Psychiatry Flashcards

Question

What is agoraphobia?

Answer 1

Fear or anxiety about 2 or more of: 1. Using public transport 2. Being in open spaces 3. Being in closed spaces 4. Standing in line or being in a crowd 5. Being outside the home alone Patients fear or avoids these situations because escape may be difficult in the event of developing panic like symptoms, where fear and anxiety is out of proportion to the actual damage.

Answer 2

Recurrent unexpected panic attacks with \> 4 of the following symptoms: STUDENTS FEAR THE 3 C's * Sweating * Trembling * Unsteadiness * Depersonalisation/ derealisation * Excessive heart rate/ palpitations * Nausea * Tingling * SOB * FEAR of dying * Chest pain, chills, choking 1 months of anxiety about panic attacks with one of the following: * persistent concern or worry about panic attacks * significant maladaptive behaviour

Answer 3

***P****hysical **D**istress **T**hat **H**ave **C**ommonly **A**ppeared **A**nxious* * Phaeochromocytoma * Diabetes * Temporal lobe epilepsy * Hyperthyroidism * Carcinoid (neuroendocrine tumours) * Alcohol withdrawal * Arrhythmias

Answer 4

1. Experienced or observed event 2. intrusions (e.g., flashbacks, intrusive images and sensory impressions, dreams/nightmares); 3. Avoidance (e.g., avoiding people, situations, or circumstances resembling or associated with the event); 4. Negative alterations in mood and cognition (e.g., feeling alienated from others, constricted affect, diminished interest in significant activities, distorted negative beliefs about oneself or the world, and inability to remember key features of the traumatic event); 5. Alterations in arousal or reactivity (e.g., hypervigilance for threat, exaggerated startle response, irritability, difficulty concentrating, and sleep problems). 6. Symptoms for greater than 1 month 7. Significant distress or impaired function

Answer 5

_Psychotherapy_ 1. CBT (trauma focused, exposure therapy) 2. Cognitive processing therapy 3. Eye movement desensitization and reprocessing – recalling memories whilst watching finger move back and forth _Pharmacotherapy_ 1. SSRI, SNRI (first line) 2. Nightmares - Prazosin is effective for improving sleep 3. Consider atypical antipsychotics for psychotic symptoms 4. Benzodiazepines can be used for hyperarousal and anxiety, but monitored closely

Answer 6

Characteristic symptoms same as PTSD, just lasts between 3 days to 1 month

Answer 7

A maladaptive emotional or behavioural response to a stressor that lasts \< 6 months following termination of the stressor. Symptoms such as stress, feeling sad, physical symptoms that occur because patients is having hard time coping. The reaction is stronger than expected for the type of event that occurred.

Answer 8

* Obsessions * **Recurrent and intrusive thoughts**, ideas, impulses or images that are usually resisted by the person and are recognized as the product of their own mind and not imposed from outside * Compulsions * **Repetitive behaviors in response to an obsession**, to prevent discomfort or some dreaded event with which is not connected in a realistic way. The person generally recognizes that their behavior is excessive or unreasonable. Performing the action provides relief from anxiety caused by obsession

Answer 9

1. Obsessions and/or compulsion * Obsessions * Recurrent/ persistent, intrusive thoughts, or urges that cause anxiety or distress * Attempts to suppress these thoughts or urges * Compulsions * Repetitive behaviours or thoughts that the individual feels forced to perform by these obsessions * Intentions to prevent or reduce anxiety, distress, or a dreaded event; behaviours are excessive or are not linked to the dreaded events at all 1. Time-consuming, or resulting in significant distress/ impairment 2. Not due to substance-use disorders or another medical condition 3. Not due to another mental disorder (anxiety disorders, eating disorders)

Answer 10

A combination of pharmacotherapy and psychotherapy has been proven effective in the treatment of OCD * Cognitive Behavioural therapy * Pharmacotherapy * Antidepressants à SSRI (sertraline, fluoxetine) * Alternatively, tricyclic antidepressants with serotonergic action (clomipramine) * Atypical antipsychotics (quetiapine)

Answer 11

Schizophrenia tends to present initially with prodrome of negative symptoms (classically withdrawal) that precedes the positive psychotic symptoms (hallucinations and bizarre behaviours) _Positive symptoms of psychosis_ 1. **Hallucinations** * A perceptual abnormality, in which sensory experiences occur in the absence of external stimuli 1. **Delusions** Fixed, false beliefs that are not amenable to reason, despite evidence to the contrary * Bizarre: impossibility of being true * Non-bizarre: possibility of being true or consistent with patient’s culture 1. **Illusions** * A perceptual abnormality, in which real external stimuli are misinterpreted 1. **Disorganised thought and speech processes** 1. Loose associations – incoherent thinking expressed as illogical, sudden, and frequent topic changes 2. Word salad 3. Neologisms – creating of new words 4. Flight of ideas 5. Clang associations – use of words based on rhyme rather than meaning 6. Circumstantial speech – non-linear thought expressed as a long-winded manner of explanation 7. Tangential speech 8. Thought-blocking 9. Pressured speech _Negative symptoms of psychosis (the 5 A’s)_ 1. **Flat affect** * Reduced or absent affective expression 1. **Avolition** * Reduced or absent ability to initiate purposeful activities 1. **Alogia** * Impoverished thinking that presents as reduced speech output or poverty of speech 1. **Anhedonia** * Inability to feel pleasure from activities 1. **Apathy** * Lack of emotion or concern, especially with regards to matters that are normally considered important _Cognitive symptoms_ 1. Inattention 2. Impaired memory 3. Poor executive functioning _Mood symptoms -_ Depression _Catatonia –_ A behavioural syndrome characterized by abnormal movements and reactivity to the environment * Retarded catatonia – immobility, posturing, negativism * Excited catatonia – excessive, purposeless movement in both the upper and lower limbs, restlessness, impulsivitiy * Malignant catatonia – fever, autonomic instability (tachycardia, tachypnea, abnormal BP and sweating), rigidity, and delirium (resembles neuroleptic malignant syndrome)

Answer 12

1. \>=2 of the following symptoms for \>= 1 month (with at least one of the first 3) 1. Delusions 2. Hallucinations 3. Disorganised speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms 1. Symptoms must cause social, occupational or personal functional impairment 2. Some sign of illness must persist for at least 6 months 3. Schizoaffective disorder and mood disorder with psychotic features have been ruled out 4. Symptoms must not be due to a medical or substance use disorder 5. If there is a history of autism spectrum disorder or other communicating disorder beginning in childhood, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month

Answer 13

Investigations 1. TFTs – elevated TSH suggests hypothyroidism 2. Metabolic panel 3. FBC – anaemia can cause fatigue 4. Serum B12 and folate 5. 24-hour urinary cortisol – elevated levels suggest Cushing’s 6. MRI, ANA, syphilis Causes * HIV/AIDS * diabetes * arthritis * strokes * brain disorders such as Parkinson's disease, Huntington's disease, multiple sclerosis, and Alzheimer's disease * metabolic conditions (e.g. vitamin B12 deficiency) * autoimmune conditions (e.g., lupus and rheumatoid arthritis) * viral or other infections (hepatitis, mononucleosis, herpes) * back pain * certain cancers (e.g., pancreatic) * hypothyroidism * anaemia

Answer 14

1. **CT/ MRI** – rule out dementia, brain tumour, traumatic brain injury 2. **EEG** - Temporal lobe epilepsy 3. **Serum HIV enzyme-linked immunosorbest essay** 4. **Serum rapid plasma regain test –** rule out syphilis 5. **FBC** * WCC - infection (also do CRP): infections such as EBV, rabies, mumps, measles * volume abnormalities in red cells can suggest vitamin deficiencies or increased alcohol intake 1. **LP** – encephalitis 2. **Urea and electrolytes** – Hypercalcemia 3. **LFTs** – most drugs processed by liver, hepatic encephalopathy 4. **Urine drug screen and plasma drug level monitoring** * Antihistamine, Dextromethorphan, anticholinergic, dopamine agonist, corticosteroid, adrenergic, thyroid hormones, cocaine, cannabis, amphetamine, alcohol 1. **Endocrine disorders – TFTs, 24-hour urine cortisol, hyperparathyroidism** 2. **Autoimmune disorders –** SLE 3. **Metabolic disorders – Wilson’s disease – copper** 4. **Chromosomal disorders – Klinefelter’s syndrome** 5. **Prolactin** **Causes** * Brain tumors * Traumatic brain injury * Epilepsy * Autoimmune disorders * Thyroid disease – hyperthyroidism * Hyperparathyroidism * Huntington’s disease * CNS infection * Multiple sclerosis * Stroke * Migraine * Carbon monoxide poisoning * Heavy metal poisoning

Answer 15

1. **Hospitalization if acutely psychotic** 2. **General approach** * Acknowledge the patients emotional state * Avoid validation of delusions or confronting patients about the delusional nature of their complaints 1. **Antipsychotic treatment** 1. Acute psychotic episodes - Short acting antipsychotics (olanzapine) +/- mood stabilizer (lithium, valproate) 2. First-line treatment: second-generation antipsychotics (olanzapine, risperidone, quetiapine) 3. Alternatively, first-generation antipsychotics (haloperidol, fluphenazine, chlorpromazine) 4. Cloazapine for treatment-resistant schizophrenia 1. **Psychoeducation** * Patient, family and group psychosocial therapy and education * CBT * Supportive social measures

Answer 16

Psychotic and residual symptoms lasting 1-6 months (Schizophrenia lasts \> 6 months)

Answer 17

* Psychotic symptoms lasting \> 1 day but \< 1 month * triggered by stressful symptoms

Answer 18

* Features of schizophrenia AND a major mood disorder (depression or bipolar) * psychosis must have been present for at least 2 weeks in the absence of any mood disturbance * mood symptoms do not appear in the absence of psychosis

Answer 19

* \>= 1 delusions with a duration of \>=1 month and no other psychotic symptoms * functioning is not markedly impaired and behaviour is not obviously bizarre or odd * sympoms are not better explained by substance abue, ot other medical illness

Answer 20

* Persecutory – affected person fears they are being stalked, spied upon, obstructed, poisoned, conspired against or harassed * Paranoid – belief one is being harmed or persecuted * Grandiose – believe they are greater or more influential * Referential delusions – e.g. radio talking to you * Delusional jealousy – spouse or partner is being unfaithful * Somatic delusion – thing something wrong with them * Control passivity – someone else controls them or they control something * Guilt delusions * Nihilism – belief that life is meaningless * Delusional parasitotis – parasites e.g. ice * Shared delusion – folie a deux * Erotomanic – someone else is in love with them (usually a famous person) * Bizarre – refers to delusions that is implausible e.g. alien invasion * Non-bizarre – delusion such as fear of being followed * Mood congruent vs not mood congruent

Answer 21

* meets criteria for a mood disorder * psychotic features appear exclusively during manic or depressive episodes * mood symptoms may be present in the absence of psychosis

Answer 22

1. Paranoid personality disorder 2. Schizoid personality disorder 3. Schizotypal personality disorder

Answer 23

*SUSPECT* * Suspects without bases that others are harming, exploiting or deceiving them * Unforgiving * Spousal infidelity suspected * Perceives attacks on reputation that are not apparent to others * Enemy or friend? Preoccupied with doubts of trust * Confiding in others is feared * Threats perceived in benign events

Answer 24

*DISTANT* * Detached or flattened affect * Indifferent to criticism or praise * Sexual experiences of little interest * Tasks done solitarily * Absence of close friends * Neither enjoys or desires close relationships * Takes pleasure in few activities

Answer 25

*ME PECULIAR* * Magical thinking/ odd belief * Experiences unusual perceptions * Paranoid ideation * Eccentric behavior/ appearance * Constricted affect * Unusual thinking and speech * Lacks close friends * Ideas of reference * Anxiety in social situations * Rule out psychotic disorder and pervasive developmental disorder

Answer 26

1. Antisocial personality disorder 2. Bordeline (EUPD) disorder 3. Histrionic peronality disorder 4. Narcissistic personality disorder

Answer 27

*CORRUPT* * Conformity to law lacking * Obligations ignored * Reckless disregard for safety of self or others * Remorse lacking * Underhanded (deceitful, lies, cons) * Planning insufficient (impulsive) * Temper

Answer 28

*IMPULSIVE* * Impulsive * Moodiness * Paranoia or dissociation under stress * Unstable self-image * Labile intense relationships * Suicidal gestures * Inappropriate anger * Vulnerability to abandonment * Emptiness – feelings

Answer 29

*PRAISE ME* * Provocative behavior * Relationships (considered more intimate than they are) * Attention (uncomfortable when not center of attention) * Influenced easily * Style of speech (impressionistic, lacks detail) * Emotions (rapidly shifting and shallow) * Made up (physical appearance used to draw attention to self) * Emotions exaggerated (theatrical)

Answer 30

* Special (believes they are special and unique) * Preoccupied with fantasies (unlimited success and power) * Envious * Entitlement * Excessive admiration required * Conceited * Interpersonal exploitation * Arrogant * Lacks empathy

Answer 31

1. Avoidant personality disorder 2. Dependent personality disorder 3. Obsessive compulsive personality disorder

Answer 32

*CRINGES* * Certainty of being liked required before willing to risk involvement * Rejection possibility preoccupies thoughts * Intimate relationships avoided * New relationship avoided * Gets around occupational activities that involve interpersonal contact * Embarrassment potential prevents new activities * Self-views as unappealing, inept, inferior

Answer 33

*RELIANCE* * Reassurance required for decisions * Expressing disagreement difficulties (fear of loss of support or approval) * Life responsibilities assumed by others * Initiating projects difficult * Alone (feels helpless and a sense of discomfort when alone) * Nurturance (goes to excessive lengths to obtain nurturance and support) * Companionship sought urgently when close relationship ends * Exaggerated fears of being left to care for self

Answer 34

*LAW FIRMS* * Loses point of activity * Ability to complete tasks comprised by perfectionism * Worthless objects (unable to discard) * Friendships (and leisure activities) excluded due to preoccupation * Inflexible, scrupulous, over conscientious * Reluctance to delegate * Miserly * Stubborn

Answer 35

1. Psychoeducation, psychotherapy, dialectical behavior therapy, group therapy, and/ or cognitive therapy 2. Symptomatic medical therapy 1. Mood stabilizers – valproate, topiramate and lamotrigine 2. Antipsychotics – especially for symptoms of delusion 3. Antidepressants - SSRIs

Answer 36

Mild substance use if 3 of the following, moderate = 4-5, severe = 6+ 1. **Impaired control** * Using substance in larger amounts and/ or for longer time than originally intended * Repeated failed attempts to cut down * Spending a great deal of time on substance related activities 1. **Social impairment** * Problems fulfilling work, school, family or social obligations * Problems with interpersonal relationships directly related to substance use * Reduced social and recreational activities 1. **Risky use** * Use in physically hazardous situations * Use despite awareness of physical problems 1. **Pharmacologic indicators** * Drug intolerance * The need for individuals to continuously increase the dose of a substance to achieve the same desired effect * Drug withdrawal * Substance-dependent collection of symptoms that appear after cessation of prolonged heady drug use

Answer 37

Dependence * Dependence specifically refers to a physical condition in which the body has adapted to the presence of a drug. If an individual with drug dependence stops taking that drug suddenly, that person will experience predictable and measurable symptoms, known as a withdrawal syndrome. Addiction * Addiction is an uncontrollable or overwhelming need to use a drug, and this compulsion is long-lasting and can return unexpectedly after a period of improvement.

Answer 38

Total of 5+ indicates increasing or higher risk, all on scale of 0-4 1. How often do you have a drink containing alcohol? 2. How many units of alcohol do you dirnk on a tyical day when you are drinking? 3. How often have you had 6 or more units if female or 8 or more if male, on a single occassion in the last year?

Answer 39

_Acute_ * Risky behavior endangering the patient such as * Suicide, drowning, homicide, rape, abuse, vehicle accidents * Aspiration of gastric contents * Metabolic imbalances * Hypothermia * Seizures _Long-term_ * Erosive gastritis * Dilated cardiomyopathy * Pancreatitis * Cirrhosis * Alcoholic liver disease * Mood disturbance: anxiety, depression, irritability, aggression * Vitamin deficiency: B1, B6, B9, B12 * Peripheral neuropathy * Wernicke-Korsakoff * Gout In pregnancy – fetal alcohol syndrome

Answer 40

1. Acute alcohol intoxication à breath alcohol level, BAC 2. Chronic alcohol intoxication * Liver damage – increased transaminase levels: GGT, ALT, AST (AST \> ALT) * Carbohydrate-deficient transferrin (CDT): CDT * Malnutrition and bone marrow damage: * decreases folic acid, vitamin B12, vitamin B1, vitamin B6, vitamin D, vitamin K * FBC - anaemia, thrombocytopenia, MCV * U&E

Answer 41

1. Psychosocial support for cessation of alcohol use (e.g. alcoholics anonymous or another support group) 2. Pharmacotherapy to promote alcohol cessation * Block positive effects of alcohol: Administer naltrexone (blocks release of endogenous opioids post alcohol) , acamprosate or topiramate * Create toxic reaction when alcohol ingested: administer disulfiram 1. Ongoing vitamin supplementation * Vitamin B1, B6, B12, folic acid Haloperidol may worsen respiratory depression secondary to alcohol intoxication

Answer 42

Cessation in alcohol use that has been heavy and prolonged 2 or more of the following develop few hours to several days after cessation * Autonomic activity (sweating or tachycardia) * Increased hand tremor * Insomnia * Nausea or vomiting * Transient visual, tactile or auditory hallucinations or illusions * Psychomotor agitation * Anxiety * Generalize tonic clonic seizures (onset 6-48 hours after last drink, if left untreated, risk of delirium tremens)

Answer 43

1. Frequent monitoring 2. Fluid therapy and correction of electrolytes disturbances 3. Pharmacotherapy * IV benzodiazepines for control of psychomotor agitation – diazepam, lorazepam * Cease benzos after 5-7 days * Anticonvulsants – carbamazepine * Antipsychotics – haloperidol, risperidone * IV vitamin B1 (thiamine) as prophylaxis of Wernicke’s encephalopathy and peripheral neuropathy * Antiemetic’s 1. Control blood pressure and severe vegetative side affects 1. _Naltrexone_ * May commence while still drinking, Start with ½ tab for 4 days, then single tablet (50mg) od * Blocks reinforcement of pleasure effect of drinking * Blocks opioid receptors * Generally low side effects – mild nausea, headache, anxiet * Non-addictive, no withdrawal 1. _Acamprosate (Campral)_ * May commence while still drinking * Non addictive, no withdrawal * Mechanism: Glutamate pathways (stimulates inhibitroy GABA-ergic NT in the brain and antagonized the effects of excitatory amina acids, such as glutamate) 1. _Disulfiram_ * Must be minimum 5 days alcohol free * Inhibits acetaldehyde dehydrogenase – nausea, flushing, dizziness, palpitations * Motivated patient, compliance improved if dosing supervised, often by a partner * Caution – coexisting significant medical conditions, potentially toxic to liver 1. _Baclofen_ * A selective GABAb receptor agonist – hence inhibitory role in CNS neuronal excitation * Reduced anxiety, reduced craving for alcohol * NNT = 7ish, NNH = 7ish, Not registered for use in alcohol relapse prevention **_How long do you prescribe for?_** Long enough for sustained change to become usual behavior: Mood disorder improved, Cravings absent or diminished – sense of control, Sense of self – improved esteem, hopefulness, Relationships recovered Min 4 months, maybe 12 or 24 months

Answer 44

Thiamine deficiency. **Wernicke's encephalopathy** Acute and reversible biochemical damage to the CNS as a result of thiamine depletion Triad of symptoms 1. opthalmoplegia (ocular disturbances) 2. Changes in mental state (confusion) 3. Ataxic gait 85% untreated progress to irreversible Korsacoff’s Maximum recovery takes 1 year of abstinence **Korsacoff syndrome** Acute onset of severe memory impairment without any dysfunction in intellectual abilities: a manifestation of Wernicke’s. Damage primarily in Thalamus and Mammillary bodies. Symptoms: 1. Anterograde amnesia 2. Retrograde amnesia 3. Confabulation 4. Minimal content in conversations 5. Lack on insight 6. Apathy Treat with IV Thiamine Mortality 10% in severe cases Dramatic increase in death from causes such as infection

Answer 45

_Opioid intoxication_ * Altered mental status * Bilateral miosis (pinpoint pupils) * Respiratory depression * Seizures * Decreased bowel sounds * Decreased heart rate and blood pressure * Rhabdomyolysis Treatment 1. Acute airway management 2. Administer opioid receptor antagonist: IV naloxone 3. Management of complications (diazepam for seizure)

Answer 46

_Opioid withdrawal_ * Flu-like symptoms: rhinorrhea, chills, myalgia, arthralgia, leg cramps * GI complaints: nausea, vomiting, abdominal pain, diarrhea, hyperactive bowel sounds * Features of sympathetic hyperactivity: mydriasis, tachycardia, hypertension, hyperreflexia * Features of CNS stimulation: insomnia, yawning, irritability, anxiety, agitation _Withdrawal symptom management_ 1. Clonidine – helps ameliorate sympathetic system overdrive 2. Metoclopramide/ odansetron – releif of nausea 3. Loperamide – relief of GIT hypermotility 4. Buscopan – relief of abdominal cramps 5. Sedative – ameliorate the anxiety, agitation and distress. Insomnia management

Answer 47

_Provide a substitute opioid_ * Methadone – full opioid agonist * Buprenorphine – partial opioid agonist _Block the reinforcing effects of continual opiate use_ * Naltrexone – mu receptor antagonist _Psychotherapy_ * Motivational interviewing * CBT, education, AA, group therapy, peer support

Answer 48

* OD * Disinhibition (aggression, high risk sexual encounters, shoplifting) * Cognitive and memory impairment * Abnormal sleep pattern with rebound insomnia

Answer 49

* Transfer to equivalent dose of diazepam * Longer acting agents promote stable levels * Prevent cycles of intoxication and withdrawal * Caution if equivalent dose \> 30mg diazepam * Use a treatment agreement contract * Rate of reduction * Plan for managing emergent symptoms * Reduce dose every 1 to 2 weeks * For daily pickup – from daily to weekly * Regular review with frequent reassurance, alternative coping strategies, maintain patient alliance

Answer 50

1. Significant deliberate reduction in body mass using strategies that include restrictive eating, purging, and excessive exercise 2. Fear of weight gain motivates compensatory behavior that promotes weight loss, even if the patient already has low body weight 3. Body image disturbance: * Excessive concern about weight and body shape, despite being considerably underweight * Lack of awareness of the seriousness of low body weight

Answer 51

1. **CNS –** hypothermia, cortical pseudoatrophy with enlargement of subarachnoid space 2. **Endocrine** * Stress hormones (cortisol , adrenaline) * Thyroid – euthyroid sick syndrome * Secondary amenorrhoea (severe weight loss suppress the hypothalamic-pituitary-gonadal axis - hypogonatotropic hypogonadism) 1. **Electrolyte abnormality –** hypokalaemia 2. **Heart -** Bradycardia, hypotension, cardiac arrhythmias 3. **Bones –** secondary osteoporosis and stress fracture 4. **Skin and hair:** dry skin, wound healing disorders, hair loss 5. **Salivary glands –** sialadenosis with dystrophy 6. **Dental status –** caries due to frequent vomiting 7. **Blood –** pancytopenia

Answer 52

* Electrolyte imbalances: increased potassium, sodium, chloride, increased bicarbonate (metabolic alkalosis) * Glucose decreased * Liver enzymes: increased AST/ ALT * proteins: hypoproteinemia, hypoalbuminemia * Blood count: pancytopenia * TFTs * ECG * Bone density scan

Answer 53

_Psychotherapy (first line)_ 1. Cognitive Behavioral therapy 2. Psychodynamic psychotherapy _Nutritional support_ 1. Monitor weight gain and provide nutritional support; usually through oral intake 2. Indications for hospitalization * \<70% ideal body weight or BMI \< 15kg/m^2 * unstable vital signs - hypothermia (\<35.5), bradycardia (\<40bpm), hypotension or symptoms of lightheadedness * acute medical complications (syncope, seizures, pancreatitis, liver failure) * arrhythmia * hypoglycaemia * electrolyte disturbances * severe refeeding syndrome

Answer 54

All 5 criteria must be met: 1. Binge eating 2. Recurrent compulsive compensatory behavior to counteract weight gain * Most frequently: self-induced vomiting after binge eating * Laxative abuse * Transient starvation periods * Other weight loss measures 1. Binge eating and inappropriate compensatory behavior both occur at least once a a week over a 3-month period 2. Sense of self-worth pathologically influenced by perception of physical appearance (body weight and shape) 3. Symptoms do not exclusively occur during an episode of anorexia nervosa

Answer 55

_Gastrointestinal tract_ * Esophagitis and/or gastritis * Poor dental status (e.g. perimylolysis) * Salivary gland swelling (parotitis) _Metabolic imbalances_ * ¯ potassium, ¯ sodium, ¯chlorine and ¯calcium * blood pH _Skin_ * Calluses on the knuckles (Russell’s sign) * Dry skin and brittle nails _Cardiovascular symptoms_ * Cardiac arrhythmias * Hypotension

Answer 56

An incongruence between a person’s experienced/ expressed gender and assigned gender over a period of at least 6 months, as manifested in \>=2 of the following: 1. Incongruence between one’s experienced/ expressed gender and primary and/ or secondary sex characteristics 2. Strong desire to be rid of one’s primary and/ or secondary characteristics of the other gender 3. Strong desire to the other gender 4. Strong desire to be treated as the other gender 5. Strong conviction that one has feelings and behaviors more typical of the other gender + clinically significant distress/ impairment in function

Answer 57

1. Persistent or recurrent difficulty with \>= 1 of the criteria below in women over a minimum period of 6 months: 1. Vaginal penetration during sexual intercourse 2. Severe vulvovaginal pain during vaginal intercourse or attempted penetration 3. Severe anticipatory anxiety related to vulvovaginal or pelvic pain during attempted vaginal intercourse or attempted penetration 4. Severe tightening of pelvic floor muscles during attempted vaginal penetration 1. Causes significant distress to the individual 1. Is not attributable to another mental illness, substance, significant relationship distress, or medical conditions

Answer 58

1. Pelvic floor physical therapy: considered best initial treatment option * Consists of a combination of modalities, as internal manual techniques, patient education, dilatation exercises, local tissue desensitization, and home exercises 1. Anxiolytic drugs – opioids, antidepressants, benzodiazepines 2. Local botox injections for refractory cases

Answer 59

**Organic** 1. Vascular – HTN, DM, CVD, hyperlipidemia 2. Neurogenic – stroke, brain or spinal cord injury, dementia, Parkinson disease, multiple sclerosis 3. Endocrine – hypogonadism, hyperprolactinemia, thyroid disorder 4. Medications: * Antihypertensives (beta-blockers, thiazide diuretics) * Antidepressants (SSRIs) * Dopamine agonists (antipsychotics) 1. Iatrogenic – radical prostatectomy, pelvic radiation 2. Trauma – pelvic fracture and urethral injury 3. Alcohol abuse **Psychiatric** 1. Depression 2. Anxiety (performance related) 3. Trauma from prior experience 4. Relationship issues 5. Stress

Answer 60

1. **Psychotherapy** * Counselling * Sensate focus exercises for performance anxiety 1. **Medical therapy** 1. Phosphodiesterase-5 inhibitors – sildenafil, tadalafil * Contraindicated in patients taking nitrates due to profound hypotension 1. Testosterone replacement if hypogonadism 2. Intracavernous injection therapy with papaverine or alprostadil 1. **Mechanical** 1. Vacuum pump with penis ring 1. **Surgical** 1. Implantation of penile prosthesis – last resort

Answer 61

Presenting with 6 months or more of the following symptoms: 1. **_DSM 18 items (core phenotype)_** 1. _9 inattentions (6 out of 9 items)_ * Careless mistakes in schoolwork * Sustain attention difficult * Does not listen * Not follow-through on instructions and fails to finish schoolwork * Disorganized * Avoid tasks that require mental effort * Loses things * Distracted by external stimuli * Forgetful in doing daily activities e.g. chores 1. _9 hyperactivity and impulsivity (6 out of 9 items)_ * Fidgets * Leaves seat when sitting expected * Runs around or climbs in inappropriate situations * Noisy – cant engage in activities quietly * ‘on the go’ e.g. uncomfortable being still for extended time * Talks excessively * Blurts out answer before question completed * Can’t wait e.g. in line * Interrupt or intrudes other 1. Several inattentive or hyperactive-impulse symptoms were present before 12 years of age 2. Several symptoms present in two or more setting (home, school, work; friends; family; other activities) 3. Symptoms interfere with, or reduce the quality of, social, academic or occupational functioning 4. Symptoms don’t occur exclusively during a psychotic disorder, and are not better explained by another mental disorder e.g. mood, anxiety, dissociative, personality, substances) **Can be:** 1. ADHD predominantly inattentive (If inattention \>= 6 out of 9) 2. ADHD predominantly hyperactive/ impulsive (If hyperactivity \>= 6 out of 9) 3. ADHD combines (If both criteria \>=6 out of 9)

Answer 62

_Either differentials, or comorbidity of:_ * Learning disorder e,g, dyslexia * IQ test, speech and language assessment, and also school attainment tests * Language disorder * Developmental coordination disorder * Anxiety disorder, depression * Autism Spectrum Disorder (ADI, ADOS) * Tourette disorder and tic disorder * OCD * Oppositional defiant disorder * Conduct disorder _Medical_ * Hearing, vision problems * Sleep, pain * Foetal alcohol spectrum disorder * Hyper/ Hypothyroidism * PMS

Answer 63

1. Persistent deficits in social communication and social interaction across multiple contexts * Deficits in social-emotional reciprocity, ranging, for example from abnormal social approach and failure of normal back and forth conversation; to failure to initiate interactions * Deficits in nonverbal communication e.g. eye contact and body language * Deficits in developing, maintaining and understanding relationships 1. Restricted, repetitive patterns of behavior, interests or activities * Stereotyped or repetitive motor movements, use of objects or speech * Insistence on sameness, inflexible adherence to routines * Highly restricted, fixated interests abnormal in intensity or focus * Hyper- or hypo reactivity to sensory input or unusual interest in sensory aspects to environment 1. Symptoms must be present in the early development period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learning strategies in later life) 1. Symptoms cause clinically significant impairment in social, occupational or other important areas of current functioning 1. These disturbances are not better explained by intellectual disability or global developmental delay. Intellectual disability and autism spectrum disorder frequent co-occur _Specify:_ 1. With or without accompanying intellectual impairment 2. With or without accompanying language impairment 3. Associated with a known medical or genetic condition or environmental factor 4. Associated with another neurodevelopmental, mental, or behavioral disorder 5. With catatonia _Severity levels:_ 1. Level 1 – Requiring support 2. Level 2 – Requiring substantial support 3. Level 3 – Requiring very substantial support

Answer 64

**_First-line treatment_****:** * Methylphenidate [Ritalin] (lower seizure threshold) * Treatment for patients \> 6yo, 5mg BD * Dexamphetamine (epileptic subjects, non-responders) * 5mg BD Common side effects of stimulants: Increased BP, tachycardia, insomnia, dry mouth, sweating, headache, loss of appetite, nervousness, moodiness, tearfulness, stomach ache. Often short-lived and subside after 1-2 weeks. Rarer: hallucinations, mania, tics. **_Second-line treatment_****:** * Atomoxetine 80mg-100mg * start 20mg, then increase every 5/7 (20/7) and wait for 4/52 for response. Response rate: 1/3. s/e nausea, dry mouth, agitation, vivid dreams. Useful for anxious, panicky individuals

Answer 65

1. Early behavior and educational management * Competence training: social skills, communication skills * Establishing clear and consistent structures 1. Family support and counseling: e.g. parental education on interaction with the child and acceptance of his/her behavior 2. Medical treatment 1. SSRIs – repetitive stereotyped behavior, anxiety 2. Antipsychotic drugs – aggression, self-injury 3. Methylphenidate – ADHD

Answer 66

A repetitive persistent pattern of disruptive behavior for \>= 12 months that violates basic rights of others or age-appropriate societal norms or rules. DSM-5 1. Aggression to people and animals 2. Destruction of property 3. Deceitfulness or theft 4. Serious rule violation 5. The disturbance in behavior significantly impairs social, academic, and/ or occupational functioning

Answer 67

_Specific learning difficulties without generalized cognitive impairment_ 1. Dyslexia 2. Dyscalculia 3. ADHD 4. Specific language impairment 5. Central auditory processing disorder 6. Developmental co-ordination disorder/ dyspraxia _Genetic disorders_ 1. Down Syndrome * Chromosomal karyotype 1. Fragile X syndrome * Learning and communication difficulties, hyperactivity and attention deficit, moto co-ordinaiton diffirulties * DNA testing – fragile site on Xp27.3 1. Tuberous sclerosis * Seizures, variable cognitive impaitment, FHx, HTN, cardiac arrhythmia * DNA test, CT brain 1. Prader-Willi syndrome 2. Turner Syndrome 3. Autism spectrum disorder _Intra-uterine causes_ 1. Intra-uterine Infections * Rubella, toxoplasmosis, CMV 1. Fetal alcohol syndrome 2. Teratogenic drugs _Perinatal causes_ 1. Prematurity 2. Perinatal hypoxia _CNS_ 1. Bacterial meningitis 2. Tumour 3. Traumatic brain injury 4. Hypoxia/ asphyxia 5. Seizures _Endocrine_ 1. Hypothyroidism 2. Inborn errors of metabolism

Answer 68

1. Consider the context of the situation– Where to manage the patient? What is your role? 2. Acute risk management 3. Diagnostic clarification 4. Management of acute symptoms - for each primary condition (Pharm and psychological) 5. Psychosocial and other contributory factors 6. Long term rehabilitation (Pharm and psychological)

Answer 69

1. FBC * Anemia can mimic depression * Some drugs cause decreased WCC * Infection can mimic delirium 1. UEC * Drugs metabolized by kidneys (if initiating drugs or if required for monitoring effects on kidney e.g. lithium) * Hyponatramia can mimic depression 1. LFTs * Drugs metabolized by liver (e.g. if initiating drugs or if required for monitoring effects on liver e.g. anticonvulsants can cause deranged (increased) LFTs) * Alcoholism/ cirrhosis 1. TFTs – Increased can mimic anxiety, mania, irritability, decreased can mimic depression 2. Drug levels (lithium, valproate for indications of compliance, toxicity, therapeutic range) 3. bHCG – pregnancy 4. Fasting BSL and fasting lipids – metabolic syndrome can be caused by drugs 5. B12, folate – deficiency mimics depression, dementia, delirium 6. Ca, Mg – parathyroid problems can mimic depression, delirium, psychosis, anxiety 7. HSV, syphilis, hepatitis, HIV, Chlamydia/ Gonorrhea PCR – esp. IVDU patients * Urine 1. MCS – for UTI in older people – delirium 2. Toxicology e.g. opiates, speed * Imaging for patients with first episode psychosis and delirium 1. CT head to exclude SOL, SDH, atrophy * ECG – for possible drug side effects (cardiotoxic medications) * EEG – temporal lobe encephalopathy (Wernicke’s encephalopathy), CJD, seizures (temporal lobe epilepsy)

Answer 70

\*Note: all take 2-4 weeks to take effect SSRI's * Sertraline (Zoloft) [50mg initial dose] , Citalopram, escitalopram (prosac) [10mg initial dose] , fluoxetine * Increases extracellular seritonin by blocking reabsorption in the presynaptic cell * Side effects: * GI (N+V), Sexual (loss libido, ED), Weight gain, CNS (Insomnia, anxiety) * Seretonin Syndrome, discontinue syndrome SNRI's * Venlafaxine (Effexor) [37.5mg BD] Duloxetine * Reversible, negative allosteric blocking of SERT and NA transporter on nerve terminals * Side effects - same as SSRI's (Except seretonin syndrome) NaSSA (NA-serotonin specific antidepressant) * Mirtazapine [15mg OD bedtime] * Antagonism of inhibitory presynaptic alpha2-adrenoceptor on NA and 5-HT nerve terminals * Side effects - dry mouth, consitpaiton, increased appetite, weight gain

Answer 71

**Typical Antipsychotics** * Haloperidol [0.5-2mg orally 2-3 times a day for moderate], Chlorpromazine * Block dopamine D2 receptor, hence they reduce dopaminergic neurotransmission in the four dopamine pathways (mesocortical pathway, mesolimbic pathway, nigrostriatal pathway, tuberoinfundibular pathway). * Mesolimbic pathway - the dopamine theory postulates that positive symptoms such as delusions, hallucinations and thought disorder might be caused by an over activity of this pathway. * Mesocortical pathway - part of the neurobiology of negative and cognitive symptoms. * Note: Can worsen parkinson symptoms (nigrostriatal pathway) * Side effects: Dry mouth, muscle stiffness, cramping, tremor, weight gain * Adverse effects: Extrapyramidal symptoms (acute dyskinesia, parkinsonism, akathisia), QT prolongation, Neuroleptic malignant symdrome Atypical Antipsychotics * Olanzapine (metabolic syndrome + weight gain) * Risperidone (postural hypotension) * Clozapine (Agranulocytosis) * Apiprazole (partial agonist) * Quetiapine (sedation) * MOA: * All antipsychotics reduce dopaminergic neurotransmission. Second generation antipsychotics have additional properties: * 5-HT_2A antagonism * some have 5-HT_1A agonism * fast dissociation * 5HT2A antagonism can increase dopaminergic neurotransmission in the nigrostriatal pathway, reducing the risk of extrapyramidal symptoms. It could also theoretically improve negative and cognitive symptoms in schizophrenia by increasing dopamine release in the prefrontal cortex. * 5HT1A agonism would increase dopamine release in the prefrontal cortex and also reduce glutamate release. * Apiprazole MOA: * Aripiprazole is a partial agonist at D2 receptors. * It may act as an antipsychotic by: * Lowering dopaminergic neurotransmission in the mesolimbic pathway. * Enhancing dopaminergic activity in the mesocortical pathway. * It has a lower risk of EPS and hyperprolactinemia than other antipsychotics. * Adverse effects * Weight gain, metabolic syndrome, sedation, anticholinergic * Lower rate of Extrapyramidal symptoms (Dyskinesia, akathisia, parkinsonism)

Answer 72

* Lithium * SE - GI (N+V), Neuro (tremor, headahce, vertigo), T wave inversion * monitor - kidney function, thyroid, parathyroid, electrolytes * Sodium Valproate * Blockage of voltage dependent NA channels and increased levels of GABA * SE - weight gain, N+V, drowsiness. Contraindicated in young females that can get pregnant

Answer 73

* Diazepam (Valium) - 2-10mg 2-4 times per day * Lorazepam, Midazolam, Clonazepam * MOA - Enhance the effect of GABA at the GABA(A) receptor * Indicated in anxiety, alcohol withdrawal * Adverse effects - Parodoxical insomnia, restlessness, hyperexcitability. Dependence.

Answer 74

A drug-related complication resulting from increased brain-stem serotonin activity, usually precipitated by the use of one or more serotonergic drugs: * SSRI, SNRI, MAOI, Amphetamines, Metoclopramide, Odansetron, opioids, CNS stimulants Symptoms 1. Cognitive effects – headache, agitation, hypomania, mental confusion, hallucinations, coma 2. Autonomic effects – shivering, sweating, hyperthermia, vasoconstriction, tachycardia, nausea, diarrhea, hypertension 3. Somatic effects – myoclonus, hyperreflexia, clonus, tremor Management Discontinue serotonergic drugs immediately Supportive care 1. Antihypertensive, fluid replacement 2. Benzodiazepines for sedation 3. Cyproheptadine – 5-HT receptor antagonist – used for cases of serotonin syndrome that do not respond to supportive care. 4. Cooling measures – ice packs, cold compress

Answer 75

Life threatening neurological disorder usually associated with antipsychotics. Blockade of dopamine receptor D2 leading to abnormal function of the basal ganglia and muscular symptoms. Atypical antipsychotics also affect serotonin, GABA and glutamate worsening the syndrome. Symptoms * F - fever * E - encephalopathy (altered mental state) * V - Vitals unstable (autonomic instability) * E - Elevated enzymes - CK --\> rhabdomyalosis * R - Rigidity of muscles Investigations * CK increased, myoglobulinuria (rhabdo) * Leukocytosis, increased transaminases * Metabolic acidosis Treatment 1. discontinue antipsychotic 2. Dantrolene (ryanodine receptor antagonist) *

Answer 76

Inhibition of cholinergic neurotransmitters at muscarinic receptor sites following ingestion of certain medications: * Anti-histamines * Anti-Parkinson’s * Atropine * Anti-spasmodic * Skeletal muscle relaxants Symptoms * Flushing, dry skin * Mydriasis * Altered mental state * Fever * Tachycardia and HTN * Myoclonic jerking * Urinary retention * Dysrhythmias * seizures

Answer 77

Symptoms that occur post rapid discontinuation of SSRIs or SNRIs * Flue like illness * Insomnia * Nausea * Imbalance * Sensory disturbance * Hyperarousal

Answer 78

CBT can be used for anxiety or depression. It aims to help a person i**dentify and challenge unhelpful thoughts** and to **learn practical self-help strategies**. These strategies are designed to bring about positive and immediate changes in the person’s quality of life. CBT aims to show people how their thinking affects their mood and to teach them to think in a less negative way about life and themselves. It is based on the understanding that thinking negatively is a habit that, like any other habit, can be broken.

Answer 79

* Whilst under general anaesthesia (e.g. propofol) and a musclerelaxant (e.g. suxamethonium),electrodes placed on patient’s head and an electrical impulse is passed through the braincontinuously and this induces a generalised convulsive seizure. Therapeutic response iscorrelated with total seizure time. [from “psychiatry made ridiculously simple” book] * Most troublesome S/E is short- term memory loss (hours to days) Other S/E: anaesthetics risk, headaches, myalgia * Contraindications: increased ICP * Indications * Acute management of cases where the patient is not eating or drinking, or imminently suicidal \< \>Severe depression (especially melancholic) \< \>Catatonic schizophrenia \< \>Severe depression during pregnancy

Answer 80

Dialectical behaviour therapy (DBT) is a modified version of cognitive-behavioural therapy (CBT) designed to treat borderline personality disorder (BPD). It can also be used to treat other conditions, like suicidal behaviour, self-harm, substance use, post-traumatic stress disorder (PTSD), depression and eating disorders. The term ‘dialectical’ means ‘working with opposites’. DBT uses seemingly opposing strategies of ‘acceptance’ and ‘change’. The therapist accepts you just as you are, but acknowledges the need for change in order for you to recover, move forward and reach your personal goals. During a course of DBT, the therapist works with you to help you move away from a chaotic life and towards a life that you find personally meaningful and fulfilling. DBT involves developing two sets of acceptance-oriented skills and two sets of change-oriented skills. 1. _Acceptance-oriented skills_ 1. Mindfulness * Focus your awareness on the present moment, acknowledge your thoughts, feelings, behaviors and bodily sensations 1. Distress tolerance * Learn how to manage and cope during a crisis, and to tolerate distress when it is difficult or impossible to change situation 1. _Change-oriented skills_ 1. Emotional regulation * Learning how to effectively manage your emotional experience, and not allow your emotions to manage you 1. Interpersonal effectiveness * Learning assertiveness strategies to appropriately ask for what you want or need

Answer 81

Criteria for an inpatient treatment: 1. The person has a mental illness requiring treatment 2. Because of the mental illness there is a significant risk fo the health or safety of the person or to the safety of another person, or a significant or serious harm to the person or to another person 3. the person does not demonstrate the capacity to make a decision about provision of treatment 4. treatment in the community cannot reasonabily be provided to the person 5. there is no alternative that would be less restrictive to the persons freedom of choice and mocement Duration: referral must be made within 48 hours, referral remains in force for 72 hours