random facts

Question 1

what are the diagnostic criteria of schizophrenia

Answer 1

A. Two or more of these characteristic symptoms should be present for much of the time over the course of a one month period: one of them has to be 1,2 or 3

1) Hallucinations
2) Delusions
3) Disorganised speech featuring incoherence
4) Catatonic or grossly disorganised behaviour
5) Negative symptoms

B. Social or occupational dysfunction that affects work, personal relationships, or self care is noticeable and has been present since the onset of symptoms
C. Disturbances of behaviour should have been present for at least six months and symptoms must be present for at least one month of that six month period.

Question 2

What are the negative symptoms

how to divide them

Answer 2

avolition, asociality, alogia, blunted effect, anhedonia

two main types:

1) the avolition, asociality, anhedonia
2) alogia, blunted effcet ones (will have negatuive symptoms)

Question 3

What are the treatment used for negative symptoms

(name 3) and wad are the drugs mechanism

Answer 3

Abilify: partial d2 agonist
Amisulpride : low dose (50-300) -> selective dopamine D2 and D3 receptor antagonist
Cariprazine : partial d2 and d3 agonist

Question 4

definition of resilience

Answer 4

ability to cope mentally or emotionally with a crisis or to return to pre-crisis status quickly.

Question 5

Definition of burn out

Answer 5

A syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.

1) Feelings of energy depletion or exhaustion
2) Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job
3) Reduced professional efficacy

Question 6

Medication that affected by smoking

Answer 6

clozapine, olanzapine, haloperidol , to some extent faverin

Question 7

What rating scales measures burnout

What measures resilience

Answer 7

burn out : Maslach Burnout Inventory (MBI) (self rated)

Resilience: resilience scale 14 (self rated)

Question 8

Rating scales for negative syndrome (2)

Answer 8

1) withdrawal-retardation subscale of the Brief Psychiatric Rating Scale
2) the Scale for the Assessment of Negative Symptoms (SANS)
3) Positive and Negative Syndrome Scale (PANSS)

Question 9

What is varenycline

Answer 9

partial agonist of the nicotinic acetylcholine receptor

Question 10

Why varenycline was discontinued in singapore

Answer 10

contaminants with carcinogens

Question 11

Three components of high EE

Answer 11

hostility, emotional over-involvement and critical comments

Question 12

What are the non pharmalogical ways to stop smoking

Answer 12

5As of intervention
Ask - ask pt about tobacco use status
Advise -advise to quit
Assess -Assess willingness to quit
Assist -provide aid for pt to quit
Arrange -arrange follow up contact, Congratulate success during each follow-up

• non pharma-logical
• help with a quit plan, practical problem solving counselling, provide social support, give supplementary support

behavioral counselling, financial incentives, hypnotherapy, acupuncture

Question 13

What are the pharmacological support for stopping smoking

Answer 13

varanicline, nicotine replacement therapy and bupropion

Question 14

S/e and dosing regime of varanicline

Answer 14

varenycline: 
day 1-3: start 0.5mg once daily 
day 4-7: 0.5mg BD
then maintenance 1mg BD
At least 11 weeks 

side effect: increased risk of cardiovascular events (AMI, angina, chest pain), disordered sleep (abnormal dreams and nightmares), somnambulism (sleepwalking), nausea/vomiting at higher doses, neuropyschiatric events (depression, suicidal ideation and behaviors), seizures (dose related)

Question 15

what are the things that suggest bipolarity depression (8) as compared to unipolar depression

Answer 15

1) hypersomnia, inc daytime napping,
2) hyperphagia
3) other atypical depressive symptoms cush as leaden paralysis
4) psychomotor retardation
5) psychotic features
6) lability of mood, racing thoughts
7) Early onset of first depression, multiple prior episode
8) positive fh of bipolar disorder

Question 16

what are the things that suggest unipolarity depression (5) as compared to bipolar depression

Answer 16

1) Initial insomnia, reduced sleep
2) poor appetite, weight loss
3) somatic complaints
4) Late onset of first depression
5) long duration of current episode
6) Neg fh of bipolar disorder

Question 17

how to treat acute manic episode step wise

Answer 17

1) 1st line mono: lithium, quetiapine, valproate, abilify, risperidone (50% will respond within 4-3 week)
2) 1st line combi: +quetiapine, abilify, risperidone, lithium/valporate

-to observe for 1-2 weeks

3) 2nd line: add on or switch therapy
olanzapine, carbamazepine, haloperidol, olanzapine + lithium/valproate, ECT

4) 3rd line: mono chlorpromazine, mono clonazepam, mono or adjuvant clozapine, mono with tamoxifen (risk of uterine cancer), combi with carbamazepine

Question 18

how to treat acute bipolar depression step wise

Answer 18

1) first line: quetiapine, lithium, lamotrigine, lurasidone
adjuvant lurasidone or lamotrigine

2) second line: olanzapine + fluoxetine, mono with valproate, antidepressant + lithium/valporate, ECT
3) third line: monotherapy carbamazepine, mono olanzapine, adjuvant abilify/levothyroxine, rtms, pramipexole, asenapine

Question 19

Maintenance treatment with bipolar 1

Answer 19

Treatment for maintenance step wise
1st line: lithium, quetiapine, valproate, abilify + lithium/valproate, lamotrigine, abilify(for mania only)

2nd line: olanzapine, paliperidone, adjuvent lurasidone, carbamazepine, risperidone(mania only)

3rd line: abilify + lamotrigine, clozapine, gabapentin, olanzapine + fluoxetine

Question 20

What is the percentage of wicnekle converting to korsakoff

Answer 20

80%

Question 21

mechanism of schizophrenia

Answer 21

dopamine hypothesis: positive symptoms: mesolimbic pathway

negative symptoms: mesocorticalpathway

Question 22

what is the age of late onset schizophrenia

Answer 22

40-60

Question 23

What is the MOH CPG guideline for schizophrenia

the pharma bit and non pharma bit

Answer 23

MOH Clinical Practice Guideline for schizophrenia:
Should be offer oral anitpsychotics: 300mg-1g equivalent of chlorpromazine, should start from lower end and slowly titrate upwards, if inadequate response by 4-6 weeks or have s/e, to consider another type of antipsychotic

For maintenance phase, antipsychotic should be reduced gradually but not be lower than half of the effective dose during acute phase

Clozapine should be offer if pt cannot respond to two adequate doses of antipsychotic (of one to be atypical)

Clozapine 18 weeks weekly blood test

Non phamra: CBT, cognitive remediation, psycho-education, assertive community treatment for those with high rates of hospitalization

Question 24

% of treatment resistant schizophrenia
% of schizophrenia in the population
Gender distribution

Answer 24

30%
1%
M=F

Question 25

what is the kane study in 2019

Answer 25

about treatment resistant schizophrenia Consensus treatment guidelines for TRS recommend that patients be reevaluated at 12 weeks after a first episode of psychosis (after 2 antipsychotic trials of ≥ 6 weeks in duration at an adequate dose [ie, ≥ 600 mg chlorpromazine equivalents/d]; Table 3). However, in some circumstances (eg, high risk of suicide), a treatment duration of 2 weeks may be sufficient before considering if additional clinical intervention is needed. The use of alternative pharmacotherapies, including clozapine, or nonpharmacologic adjunctive treatments (eg, CBTp, ECT, rTMS, HIT) should be considered if treatment response is not optimal.

Question 26

Landmark study for schizophrenia (2)

Answer 26

1) catie (clinical antipsychotic trials for intervention effectiveness) - compare SGA (olanz, risperidone, quetiapine) to FGA perphenazine - olanzapine longer time to discontinuation, hence greater effectiveness - phase 2: clozapine is more effective than other SGA 2) CUTLASS (cost utility) - compare quality of life SGA vs FGA. NO disadvantage across 1 year in terms of QOL, symptoms or associated cost of care in FGA

Question 27

% of schizophrenia relapse if no meds

Answer 27

80% in the first year

Question 28

``` Schizophrenia scales (3) name three rating scales for EPSE ``` functional scale (1) Cognitive

Answer 28

PANNS (The positive and negative syndrome scale) BPRS Brief negative symptoms scale Simpson Angus EPSE scale Abnormal involuntary movement scale Barnes Akathesia Rating scale SOFAS (social and occupational functioning assessment scale) Brief assessment of cognition in schizophrenia

Question 29

What to run through when one is not reacting to meds (5)

Answer 29

-med non adherence, drug drug interaction, check other things that evaluate metabolism (smoking), reevaluate diagnosis, cormobid diagnosis (substance use)

Question 30

Resources for schizophrenia

Answer 30

specialised services: CHAT, SWAP, EPIP | Occupation: Octave, Fame club (Friendship And Mind Enrichment club)

Question 31

Causes of hyperprolactinemia (7)

Answer 31

dopimine blocking meds, stress, pregnancy, lactation, seizure, renal impairment, prolactinoma

Question 32

Symptoms of hyperprolactinemia

Answer 32

breast growth, changes in libido, changes in breast growth, reduction in bone mineral density and inc risk of breast ca

Question 33

Higher risk of hyperprolactinemia for medication (5)

Answer 33

halo, CPZ, risperidone, sulpiride, paliperidone, amisupiride

Question 34

Antipsychotic that are prolactin sparing (5)

Answer 34

low risk: clozapine, olanzapine, ziprsidone | sparing: Abilify, quetiapine

Question 35

Name two ratings scales for suicide

Answer 35

COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS) | SADS PERSON SCALE

Question 36

which side effect for clozapine is dose dependent

Answer 36

everything except for neutropenia

Question 37

Titrate dosage for clozapine | What to do when miss a dose

Answer 37

Clozapine 12.5mg once a day then can inc to 12.5mg BD the next day, then inc by 25-50mg a day until a dose of 300mg is reached. Further inc is 50-100mg each week. When clozapine need to start from scratch When miss dose for more than 2 days but faster, if more than a week retitrate as if new inpatient

Question 38

What are the target dose for clozapine

Answer 38

Target dose 250mg: female non smoker 350mg: male non smoker 450mg: female smoker 550mg: male smoker

Question 39

Clozapine augmentation evidence When What (5)

Answer 39

Evidence: small effect size with antipsyhcotic augmentation When?: 3–6 months of optimised clozapine alone has not provided satisfactory benefit Add wad? ECT, amisupride 400-800mg, abilify 15-30mg. haloperidol 2-3mg, lamotrigine 25-300mg, risperidone 2-6mg

Question 40

What are the alternatives for clozapine

Answer 40

Alternative: allupurinol + antipsychotic, high dose olanzapine up to 60mg, CBT, donepezil + antipsychotic, memantine + antipsychotic, ECT

Question 41

What is the target dose for clozapine in terms of clozapine blood level

Answer 41

Target threshold 350-420 ug/L

Question 42

common s/e of clozapine

Answer 42

Side effect Sedation may wear off to some extend Hypersalivation Constipation, highest risk in the first 4 months Hypotension first 4 weeks Tachycardia first 4 weeks, can give atenolol/bisoprolol +fever, hypotension, chest pain may be indicative of myocarditis Weight gain Fever, first 4 weeks due to clozapine induced inflammatory response Seizure, to give anticonvulsant if >600mg Neutropenia first 18 weeks Myoclonus

Question 43

What to give for hypersalivation from clozapine (5) | Why

Answer 43

can give atropine, amisuplride, benzhexol, glycopyrrolate, ipratropium, metoclopramide due to muscarinic agonism

Question 44

Clozapine with serious side effect

Answer 44

serious s/e agranulocytosis 0.8% Thromboembolism 20x more Cardiomyopathy, show of heart failure Myocarditis 3% of patient , usually first 6-8 weeks, ECG signs: ST depression, eosinophilia If CRP >100 and trop twice upper limit, to stop clozapine and repeat echo colitis ?anticholinergic Hepatic failure Pancreatitis Pericardial effusion : fatigue, chest pain, dyspnea, tachycardia. raised pro BNP< trop

Question 45

What ECG show on myocarditis for clozapine | what other signs

Answer 45

ST depression | eosinophilia

Question 46

Issues with clozapine and chemotherapy

Answer 46

Neutropenia, ethical issue to decrease clozapine

Question 47

What is NMS | What is the mortality %

Answer 47

NMS is a life threatening neurologic emergency associated with use of neuroleptic agents and characterised by clinical syndrome of mental status change, rigidity, fever, dysautonomia. 20%

Question 48

Med that cause NMS (3 categories)

Answer 48

antipsychotic agents Antiemetic agents: metoclopramide, domperidone, promethazine Withdrawal of l-dopa or dopamine agonist therapy

Question 49

Risk of NMS (5)

Answer 49

recent or rapid dose escalation, higher doses, higher potency, male, catatonia, extreme agitation, substance abuse or neurologic disease

Question 50

Symptoms of NMS | tetrad

Answer 50

- mental status change - muscular rigidity - hyperthermia >38 - autonomic instability (tachycardia, high bp, tachypnea, diaphoresis)

Question 51

Labs signs of NMS (5)

Answer 51

elevated CK at leat 4 times upper limit Low iron Leukocytosis Transaminase, lactate dehydrogenase elevation Electrolyte imbalance: hypocalcemia, hypomagnesemia, hyperkalemia, hyper/hyponat Myoglobinuric acute renal failure

Question 52

Treatment of NMS ``` supportive (5) Medical treatment (4) ```

Answer 52

1) Stop causative agent 2) Supportive care: - Maintain cardiorespiratory stability. Mechanic ventilation, antiarrhythmic agents, or pacemakers may be required - Maintain euvolemic state using intravenous fluids. Insensible fluid loss from fever and from diaphoresis should also be considered. If creatine kinase (CK) is very elevated, high-volume intravenous fluids with urine alkalinization may help prevent or mitigate renal failure from rhabdomyolysis - Lower fever using cooling blankets. More aggressive physical measures may be required: ice water gastric lavage and ice packs in the axilla. - Lower blood pressure if markedly elevated. Clonidine is effective in this setting - Use benzodiazepines (eg, lorazepam 0.5 to 1 mg) to control agitation, if necessary Specific medical treatment: benzodiazepine 10mg every 8 hours, dantrolene (muscle relaxant) 1-2.5mg/kg, bromocriptine(dopamine agonist) 2.5mg up to 40mg/day, and amantadine (dopaminergic and anticholinergic effects) ECT

Question 53

When and how to restart antipsychotic for NMS (3)

Answer 53

When and how to restart antipsychotic for NMS (3): wait for at least 2 weeks, use lower potency agents, start low dose and titrate upwards, avoid dehydration, cont monitor symptoms of NMS

Question 54

Complication of NMS (7)

Answer 54

Complication of NMS ●Dehydration ●Electrolyte imbalance ●Acute renal failure associated with rhabdomyolysis ●Cardiac arrhythmias, including torsades de pointes and cardiac arrest ●Myocardial infarction ●Cardiomyopathy ●Respiratory failure from chest wall rigidity, aspiration pneumonia, pulmonary embolism ●Deep venous thrombophlebitis ●Thrombocytopenia ●Disseminated intravascular coagulation ●Deep venous thrombosis ●Seizures from hyperthermia and metabolic derangements ●Hepatic failure ●Sepsis

Question 55

What are the psychological help for PTSD and what kind of intervention was included

Answer 55

``` Trauma focus CBT: cognitive processing therapy cognitive therapy for PTSD narrative exposure therapy prolonged exposure therapy. ``` EMDR: eye movement desensitization reprocessing therapy

Question 56

What are the approved drugs for ptsd | other non label use?

Answer 56

SSRI: paroxetine and sertraline Non labeled use: venlafaxine Risperidone if not responding

Question 57

PTSD dsm criteria

Answer 57

for age of more than 6 years old criterion A: exposure to actual or threatened death, serious injury or sexual violence in 1) direct 2) witness in person as it occur to others 3) learning tat occur to a close family member or close friend 4) experiencing repeated or extreme exposure to aversion details of the traumatic event B: intrusion 1 of 5 1) recurrent, involuntary, intrusive distressing memories of the traumatic event 2) Recurrent distressing dreams with is related to the traumatic events 3) Dissociation reactions (flashback), feels and acts as if the traumatic events were recurring 4) Intense or prolonged psychological distress at exposure to internal or external cues 5) Marked physiological reactions to internal or external cues C: avoidance: 1 of 2 1) avoidance of or effort to avoid distressing memories, thoughts or feelings about or closely associated with the traumatic events 2) avoidance of or effort to avoid external reminders D: negative altercation in cognition and mood 2 of 7 1. inability to remember an important aspect fo the event 2. Persistent and exaggerated negative belief or expectation 3. Persistent, distorted cognition about the cause or consequences of the traumatic events that leads ppl to blame oneself 4. Persistent neg emotional state 5. Marked diminished interests in activities 6. Feeling of detachment 7. persistent inability to experience positive emotions E: Hyper arousal: 2 of 6 1) Irritable behavior or angry outburst 2) Reckless or self destructive behavior 3) Hyper vigilance 4) Exaggerated startle response 5) Problems with concentration 6) Sleep disturbance All more than 1 month caused clinically sig impairment in social, occupational or other areas of functioning

Question 58

Specifier for PTSD

Answer 58

With dissociative symptoms + have depersonalisation or derealisation with delayed expression-> after more than 6 months

Question 60

Risk factors for tardive dyskinesia (9)

Answer 60

Risk factors for tardive dyskinesia Patient characteristics Older age Female sex ``` Drug exposure characteristics* First > second-generation antipsychotics Cumulative duration Higher dose Early occurrence of drug-induced movement disorders ``` ``` Co-morbidities Schizophrenia and other psychotic disorders Intellectual disability Preexisting mood disorder Alcohol or substance use disorder Dementia Diabetes ``` Others Prior electroconvulsive therapy

Question 61

Causative agents for TD:

Answer 61

``` Causative agents: all dopamine receptor blocking agents Antipsychotic drugs metochlopramide, other emetics Amoxapine, aripiprazole ```

Question 62

Meds for persistent moderate to severe TD

Answer 62

Meds for persistent moderate to severe TD ->For patients with persistent and bothersome TD, vesicular monoamine transporter type 2 (VMAT2) inhibitors (valbenazaine, tetrabenazaine, Deutetrabenazine) are the primary symptomatic therapy. Benzodiazepine therapy is sometimes helpful for mild symptoms but is unlikely to help more severe TD. Other meds include amantadine, glingko Biloba, vit E, vit B6, beta blockers) ->For the subset of patients with tardive dystonia (eg, cervical and truncal dystonia, blepharospasm), botulinum toxin injections are a localized option that may spare the need for systemic drug therapy. ->Patients with refractory TD despite symptomatic therapies should be referred to a movement disorder specialist for consideration of deep brain stimulation (DBS).

Question 63

Treatment for AD

Answer 63

pharmacological management of AD NICE guideline, for donepezil, galantamine, rivastigmine monotherapy for mind to moderate AD memantine monotherpy is recommended when mod AD who cannottake AChI or severe AD KIV add memantine if oledi on an AChE

Question 64

Treatment of lewy body dementia

Answer 64

Offer donepezil or rivastigmine to people with mild to moderate dementia with Lewy bodies. Only consider galantamine for people with mild to moderate dementia with Lewy bodies if donepezil and rivastigmine are not tolerated. Consider donepezil or rivastigmine for people with severe dementia with Lewy bodies. Consider memantine for people with dementia with Lewy bodies if AChE inhibitors are not tolerated or are contraindicated.

Question 65

Treatment of vascular and frontal lobe dementia

Answer 65

Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer's disease, Parkinson's disease dementia or dementia with Lewy bodies. Do not offer AChE inhibitors or memantine to people with frontotemporal dementia.

Question 66

Dosing for 1) donepezil 2) rigvastigmine (oral and patch) 3) memantine

Answer 66

Dosing for donepezil 2.5mg OM then max is 10mg Daily rivastigmine 1.5mg bD or 4.6mg/24 hour patch 3-6mg BD dosing or 9.5mg/24 hour patch Dosing for memanine 5mg then up to 20mg daily, inc 5mg weekly

Question 67

S/E memantine

Answer 67

s/e for memantine: hepatic impairment and epilepsy/seizures, AGITATION, dizziness, bradycardia

Question 68

S/E for Acetylcholinesterase inhibitor

Answer 68

s/e for cholineterase inhibitor: excess cholinergic stimulation can lead to nausea, vomiting, dizziness, insomnia and diarrhoea which is dose related urinary incontinence, neuropsych symptoms, bradycardia, need ECG,

Question 69

Drug Drug interaction with donepezil

Answer 69

drug drug interaction with donepezil: in with fluoxetine, paroxetine, dec by carbamazepine, alcohol, phenytoin bradycardia, to watch out for beta blockers, calcium channel blockers

Question 70

BPSD non drug measures (5)

Answer 70

BPSD non drug measures: check for underlying cause, medication side effects, pain assessment, sleep wake disturbances, depression, delusions Snoezelen (specially designed rooms with a soothing and stimulating environment) Exercise training in combination with caregiver education aromatherapy music therapy Massage and touch therapy

Question 71

Treatment for akathesia pseudoparkinism dystonia

Answer 71

treatment for akathesia propanolol, clonazepam, 5-ht antagonist like trazodone, mirtazapine, cyproheptadine no anticholinergic Treatment for pseudoparkinism anticholinergic Treatment for dystonia Benzodiazepine, anticholinergic

Question 72

antipsychotic to giv if weight gain (5)

Answer 72

Haloperidol, amisulpride, sulpride, lurasidone, stelazine

Question 73

lab test for catatonia (3)

Answer 73

There is no laboratory test specific for catatonia. However, malignant catatonia is associated with non-specific test results that include leukocytosis, increased creatine kinase, and low serum iron

Question 74

Treatment for catatonia

Answer 74

Treatment for catatonia Benzodiazepine Then ECT if not getting better Treatment for underlying disorder supportive Hyperthermia: rapid cooling Hypertension Hydration and ngt for feeding Compression stockings, ant thrombolytic for DVT Pressure ulcers treatment: frequent turning

Question 75

Wad are the prolactin sparing antipsychotic drugs (4) Wad are the high risk ones (4)

Answer 75

low: - abilify - asenapine - clozapine - quetiapine high: - FGA - amisulpride - risperidone - Paliperidone - Sulpride

Question 76

How to approach hyperprolatinemia for ppl with antipsychotics

Answer 76

switch, is not successful, add adjustive abilify | If cannot, add dopamine agonist, amantadine, bromocriptine, or metformin

Question 77

How to approach sexual dysfunction for peeps with antipsychotics

Answer 77

TReatment of secual dysfunction 1) physical pathology (diabetes, hypertension, cardiovascular disease, etc.) has been excluded 2) DEc dose or discontinue offending drug 3) switch to less propensity (abilify, lurasidone, quetiapine, asenapine) 4) add abilify 5-10mg to normalise prolactin 5) antidote drug eg: mirtazapine, cyproheptadine 6) sinedafil for erectile dysfunction

Question 78

General recommendation of antipsychotic to switch 1) akathisia(3) 2) postural hypotension (3) 3) TD (3)

Answer 78

1) akathisia olanzapine, quetiapine, clozapine 2) postural hypotension amisulpride, lurasidone, abilify 3) TD clozapine, abilify, quetiapine, olanzapine

Question 79

Substance/ medication that cause mania

Answer 79

Substance: alcohol, Cocaine, amphetamines, phencyclidine, hallucinogens Meds: antidepressants, methylphenidate, steroids

Question 80

Wad r the components of interpersonal psychotherapy

Answer 80

Role transition, Role dispute, interpersonal deficits, grief

Question 81

what is SSRI emotional blunting

Answer 81

ssri emotional blunting/emotional difference - due to serotoninergic ability - management: make sure is not depression first, then look into cutting dose, switching it over bupropion (may worsen psychosis), vortioxetine, agomelatonin, TCA