Renal colic** **Liver diseases** **Metabolic acidosis**

Answer 305

Paracetamol level Full Blood Count (FBC) Urea and Electrolytes Clotting Screen Liver Function Tests Venous Blood Gas Decisions on treatment are guided by a nomogram which plots paracetamol levels.

Answer 306

**Patient presents <1 hour after ingestion**: Give Activated Charcoal **N-Acetylcysteine** should be given if: * Plasma PCM concentration is on or > single treatment line of 100mg/L at 4 hours and 15ml/L at 15 hours. * Staggered overdose or doubt over time of PCM ingestion * Patient presents 8-24 hours after ingestion of 150mg/kg * Patients who present >24 hours after ingestion if clearly jaundiced, have RUQ tenderness or ALT is > normal levels

Answer 307

Over 21 hours * 1st infusion - 150 mg/kg over 1 hour (loading dose) * 2nd infusion - 50 mg/kg over 4 hours * 3rd infusion - 100 mg/kg over 16 hours

Answer 308

Acute Liver Failure

Answer 309

It can be described as a fatal act of self-harm initiated with the intention of ending one's own life

Answer 310

* Male sex * History of deliberate self-harm/suicide attempts * History of alcohol or drug misuse * History of mental illness: Depression, Schizophrenia * History of chronic disease * Advancing age * Unemployment or social isolation/living alone * Being unmarried, divorced or widowed

Answer 311

* Previous Suicide attempts * Efforts to avoid discovery * Planning/preparation * Leaving a written note * Final acts such as sorting out finances * Violent method * Feelings of hopelessness, impulsiveness

Answer 312

* A strong religious faith. * Family support to find alternative solutions to their problems. * Having children at home. * Access to mental health support * A sense of responsibility for others. * Resilience, Coping mechanisms, Problem-solving skills.

Answer 313

A comprehensive clinical interview (NICE recommends that no score systems should be used)

Answer 314

**Introduction** Establish rapport, develop a trusting relationship. Establish current anxieties or problems. Observe behaviour and be alert to any mismatch between words and behaviour. Suicidal intent be denied. **Assess Risk Factors** **Assess Current Plans and Intent** 'Red flags' to consider may include a sense of hopelessness, a feeling of entrapment, well-formed plans, perception of no social support, distressing psychotic phenomena and significant pain/physical chronic illness. **Assess Needs** Social problems. Untreated mental health disorders. Physical symptoms and disorders. Coping strategies. Skills, strengths and assets. Psychosocial and occupational functioning. Personal and financial difficulties. Needs of dependants.

Answer 315

Once a risk assessment has been performed, subsequent action will depend on the level of risk believed to be present. Formulate a Care Plan (including a risk management and crisis plan) Specific treatment e.g. Medication Counselling Cognitive behavioural therapy (CBT) Dialectical behaviour therapy (DBT) Provide follow up at regular intervals

Answer 316

**Check TOXBASE** * Activated charcoal can also be given within 1 hours of overdose to reduce absorption for: * Paracetamol * Aspirin * SSRIs * TCAs * Antipsychotics * Benzodiazepines * Quinine

Answer 317

* Activated Charcoal if ingested <1 hour ago * N-Acetylcysteine (NAC) * Liver Transplantation

Answer 318

* Urinary alkalinisation with **IV Bicarbonate** * Haemodialysis

Answer 319

Flumazenil **Carries a high risk of seizures**

Answer 320

* IV Bicarbonate

Answer 321

* **Mild/Moderate:** Volume resuscitation with normal saline * **Severe** may need haemodialysis

Answer 322

* Fomepizole or Ethanol * Haemodialysis

Answer 323

Vitamin K or Prothrombin complex

Answer 324

Protamine Sulphate

Answer 325

**If bradycardic** then Atropine **If HF or cardiogenic shock** then Glucagon

Answer 326

* Dicobalt edetate * Hydroxycobalamin

Answer 327

* Calcium chloride * Calcium gluconate

Answer 328

* 100% oxygen * Hyperbaric oxygen

Answer 329

* Atropine

Answer 330

Desferroxamine

Answer 331

* Dimercaprol * Calcium edetate

Answer 332

Digoxin-specific antibody fragments

Answer 333

It provides legal structures to define and manage procedures associated with the treatment and rights of people with mental health disorders.

Answer 334

Approved Mental Health Professional * Primary person making an MHA assessment and organising the admission

Answer 335

A Section 12 doctor is a qualified and approved doctor (usually a psychiatrist) who can undertake Mental Health Act assessments. The Responsible Clinician is the person with overall responsibility for the patient’s care (generally the consultant). The Nearest Relative is someone close to the patient who is responsible for looking out for the patient’s interests. The Mental Health Act has an ordered list that dictates who fits this role. An Independent Mental Health Advocate (IMHA) is an independent person allocated to a patient being detained under the Mental Health Act. Their role is to support the person, help them understand the situation, and express themselves.

Answer 336

**2 doctors** * One must be a "Section 12 doctor" * Another doctor (preferably with involvement with the patients care) **An AMHP**

Answer 337

* Least Restrictive Option and Maximising Independence * Empowerment and Involvement * Respect and Dignity * Purpose and Effectiveness * Efficiency and Equity

Answer 338

It is a legal process through which an individual who is deemed by a qualified agent to have symptoms of severe mental disorder is detained in a psychiatric hospital where they can be treated involuntarily.

Answer 339

**Compulsory admission for mental health assessment** for up to 28 days, * Non-renewable - must end in either discharge or detainment under section 3 * For assessment (may be followed by treatment) * Requires 2 doctors and an AMHP

Answer 340

**Compulsory admission for Treatment** * Maximum period of 6 months * Can then be renewed if requiring further treatment * Nearest Relative can object

Answer 341

**Used to detain patients for up to 72 hours in urgent scenarios** * Used where other procedures cannot be arranged in time. * It requires an AMHP and one doctor. * It is followed by a Mental Health Act assessment. Designed for emergencies when applying Section 2 would cause an unnecessary delay.

Answer 342

Enables a doctor to legally detain a patient who attended the hospital voluntarily (already in hospital) * For a **period of 72 hours**. * Only requires 1 Doctor **Section 5(4) enables 1 nurse to do the same for 6 hours** These are followed by a MHA Assessment

Answer 343

Allows for a Supervised Community Treatment (also known as a Community Treatment Order).

Answer 344

Court order enabling the police to enter a property to escort a person to a Place of Safety (either the police station or, more commonly, an Accident and Emergency Department (A&E)).

Answer 345

Provides police officers the authority to take an individual, who seems to be suffering from a mental disorder and is in a public place, to a Place of Safety. * Lasts up to **24 hours** * Followed by a MHA Assessment

Answer 346

**Section 37:** Hospital Order * Court can order an individual with a mental disorder to be detained in a hospital instead of serving a prison sentence * Initial duration is up to 6 months but can be reviewed **Section 41:** Restriction order * Applied when the court deems it necessary to protect the public * Ministry of Justice must be involved in decisions about a patients leave, transfer or discharge.

Answer 347

**Common** * Alzheimer's disease * Depression **Infrequent** * Vascular dementia * Fibromyalgia * Lewy body dementia * Chronic fatigue syndrome * Normal pressure hydrocephalus **Rare** * Frontotemporal lobar degeneration * Huntington's disease * Creutzfeldt-Jakob disease * Duchenne muscular dystrophy * Wilson's disease

Answer 348

CBT is a term that has come to be used to refer to behavioural therapy, cognitive therapy and therapy that combines both of these approaches.

Answer 349

It is a treatment approach based on clinically applying theories of behaviour that have been extensively researched over many years.

Answer 350

Is a treatment focussing on the role of cognitions in the development of emotional disorders.

Answer 351

* Depression * Generalised anxiety disorder (GAD) and panic disorder * OCD * Body dysmorphic disorder (BDD) * Post-traumatic stress disorder (PTSD) * Suicide/self harm

Answer 352

* Identify negative thought patterns that contribute to emotional distress. * Challenge these thoughts by examining evidence for and against them. * Develop more balanced thinking and coping strategies such as changing behaviours * Apply new skills in real-world situations, leading to lasting change.

Answer 353

Hypnotics are a class of drugs that will produce drowsiness and facilitates sleep and maintains sleep

Answer 354

Anxiolytics are drugs that will decrease activity, relax the patient and calm the recipient

Answer 355

Benzodiazepines Fall into the category of both anxiolytic and hypnotic drugs

Answer 356

Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels.

Answer 357

sedation hypnotic anxiolytic anticonvulsant muscle relaxant

Answer 358

2-4 weeks This is because patients commonly develop a tolerance and dependence to benzodiazepines.

Answer 359

It presents very similarly to Alcohol Withdrawal syndrome Perspiration Perceptual disturbance Insomnia Irritability Tinnitus Tremors Seizures Anxiety Decreased appetite

Answer 360

* Anorexia Nervosa * Avoidant/Restrictive Food Intake Disorder (ARFID) * Bulimia Nervosa * Binge Eating Disorder

Answer 361

Anorexia Nervosa It is the most common cause of admissions to child and adolescent psychiatric wards

Answer 362

Females Teenagers/Young adults

Answer 363

Person feels they are overweight despite evidence of normal/low body weight.

Answer 364

* 90% of patients are female * Affects teenage-young adults

Answer 365

1. Significantly Low Body Weight (BMI < 18.5) 2. Low body weight not caused by another medical condition or unavailability of food 3. Persistent pattern of restrictive eating **often associated with intense fear of weight gain** 4. Excessive Preoccupation with body weight or shape (such as weighing themselves excessively) 5. Significant functional impairment

Answer 366

* Weight loss/reduced BMI * Amenorrhoea * Lanugo hair (fine, soft hair across most of the body) * Hypotension * Hypothermia * Mood changes, including anxiety and depression

Answer 367

* Hypokalaemia * Low FSH, LH, Oestrogen, Testosterone * Raised cortisol and GH * Impaired glucose tolerance * Low T3 * Hypercholesterolaemia, Hypercarotinaemia

Answer 368

* Amenorrhoea due to disruption of HPG axis. (**Hypogonadotrophic hypogonadism**) * Cardiac complications: arrhythmia, cardiac atrophy, sudden cardiac death * Low bone mineral density

Answer 369

**First Line:** Anorexia Focused Family Therapy **Second Line:** Cognitive Behavioural Therapy - Eating disorder focused

Answer 370

* Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) * Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) * Specialist supportive clinical management (SSCM).

Answer 371

Admission for observation of refeeding and monitoring for refeeding syndrome Typically when BMI is less than **BMI <13**

Answer 372

An eating disorder characterized by a **persistent pattern of inadequate eating** typically due to avoidance of certain **textures, colours, smells or appearance**

Answer 373

**Limited Food Selection:** Eating only a few specific foods, often with little variety in textures or types. **Strong Reactions to Certain Foods:** Extreme aversion or disgust to specific foods, which can provoke anxiety, gagging, or even vomiting. **No Concern for Body Image:** Unlike anorexia nervosa, individuals with ARFID typically do not have a distorted body image or fear of weight gain **Physical Symptoms:** Possible physical health complications arising from nutritional deficiencies, such as fatigue, weakness, or gastrointestinal issues.

Answer 374

* Avoidance or restriction of food intake * Insufficient quantity or variety of food for nutritional requirements * Significant functional impairment * Pattern of eating is not motivated by preoccupation of food * Restricted intake leads to health problems

Answer 375

* Nutritional Counselling * Family Focused Therapy and CBT * Exposure Therapy

Answer 376

An eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviour

Answer 377

* Erosion of teeth * Swollen salivary glands * Mouth Ulcers * GORD * Calluses on Knuckles **Russel's Sign** **Often have a normal body weight** **Alkalosis** due to repeated vomiting of HCL from the stomach

Answer 378

1. Frequent recurrent episodes of Binge eating (> 1x per week for 1 month) 2. Repeated inappropriate compensatory behaviours to prevent weight gain (> 1x per week for 1 month) 3. Excessive preoccupation with body weight or shape 4. Significant impairment in personal, family, social or occupational areas 5. Doesnt meet criteria for Anorexia Nervosa

Answer 379

**Bulimia nervosa focused family therapy**

Answer 380

**First Line:** * Bulimia focused guided self-help * Trialled for 4 weeks of treatment **Second Line:** * Eating Disorder focused Cognitive Behavioural Therapy * If 1st line not effected after 4 weeks

Answer 381

Characterised by episodes where the person excessively over-eats often due to underlying psychological distress.

Answer 382

* recurrent episodes of binge eating (1 or more episodes a week) for at least 3 months * Feelings of loss of control over eating * Not regularly associated with purgative behaviours * Not explained by a medical condition (Prader will) * Causes significant distress or impairment

Answer 383

* Regular consumption of non-nutritional/non-food sources * Ingestion is persistent or severe enough to require medical attention * Occurs at age which would be inappropriate (> 2 years) * Symptoms or behaviours not attributed to another medical condition

Answer 384

clay, soil, chalk, plaster, plastic, metal and paper

Answer 385

Anaemia (normochromic, normocytic) Leukopenia Thrombocytopenia Hypokalaemia

Answer 386

Refeeding syndrome

Answer 387

* Occurs when someone of severe nutritional deficit resumes eating. During prolonged starvation, **intracellular potassium, phosphate, magnesium** are delpleted as the ions move into the blood to maintain normal levels * refeeding causes salt shifts due to insulin driving the ions back into cells and sodium out of cells. * This leads to **Hypomagnesaemia, Hypokalaemia, Hypophosphataemia, Fluid overload**

Answer 388

* Hypomagnesaemia (low serum magnesium) * Hypokalaemia (low serum potassium) * Hypophosphataemia (low serum phosphate) * Fluid overload (due to water following the extra sodium into the extracellular space)

Answer 389

Arrhythmia Heart failure Death

Answer 390

* **Slowly** reintroduce food with limited calories * **Supplementation with electrolytes and vitamins (B and Thiamine)** * Magnesium, potassium, phosphate, glucose monitoring * Fluid balance monitoring * ECG monitoring for cardiac complications

Answer 391

Disorders of consciousness, memory, identity or perception Often occurring as a coping mechanism following significant trauma or distress

Answer 392

* Depersonalisation-Derealisation Disorder * Dissociative Amnesia * Dissociative Identity Disorder

Answer 393

* Borderline Personality Disorder * Post Traumatic Stress Disorder

Answer 394

Depersonalisation which is a feeling of being separated or outside of their body and derealisation where they feel the world is not real

Answer 395

Involves forgetting autobiographic information (details about themselves or events that happened to them) often following a traumatic experience leading to gaps in their memory

Answer 396

**Multiple Personality Disorder** * Involves a lack of clear individual identity. * Multiple separate identities with unique names, personalities and memories * Often associated with severe stress and childhood trauma

Answer 397

Abnormal movement, communication and behaviour * Patients are awake but don't behave normally * May hold unusual postures, perform odd actions or remain blank and unresponsive **Management:** Benzodiazepines (Lorazepam) is first line

Answer 398

* Severe Depression * Bipolar Disorder * Psychosis and Schizophrenia

Answer 399

**Munchhausen Syndrome:** * Compelled to fake illness and take on the sick role, seek medical attention for sympathy * Symptoms are invented, exaggerated or self induced * Get satisfaction from puzzling medical professionals

Answer 400

Where a person fakes or produces symptoms in someone else (often their child) to get attention

Answer 401

fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

Answer 402

* Patient loses control of one of their hands * Acts with a mind of its own performing spontaneous actions such as touching or grabbing * Often result of underlying brain lesions

Answer 403

* False belief (delusion) that they are dead or actively dying. * Known as **Walking Corpse Syndrome** * Caused by Depression, Schizophrenia, brain lesions

Answer 404

* Delusion than in identical duplicate has replaced someone close to them * Person may be suspicious or aggressive towards the imposter

Answer 405

**Also called Erotomania** Delusion that a famous or high social status individual is in love with the patient.

Answer 406

**Todd Syndrome** Incorrectly perceiving the size of body parts or objects. * Associated with perception of time changes * Associated with symptoms of migraines

Answer 407

Delusion that the sex organs are retracting/shrinking and ultimately disappear. * This often leads to panic attacks.

Answer 408

**Conversion Disorder** Sensory and motor symptoms that are not explained by any neurological disease and may be due to psychological factors.

Answer 409

* Weakness * Gait disturbance * Seizures * Loss of sensations * visual disturbances.

Answer 410

**Hypochondriasis** * Persistent belief in the presence of an underlying serious DISEASE, e.g. cancer * Patient again refuses to accept reassurance or negative test results

Answer 411

* Multiple physical SYMPTOMS present for at least 2 years * Patient refuses to accept reassurance or negative test results

Answer 412

**Appearance:** * General appearance * Hygiene * Clothing * Weight **Behaviour:** * Engagement * Eye contact * Facial Expression * Body Language * Psychomotor activity * Abnormal movements/postures **Speech:** * Rate: pressure, slow * Quantity: Poverty/Excessive speech * Tone: Monotonous, Tremulous * Volume: Quiet/Loud * Fluency: Stammering, Slurred, Stilted(thought blocked) **Mood and Affect:** * Mood: subjective how the patient feels * Affect: Observational such as facial expressions * Intensity: Blunted/flat/heightened * Congruency **Thought Form:** * Speed of thoughts: racing * Flow and coherence: circumstantiality, tangentality, flight of ideas etc. **Thought Content:** * Delusions * Obsessions * Compulsions * Overvalued Ideas * Suicidal ideation * Violent thoughts **Thought Possession:** * Thought insertion * Thought withdrawal * Thought Broadcasting **Perception:** * Hallucinations * Pseudohallucinations * Illusions * Depersonalisation * Derealisation **Cognition** * Orientated to time, place, person * Attention span * Short term memory * AMTs **Insight:** * Do they understand that they have a mental health problem **Judgement:** * Make considered decisions and sensible conclusions **Risk to Self and others:** * Thoughts of self-harm * Substance mis-use * Self-neglect * Thoughts of harming others

Answer 413

Reasoning that's based on what you can see, hear, feel, and experience in the here and now.

Answer 414

moving rapidly from one topic to another with no apparent connection between the topics.

Answer 415

A neuropsychiatric disorder wherein a patient generates a false memory without the intention of deceit

Answer 416

A Schneiderian first-rank symptom in which a patient has the impression that his or her feelings or actions are those of another or others, usually an unknown outside power **Eg. somatic passivity is experiencing actions, thoughts, emotions that are not their own**

Answer 417

when you feel emotions but show practically nothing visually

Answer 418

Where a patients affect does not match the content of their speech: eg. appearing happy and laughing when talking about something distressing or depressive

Answer 419

A decreased ability to express emotion through your facial expressions, tone of voice, and physical movements.

Answer 420

A paradoxical absence of psychological distress despite a serious medical illness or symptoms of a health condition.

Answer 421

* Psychomotor retardation: associated with a paucity of movement and delayed responses to questions. * Restlessness: the patient may continuously fidget, pace and refuse to sit still.

Answer 422

these are thoughts which include lots of irrelevant and unnecessary details but do eventually come back to the point.Def

Answer 423

digressions from the main conversation subject, introducing thoughts that seem unrelated, oblique, and irrelevant.

Answer 424

seen with fast, pressured speech. Ideas run into one another, making it difficult for the observer to follow the flow of speech

Answer 425

sudden cessation of thought, typically mid-sentence, with the patient unable to recover what was previously said.

Answer 426

refers to the repetition of a particular response (such as a word, phrase or gesture) despite the absence/removal of the stimulus (e.g. a patient is asked what their name is, and they then continue to repeat their name as the answer to all further questions).

Answer 427

words a patient has made up which are unintelligible to another person.

Answer 428

speaking a random string of words without relation to one another.

Answer 429

a solitary, abnormal belief that is neither delusional nor obsessional but preoccupying to the extent of dominating the person’s life (e.g. the perception of being overweight in a patient with anorexia nervosa)

Answer 430

a firm, fixed belief based on inadequate grounds, not amenable to a rational argument or evidence to the contrary and not in sync with regional and cultural norms.

Answer 431

the same as a hallucination, but the patient knows it is not real.

Answer 432

the misinterpretation of an external stimulus (e.g. mistaking a shadow for a person).

Answer 433

the patient feels that they are no longer their ‘true’ self and are someone different or strange.

Answer 434

a sense that the world around them is not a true reality.

Answer 435

Development of Tics that are persistent for over a year

Answer 436

Involuntary movements or sounds that are performed repetitively throughout the day. They become more prominent when the individual is under pressure or excited.

Answer 437

Clearing throat Blinking Head jerking Sniffing Grunting Eye rolling

Answer 438

Performing physical movements, such as twirling on the spot or touching objects Copropraxia involves making obscene gestures Coprolalia involves saying obscene words Echolalia involves repeating other people’s words

Answer 439

**Mild tics/no underlying disease** * May only require monitoring and reassurance * Take measures to reduce stress, anxiety and triggers **Severe or troublesome tics** * Referral to a specialist * **Habit reversal training** * **Exposure with response prevention** * Medications - used in very severe cases (often use antipsychotics)