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PSYCHIATRY Flashcards

1
Q

what is hyperactive delirium?

A
  • inappropriate behaviour
  • hallucinations

agitation.

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2
Q

what is hypoactive delirium?

A
  • lethargy
  • reduced concentration
  • reduced appetite.
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3
Q

what are the clinical features of delirium?

A
  • Impaired ability to direct, sustain, and shift attention.
  • Global impairment of cognition with disorientation, and impairment of recent memory and abstract thinking.
  • Disturbance in sleep–wake cycle with nocturnal worsening.
  • Psychomotor agitation.
  • Emotional lability.
  • Perceptual distortions, illusions, and hallucinations—characteristically visual.
  • Speech may be rambling, incoherent, and thought disordered.
  • There may be poorly developed paranoid delusions.
  • Onset of clinical features is rapid with fluctuations in severity over minutes and hours
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4
Q

how is delirium managed?

A
  • environmental reorientation

- oral haloperidol or oral lorazepam

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5
Q

what are the clinical features of ADHD?

A
  • Failure to pay close attention to details or making careless mistakes in school work, work or other activities
  • Difficult sustaining attention in tasks or play activities
  • Does not seem to listen when spoken to directly
  • Does not follow through on instructions and fails to finish school work, chores or duties in the workplace
  • Often has difficult organising tasks and activities
  • Avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort
  • Often loses things
  • Easily distracted by extraneous stimuli
  • Forgetful in daily activities
  • Fidgets
  • Leaves seat when remaining seated is expected
  • Runs or climbs excessively and inappropriately
  • Difficulty plating
  • Often in the go
  • Talks excessively
  • Blurts out answers before question is finished
  • Difficulty awaiting turns
  • Interrupts and intrudes
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6
Q

how are children under 5 with ADHD managed?

A

-Offer an ADHD-focused group parent-training programme

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7
Q

how are children aged over 5 with ADHD managed?

A
  • environmental modifications
  • methylphenidate
  • lisdexamfetamine 2nd line
  • dexamfetamine 3rd line
  • atomoxetine or guanficine 4th line
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8
Q

how are adults with ADHD managed?

A
  • CBT
  • lisdexamfetamine or meythlphenidate first line
  • dexamfetamine
  • atomoxetine
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9
Q

how long does a section 2 last for and which professionals are needed?

A
  • 28 days

- 1 doctor, 1 AMHP and 1 section 12 approved doctor

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10
Q

how long does a section 3 last for and which professionals are needed?

A
  • 6 months

- 1 doctor, 1 AMHP and 1 section 12 approved docto

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11
Q

how long does a section 4 last for and which professionals are needed?

A
  • 72 hours

- 1 doctor and 1 AMHP

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12
Q

how long does a section 5(4) last for and which professionals are needed?

A
  • 6 hours

- 1 nurse

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13
Q

how long does a section 5(2) last for and which professionals are needed?

A
  • 72 hours

- 1 doctor

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14
Q

what are the clinical features of GAD?

A
  • Excessive worry for at least 6 months
  • Anxiety not confined to another condition or substance
  • Muscle tension
  • Sleep disturbance
  • Fatigue
  • Restlessness
  • Irritability
  • Poor concentration
  • Headache
  • Sweating
  • Dizziness
  • GI symptoms
  • Muscle aches
  • Tachycardia and palpitations
  • Shortness of breath
  • Tremor
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15
Q

what is the stepwise management of GAD?

A
  • education and active monitoring
  • low intensity psychological therapy
  • High intensity psychological therapy
  • SSRI
  • Pregabalin
  • tertiary referral
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16
Q

what is mania?

A

-A distinct period of abnormally and persistently elevated, expansive, or irritable mood, with 3 or more characteristic symptoms lasting at least 1 week

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17
Q

what is hypomania?

A

-Three or more characteristic symptoms lasting at least 4 days, and are clearly different from ‘normal’ mood, that are not severe enough to interfere with social or occupational functioning

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18
Q

what is bipolar I disorder?

A

-the occurrence of one or more manic episodes or mixed episodes, with or without a history of one or more depressive episodes (2 manic episodes with no depressive episode or 1 depressive and 1 manic episode)

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19
Q

what is bipolar II disorder?

A

-the occurrence of one or more depressive episodes accompanied by at least one hypomanic episode.

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20
Q

how is mania/hypomania managed?

A
  • stop anti-depressant
  • antipsychotic such as haloperidol, olanzapine, quetiapine or risperidone
  • lithium
  • valproate
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21
Q

how is bipolar depression managed?

A
  • fluoxetine combined with olanzapine, or quetiapine on its own, or in addition with current bipolar treatment
  • lamotrigine with lithium
  • lamotrigine and valproate
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22
Q

what are the clinical features of cyclothymia?

A
  • Persistent instability of mood
  • numerous periods of mild depression and mild elation
  • not sufficiently severe or prolonged to fulfil the criteria for bipolar affective disorder or recurrent depressive disorder.
  • The mood swings are usually perceived by the individual as being unrelated to life events.
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23
Q

what are the clinical features of panic disorder?

A
  • Unexpected onset
  • Apprehension and worry
  • Behavioural avoidance
  • Tachycardia
  • Palpitations and chest discomfort
  • Nausea and abdominal pain
  • Dizziness
  • Perceptual abnormalities
  • Hyperventilation, shortness of breath and a feeling of choking
  • Paraesthesia
  • Muscle shaking
  • Sweating
  • Fainting
  • Chills or hot flushes
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24
Q

how is panic disorder managed?

A
  • individual non-facilitated self-help
  • individual facilitated self-help
  • CBT
  • SSRIs, SNRIs or TCAs
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25
Q

what is agoraphobia?

A

-Anxiety and panic symptoms associated with places or situations where escape may be difficult or embarrassing leading to avoidance.

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26
Q

what are the clinical features of phobia?

A
  • Anticipatory anxiety
  • Behavioural avoidance
  • Nausea
  • Dizziness
  • Fainting
  • Tachycardia
  • Hyperventilation
  • Exaggerated startle
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27
Q

how are phobias managed?

A

-Offer psychological interventions including systematic desensitisation and flooding, along with CBT.

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28
Q

how is social phobia managed in adults?

A
  • CBT
  • SSRI
  • SNRI
  • MAOI
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29
Q

how is social phobia managed in children?

A

-Offer individual or group CBT focused on social anxiety

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30
Q

what are the clinical features of OCD?

A
  • Intrusive, unwanted, anxiogenic thoughts that result in marked distress.
  • Patient typically recognises that these thoughts are irrational.
  • Repetitive behavioural or mental acts that are designed to neutralise the anxiety that results from obsessions.
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31
Q

how is OCD managed in adults?

A
  • CBT
  • ERP
  • SSRIs
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32
Q

how is OCD managed in children?

A
  • CBT
  • SSRI
  • Clomipramine
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33
Q

what are the clinical features of depression?

A
  • Depressed mood
  • Anhedonia
  • Fatigue or loss of energy.
  • Weight change associated with change in appetite
  • Disturbed sleep with early morning wakening
  • Psychomotor agitation or retardation
  • Reduced libido
  • Feelings of worthlessness or excessive guilt
  • Diminished ability to think or concentrate or indecisiveness
  • Recurrent thoughts of death or suicide
  • Delusions: poverty, personal inadequacy, guilt over presumed misdeeds, responsibility for world events, deserving of punishment or nihilistic delusions
  • Hallucinations – auditory, olfactory, visual that may be mood congruent or incongruent
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34
Q

how is depression managed?

A
  • Individual guided self-help based CBT
  • Computerised CBT
  • A structured group physical activity programme
  • Group CBT
  • SSRIs
  • SNRI, TCA or MAOI
  • augmentation
  • ECT
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35
Q

what are the clinical features of paranoid PD?

A
  • Sensitive
  • Suspicious
  • Preoccupied with conspiratorial explanations
  • Self-referential
  • Distrust of others
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36
Q

what are the clinical features of schizoid PD?

A
  • Emotionally cold
  • Detachment
  • Lack of interest in others
  • Excessive introspection
  • Fantasy
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37
Q

what are the clinical features of schizotypal PD?

A

-Interpersonal discomfort with peculiar ideas, perceptions, appearance and behaviour

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38
Q

what are the clinical features of anti-social PD?

A
  • Callous lack of concern for others
  • Irresponsibility
  • Irritability
  • Inability to maintain enduring relationships
  • Disregard and violation of other’s rights
  • evidence of childhood conduct disorder
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39
Q

what are the clinical features of emotionally unstable PD?

A
  • Unclear identity
  • Intense and unstable relationships
  • Unpredictable affect, threats or acts of self harm
  • Impulsivity
  • Chronic feelings of emptiness
  • Thoughts and acts of self harm/ suicide
  • Fear of/ attempts to avoid abandonment
  • Intense/ unstable relationships
  • Uncertainty regarding self image, aims and preferences
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40
Q

what are the clinical features of histrionic personality disorders?

A
  • Self-dramatization
  • Shallow affect
  • Egocentricity
  • Craving attention and excitement
  • Manipulative behaviour
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41
Q

what are the clinical features of narcissistic personality disorders?

A
  • Grandiosity
  • Lack of empathy
  • Need for admiration
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42
Q

what are the clinical features of anxious personality disorders?

A
  • Tension
  • Self-consciousness
  • Fear of negative evaluation by others
  • Timid
  • Insecure
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43
Q

what are the clinical features of anankastic personality disorders?

A
  • Doubt
  • Indecisiveness
  • Caution
  • Pedantry
  • Rigidity
  • Perfectionism
  • Pre-occupation with orderliness and control
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44
Q

what are the clinical features of dependent personality disorders?

A
  • Clinging
  • Submissive
  • excess need for care
  • Feels helpless when not in a relationship
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45
Q

how is paranoid, schizoid or schizotypal PD managed?

A
  • Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.
  • Offer a low dose antipsychotic such as arirpiprazole, haloperidol or perphenazine
  • Offer fluoxetine, sertraline or venlafaxine if there is self-harm or suicidality
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46
Q

how is borderline PD managed?

A
  • For women with borderline personality disorder for whom reducing recurrent self-harm is a priority, consider a comprehensive dialectical behaviour therapy programme.
  • Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder
  • Provide people with borderline personality disorder who have sleep problems with general advice about sleep hygiene
  • Offer treatment with zapleplon, zolpidem or zopiclone for insomnia
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47
Q

how is anti-social PD managed?

A
  • Establishment of a stable, supportive physician-patient relationship lies at the core of the approach to managing personality-disordered patients.
  • Offer contingency management treatment or CBT
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48
Q

how is avoidant, dependent and anankastic PD managed?

A
  • Offer social skills training, CBT and psychodynamic approaches
  • Offer pharmacotherapy with fluoxetine, sertraline or venlafaxine for issues with self-harm and suicidality
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49
Q

define illusion

A

-perception that occurs when a sensory stimulus is present but is incorrectly perceived and misinterpreted

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50
Q

define hallucination

A

-a perception in the absence of external stimulus that has qualities of real perception

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51
Q

define overvalued idea

A

-a false or exaggerated and sustained belief that is maintained with much less than with delusional intensity (the individual can accept that the idea may not be true)

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52
Q

define delusion

A

-an unshakeable false belief that is strongly held, even with evidence to the contrary, not in sync with regional, cultural and educational background

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53
Q

define delusional perception

A

-a true perception to which the patient attributes a false meaning

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54
Q

define thought alienation

A

-patients feel that their thoughts are in some way no longer within their control

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55
Q

define loosening of association

A

-a thought disorder consisting of a sequence of unrelated or remotely related ideas

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56
Q

define circumstantiality

A

a disturbed pattern of speech or writing characterised by delay in getting to the point because of the interpolation of unnecessary details and irrelevant remarks

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57
Q

define perseveration

A

-the repetition of a particular response regardless of the absence or cessation of a stimulus

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58
Q

define confabulation

A

-a memory error defined as the production of fabricated, distorted or misinterpreted memories about oneself or the world

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59
Q

what are the first rank symptoms of schizophrenia?

A
  • Thought alienation
  • Passivity phenomena
  • 3rd person auditory hallucinations
  • Delusional perception
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60
Q

what are the second rank symptoms of schizophrenia?

A
  • Delusions
  • 2nd person auditory hallucinations
  • Hallucinations in any other modality
  • Thought disorder
  • Catatonic behaviour
  • Negative symptoms
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61
Q

how is first episode psychosis managed?

A
  • oral antipsychotic medication (second generation anti-psychotics are preferred)
  • psychological interventions (family intervention and individual CBT).
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62
Q

how is an exacerbation of schizophrenia managed?

A

oral antipsychotic medication or review existing medication.

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63
Q

how is resistant schizophrenia managed?

A

-clozapine

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64
Q

what are the clinical features of schizoaffective disorder?

A
  • Hallucinations, delusional ideation and thought disorder
  • Anhedonia, amotivation, social isolation or flat affect
  • Disturbances in emotions
  • Disorders of thought
  • Executive function and working memory abnormalities
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65
Q

what are the clinical features of delusional disorders?

A
  • Level of consciousness is unimpaired
  • observed behaviour, speech, and mood may be affected by the emotional tone of delusional content
  • thought process is generally unimpaired, but thought content reflects preoccupation with circumscribed
  • non-bizarre delusions
  • hallucinations may occur, but generally are not prominent and reflect delusional ideas
  • cognition and memory are generally intact
  • insight and judgement are impaired to the degree that the delusions influence thought and behaviour
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66
Q

how is delusional disorder managed?

A
  • Separation from source or focus of delusional ideas
  • Pharmacological: SSRIs and antipsychotics
  • Individual therapy
  • Supportive therapy
  • Cognitive technique - reality testing and reframing.
  • Educational and social interventions, such as social skills training
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67
Q

what is the capgras delusion?

A

-the patient believes others have been replaced by identical or near identical imposters. Can apply to animals and other objects, and often associated with aggressive behaviour.

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68
Q

what is the fregoli delusion?

A

-an individual, most often unknown to the patient, is actually someone they know ‘in disguise’. The individual is often thought to be pursuing or persecuting the patient.

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69
Q

what is the cotard delusion?

A

-belief that patient or patients body parts are dead/rotting

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70
Q

what is Charles bonnet syndrome?

A

-Visual hallucinations in visually impaired people in the absence of a psychiatric disorder

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71
Q

what are the criteria required for an anorexia nervosa diagnosis?

A
  • A body weight more than 15% below the standard weight, or a body mass index (BMI) below 17.5 (ICD-10)
  • Weight loss is self-induced by avoidance of fattening foods, vomiting, purging, exercise, or appetite suppressants
  • A distortion of body image so that the patient regards her/himself as fat when she/he is thin
  • A morbid fear of fatness
  • Amenorrhoea in women/Delayed or arrested puberty
  • Endocrine disorders – HPA axis
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72
Q

what are the clinical features of anorexia nervosa?

A
  • Significantly low body weight
  • Fear of gaining weight or becoming fat
  • Disturbed body image
  • Calorie restriction
  • Binge eating and/or purging
  • Amenorrhoea
  • Decreased subcutaneous fat
  • General fatigue, weakness and poor concentration
  • Significant pre-occupation with thoughts of food
  • Orthostatic hypotension
  • Non-specific GI symptoms: fullness, bloating, cramping and constipation
  • Bradycardia, QT prolongation, first degree AV block and non-specific T wave changes
  • Fine, lanugo body hair
  • Dry skin and cracked nails
  • Oedema
  • Osteopenia
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73
Q

how is anorexia nervosa managed?

A
  • dietary counselling
  • multi-vitamins
  • family therapy for CYP
  • CBT
  • MANTRA
  • supportive clinical management
  • Consider transdermal 17-B-estradiol, incremental physiological doses of oestrogen or bisphosphonates for women with anorexia nervosa
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74
Q

what are the clinical features of bulimia?

A
  • Binge eating
  • Inappropriate compensatory behaviours such as vomiting
  • Depression and low self-esteem
  • Concern about weight and body shape
  • Dental erosion
  • Parotid hypertrophy
  • Scarring over the dorsum of the hands (Russell’s sign)
  • Arrhythmias
  • Menstrual irregularity
  • GORD
  • Diarrhoea or constipation
  • Abdominal pain
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75
Q

how is bulimia managed?

A
  • family therapy
  • CBT
  • guided self-help
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76
Q

what are the clinical features of anti-psychotic induced Parkinsonism?

A
  • Tremor
  • Rigidity
  • Bradykinesia
  • Bradykinesia and resting tremor may be less prominent
  • Symptoms are bilateral
  • Occurs within 4 weeks of commencing treatment with anti-psychotics
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77
Q

how is anti-psychotic induced Parkinsonism managed?

A
  • Reduce the dose of anti-psychotic
  • Switch to another anti-psychotic agents e.g. clozapine, quetiapine, olanzapine, aripiprazole and risperidone
  • Add an anti-cholinergic agent such as procyclidine or amantadine
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78
Q

define akathisia

A
  • Akathisia is an unpleasant, distressing side-effect of antipsychotic treatment.
  • Characteristically manifests with a subjective component—a feeling of inner restlessness (with the drive to engage in motor activity), and an objective component—movements: such as pacing constantly; inability to stand, sit, or lie still; rocking; crossing/ uncrossing legs.
79
Q

how is akathisia managed?

A
  • Identify causative agent and reduce the dose
  • Change the antipsychotic to a low potency first generation antipsychotic (chlorpromazine) or an SGA with low akathisia liability such as quetiapine
  • Consider clozapine if akathisia is intractable
  • Consider propranolol or low dose mirtazapine first line
  • Alternatively, offer mianserine or cyproheptadine
  • If patient has concurrent Parkinsonism consider use of anticholinergic agents (e.g. benzatropine, orphenadrine, procyclidine, trihexyphenidyl).
  • Consider benzodiazepines (e.g. clonazepam, diazepam, lorazepam) alone or with propanolol esp. in chronic akathisia.
  • Amantadine (100mg/day) or clonidine (up to 0.15mg/day) may be tried if these treatments are ineffective.
80
Q

what are the clinical features of tardive dyskinesia?

A
  • Peri-oral movements
  • trunk twisting
  • Torticollis
  • Retrocollis
  • shoulder shrugging
  • pelvic thrusting
  • rapid movements of the fingers or legs
  • hand clenching
  • Symptoms can be consciously suppressed, worsen with distraction, are exacerbated by stress and anti- Parkinsonian agents, and disappear during sleep.
  • Peripheral TD is more frequently associated with comorbid acute movement disorders (akathisia, tremor, Parkinsonism) than orofacial TD.
81
Q

how is tardive dyskinesia managed?

A
  • Reduce dose of potential causative agent
  • stop anti-cholinergics
  • switch anti-psychotic: clozapine, quetiapine, olanzapine or risperidone
82
Q

what are the clinical features of SSRI discontinuation?

A
  • Sensory symptoms: paraesthesia, visual disturbance, shock-like sensations and numbness.
  • Disequilibrium symptoms: dizziness, vertigo, and light-headedness.
  • General somatic complaints: flu-like symptoms (myalgias and chills), fatigue, headache, sweating, and tremor.
  • GI symptoms: diarrhoea, vomiting, and nausea/emesis.
  • Affective symptoms: irritability, anxiety/agitation, low mood, and tearfulness.
  • Sleep disturbance: nightmares, vivid dreams, and insomnia.
83
Q

what are the clinical features of TCA discontinuation?

A
  • General somatic complaints: flu-like symptoms (myalgias and chills), fatigue, headache, sweating, and tremor.
  • GI symptoms: diarrhoea, vomiting, and nausea/emesis.
  • Affective symptoms: irritability, anxiety/agitation, low mood, and tearfulness.
  • Sleep disturbance: nightmares, vivid dreams, and insomnia.
84
Q

what are the clinical features of MAOI discontinuation?

A
  • More severe than with other antidepressants
  • worsening of depressive symptoms
  • acute confusion
  • hallucinations
  • paranoid delusions
  • anxiety symptoms with depersonalization.
85
Q

how is anti-depressant discontinuation syndrome managed?

A
  • taper antidepressant

- If severe, reintroduction of the original antidepressant rapidly resolves the symptoms.

86
Q

what are the clinical features of body dysmorphic disorder?

A
  • preoccupation with the idea that some specified aspect of their appearance is grossly abnormal, markedly unattractive, or diseased.
  • Patients believe that the supposed deficit is noticeable to others and attempt to hide or minimize it.
  • These beliefs may develop delusional intensity.
  • There is associated functional impairment, agoraphobia, and risk of suicide.
  • Comorbid behaviours such as skin picking, rubbing, topical applications may cause worse secondary problems.
  • Clinically significant disorder causes severe functional impairment, restriction of relationships and employment opportunities, and the risk of iatrogenic morbidity by unwarranted surgical procedures.
87
Q

how is body dysmorphic disorder managed in adults?

A
  • CBT
  • Cognitive therapy with exposure response prevention
  • fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram.
88
Q

how is body dysmorphic disorder managed in children?

A
  • CBT
  • SSRI
  • Clomipramine
89
Q

what are the clinical features of acute dystonia?

A
  • torticollis
  • trismus
  • jaw opening
  • forceful protrusion of the tongue
  • blepharospasm
  • grimacing
  • oculogyric spasm
  • opisthotonus
  • involvement of pharyngeal and laryngeal muscles can cause serious symptoms such as dysphagia and laryngospasm.
  • May fluctuate over hours, but most last minutes to hours without treatment.
90
Q

how is acute dystonia managed?

A
  • If severe, discontinue suspected agent.
  • Emergency treatment with IM anticholinergic agents (e.g. procyclidine 5mg, benzatropine 2mg).
  • Continue use of anticholinergic prophylactically for 5 to 7 days in addition to antipsychotic medication and taper it off over 2–3wks
  • Consider switching to antipsychotic with low propensity to cause EPSEs
  • Alternative treatment includes use of amantadine.
91
Q

what are the clinical features of Neuroleptic Malignant Syndrome?

A
  • Confusion, delirium and stupor
  • Muscle rigidity
  • Tachycardia
  • Labile hypertension
  • Diaphoresis
  • Tachypnoea
  • Urinary incontinence
  • Hyperthermia
92
Q

what do blood tests show in neuroleptic malignant syndrome?

A
  • raised WCC

- raised CK

93
Q

how is neuroleptic malignant syndrome managed?

A
  • Withdraw anti-psychotics and dopamine antagonists, or restore dopamine agonist
  • Administer cooled IV fluids to rehydrate and prevent AKI
  • Use physical cooling measures for hyperthermia e.g. ice packs and cooling blankets
  • Offer lorazepam or dantrolene, bromocriptine or amantadine to treat rigidity and agitation
  • ECT may be useful following failed pharmacotherapy
94
Q

what are the clinical features of serotonin syndrome?

A
  • Clonus
  • Hyperreflexia
  • Agitation
  • Confusion
  • Tremor, shivering and myoclonus
  • Sweating
  • Headache
  • Tachycardia
  • Hypertonia/rigidity
  • Diaphoresis
  • Flushing
  • Dilated pupils
  • Hyperthermia
95
Q

how is serotonin syndrome managed?

A
  • Stop all serotonergic drugs
  • If the reaction is severe, it is best to perform early sedation, intubation and ventilation
  • Give activated charcoal if serotonin syndrome is associated with an overdose in the last hour
  • Give cooled IV fluids and use physical cooling methods
  • If there is neuromuscular excitation or agitation, give lorazepam or cyproheptadine
96
Q

what are the clinical features of a conversion disorder?

A
  • Paralysis
  • Aphonia
  • Sensory loss
  • Seizures
  • Amnesia
  • Fugue
97
Q

what are the clinical features of hypochondriasis?

A
  • the pre- occupation with the idea of having a serious medical condition, usually one which would lead to death or serious disability.
  • The patient repeatedly ruminates on this possibility and insignificant bodily abnormalities, normal variants, normal functions, and minor ailments will be interpreted as signs of serious disease.
  • The patient consequently seeks medical advice and investigation but is unable to be reassured in a sustained fashion by negative investigations.
  • The form of the belief is that of an over-valued idea; the patient may be able to accept that their worries are groundless but nonetheless be unable to stop dwelling and acting on them.
98
Q

how is hypochondriasis managed?

A
  • Allow patient time to ventilate their illness anxieties.
  • Aim to plan continuing relationship and review, not contingent upon new symptoms.
  • fluoxetine or imipramine
  • CBT
99
Q

what is somatisation disorder?

A

-a disorder in which there is repeated presentation with medically unexplained symptoms, affecting multiple organ systems, first presenting before the age of 40.

100
Q

what are the clinical features of somatisation disorder?

A
  • long, complex medical histories (‘fat-file’ patients)
  • Symptoms may occur in any system and are to some extent suggestible.
  • most frequent symptoms are non-specific and atypical.
  • discrepancy between the subjective and objective findings
  • Symptoms are usually concentrated in one system at a time but may move to another system after exhausting diagnostic possibilities in the previous one.
  • Diagnosis is usually only suspected after negative findings begin to emerge because normal medical practice is to take a patient’s complaints at face value.
  • The key diagnostic feature is multiple, atypical, and inconsistent medically unexplained symptoms in a patient under the age of 40.
101
Q

define somatoform pain disorder

A

-there is a complaint of persistent severe and distressing pain which is not explained or not adequately explained by organic pathology.

102
Q

what are the clinical features of factitious disorder?

A
  • History of unexplained complaints or inconsistency over time
  • Unusual presentation relative to demographic
  • Symptoms more exaggerated when aware of observation
  • Presentation for care at many different hospitals
  • Evidence of the patient manipulating findings
103
Q

what are the risk factors for development of factitious disorder?

A
  • Female
  • Medically related employment
  • Cluster B personality subtypes
  • Single
  • Aged 40-50
104
Q

how is factitious disorder managed?

A
  • Treat any objective findings (such as infection or hypoglycaemia induced by the patient) as medically indicated
  • Offer psychological treatments such as psychoanalytic psychotherapy, CBT and supportive therapy
  • If there is factitious disorder by proxy, report to appropriate authorities to ensure the safety of the dependent involved.
105
Q

what are the clinical features of acute stress disorder?

A
  • Exposure to trauma
  • Intrusion symptoms: flashbacks
  • Avoidance symptoms: avoiding people, situations or circumstances resembling or associated with the event
  • Negative alterations in cognitions and mood
  • Alterations in arousal and reactivity, including hypervigilance, exaggerated startle response, angry outbursts and self-destructive behaviours
106
Q

what are the clinical features of PTSD?

A
  • Exposure to trauma
  • Intrusion symptoms: flashbacks
  • Avoidance symptoms: avoiding people, situations or circumstances resembling or associated with the event
  • Negative alterations in cognitions and mood
  • Alterations in arousal and reactivity, including hypervigilance, exaggerated startle response, angry outbursts and self-destructive behaviours
107
Q

how is PTSD managed in adults?

A
  • trauma focussed CBT
  • EMDR
  • venlafaxine or an SSRI
  • risperidone for severe hyperarousal
108
Q

how is PTSD managed in children?

A
  • trauma focussed CBT
  • Group trauma focussed CBT for a large scale event
  • EMDR
109
Q

what are the clinical features of post-natal affective disorders?

A
  • Depressed mood
  • Anhedonia
  • Decreased energy or increased fatigability
  • Suicidal ideation
  • Unreasonable feelings of self-reproach or excessive guilt
  • Poor concentration
  • Change in psychomotor activity
  • Sleep disturbance
  • Change in appetite
  • Change in weight
  • Obsessive thoughts
  • Self-harm or neglect or mistreatment of children
  • Psychotic symptoms
110
Q

what are the risk factors for post-natal affective disorders?

A
  • History of a mental illness
  • Poor social support
  • Discontinuation of psychopharmacological treatments
  • Sleep deprivation
  • Family history
  • Domestic violence
  • Birth complications
  • Poor socio-economic status
  • Age less than 16 years
111
Q

How are postnatal affective disorders managed?

A
  • facilitated self-help.
  • TCA
  • SSRI
  • SNRI
  • CBT
  • Refer to a secondary mental health service, ideally a specialist perinatal mental health service, for immediate assessment (within 4 hours of referral) if a woman has a sudden onset of symptoms suggestive of postpartum psychosis.
  • admit to mother baby unit
112
Q

what are the clinical features of narcolepsy?

A
  • Excessive daytime sleepiness
  • Cataplexy
  • Hypnagogic and hypnopompic hallucinations
  • Sleep paralysis
  • Chronic fatigue
  • Poor memory and concentration
  • Sleep attacks
  • Fragmented nocturnal sleep
113
Q

how is narcolepsy disguised on multiple sleep latency testing?

A

sleep latency ≤8 minutes plus ≥2 sleep-onset rapid eye movement (REM) periods (SOREMS)

114
Q

How are adults with narcolepsy managed?

A
  • Promote sleep hygiene
  • Offer modafinil or CNS stimulants such as methylphenidate or dexamfetamine
  • If there is associated cataplexy give sodium oxybate, an SSRI/SNRI or TCAs
  • If the patient is resistant to this treatment, consider MAOIs as a last resort
115
Q

How are children with narcolepsy managed?

A
  • Promote sleep hygiene
  • Offer modafinil or methylphenidate
  • For cataplexy, avoid triggers and give SSRI/SNRI or TCAs
116
Q

what are the clinical features of periodic limb movement disorder?

A
  • Poor sleep
  • Daytime somnolence and fatigue
  • Periodic limb movements
117
Q

how is periodic limb movement disorder diagnosed on EMG/EEG

A
  • PLMS index (number of PLMS per hour of sleep) >15 for the whole night
  • PLMS predominantly during non-rapid eye movement (REM) stages 1 and 2 of sleep, and progressively diminishing during deep sleep stages 3 to 4
118
Q

define insomnia

A

-difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality.

119
Q

what are the clinical features of insomnia?

A
  • Complaints from the sleep partner
  • Delayed sleep onset
  • Multiple or long awakenings
  • Impaired functioning
  • Accidents
  • Decreased sleep time
  • Daytime napping
  • Symptoms of sleep apnoea
120
Q

how is insomnia managed?

A
  • sleep hygiene advice
  • short course of hypnotic such as zopiclone
  • CBT-insomnia
  • a z-drug or prolonged released melatonin if over 55 years of age
121
Q

what are the clinical features of jet lag/shift work sleep disorders?

A
  • History of travel across 2 time zones or shift work
  • Difficulty initiating and maintaining sleep
  • Daytime sleepiness
  • Reduced daytime alertness
  • Nausea and constipation
122
Q

how is shift work sleep disorder managed?

A
  • Advise on the use of a sleep diary to assess the nature of any suspected sleep disturbance.
  • Advise on measures to promote sleep
  • Advise the person to consider the use of caffeinated drinks just before, and during shifts to counteract sleepiness.
  • Advise the person on optimal working schedules and environment, and the need to liaise with the Occupational Health department if appropriate.
  • Encourage the person to balance family, social, work, and sleep commitments
  • Consider seeking advice or arranging referral to the local sleep clinic if there are ongoing troublesome symptoms
123
Q

how is jet lag managed?

A
  • For short travel stays (of two days or less), advise to consider continuing activities such as sleeping and eating on ‘home time’, to minimise disruption to the normal sleep/wake cycle.
  • pre-flight sleeping and consider moving bedtimes at home to be more similar to abroad
  • eat light meals and maintain hydration
  • Try to get as much sleep as normal during a 24-hour period, with a minimum block of four hours during the local night-time period in the new time zone.
  • Take naps in response to sleepiness.
  • Try to get timely exposure to light and darkness (scheduled sleep), and consider the use of sunglasses to help this.
124
Q

what are the clinical features of restless legs syndrome?

A
  • Dysaesthesias
  • Evening symptoms
  • Relieving factors: movement, stretching and massage
  • Occurring in lower extremities
125
Q

how is restless leg syndrome managed?

A
  • treat any underlying cause
  • self-help advice
  • non-ergot dopamine agonist e.g. pramipexole
  • alpha-2-delta ligand (pregabalin or gabapentin)
126
Q

define parasomnia

A

-Parasomnias are undesirable sleep-related events that may occur during sleep or during the transition into sleep or out of sleep

127
Q

what are the clinical features of parasomnias in children?

A
  • Disturbed cognition during the events (confusional arousals, sleep terrors and sleepwalking)
  • Vigorous activity or violent behaviour (confusional arousals, sleepwalking, sleep terrors, RBD)
  • Episodes of inability to move (sleep paralysis)
  • Autonomic hyperactivity during event (sleep terrors)
  • Amnesia
  • Abnormal demeanour and facial expressions (confusional arousals, sleep walking, sleep terrors)
128
Q

what are the clinical features of parasomnias in adults?

A
  • Cognitive disturbances between episodes (RBD)
  • Sensation of sudden loud noise in the head (exploding head syndrome)
  • Eating behaviour during the night (sleep related eating disorder)
  • Evidence of external injuries (RBD)
129
Q

how are confusional arousals, sleep walking and sleep terrors managed?

A
  • Educate and encourage good sleep hygiene
  • Implement safety measures
  • Consider scheduled awakening
  • For children with very frequent episodes, biofeedback and relaxation techniques
  • Avoid sleep deprivation and treat other sleep disorders
  • In adults, consider CBT or hypnosis
  • low dose hypnotics on benzodiazepines or TCAs
  • Sleep related eating disorder is managed by offering topiramate or dopamine agonists such as pramipexole
130
Q

how are REM behaviour disorders managed?

A
  • Avoid precipitating factors and implement environmental protective measures
  • Offer melatonin in children and adults
  • CBT with systematic desensitisation and relaxation techniques may be useful in nightmare disorder
131
Q

what are the clinical features of simple alcohol withdrawal?

A
  • Alcohol dependence
  • Cessation or reduction in alcohol intake
  • Anxiety
  • Nausea and vomiting
  • Tremor
  • Tachycardia
  • Sweating
  • Palpitations
  • Insomnia
  • Hypertension
132
Q

what are the clinical features of delirium tremens?

A
  • 48 to 72 hours after last alcoholic drink
  • Profound confusion that fluctuates
  • Clouding of consciousness
  • Hallucinations: classically Lilliputian hallucinations that can be visual, auditory or tactile
  • Coarse tremor
  • Autonomic dysfunction
133
Q

what is seen VBG in alcohol withdrawal?

A
  • respiratory alkalosis in DT
  • hypochloraemic metabolic acidosis with vomiting
  • metabolic acidosis with a high anion gap if alcoholic ketoacidosis
  • hypoglycaemia
134
Q

how is acute alcohol withdrawal managed?

A
  • offer chlordiazapoxide or clomethiazole

- lorazepam in liver disease

135
Q

how are alcohol withdrawal seizures managed?

A
  • consider offering a quick-acting benzodiazepine (such as lorazepam)
136
Q

how is delirium tremens managed?

A
  • offer oral lorazepam as first-line treatment.

- If symptoms persist or oral medication is declined, offer parenteral lorazepam or haloperidol

137
Q

what are the clinical features of an alcohol use disorder?

A
  • Withdrawal symptoms on cessation of alcohol
  • Tolerance
  • Signs of alcoholic liver disease
  • Peripheral Neuropathy
  • Impaired nutritional status
138
Q

how is alcohol use disorder. diagnosed?

A
  • AUDIT >15
  • raised carbohydrate deficient transferrin
  • Raised LFTs
  • Low MCV and thrombocytopenia
139
Q

how is alcohol use disorder managed?

A
  • prophylactic thiamine
  • CBT
  • Nalmefene
  • detox with chlordiazepoxide or diazepam
140
Q

How is abstinence maintained following alcohol detox?

A
  • Acamprosate
  • naltrexone
  • Disulfiram
141
Q

what are the side effects of acamprosate?

A
  • GI upset
  • pruritus
  • rash
  • altered libido
142
Q

what are the side effects of naltrexone?

A
  • GI upset
  • anxiety
  • headache
  • fatigue
  • sleep disturbance
  • flu-like symptoms
143
Q

what are the side effects of disulfiram?

A
  • Halitosis

- headache

144
Q

what are the clinical features of cocaine abuse?

A
  • Hypertension
  • Tachycardia
  • Chest pain
  • Mydriasis
  • Diaphoresis
  • Tremor
  • Agitation
  • Mood changes
  • Anxiety
  • Tactile hallucinations
145
Q

what are the clinical features of opioid abuse?

A
  • Blunting of pleasurable effects
  • Miosis
  • Dilated pupils
  • Shallow and slow respirations
  • Needle track marks
  • Chronic constipation
  • Weight loss
146
Q

what are the symptoms of opioid withdrawal?

A
  • Nausea/vomiting
  • Sedation
  • Insomnia
  • Memory impairment
  • Yawning
  • Abdominal cramps
  • Hypotension
  • Shallow and slow respirations
  • Aggressive behaviour
  • Rhinorrhoea
  • Restlessness
  • Piloerection
147
Q

how is opioid withdrawal managed?

A
  • substitute prescribing: methadone or buprenorphine

- lofexidine

148
Q

what are the clinical features of wernicke’s encephalopathy?

A
  • Mental slowing, impaired concentration and apathy
  • Confusion
  • Ocular motor findings, most commonly gaze palsies, 6th nerve palsies, impaired vestibulo-ocular reflexes, nystagmus and ophthalmoplegia
  • Ataxia
  • Tachycardia
149
Q

how is wernicke’s encephalopathy managed?

A

-thiamine

150
Q

what are the clinical features of korsakoff’s psychosis?

A
  • Absence or significant impairment in the ability to lay down new memories, together with a variable length of retrograde amnesia.
  • Working memory (e.g. ability to remember a sequence of numbers) is unimpaired as is procedural and ‘emotional’ memory.
  • Confabulation for the episodes of amnesia may be prominent.
151
Q

how is wernicke-korsakoff’s syndrome managed?

A

-supported living

152
Q

what are the clinical features of autism spectrum disorder?

A
  • Language delay or regression
  • Verbal and non-verbal communication impairment
  • Social impairment
  • Repetitive, rigid or stereotyped interests, behaviour or activities
  • Motor stereotypies
  • Sensory interests
153
Q

how is autism managed?

A
  • offer the child or young person a psychosocial intervention (informed by a functional behavioural analysis)
  • anti-psychotic medication
  • CBT
  • sleep plan
  • supported schooling and employment
154
Q

what are the clinical features of dyspraxia?

A
  • handwriting, which is typically awkward, messy, slow, irregular and poorly spaced
  • dressing (buttons, laces, clothes)
  • cutting up food
  • poorly established laterality
  • copying and drawing
  • messy eating from difficulty in coordinating biting, chewing and swallowing (oromotor dyspraxia). Dribbling of saliva is common.
155
Q

how is gender non-conformity managed?

A
  • Observation in changed sex role for >1 year
  • For male-to-female, give spironolactone, cyproterone acetate or GnRH agonists as anti-androgens, and oestrogen replacement either orally, IM or by patch
  • For female-to-male, give oral or transdermal testosterone
  • For male-to-female, offer thyroid cartilage reduction, craniofacial surgery, augmentation mammoplasty, and removal of penis with formation of vulva
  • For female-to-male, offer bilateral mastectomy, hysterectomy, bilateral oophorectomy and phalloplasty
156
Q

what are the risks of feminising hormone therapies?

A
  • VTE
  • Gallstones
  • Elevated liver enzymes
  • Weight gain
  • Hypertriglyceridaemia
  • Cardiovascular disease
  • Hypertension
  • Hyperprolactinaemia
  • Type 2 diabetes
  • Breast cancer
157
Q

what are the risks of masculinising hormone therapies?

A
  • Polycythaemia
  • Weight gain
  • Acne
  • Androgenic alopecia
  • Sleep apnoea
  • Elevated liver enzymes
  • Hyperlipidaemia
  • Destabilisation of psychiatric disorders
  • Cardiovascular disease
  • Hypertension
  • Type 2 diabetes

-Loss of bone density
Cancer of breast, cervix, ovary and uterus

158
Q

what are the clinical features of chronic fatigue?

A
  • Persistent disabling fatigue
  • Post-exertional malaise and fatigue
  • Short-term memory and concentration impairment
  • Sore throat
  • Generalised arthralgia without inflammation
  • Headache/migraine
  • Unrefreshing sleep
  • Orthostatic intolerance
  • Diffuse muscular, tendon and fascial pain
159
Q

how is chronic fatigue managed?

A
  • manage nausea with conservative advice and anti-emetics
  • tailored sleep management advice
  • Advise on the role of rest, how to introduce rest periods into their daily routine, and the frequency and length appropriate for each person
  • relaxation techniques
  • CBT
  • graded exercise therapy
  • low dose TCA if pain or poor sleep
  • melatonin
160
Q

what are the clinical features of foetal alcohol spectrum disorders?

A
  • Gestation <37 weeks
  • Low height, weight and head circumference
  • Characteristic facial dysmorphology: short palpebral fissure, thin upper lip or vermillion border and smooth philtrum
  • Presence of cardiac anomalies: ASD, VSD, tetralogy of Fallot
  • Presence of MSK anomalies: hypoplastic nails, shortened 5th finger, radioulnar synostosis, flexion contractures, camptodactyly, pectus excavatum or carinatum, scoliosis and hockey-stick palmar creases
  • Presence of renal anomalies
  • Presence of ocular anomalies: strabismus, retinal vascular anomalies
  • Developmental delay
  • Mental health problems
  • Poor feeding
  • Irritability
161
Q

how are foetal alcohol spectrum disorders managed?

A
  • education and learning strategies
  • child friendship training
  • surgery for organ defects
162
Q

by which 3 mechanisms does Down’s syndrome arise?

A
  • meiotic non-disjunction
  • translocation
  • mosaicism
163
Q

what are the head and neck features of Down’s syndrome?

A
  • Brachycephaly and reduced anteroposterior (AP) diameter
  • maxilla reduced more than mandible
  • underdeveloped bridge of nose
  • eyes close together
  • Brushfield’s spots—grey or very light yellow spots of the iris
  • epicanthic fold
  • low-set ears
  • high-arched palate
  • protruding tongue
  • instability of atlanto-axial joint
  • narrowed hypopharynx (may lead to sleep apnoea).
164
Q

what congenital defects are associated with Down’s syndrome?

A
  • AVSD
  • Mitral valve disease
  • PDA
  • Oesophaeal atresia
  • Duodenal atresia
  • Hirschprung’s disease
  • Hernias
165
Q

what are the hand features of downs syndrome?

A
  • Short broad hands with a single palmar crease (simian crease)
  • syndactyly (webbed fingers)
  • clinodactyly (incurving of fingers)
  • altered dermatoglyphics.
166
Q

what are the eye and ear features of Down’s syndrome?

A
  • Strabismus
  • Myopia
  • blocked tear ducts
  • nystagmus
  • late-life cataracts
  • Keratoconus
  • Structural anomalies may lead to recurrent otitis media, sensorineural deafness.
167
Q

how is Down’s syndrome managed?

A
  • management of associated congenital defects
  • physiotherapy
  • occupational therapy
  • SALT
  • educational plan
  • regular hearing, thyroid, ophthalmic and dental examinations
168
Q

which drugs increase the plasma concentration of lithium?

A
  • ACE inhibitors/angiotensin-II receptor antagonists
  • analgesics (esp. NSAIDs)
  • antidepressants (esp. SSRIs)
  • anti-epileptics
  • antihypertensives (e.g. methyldopa)
  • antipsychotics (esp. haloperidol)
  • calcium-channel blockers
  • diuretics
  • metronidazole.
169
Q

which drugs decrease the plasma concentration of lithium?

A
  • antacids

- theophylline.

170
Q

what are the contraindications to the use of lithium?

A
  • Addison’s disease
  • cardiac disease associated with rhythm disorder
  • cardiac insufficiency
  • Dehydration
  • family history of Brugada syndrome
  • low sodium diets
  • personal history of Brugada syndrome
  • untreated hypothyroidism
171
Q

what are the side effects of lithium?

A
  • Polyuria/polydipsia
  • weight gain
  • cognitive problems
  • tremor
  • sedation or lethargy
  • impaired co-ordination
  • GI distress (e.g., nausea, vomiting, dyspepsia, diarrhoea)
  • hair loss
  • benign leucocytosis
  • acne
  • oedema.
172
Q

how are the adverse effects of lithium managed?

A
  • B-blockers (tremor)
  • thiazide or loop diuretics (polyuria, polydipsia or oedema)
  • topical antibiotics or retinoic acid (acne).
173
Q

what are the long term effects of lithium?

A
  • Renal impairment
  • Hypothyroidism
  • Ebstein’s anomaly in children born to mothers taking lithium
174
Q

what are the clinical features of lithium toxicity?

A

-Marked tremor, anorexia, nausea/vomiting, diarrhoea (sometimes bloody), with dehydration and lethargy.

-Severe neurological complications—restlessness, muscle fasciculation/myoclonic jerks, choreoathetoid movements, marked hypertonicity.
This may progress to ataxia, dysarthria, increased lethargy, drowsiness, and confusion/delirium.

-Hypotension and cardiac arrhythmias precede circulatory collapse, with emerging seizures, stupor, and eventual coma

175
Q

how is lithium toxicity managed?

A
  • forced diuresis with intravenous isotonic saline

- in cases where toxicity is severe or accompanied by significant renal failure, haemodialysis.

176
Q

what are the side effects of SSRIs?

A
  • nausea
  • anorexia
  • insomnia
  • loss of libido
  • failure of orgasm
  • serotonin syndrome
  • risk of bleeding
  • hyponatraemia
177
Q

what are the contraindications to SSRI use?

A
  • manic episodes
  • concomitant use of MAOIs
  • poorly controlled epilepsy
178
Q

what are the side effects of TCAs

A
  • dry mouth
  • blurred vision
  • constipation
  • urinary retention
  • postural hypotension
  • QT prolongation in overdose.
  • Drowsiness
  • Tachycardia
  • sexual dysfunction.
  • sedation.
179
Q

what are the contraindications to TCA use?

A
  • acute MI
  • heart block
  • Arrhythmias
  • IHD
  • severe liver disease
  • Pregnancy
  • lactation
180
Q

what are the side effects of venlafaxine?

A
  • arrhythmias
  • asthenia
  • depersonalisation
  • movement disorders
  • mydriasis
  • palpitations
181
Q

what are the side effects of duloxetine?

A
  • dry mouth
  • GI discomfort
  • sexual dysfunction
  • skin reactions
  • sleep disorders
  • sweat changes
  • vision changes
  • weight changes
182
Q

what are the side effects of mirtazapine?

A
  • Sedation
  • increased appetite
  • weight gain.
  • transaminase elevation
  • jaundice
  • oedema
  • orthostatic hypotension
  • tremor
  • myoclonus
  • blood dyscrasias
183
Q

in which patients should mirtazapine be used with cautions?

A
  • cardiac disease
  • DM
  • elderly
  • history of bipolar
  • seizures
  • urinary retention
  • hypotension
  • psychoses
  • susceptibility to angle closure glaucoma
184
Q

what are the side effects of MAOIs?

A
  • Cheese reaction with foods high in tyramine - acute hypertension, giving rise to a severe throbbing headache and occasionally even to intracranial haemorrhage.
  • Anticholinergic effects - urinary retention, blurred vision, dry mouth, constipation
  • drowsiness
  • postural hypotension
  • tachycardia
  • sexual dysfunction.
  • sedation
  • weight gain
185
Q

in which patients should MAOIs be used with caution?

A
  • cardiovascular disease
  • hepatic failure
  • poorly controlled hypertension
  • Hyperthyroidism
  • Porphyria
  • phaeochromocytoma
186
Q

what are the side effects of benzodiazepines?

A
  • Sedation and memory problems.
  • Dependence and tolerance, particularly in those with dependent personalities.
  • A withdrawal syndrome can occur after 3 weeks of continuous use a
  • Interaction with alcohol, producing a long-lasting ‘hangover syndrome’.
  • Ethanol enhances the action of GABA on GABAA receptors
187
Q

what are the contraindications to benzodiazepines?

A
  • Acute pulmonary insufficiency
  • marked neuromuscular respiratory weakness
  • not for use alone to treat chronic psychosis

-not for use alone to treat depression,
obsessional states, phobic states

  • sleep apnoea syndrome
  • unstable myasthenia gravis
188
Q

what are the indications for ECT?

A
  • severe depressive episode
  • need for rapid antidepressant response
  • failure of drug treatments
  • treatment resistant psychosis and mania
  • catatonia
  • NMS
  • intractable seizure disorders
189
Q

what are the relative contraindications to ECT?

A
  • cerebral aneurysm
  • recent MI
  • cardiac arrhythmias
  • intracerebral haemorrhage
  • retinal detachment
  • phaeochromocytoma
190
Q

what are the side effects of ECT?

A
  • retrograde amnesia
  • headache
  • temporary confusion
  • nausea/vomiting
  • clumsiness
  • muscular aches
  • loss of long-term memory
191
Q

what are the contra-indications to light therapy?

A
  • agitation
  • insomnia
  • history of hypomania and mania
192
Q

with which drugs does clozapine interact?

A
  • lithium
  • acetylcholinesterase inhibitors
  • smoking cigarettes
  • caffeine
  • anti-hypertensives
  • H2 blockers
  • phenothiazines
  • TCAs
  • digoxin
  • heparin
  • phenytoin
  • warfarin
193
Q

what are the contraindications to clozapine use?

A
  • Previous/current neutropenia or other blood dyscrasias
  • previous myocarditis, pericarditis and cardiomyopathy
  • severe renal or cardiac disorders
  • active or progressive liver disease/hepatic failure.
194
Q

what are the side effects of clozapine?

A
  • agranulocytosis
  • constipation
  • hypersalivation

FINALS (18 decks)

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