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Questions Flashcards

1
Q

Describe the mechanism of action of first- and second-generation antipsychotics.

A

FGAs: dopamine 2 blockade in the mesolimbic and mesocortical pathways

SGAs: serotonin receptor blockade and lower affinity for D2 receptors

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2
Q

What mediates the extrapyramidal side effects of the antipsychotic agents?

A

Antagonist activity at dopamine receptors in the basal ganglia and other dopamine receptor sites in the CNS

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3
Q

Which autonomic nervous system receptors are antagonized by antipsychotic agents?

A

Alpha-adrenoceptors and muscarinic receptors

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4
Q

List 2 clinical features of the neuroleptic malignant syndrome.

A
  • Delirium
  • Muscle rigidity
  • Hyperthermia
  • Autonomic instability
  • Elevated creatinine phosphokinase
  • Leucocytosis
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5
Q

Outline the management principles of the neuroleptic malignant syndrome

A

(1) Stop antipsychotic
(2) Administer benzodiazepine
(3) Monitor vital functions
(4) Refer as clinically indicated

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6
Q

. List 2 indications for the prescription of Clozapine

A
  • Treatment resistance (failure to respond to 2 different classes of antipsychtics at adequate dosages for sufficient time, i.e. 6 – 8 weeks)
  • Intolerable side-effects (particularly extra-pyramidal side-effects)
  • Mood disturbances
  • Negative features
  • Neurocognitive impairments
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7
Q

What is the major adverse effect of Clozapine, and how is it monitored in patients?

A

Agranulocytosis – monitored by carrying out a WBC before starting treatment, then weekly for 18 weeks and thereafter monthly

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8
Q

List 3 toxic effects of lithium and the plasma concentration of lithium above which toxicity usually occurs.

A 
•	Anorexia
•	Nausea
•	Vomiting
•	Diarrhoea
•	Drowsiness
•	Coarse tremor
•	Ataxia leading to seizures
•	Delirium 
Toxicity occurs above plasma levels of 1, 5 mmol/L
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9
Q

Why should benzodiazepines not be prescribed for longer than 2 – 4 weeks?

A

Prolonged use poses a risk of dependency syndrome (tolerance and withdrawal symptoms).

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10
Q

Briefly describe the mechanism of action of benzodiazepines

A

potentiates inhibitory action of gamma-aminobutyric acid (GABA) by binding to the benzodiazepine receptor on the GABA receptor complex and allosterically modulate the GABA receptor.

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11
Q

list the 4 groups into which benzodiazepines are classified

A
  • Ultra-short: < 6 hours
  • Short: 6 – 12 hours
  • Intermediate 12 – 24 hours
  • Long-acting: > 24 hours
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12
Q

Describe the mechanism of action of Tricyclic Antidepressants (TCAs)

A

TCAs block the reuptake of NE and 5HT at the presynaptic membrane, enhancing the transmission of these two neurotransmitters.

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13
Q

Outline the serotonin syndrome (in terms of cause and pathogenesis) and list 2 clinical features.

A

The serotonin syndrome is a serious, potentially life-threatening complication that may occur following use of SSRIs, for example. It occurs as a consequence of excess serotonergic activity in the CNS and peripheral serotonin receptors, which produce various symptoms (2)

Clinical features include (any 2): (2 x ½ = 1)
• Neuromuscular hyperactivity (tremor, clonus, hyperreflexia)
• Altered mental state (agitation, excitement)
• Autonomic hyperactivity (fever, sweating, tachycardia, tachypnoea)

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14
Q

Discuss the CAGE screening tool and list 3 pros and 3 cons of this tool.

A

It is a screening tool for alcohol dependence and is composed of the following questions:
• C - Have you ever felt you should cut down on your drinking? (0.5)
• A - Have people annoyed you by criticizing your drinking? (0.5)
• G - Have you ever felt bad or guilty about your drinking?(0.5)
• E - Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (0.5)

Two positive responses are considered a positive test for a current or past alcohol problem and indicate whether further assessment is warranted. (1)

PROS

  • Short and simple (0.5)
  • Easy to remember (0.5)
  • Proven effective for detecting a range of alcohol problems (0.5)

CONS

  • It fails to identify binge drinkers (0.5)
  • Not useful to diagnose hazardous drinking (0.5)
  • Must be done face to face (0.5)
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15
Q

b. Pharmacological management of alcohol dependence

A
  • Treat alcohol withdrawal with Benzodiazepines. Usually Diazepam is given at 5-15mg, 2-3 times per day, for 4-5 days. In pregnant patients; risk management assessment should be done before prescribing benzodiazepines. (1)
  • Daily thiamine and Vitamin B complex is given to prevent Wernicke Korsakoff syndrome. (1)
  • If relapse prevention is required, disulfiram can be prescribed along with psychosocial interventions. Be sure to inform patients of drinking alcohol when on disulfiram.(1)
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16
Q

The key features of motivational interviewing in alcohol dependence

A
  • Motivational interviewing should be patient centred. (0.5)
  • The health care worker must be empathetic, establish rapport and display non-judgmentatalism (0.5)
  • It must facilitate the patient’s movement toward change and support self-efficacy by giving positive affirmation. (0.5)
  • It should identify the readiness of the patient to change and the stage of change the patient is in according to the cycle of change. (0.5)
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17
Q

The aim of CBT in alcohol dependence

A
  • Therapy that focusses on alcohol abuse as a disorder of beliefs, behavior and core belief systems (0.5)
  • CBT aims to modify these factors (0.5)
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18
Q

The aim of psychotherapy and the application of it in terms of psychoeducation, the patient, the family and group therapy for alcohol dependence

A

The aim is to alleviate the patient’s illness by promoting the desire to change and developing ability to cope with change.

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19
Q

Psychoeducation in alcohol dependence

A
  • Educate patient about alcohol and drug use (0.5)
  • Give input on alternative methods of coping (0.5)
  • Give information about self-help groups and local facilities (0.5)
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20
Q

Individual in alcohol dependence

A

Aims to understand the thoughts and feelings leading to the behavior of substance dependence e.g. abuse and violence (0.5)
It explores the meaning the patient attaches to alcohol abuse and dependence (0.5)
It is supported by therapy (0.5)

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21
Q

Group in alcohol dependence

A
  • The same group of individuals meet regularly with a trained leader (0.5)
  • It provides a public forum (0.5)
  • It is a place where patients can share their experiences (0.5)
  • It provides a place of support and confrontation where the seriousness of the alcohol abuse can be discussed, the effect it has on the life of the patient and others as well as confrontation of peers and by peers. (0.5)
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22
Q

Family in alcohol dependence

A
  • Aims to address family members that enhances/reinforce alcohol abuse and dependence (0.5)
  • It allows the family to describe the effects patient’s alcohol abuse and dependence has on them (0.5)
  • It helps create structural family changes to prevent relapse (0.5)
  • It prevents premature relapse (0.5)
  • It improves outcome (0.5)
23
Q

Define withdrawal

A

Withdrawal is a substance-specific syndrome following cessation/ reduction in use

24
Q

Define detoxification

A

Detoxification is the removal of toxic substances from the body using medication to reduce tolerance and to alleviate or prevent withdrawal

25
Q

Process of Alcohol withdrawal

A

Features- List 5 (5 x ½): anxiety, agitation, nausea, vomiting, insomnia, cravings, tremor and transient hallucinations. (2.5)
Onset is 6-8 hours post cessation (1/2). Can develop Delirium Tremens, which can be fatal (1).
Complicated and uncomplicated withdrawal- List 5 (5 x ½) : Complications are withdrawal delirium, psychosis, seizures, suicidality, hepatic disease, failed out-patient detox and inadequate support. (2.5)

26
Q

Process of alcohol detox

A

Uncomplicated- out-patient management (1/2), thiamine and diazepam (1), monitor complications (1/2)
Complicated- in-patient management with constant monitoring (1/2), exclude other causes (1/2), give BDZs (1/2) or haloperidol if severe (1/2).
Counseling and motivational interviewing (1/2).

27
Q

Opioid withdrawal: 4 symptom groups

A
  • GI (1/2), pain (1/2), anxiety (1/2) and insomnia (1/2).
28
Q

Opioid detox patient groups

A

Mild- out-patient basis

Moderate to severe- in-patient on Opioid Substitution Treatment (OST)

29
Q

Benzodiazepine withdrawal: features

A

arousal, restlessness, anxiety, perceptual changes and autonomic hyperactivity

30
Q

Benzodiazepine detox

A

Replace short-acting with long-acting at the equivalent dose; decrease the dose every 2 weeks
Monitor and motivate

31
Q

Discuss alcohol withdrawal

A

Withdrawal syndrome develops within 6 hours (1/2); acute psychotic attack and seizures within 72 hours (1/2). It can be uncomplicated and complicated. Uncomplicated withdrawal can be managed at outpatient level (1/2) and is the responsibility of the client’s nearest CHC (1/2). Complicated withdrawal is requires hospital admission (1/2). Patients experience convulsions (1/2), psychosis (1/2), suicidal ideation (1/2), significant medical comorbidity (1/2), inadequate support (1/2) or history of withdrawal delirium (1/2).

32
Q

Management of alcohol withdrawal

A

For uncomplicated- thiamine 100mg daily po for 14 days (1); diazepam 10mg immediately po (1/2), then 5mg 6 hourly for 3 days (1/2); then 5mg 12hourly for 2 days (1/2); then 5mg daily for 2 days (1/2); then stop (1/2).

33
Q

Alcohol Withdrawal Delirium

A

Occurs 2-3 days after prolonged alcohol use has ceased, peaks around 5 days (1/2). Typical features include visual hallucinations (1/2), disorientation (1/2), agitation (1/2), tachycardia (1/2), hypertension (1/2), low-grade fever (1/2) and possible tonic-clonic seizures between 24-48 hours after cessation (1/2). Important to exclude withdrawal from other sedative-hypnotic agents (1/2). Symptoms worsen in subsequent episodes (1/2).
Must be hospitalised for physical and environmental support (1/2). Monitor vital signs regularly (1/2). Monitor for dehydration (1/2), electrolyte imbalances (1/2) and nutrition (1/2).
Medication-
Benzodiazepines (1 of the following)- Diazepam slow IV; clonazepam IM (if IV not possible) or lorazepam IM (1)
Once sedated, maintain mild sedation by giving diazepam po (1/2).
If severe agitation and restless, can add a neuroleptic such as haloperidol (1/2).

34
Q
  1. Distinguish between bipolar type 1 and type 2.
A

type 1: characterised by one or more episodes of mania or mixed affective episode , which may be the presenting feature and this is usually but not always associated with a history of major depressive episode

type 2: characterised by by one or more episode of hypomania and a history of recurrent depressive episode.

35
Q

briefly discuss lithium with regards to pre-treatment considerations

A

pre-treatment considerations:
● prior to initiation, renal and thyroid function must be measured.
● an ECG should be performed in individuals with family history of cardiac disease or arrhythmia
● exclude pregnancy: teratogenic
● not recommended for children under 12 years.

36
Q

briefly discuss lithium with regards to adverse effects

A

adverse effects and toxicity:
dose related toxicity effects include ataxia, lethargy, weakness, drowsiness gastric effects, weight gain, fine tremor and fatigue.

It is vital that one is able to identify lithium intoxication. Signs and symptoms include:
o CNS symptoms (mental retardation, tremor hyperreflexia, convulsions and coma)
o GIT disturbances (anorexia, nausea, vomiting, diarrhoea)
increased aldosterone secretion therefore resuulting in oedema and sodium retention
hypothyroidism
extrapyramidal side effects

37
Q

briefly discuss lithium with regards to contraindications

A 
Contra-indications: 
o    < 12 years old
o    Pregnancy
o    Cardiac disease
o    CNS disorders (eg. Epilepsy)
o    Renal impairment (lithium excreted unchanged in urine) or urinary retention
38
Q

outline the management of acute manic episode

A
  1. detailed assessment and a commitment to care: manic patients turned to be very persuasive and manage to convince health care workers that they dont need treatment. but treatment in the context of the havoc caused in the preceeding days
  2. a safe environment: a safe environment where the patient can be contained to ensure his/her safety and the safety of others. special considerations should be given to children, elderly or physically frail
  3. antidepressant medication should be withdrawn
  4. antipsychotics are 1st line medication: usually treat with an atypical (eg risperidone) to reduce to extrapyramidal side effects but an typical such as haloperidol or chlorpromazine also helps
  5. mood stabilisers: used as treatment and as maintenance to prevent relapses
    valproate: safe and sedates but teratogenic
    lithium : if there is a family history
  6. benzodiazepines: useful in the acute phase for extra sedation. lorazepam or diazepam are given
  7. electro-convulsive treatment
  8. supportive psychotherapy with patient and family to encourage acceptance and explain to the family the patients behaviour before treatment
39
Q

List causes of acute violence in medical settings and provide an example of each

A

Non-medical- criminal behaviours
Aggressive personalities- e.g Antisocial PD with/without other mental illness
Mental illness- acute psychotic episodes of Schizophrenia, mania or agitated depression, dementia, anxiety or severe emotional states (rare)
Substance abuse or dependnace- alcohol, cannabis, methametamine (tik) intoxication or withdrawal
Medical conditions- delirium, epilepsy (pre-ictal irritability or post-ictal confusion), cerebral infections, intracerebral bleeds (subdural heamtomas) or TBI

40
Q

List the 3 levels of violence when performing a risk assessment on the violent or agitated patient, and name the principal method by which way level should be managed

A 
Potentially Violent (1/2 mark): prevention and management (time to plan strategy) (1/2 mark)
Urgent Situation (1/2 mark): de-escalation via the calming interview (1/2 mark)
Emergent violence (1/2 mark): physical or chemical restraints (1/2 mark)
41
Q

Describe the process of de-escalation via the calming interview

A

Approach with both hands in sight
Introduction - “Excuse me, may I talk to you for a minute?”
Safe distance
Calm voice, clear and slow speech - “You seem upset, what is the problem?”
Allow to ventilate, clarify
“How can we help?”
Reasonable demands = comply!
Unreasonable demands = “promote vegetative responses that do not compliment rage”
Humour, eating, “Have a seat, relax”, offer a quiet space
Compliment cooperativeness

42
Q

Describe and explain the 5C’s of containment

A

Be Calm and don’t hide your hands behind your back. A suspicious patient may think you are drawing a weapon and you are open to attack.
Take Control, or at least appear to. This calms staff and patients.
Confidently manage your staff according to the prearranged plan suitable for your setting.
Contain the patient with reassurances. Close down the space by relocating to a smaller, quieter room and instructing the patient to be seated.
Physical or pharmacological Control depends on the situation and should be exercised after giving the patient the option of co-operation and either sublingual or oral medication.

43
Q

Name the classes of drugs used for tranquilisation and provide an appropriate example for each

A

Benzodiazepines -Lorazepam

Antipsychotic agents - Haloperidol

44
Q
  1. Name the stages of the cycle of violence briefly describe the characteristics of each stage
A

Tension Building phase
• Minor incidents of physical/emotional abuse
• Victim feels growing tension
• Victim tries to control the situation to avoid violence; “walking on eggshells”
• Victim cannot control the abuser
Explosion phase
• Incident of violence occurs
Honeymoon Phase
• Abuser is sorry and apologetic
• Abuser promises the abuse will not continue
• Idealised and romantic period; often disappears with time

45
Q
  1. Use the acronym SAFE to formulate four questions (one for each letter of the acronym) you would ask a patient whom you suspect is a possible victim of intimate partner violence
A

S - What STRESS do you experience in your relationship?
Do you feel SAFE in your relationship?
A - Are there situations in your relationship where you have felt AFRAID?
Has your partner ever threatened or ABUSED you or your children?
F - Are your FRIENDS aware that you have been hurt?
Do your FAMILY members know about the abuse?
E - Do you have a safe place to go in an EMERGENCY?
If you needed to leave now, do you have an ESCAPE plan?

46
Q
  1. How would you manage victims of IPV?
A
  1. Provide a safe environment
    a. Do no harm (No debriefing)
    b. Confidentiality
  2. Dx & Rx physical Injuries and other medical/surgical problems
    a. Check for STIs/HIV
    b. Check for injuries: adequate forensic documentation
    c. Check for pregnancy, contraception, TOP, sterilization appropriately
  3. Educate and Plan
  4. Refer as appropriate
    a. Protection Order (80% reduction in physical violence)
    b. Victim empowerment Unit at Police stations
    c. Women’s Group e.g. NICRO
  5. Follow up plan
    a. Depression
    b. Anxiety disorders (PTSD)
    c. Substance misuse
47
Q
  1. Name the psychiatric symptoms and the predominant symptom cluster
A

Bizarre Delusions, Hallucinations, Disorganized behaviour and thoughts/speech
The predominant cluster is psychosis

48
Q
  1. Which causes, other than a psychiatric one, must be considered and investigated(in psychosis)
A

Delirium, Neurosyphilis, HSV encephalitis, HIV-related Psychosis, intoxication, substance induced psychotic disorder (any four)

49
Q
  1. How would you go about narrowing your differential diagnosis, and excluding another medical condition?
A

History and Physical exam. Then tests to exclude AMC, drug use, eliciting other psych sx (2)
RPR (then FTA-Abs if req.), HIV, TSH, fT4, WCC, FBC w Diff, U&E w Creatinine, Urine drug levels, Lumbar puncture for CSF PCR (HSV if indicated by other tests, and results of exam: Seizures NB, papilledema, Temporal relationship w facial lesion NB, etc.) Head CT or MRI if required (Tumours, trauma, etc). Reasoning must be given for these, only if infective causes and psych causes excluded. (2)

50
Q
  1. What is the difference between the presentation and basic management of Delirium and Psychosis?
A

Delirium is characterized by a sudden onset (hours or day) of fluctuating (0.5) awareness (0.5), impairment of memory and attention (0.5), and disorganized thinking (0.5) due to one or more structural and/or physiological abnormalities directly or indirectly affecting the brain (0.5). There is rapid improvement once the underlying cause is found and eliminated. Therefore the management is to find and treat the underlying cause (1)
Psychosis is defined by the presence of one or more of the following hallucinations, delusions, disorganized speech or, grossly disorganized or catatonic behaviour (2). This is not fluctuating (0.5). The management of psychosis requires referral to a psychiatric hospital/ward and antipsychotics. (1)

51
Q
  1. Discuss the direct and indirect effects of HIV on psychiatric illness
A

Direct effects:
• HIV crosses BBB via ‘trojan horse’-method by infecting CD4+ cells. (0.5)
• HIV then directly invades brain parenchyma → neuronal damage → variable sx: psychosis, mania, depression, seizures, memory loss, dementia, etc. (1.5)
• Exact mechanism of direct effects of HIV on the brain unknown (0.5)

Indirect effects: (2.5)
•	Opportunistic infections
•	Effects of ARVs on the brain
•	Increased prevalence of substance use in HIV
•	Social stigma
•	Initial shock of diagnosis
52
Q

Discuss 5 risk factors for suicidality. Assign them to either modifiable or non-modifiable categories

A

Male gender(non mod), unemployment(mod), family hx of suicide(non mod), physical and mental illness(mod), isolation(part mod?), middle aged/elderly(non mod)

53
Q

What are the 4 questions that need to be answered by the end of your assessment of a suicidal patient?

A

What is the likely risk of further self-harm/risk of completed suicide?(high risk vs low risk patients)
Is there a treatable mental illness?(Depression? Bipolar? Schizophrenia?)
What psychosocial problems need to be addressed to help this patient?(finances, accommodation, employment?)
What intervention/support/care is required to reduce the patients risk (management—inpatient vs out patient)

54
Q

List 10 questions to ask if someone presents with attempted suicide

A
  • Did you intend to kill yourself?
  • Why did you want to harm yourself? (was there a trigger?)
  • When did you first think about harming yourself?
  • Why at this time?
  • Previous suicidal thoughts?
  • was this act impulsive? Planned? Precautions? (were precautions taken to ensure they would not be found/rescued)
  • What did you expect would happen?
  • What were your thoughts before the incident, during and after?
  • What are your thoughts now? (regrets of still being alive?)
  • What are your coping strategies? What support to you have?

Michael (7 decks)

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